The purpose of this module is to provide
comprehensive information pertaining to child maltreatment and intimate partner
At the completion of this module, you
will be able to:
Describe national statistics associated
with child maltreatment.
Explain your responsibilities as a
Identify the state agency that
investigates allegations of child maltreatment.
Describe barriers that contribute to under recognition and underreporting of suspected
cases of child maltreatment.
Describe the role of the sexual assault
List the four major types of child
Define the terms, medical neglect,
educational neglect, emotional neglect, economic abuse, and abandonment.
Explain how parent substance use
disorder affects the child.
Identify risk factors for child
Identify protective factors that reduce
the risk of child maltreatment.
Describe actions the nurse should take
when assessing a child when maltreatment is suspected.
Explain how to document the care of a
child who has a physical injury and physical abuse is suspected.
Discuss the responsibility of the nurse
when working with clients experiencing intimate partner violence.
Identify the components of primary,
secondary, and tertiary prevention levels of intervention.
Discuss actions for the nurse to take
when experiencing moral distress.
Locate the number for the national hotline
which can be used to determine where to report suspected abuse.
Child maltreatment includes all types of abuse and neglect of a
child under the age of 18 by a parent, caregiver, or another person in a
custodial role (e.g., clergy, coach, or teacher). There are four common types
of maltreatment: Physical Abuse, Sexual Abuse, Emotional Abuse, and Neglect.
Statistics and Data
Data from U.S. Department of Health and Human Service’s report, Child Maltreatment 2014, is provided
In 2014, approximately 702,000 children were victims of
Approximately 1,546 children died from abuse or neglect
Neglect accounted for 75% of the cases of maltreatment
Physical abuse accounted for 17% of the cases of maltreatment
Younger children are most vulnerable
And 8.3% were sexually assaulted
According to the Child Welfare Information Gateway (CWIG) fact
sheet, federal legislation provides the basis for state laws on child
maltreatment by providing a list of acts or behaviors that define child abuse
or neglect. The Federal Child Abuse Prevention and Treatment Act defines child
abuse and neglect as, at minimum:
recent act or failure to act on the part of a parent or caretaker which results
in death, serious physical or emotional harm, sexual abuse or exploitation; or
any act or failure to act which presents an imminent risk of serious harm.”
All 50 states and the District of Colombia have mandatory
reporting statutes stipulating individuals required to report suspected cases.
However, the specific circumstances and the individuals who are mandatory
reporters vary from state to state. Most state child protection laws include
harm caused by parents or caregivers but not harm caused by other people.
However, some state laws include intimate partner violence witnessed by the
child as abuse of neglect.
The state child protective service agencies determine the response
to the allegations of child maltreatment. In most states, the majority of the reports
are investigated. If the results of the investigation show that the charges of
child maltreatment are founded according to the statutes and policies of the
state, then the disposition is substantiated. If the results of the
investigation show that the charges of child maltreatment are unfounded
according to the statutes and policies of the state, then the disposition is
Despite mandatory reporting statutes, child maltreatment is
considerably unrecognized and unreported. In fact, there is evidence that shows
only one in three children who experience maltreatment is identified and
reported to child protective services.
It is especially important for nurses to serve as advocates for
children who are maltreated. Nurses are frequently the first health care
professional to come in contact with a child and his or her family and in that case,
should be the one to identify a potential incidence of child maltreatment. Plus,
nurses who work in inpatient settings have lengthy interactions with children
and their families which provides them the opportunity to identify indications
of abuse or neglect.
Although nurses who work with children should always be aware of
indications of neglect or abuse, Kraus, a pediatric emergency room nurse shares
her story and offers the following advice:
If the story doesn’t fit the injury, be suspicious
Always perform a head-to-toe assessment
Child maltreatment occurs in all social, economic, racial and
Even though nurse- opportunity to take action when there is a
reason to suspect child maltreatment, a number of barriers contribute to under
recognition and underreporting of suspected cases of child maltreatment.
Health care providers, including nurses, have an inadequate understanding
of what child maltreatment is, how to identify at risk children, and how to
Often, health care workers are unfamiliar with the statues in
their state or jurisdiction that set out the mandatory reporter obligations.
The health care provider may lack the confidence to function in
the role of mandatory reporter.
Fear of litigation or being sued for reporting suspected
Damage to the nurse-client relationship is a fear of some nurses
along with the fear that a report to child protective service puts the child at
greater risk because the family will discontinue the nurse-client relationship
and avoid seeking treatment for the child.
It is critical that all health care providers who work with
children have the requisite knowledge and skills to recognize and report to act
when there are indications of child maltreatment.
Most states identify four major types of maltreatment: physical
abuse, neglect, sexual abuse and emotional abuse. Some states include
abandonment and parenteral substance use disorder as a form of neglect. See the
link below to review the child maltreatment statues in your state.
PHYSICAL Abuse is physical injury that did not occur due to an accident. Physical abuse
can range from minor bruises to broken bones or even death. Such injuries are
considered abuse even when the caregiver did not intent to harm the child. Obvious
indications of physical abuse include bruises that are in various stages of
healing and look like they are from a hand or belt, burns from cigarettes or
scalding water, fractures, internal bleeding, strangulation marks on the neck,
injuries to the face or head and perforated ear drum. Less obvious indications
of violence include headaches, dizziness, falls, insomnia, and depression.
Consider the possibility of abuse if you notice that the child shrinks when
touched or seems frightened by the caretaker. The nurse should be alert when there are
frequent visits to the health care setting and/or the caregiver labels the
child as “accident prone.”
SEXUAL Abuse as defined by Child Abuse Prevention and Treatment Act (CAPTA) is
Employment, use, persuasion, inducement, enticement, or
coercion of any child to engage in any sexually explicit conduct or stimulation
of such conduct for the purpose of producing any visual depiction of such
conduct; or rape, and in the case of caretaker or inter-familial relationships,
statutory rape, molestation, prostitution, or other forms of sexual
exploitation of children or incest with children.
Child Welfare Information Gateway (CWIG) provides information about possible
indications of sexual abuse displayed by the child:
Has difficulty walking or sitting.
Wets the bed.
Refuses to change clothes for gym.
Demonstrates bizarre, sophisticated or unusual sexual knowledge or
Becomes pregnant or acquires asexually transmitted infection.
Attaches quickly to strangers.
CWIG provides information about possible indications of sexual
abuse displayed by the caregiver:
Is unduly protective of the child or severely limits the child’s
contact with other children, especially of the opposite sex.
Is secretive and isolated.
Is jealous or controlling with family members.
Rape is forced sexual intercourse a nonconsensual activity that
involves penetration of the vagina or anus or oral cavity by a body part or
inanimate object. Both men and women can be victims of rape. However,
statistics show that the highest risk is for females under the age of 34, in a
low income bracket and live in a rural community.
A sexual assault nurse examiner (SANE) is a register nurse who has
special training to conduct sexual assault evidentiary examination for rape
victims. The SANE is also qualified to serve as an expert witness in court. Be
prepared to assist the SANE with the physical examination and support the
client during the examination. Sexual assault evidence kits are used for
collecting blood, oral swabs, hair samples, nail swabs, or scrapings and
genital, anal, or penile swabs.
Emotional Abuse includes
behavior that minimizes the child’s feelings of self‑worth or humiliates, threatens,
or intimidates. Blaming the child for situations over which he or she has no
control, isolating the child from friends, and punitive, inconsistent discipline
are examples of emotional abuse.
CWIG provides information about possible indications of emotional
abuse displayed by the child:
Displays extremes in behavior, such as overly compliant or
Is either inappropriately adult or inappropriately infantile (head
Is delayed in physical or emotional development.
Has attempted suicide.
Reports a lack of attachment to a parent.
CWIG provides information about possible indications of emotional
abuse displayed by the child:
Constantly blames, belittles or berates the child.
Is unconcerned about the child or refuses to consider offers of
help for the child’s problems.
Overtly rejects the child.
NEGLECT includes the failure
on the part of the caregiver to provide physical, medical, educational,
financial or emotional needs.
Neglect is the failure to provide
food, shelter, hygiene or appropriate supervision.
Neglect is the failure to provide
needed medical care including untreated medical or mental health conditions,
dental care, or glasses.
Neglect is the failure to provide
education for the child, including special education when needed.
Neglect is the failure to provide a
child the love and support needed to thrive and to develop into a healthy
Economic Abuse is the failure to provide for the needs of the child when adequate funds
occurs when the parent
leaves the child behind and his or her whereabouts are unknown. Some states identify abandonment as a form of
Disorder is also included in the
definition of child maltreatment in some states.
Partner Violence is another type of abuse
that is included in the definition of child maltreatment in some states. Certainly,
living in a chaotic environment where children frequently witness has a
negative effect on the growth and development of a child. Information about
this topic is provided later in the module.
When states include substance use disorder as a definition of
abuse, according to CWIG the following parental actions constitute abuse:
Child harm due to the mother’s use of an illegal drug or substance
Manufacture of methamphetamine in the presence of a child
Selling, distributing, or giving illegal drugs to a child
Use of controlled substances by a caregiver that impairs the
ability to provide care for the child
Check the website below for more information about substance use
disorder by a parent.
Does your state statute address the
issue of parental substance use disorder as child abuse?
Individual Risk Factors For Child Maltreatment:
Children younger than 4 years of
Special needs that may increase
caregiver burden (e.g., disabilities, mental retardation, mental health
issues, and chronic physical illnesses)
Risk Factors for Perpetrators of Abuse
Individual Risk Factors:
Parents’ lack of understanding of
children’s needs, child development and parenting skills
Parents’ history of child
maltreatment in family of origin
Substance use disorder and/or
mental health issues including depression in the family
Parental characteristics such as young
age, low education, single parenthood, large number of dependent children,
and low income
caregivers in the home (e.g., mother’s male partner)
Parental thoughts and emotions
that tend to support or justify maltreatment behaviors
Family Risk Factors
dissolution, and violence, including intimate partner violence
Parenting stress, poor
parent-child relationships, and negative interactions
Community Risk Factors
disadvantage (e.g., high poverty and residential instability, high
unemployment rates, and high density of alcohol outlets) and poor social
Protective Factors for Child Maltreatment
Protective factors buffer children from being abused or neglected.
These factors exist at various levels. Protective factors have not been studied
as extensively or rigorously as risk factors. However, identifying and
understanding protective factors are equally as important as researching risk factors.
There is scientific evidence to support the following protective
Family Protective Factors
Supportive family environment and
Several other potential protective
factors have been identified. Research is ongoing to determine whether the
following factors do indeed buffer children from maltreatment.
Nurturing parenting skills
Stable family relationships
Household rules and child
Access to health care and social
Caring adults outside the family
who can serve as role models or mentors
Community Protective Factors
Communities that support parents
and take responsibility for preventing maltreatment
Individual Risk Factors for Violence
History of being abused or
exposure to violence
Fear and distrust of others
Inadequate social skills
Minimal social support/isolation
Immature motivation for marriage
Weak coping skills
Recognizing Potential Child Maltreatment/Neglect
Unexplained injury or injuries
Unusual fear of the nurse and
Injuries/wounds not mentioned in
Fractures, including older healed
injuries/wounds/fractures in various stages of healing
Cigarette or immersion burns
Robe or belt marks
Trauma to genitalia
Malnourishment or dehydration
General poor hygiene or
inappropriate dress for weather conditions
Parent considers child to be a
Accidental injuries usually occur along the most bony areas
(knees, shins, elbows), whereas suspicious bruising can be seen in places like
the inner thighs, stomach, feet, hands, back, buttocks, neck and back of arms
Social and Community Violence Risk Factors
Media exposure to violence
Crowded living conditions
Feelings of powerlessness
Lack of community resources (playgrounds, parks, theaters)
Nursing Assessment of a Child when Maltreatment is Suspected
Hold the interview in a private setting.
Be understanding and attentive.
Avoid using terminology that might place
the parent on the defensive for example, abuse or violence.
When abuse is suspected, let the parent
know a report will be made to child protective services.
Initially interview the parent and the
Ask the parent about injuries to the
If abuse is suspected, the nurse should ask
the parent to speak with the child in private. Refusal could mean there is a
Ask the parent if the child’s behavior
has changed or if he/she has voiced new physical complaints.
Observe the infant for excessive crying
Observe the child for developmental
For preschool children, observe how they
play or what they draw.
Ask the child who takes care of them.
Ask the child what he/she does for fun.
Ask older children to tell you what
Ask older children if they are
Ask what happens when someone in the
household gets angry.
It’s always important for the nurse
perform accurate and complete documentation. Accurate, complete documentation
provides the nurse, the nurse’s coworkers and the agency legal protection. Good
documentation is the best defense against malpractice. Know your agencies
policies regarding documentation and follow the policies diligently in all
situations and especially in high-risk situations such as when there is
suspicion of abuse. Include a description of the client’s medical history, the
family’s psychosocial history, and observations you made regarding interaction
among family members. Document direct quotes regarding when the injury occurred
and who caused it. Document physical injuries in narrative form as well as in pictorial
form such as a body map.
According to the U.S. Department of
Justice intimate partner violence (IPV), also known as domestic violence is the
use of behavior that is used by an intimate partner to gain control or to
maintain power and control of the other intimate partner. IVP can be physical,
sexual, emotional, economic, or psychological actions or threats of actions
that influence another person. This includes any behaviors that intimidate,
manipulate, humiliate, isolate, frighten, terrorize, coerce, threaten, blame,
hurt, injure, or wound someone.
Children who live in a home where there
is violence may witness the violence first hand, come home to find the after
effects of violence or see the perpetrator removed from the home by the police.
IPV is associated with a number of long-term adverse effects including
depression, low self-esteem, antisocial behavior, academic difficulty,
seductive behavior, and difficulty with the law. Older children may attempt to
run away from home.
There are three phases to the cycle of
violence, the tension-building phase, the serious battering phase, and the honeymoon
In the tension building phase, the
abuser is jittery and has minor flare ups where the victim may be abused
verbally or hit or slapped. The victim feels like she is “walking on eggs,” and
In the serious battering phase, serious
injury can occur. The abuser’s mind set is “I just want to teach her a lesson.”
The victim can be so tense; she provokes the abuser, “just to get it over
with.” During this phase, the victim may come to the emergency department for
medical care if there is severe physical injury. Emergency department nurses
have a unique opportunity to identify intimate partner violence and to provide
support and assistance to victims and their families. In this phase, the victim
may conclude that she needs a safe place to hide from the abuser, especially if
she fears for her own life and the lives of her children.
In the honeymoon phase, the abuser
displays loving behavior and may shower the victim with gifts. He apologizes, promises
to change. The victim responds because she wants to believe that he is able to
change and hopes that the cycle will not start again.
Nurses who provide care for victims of
abuse have the opportunity to support the victim and offer resources for
assistance. The nurse should
Start by establishing rapport with the
victim. Reassure her that she did nothing wrong.
Allow the victim to tell the story
Ask the victim to tell what happened.
Encourage the victim to work with a
counselor who can direct her to resources and assist her to decide her plan of
Direct the victim to support groups to
minimize her feelings of isolation.
Below are the questions from an extensively used
Abuse Assessment Screen that was developed by Soeken and colleagues.
Within the year, have you been hit,
slapped, kicked or otherwise physically hurt by someone?
Since you have been pregnant, have you
been hit, slapped, kicked or otherwise physically hurt by someone?
Within the last year, has anyone forced
you to have sexual activities?
Have you ever been emotionally or
physically abused by your partner or someone important to you?
Are you afraid of your partner or anyone
As discussed above, the nurse should
encourage the victim to talk about the incident, discuss the importance of
personal safety, provide the victim with written information about referral
information such as a mental health clinic and community advocacy groups. The
nurse should offer support while remembering that it’s the victim who makes the
decision about what to do.
Looking from the outside in the question
is, “why doesn’t she leave him?” The
victim may choose to stay in the relationship for one or more reasons:
Fear of retaliation-the abuser may
threaten to kill her or the children if she leaves.
Financial reasons-she may not have the
money to leave and she may not have job skills to support herself and her
Lack of a support network-family members
want her to stay in the relationship.
Fear of losing the children-she might
lose custody of the children if she leaves.
The victim needs information about
community safe houses and shelters. These facilities provide the victim with a
place where she can feel safe and protected. Additionally, facility staff
provides victims with emotional support, group counseling, legal representation
and social services.
The nurse should provide the victim with
information about a nearby shelter even if the victim’s decision is to stay in
the relationship at the present time. The nurse should also recommend that the
victim pack a bag with needed items and place it somewhere that the abuser will
not find it. A partial list is found below.
Money for living expenses
Emergency phone numbers
Clothing for self and children
Keys to the house and the car
Legal documents-birth certificates,
driver’s license, social security cards
Items of sentimental value
Teach alternative methods of conflict
resolution, anger management, and coping strategies in community
Organize parenting classes to
provide anticipatory guidance of expected age‑appropriate
behaviors, appropriate parental responses, and forms of discipline.
Educate clients about community
services that are available to provide protection from violence.
Assist in removing or reducing
factors that contribute to stress by referring caretakers to respite
services, assisting an unemployed parent in finding employment, or
increasing social support networks for socially isolated families.
Teach individuals that no one has
a right to touch or hurt another person, and make sure they know how
to report cases of abuse.
Identify and screen those at risk
for abuse and individuals who are potential abusers.
Assess and evaluate any
unexplained bruises or injuries of any individual.
Screen all pregnant women for
potential abuse. This might be the one time in some women’s lives
that they can access the health care system on a regular basis.
Refer sexual assault or rape
survivors to a local emergency department for assessment by a SANE/sexual assault
abuse team. Caution the client not to bathe following the assault
because it will destroy physical evidence.
Assess and counsel anyone
contemplating suicide or homicide, and refer the individual to
the appropriate services.
Support and educate the offender,
even though a report must be made.
Assess and help offenders address
and deal with the stressors that can be causing or contributing to
the abuse, such as mental illness or substance use disorder.
Alert all involved about available
resources within the community.
Advocate for legislation designed
to assist caregivers and to increase funding for programs that supply
services to low‑income, at‑risk individuals.
Establish parameters for long‑term
follow‑up and supervision.
Make resources in the community
available to survivors of violence (telephone numbers of crisis
lines and shelters).
If court systems are involved,
work with parents while the child is out of the home (in foster
Refer to mental health
professionals for long‑term assistance.
Provide grief counseling to
families following the death of a family member to suicide or
Develop support groups for
caregivers and survivors.
Caring for Clients Who Experience Violence
Build trust and confidence with a client.
Focus on the client rather than the situation.
Assess for immediate danger.
Provide emergency care as needed.
It is NOT the job of the nurse to interrogate or investigate, reasonable cause is all that is needed to report to the agencies who will investigate.
If you suspect with reasonable cause that abuse may have occurred, complete mandatory reporting, following state and agency guidelines.
Awareness of Personal Emotions and Thoughts
As a nurse who provides care for children who are
victims of maltreatment, you must be aware of your own emotions. First examine
your personal views about child maltreatment. It’s important, even though it may be difficult,
to set aside negative bias because you need to provide nonjudgmental care to
the child and to the family. Some common emotions you might feel are as
Anguish can occur when the nurse has been a victim
Fear might be present if the perpetrator turns anger
toward others (the nurse).
Confusion is experienced when the nurse realizes
child maltreatment could be a problem with one’s own family.
Helplessness because the nurse cannot intervene to
“fix the problem.”
Discouragement because the problem is still present
and a long-term solution has not been achieved.
Embarrassment because the situation reminds the
nurse of something in one’s own home.
Blame the victim for actions the nurse sees as
provoking the perpetrator or when the nurse just feels overwhelmed.
When nurses are unable to do what they feel is best for the client
due to constrains such as family decisions, lack of resources, or agency
polices, they can feel alone and frustrated. This phenomenon is known as moral
distress. According to the American Association of Critical Care Nurses, the
definition of moral distress is when a person knows the right thing to do, but
is constrained from taking it.
Initial moral distress occurs in the acute phase of the dilemma.
For example, a provider decides to pursue aggressive medical treatment for an
infant who has a massive head injury with no hope of recovery. The nurse feels angry
and resentful and has feelings of distress for the infant who must endure the
Residual moral distress is when, after a period of time, there is
still no acceptable resolution to the problem.
The American Association of Critical Care Nurses recommends the 4
A’s to rise above moral distress.
Ask: Is this moral distress. During this step the nurse becomes
aware of personal moral distress.
Affirm: Recognize moral distress and accept the professional and
personal responsibly to resolve the issue.
Assess: View the situation and feelings of all persons involved
including the client, the family, other health care providers and the agency.
This allows you to begin to problem solve.
Act: Take deliberate action to reconcile differences and resolve
Experts in the field of ethics also suggest that nurses:
Follow the nurse’s code of ethics.
Create an environment where nurses feel free to speak up.
Bring disciplines together.
Hold frequent conferences with families.
Use resources provided by professional associations.
Offer counseling services for nurses who are distressed about work
place ethical dilemmas.
Each state has an agency designated to receive reports, it is usually child protective services (CPS). To determine who to report to, you can call the national hotline 1-800-4-A-CHILD
QIDs 65847, 65846, 65843, 65841, 65840, 65838
Berman, A., Snyder, S., & Frandsen, G. (2016). Kozier
& Erb’s fundamentals of nursing: Concepts, process, and
practice (10th ed.). Upper Saddle River, NJ: Prentice-Hall.
The Centers for Disease Control and Prevention (CDC, 2017)
(Centers for Disease Control and Prevention [CDC], 2017)
Dudek, S. G. (2014). Nutrition essentials for nursing practice
(7th ed.). Philadelphia: Lippincott Williams & Wilkins.
Eliopoulos, C. (2014). Gerontological nursing (8th ed.).
Philadelphia: Lippincott Williams & Wilkins.
Halter, M. J. (2014). Varcarolis’ foundations of psychiatric
mental health nursing: A clinical approach (7th ed.). St. Louis, MO: Saunders.
Hockenberry, M. J., & W Wilson, D. (2015) Wong’s nursing care
of infants and children (10th ed.). St. Louis, MO: Mosby.
Ignatavicius, D. D., & Workman, M. L. (2016). Medical‑surgical
nursing (8th ed.). St. Louis, MO: Elsevier.
Karakachain, A., Colbert, A., Moral
Distress: A Case Study, Nursing 2017 47(10): 13-15, 2017.
Kraus, D., Why is Child
Abuse Awareness Important to Trauma Nurses? Journal of Trauma Nursing
23(3): 116, 2016.
Jordan, K., Steelman, S.,
Child Maltreatment: Interventions to Improve Reporting, Journal of Forensic
Nursing 11 (2) 107-113, 2015.
Lavigne, J., et.all,
Pediatric Inpatient Nurses’ Perceptions of Child Maltreatment, Journal of
Pediatric Nursing 34:17-22 (2017).
Lowdermilk, D. L., Perry, S. E., Cashion, M. C., & Aldean, K.
R. (2016). Maternity & women’s health care (11th ed.). St. Louis, MO:
Marquis, B. L., & Huston, C. J. (2015). Leadership roles and
management functions in nursing: Theory and application. (8th ed.).
Philadelphia: Lippincott Williams & Wilkins.
Potter, P. A., Perry, A. G., Stockert, P., & Hall, A. (2013).
Fundamentals of nursing (8th ed.). St. Louis, MO: Mosby.
Townsend, M., Morgan, K., (2017). Essentials of Psychiatric Mental Health Nursing: Concepts of Care in
Evidenced-Based Practice (7th ed.) Philadelphia, F.A. Davis