Injuries Indicative of Abuse

Neglect: Signs and Symptoms

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”)

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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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