Screen Every Child for Signs of Physical Abuse, Expert Urges

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To reduce the incidence of child physical abuse, clinicians are urged to take the time to screen for signs of abuse at every encounter with a child and their family.

Nearly 1 million children are victims of physical abuse every year and every day, 4 to 7 children die from their injuries. These statistics are particularly grim because children who die from maltreatment often have had a health care encounter prior to their death.

“We all know what physical abuse is, but it’s so much bigger than a lot of us recognize,” said Sheri Carson, DNP, APRN, CPN, CPNP-PC, assistant clinical professor at the University of Arizona. “I want to stress that child maltreatment involves a lot of different things and abuse has a lot of different components to it.”

With every child and family encounter, Dr Carson urged practitioners to screen the child for physical abuse, during a presentation at the National Association of Pediatric Nurse Practitioners (NAPNAP) National Conference on Pediatric Health Care held March 15 to 18, 2023, in Orlando, Florida.

Early Detection Is Often Missed

The early detection of child physical abuse is estimated to be around only 10%, and overall, 1.3% to 15% of emergency department visits for a childhood injury are caused by physical abuse, Dr Carson said. If abuse is not detected at the initial health care visit, the recurrence rate is 35% to 50% and the risk for death is 10% to 30%. In 2021, 1820 children died from maltreatment, or 2.46 children per 100,000, according to a report from the Child Welfare League of America.

Sheri Carson, DNP, APRN, CPN, CPNP-PC
We must report any suspicion of abuse or neglect. We do not need proof to report, only reasonable belief or suspicion.

Nurse practitioners (NPs) and other pediatric providers are often the first medical contact during a health care encounter, and sometimes the only medical contact, placing pediatric NPs in the ideal position to not only start, but also advance, the screening process for child physical abuse, Dr Carson said.

Unfortunately, standardized screenings are not uniformly completed. Child abuse laws mandate reporting rather than screening; therefore, appropriate screening procedures are not part of standard health care curriculum and time pressures on clinicians may prevent proper screening. These factors contribute to the trend that child abuse is often missed until the abuse results in serious injury or death.

What Is Child Abuse?

Child physical abuse is defined as any nonaccidental action that results in physical impairment of the child. As such, abuse can manifest by multiple means, including hitting, beating, kicking, biting, burning, shaking, throwing, and choking, among others, Dr. Carson noted. Signs associated with abuse are shown in the Table.

Table. Red Flags Associated with Child Abuse

Inadequate, conflicting, or inconsistent history of injury
Injury incompatible with a child’s developmental stage
Injuries at various stages of healing
Multiple injuries/types of injuries
Clustered or patterned injuries
Unnecessary delay in seeking medical attention for injury
Poor hygiene
Fussiness in infant without a discernable cause

Both the child and the caretaker may exhibit specific behavioral clues when injuries are related to abuse. For children, be on the lookout for a child showing fear of parents, becoming apprehensive when other children cry, wearing covering clothing that is inconsistent with the weather, and exhibiting psychoneurotic reactions, self-injurious behaviors, aggression, or passivity. For parents and caregivers, potential behavioral clues can include inattentiveness or lack of concern about the child, attempting to conceal a child’s injury or becoming defensive about the injury, providing conflicting explanations, refusing diagnostic testing or evaluations, habitually taking their child to a different doctor or center for each injury, and delaying medical care for an injury.

Specific Injuries


Fractures are common in children and usually result from accidental trauma. However, there are specific fractures that are more indicative of an abusive injury. “One of the things that I want to get rid of in all of our minds, because we were all taught it when we went to nursing school, [is about] spiral fractures. Spiral fractures are not synonymous with abuse unless it’s in a child who cannot walk,” said Dr Carson.

The fracture type that is most specific to abuse is a metaphyseal fracture (classic metaphyseal lesion), which occurs when torsional force is applied to the immature spongiosa adjacent to the cartilaginous growth plate. The 2 major types of metaphyseal fracture are bucket-handle fracture, extending across the metaphysis, and corner fracture, at the end of a long bone.

In general, any fracture in a nonambulatory infant, rib or midshaft humerus/femur fracture in an infant or toddler, and metaphyseal lesions or scapula, spinous process, sternum, or acromion fractures in a child of any age should raise a red flag.


When encountering a bruising injury, Dr Carson recommended using the TEN-4 bruising rule. This rule states that in general, bruising on the torso, ears, or neck (TEN) in any child aged 4 years and younger is concerning for abuse, as is any bruise on a child aged 4 months and younger. “If the baby isn’t cruising, it shouldn’t be bruising,” said Dr Carson.

In addition, clinicians should also think about the type of bruised tissues. For example, bony prominences, such as knees, elbows, and foreheads often bruise in childhood, whereas bruises on soft tissues, such as the back of thighs, back of arms, and the abdomen may indicate abuse.

Other Injuries

The most fatal abusive injury is head trauma, and it is most commonly observed in infants. Signs of abusive head trauma are often mild and nonspecific, including fussiness in infants. Bruising may or may not be present, but if it is present in infants — especially infants who are not yet mobile — it should not be discounted.

The second leading cause of fatal abuse is abdominal trauma, which is most common among infants and toddlers. In these cases, abdominal bruising may not occur. In addition to solid organ injury, abused children can have hollow viscus injuries caused by rapid deceleration after being thrown. Symptoms can include signs of peritonitis or hemorrhage; however, many children do not display overt signs of this type of trauma.

Abuse Screening Tips

To screen for child abuse, Dr Carson recommended the ESCAPE instrument, which is a validated, 6-item screening questionnaire that can be used by any member of the health care team. This instrument was developed by Louwers et al in 2014 and has an accuracy of 99.2%, specificity of 98%, and negative predictive value of 99%.

The 6 questions are:

  1. Is the history (the story of how the injury occurred) consistent?
  2. Was there an unnecessary delay in seeking medical attention?
  3. Does the injury fit with the developmental stage of the child?
  4. Are the child and family behaving appropriately?
  5. Do the findings from the examination fit with the history (story of injury)?
  6. Are there other signs that make you concerned about the safety of the child or other family members?

A positive screen for ESCAPE, indicating potential child physical abuse, occurs when any 1 (or more) of the 6 questions is answered atypically. The aberrant answers are “No” to questions 1, 3, 4, and 5 and “Yes” to questions 2 and 6.

Although the ESCAPE tool is easy to use, the answers to each question are not always readily apparent. For example, Dr Carson cited a case study in which a 9-year-old girl presented with diabetic ketoacidosis. During the examination, bruising on the back, flank, and dorsal surfaces of both thighs was observed. The patient explained that she sustained the injury while going down the slide after falling from the bottom of the slide onto the turf. Both parents confirmed the child’s report.

When the audience was asked whether they would screen this child as positive or negative using ESCAPE, 68% thought ESCAPE should be positive and 32% negative.

Dr Carson agreed that this situation should be screened as positive, as the answer to question 5 of ESCAPE was aberrant. The findings of the physical examination were not consistent with the explanation of the injury because a short distance fall from the bottom of a slide onto soft turf should not result in such extensive soft tissue bruising.

If the screen is negative, no further action is required. If the screen is positive, the nurse should notify the clinician and document. If the clinician does not also screen the child as positive, no further action is required. In the cases where both the nurse and clinician screen the child as positive, and the clinician’s physical exam raises concern or confirms the suspicion for child abuse, the child’s safety should be insured; social workers, child protective services (CPS), and/or law enforcement should be contacted as necessary; and the institution’s process for evaluation and management of suspected child physical abuse should be initiated.

“Screening is a route to identify [physical abuse]; it does not necessarily trigger CPS removal of the child and prosecution,” concluded Dr Carson. “We must report any suspicion of abuse or neglect. We do not need proof to report, only reasonable belief or suspicion. Don’t look for proof. Don’t try to interview the child. Just do your due diligence in taking care of the child and ensuring the child’s safety and well-being, she said. “Regardless of screening results, if you are concerned, report, report, report!”

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This article originally appeared on Clinical Advisor


Carson S. Learning to ESCAPE: screening and identification of child physical abuse. Presented at: NAPNAP National Conference; March 15-18, 2023; Orlando, FL.