Injuries Indicative of Abuse

When identifying neglect, be sensitive to:

Issues of poverty vs. neglect
Differing cultural expectations and values
Differing child-rearing practices

The following was adapted from the Massachusetts Department of Social Services Investigation Training manual, “Evidence and Indicators of Maltreatment.”(1)

Indicators of Lack of Supervision
Indicators of Environmental Neglect (Including Failure to Provide Food/Fluids)
Indicators of Medical Neglect

Indicators of Lack of Supervision

Physical Indicators:
Dirty clothes
Poor hygiene
Burns from cooking for themselves

Environmental Indicators:
Locks on the outside of interior doors
Dirty house
Unsafe conditions, hazardous house
Not enough food in house
TV on and doors open
Neighborhood kids “hang out ”
No answer at the door, but evidence that someone is home
Small child spends excessive amounts of time in crib or playpen

Child Behavioral Indicators:
Exhibits anger
Seems fearful
Either overeats or is hungry
Children relate different stories about who is watching them
Looks at parent/caretaker before answering question
Does not attend school regularly; frequently absent or tardy
Easily distracted and seems nervous
Experiences delays in speech or motor development
Excessively shy or excessively demanding of attention

Caregiver Behavioral Indicators:
Seems apathetic
Gives conflicting stories about whereabouts of children
Makes statements like “she can take care of herself”
Seems unconcerned about appearance of house or children
Shows immaturity and bad judgment
Lacks planning and organizational skills
Offers excuses to minimize the situation (i.e.“I was only gone five minutes” or “this is the first time this has happened”)

Indicators of Environmental Neglect (Including Failure to Provide Food/Fluids)

Physical Indicators:

Environmental Indicators:

Failure to thrive or low weight/height
Chemical burns or heat burns
Inappropriate dress
Skin infections/head lice/scabies
Malnourishment/acute starvation
Dehydration
Anemia
Sunken/hollow eyes
Excessively dirty, foul body odor
Poor quality food dominates the diet
Residue of fecal material in genital area or underwear of child
Severe diaper rash
Runny noses that have become excessively crusty
Untreated scrapes or infections

Broken glass or missing doors
Chipping paint that may contain lead
Missing glass/screens on windows from which a child could fall
Abandoned appliances in which a child could be trapped
Exposed garbage
Child has no place to sleep or bed is unacceptably unclean
Lack of heat
Rotten, moldy, or insect infested food
Human or animal feces which threaten the health of the child
Alcohol/harmful substances accessible to child
Stagnant water in the sink, shower, or bath - indicating unsanitary plumbing
Rodent or insect infestation
Lack of access to clean water

Child Behavioral Indicators:	Caregiver Behavioral Indicators:
Delinquency or stealing Unwilling to bring peers home Delay in speech or presence of speech impediment Begging or stealing food Delays in motor development Excessively shy or, excessively demanding of attention Withdrawn or angry	Depression or apathy Immaturity and bad judgment Lack of planning and organizational skills Seems unconcerned about appearance of house or children Alcohol or substance abuse Has a sense of being overwhelmed Feeling of isolation, helplessness

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Indicators of Medical Neglect

Physical Indicators:	Environmental Indicators:
Child has a medical condition which needs attention Child’s condition has worsened from lack of health care or will worsen without care Child is developmentally delayed Child has rotten teeth Child has open sores or infection	No medical records available Little food in refrigerator Lack of prescribed home health equipment Unfilled prescriptions (though there are resources to do so) No preventative care (immunizations, checkups) Standards of cleanliness not followed

Child Behavioral Indicators:	Caregiver Behavioral Indicators:
Excessive crying Listlessness No smiles or animation Statements of pain or lack of care Symptoms of illness or disability requiring medical care	Doesn’t make or keep doctor appointments Unable to demonstrate proper use of medical equipment Doesn’t properly use or maintain prescribed medications Ignores symptoms of serious medical problems Lacks concern for physical well-being of the child Does not take child to healthcare provider despite symptoms of medical problem

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References:
(1) Massachusetts Department of Social Services. Investigation Training: Evidence and Indicators of Maltreatment. March 2002.
(2) U.S. Department of Justice. Portable Guides to Investigating Child Abuse: Child Neglect and Munchausen Syndrome by Proxy. September 1996.
(3) U.S. Department of Justice. Portable Guides to Investigating Child Abuse: Recognizing When a Child’s Injury or Illness is Caused by Abuse. June 1996.
(4) Kendall-Tackett KA, Williams LM, Finklehor D. Impact of sexual abuse on children: a review and synthesis of recent empirical studies. Psychol Bull, 1993; 113:164-80.
(5) Friedrich WN, Fisher J, Broughton D, Houston M, Shafran CR. Normative sexual behavior in children: a contemporary sample. Pediatrics, 1998; 101(4):E9.
(6) Cavanaugh Johnson T. Understanding the sexual behaviors of young children. Siecus Report, August/September.

Adams Classification Table Specific References:
(i) Berenson A, Heger A, Andrews S. Appearance of the hymen in newborns. Pediatrics, 1991; 87:458-465.
(ii) Berenson AB, Heger AH, et al. Appearance of the hymen in prepubertal girls. Pediatrics, 1992; 89:387-394.
(iii) McCann J, Wells R, Simon M, Voris J. Genital findings in prepubertal girls selected for non-abuse: A descriptive study. Pediatrics, 1990; 86:428-439.
(iv) Heger AH, Ticson L, Guerraq L, et al. Appearance of the genitalia in girls selected for nonabuse: Review of hymenal morphology and non-specific findings. J Pediatr Adolesc Gynecol 2002;15:27-35.
(v) Berenson AB, Chacko MR, Wiemann CM, Mishaw CO, Friedrich WN, Grady JJ. A case-control study of anatomic changes resulting from sexual abuse. Am J Obstet Gynecol, 2000;182:820-834.
(vi) McCann, J, Voris J, Simon M, Wells R. Perianal findings in prepubertal children selected for non-abuse: A descriptive study. Child Abuse & Neglect, 1989; 13:179-193.
(vii) Centers for Disease Control and Prevention (CDC) Guidelines, MMWR, Vol. 51, May 10, 2002. http://www.cdc.gov/std/treatment/rr5106.pdf
(viii) McCann J, Voris J, Simon M. Genital injuries resulting from sexual abuse, A longitudinal study. Pediatrics, 1992; 89:307-317.
(ix) McCann J, Voris J. Perianal injuries resulting from sexual abuse: A longitudinal study. Pediatrics, 1993; 91:390-397.
(x) Emans SJ, Woods ER, Allred EN, Grace E. Hymenal findings in adolescent women: Impact of tampon use and consensual sexual activity. J Pediatr,1994; 125:153-160.
(xi) Berenson AB, Grady JJ. A longitudinal study of hymenal development from 3 to 9 years of age. J Pediatr 2002;140:600-607.

Last Updated: February 7, 2004
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