Abuse and Neglect: Pediatric (Hospice and Palliative Care) - CE/NCPD

The content in Clinical Skills is evidence based and intended to be a guide to clinical practice. Always follow your organization’s practice.

ALERT

A patient who is in danger should not be left in an abusive environment. Follow the organization’s policy for removing a pediatric patient from an unsafe home and provide for further examination, treatment, and protection.

Nonaccidental trauma should always be considered as a differential diagnosis when a minor presents with an injury.^{undefined#ref7">7}

OVERVIEW

The maltreatment of children and adolescents (i.e., child maltreatment [CM]) involves intentional acts, or lack of action(s), that cause injury or harm, or risk thereof, to a child or an adolescent.⁹ CM includes varying forms of abuse (Table 1).⁹ Risk and protective factors associated with CM involve characteristics of the patient, the caregiver, and the surrounding environment (Table 2).⁷

Every nurse should be aware of the possibility of CM when interacting with pediatric patients. The nurse’s responsibility is to know the resources available and when to reach out to those experts for further assessment and an interview. The nurse is not expected to do, and should not attempt to do, a full assessment for abuse or an official interview. The nurse’s role is to remove the patient from imminent harm and to notify appropriate authorities. These should be done by experts in CM. The official interview should be done only once to avoid leading patients to answer as they think the interviewer wants; repeated questioning leads patients to want to give the “right” answer.

Nurses in every state in the United States and in most countries are mandated reporters and must report suspicion of CM.¹ A mandated reporter who makes a CM report in good faith is generally immune from criminal and civil liability.⁶ A mandated reporter who fails to report suspected or disclosed abuse may be held liable for failing to make a report.⁶ The goals of government agencies (e.g., child protective services, law enforcement) are to prevent recurring and escalating maltreatment of the child, identify others at risk for maltreatment, and prevent others from experiencing maltreatment.⁴ The mandated reporter should avoid judging others and keep in mind that identifying the abuser is the responsibility of law enforcement, not the health care team. The nurse’s first responsibility is the care, stabilization, and safety of the child.

EDUCATION

• Give developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, preferred learning style, and overall neurologic and psychosocial state.
• Give information about mandated CM reporting, including the specific suspicions and injuries.

ASSESSMENT AND PREPARATION

Assessment

1. Determine if the patient or family has health literacy needs or requires tools or assistance to effectively communicate. Be sure these needs can be met without compromising safety.
2. Be alert for compassion fatigue, secondary traumatic stress, or vicarious trauma among health care team members.

   Rationale: Compassion fatigue, secondary traumatic stress, and vicarious trauma among health care team members can affect the quality of patient care and team members’ health.

PROCEDURE

1. Be familiar with and follow the abuse and mandated reporting laws.
2. Observe the patient for indicators of dysregulation (e.g., flat affect, restlessness, motor and verbal hyperactivity, hyperresponsiveness, emotional tension, difficulty communicating) for early recognition and reporting.
3. Observe the communication between the patient and family or caregiver (e.g., watch for signs of trust or fear; note if the patient is withdrawn, timid, or anxious).³
4. If the patient discloses CM, request a referral for official interviews of the patient and the family or caregiver to be carried out separately. Protect the patient from harm and notify designated authorities.

   Rationale: The patient may be fearful of the family or caregiver and is more likely to share information if the family or caregiver is absent from the interview.

5. Assess for red flags or factors associated with an increased risk for CM (Box 1) (Table 2).²
6. Determine the best team to complete a full, head-to-toe assessment, with collection of evidence for physical signs or symptoms of CM.
   1. Consult a medical forensic professional or child abuse team to perform the physical examination.⁷
   2. Consult a pediatric sexual assault nurse examiner or refer the patient to a child advocacy center.
   3. If these services are not available, collaborate with the team to transport the patient to an organization with necessary resources.
7. If an assessment must be done, avoid any invasive assessment. Limit the assessment to visual observation for physical signs or symptoms of CM (Table 3) (Box 1) (Box 2).
   1. Have a chaperone present, as indicated.⁷
   2. Note clothing (size and weather appropriate) and overall hygiene.¹
   3. Palpate scalp, face, and limbs for tenderness.¹
   4. Evaluate gait and ambulation stability.¹
   5. Do a neurologic examination if an intracranial injury is suspected.¹
   6. Avoid asking the patient any questions related to suspected abuse at this time. These questions will be asked during the one-time official interview.
8. Consult the practitioner or the CM specialist if a physical examination cannot be completed (e.g., the patient does not feel comfortable, consent or assent is not given).

   Rationale: Legal age of consent for certain examinations (e.g., forensic examinations) varies by state.¹

9. Facilitate laboratory or diagnostic tests, as ordered (Table 4).

   Rationale: Laboratory and diagnostic tests can identify pathophysiologic, clinical causes that can mimic CM.⁶

10. Based on initial assessment results, address the patient’s immediate health care needs or concerns (e.g., treat physical injury).
11. Get a thorough history from the family about the current injury or signs of illness.
12. If CM is suspected, identified, or disclosed:
    1. Offer emotional support to the patient, especially if CM is disclosed by the patient.
    2. Consult with specialists.
       1. A child abuse pediatrician can assist with and guide additional or more comprehensive assessments.^6,8
       2. Social workers or other members of multidisciplinary child protection teams can begin family interventions and education (e.g., discussing the situation and potential next steps).⁸
    3. Report the suspected, identified, or disclosed CM to child protective services per federal, state, and local laws.

       Rationale: Reporting requires reasonable suspicion. Proof is up to law enforcement.

13. Follow the organization’s practice to create a safe environment for the patient with suspected CM.
14. Work with the team to admit the patient, facilitate custody arrangements, or discharge the patient to child protective services.

EXPECTED OUTCOMES

• A pathophysiologic, clinical diagnosis is identified.
• Suspected, identified, or disclosed CM is reported per jurisdictional laws.
• Physical injuries are stabilized.
• The patient is safe.

UNEXPECTED OUTCOMES

• Injuries cannot be stabilized.
• The family takes the patient against medical advice, and the patient remains in danger.

DOCUMENTATION

• Objective documentation of screenings, history, and assessments
  • Body diagrams and confidential forensic photographs to document injuries, per the organization’s practice⁷
  • Specific quotes from both patient and family⁷
• Laboratory or other diagnostic tests, as ordered
• Presence of chaperone (if applicable)
• Consultation with or referral to specialists
• External referrals (e.g., community supports, abuse and neglect advocates)
• Reports made to designated authorities (e.g., child protective services, law enforcement)
• Education
• Unexpected outcomes and related interventions

ADOLESCENT CONSIDERATIONS

• In addition to CM, adolescents are also at risk for experiencing teen dating violence (TDV).⁵
• TDV, which is considered a type of intimate partner violence (IPV), occurs between two adolescents and includes acts of physical violence, psychological aggression, sexual violence, and stalking.⁵
• Experiencing TDV can contribute to depression, unhealthy or excessive substance use, and unhealthy eating behaviors.⁵

SPECIAL CONSIDERATIONS

• Peer victimization (PV) is the repetitive, intentional, verbal or physical abuse by one or more peers directed at another peer. PV is associated with a power imbalance and peaks in early adolescence.⁵
• PV can happen in person or through social media.
• PV may cause adverse mental health outcomes (e.g., depression, suicidal ideation, low self-esteem), affect development of future healthy interpersonal relationships, and normalize aggression in interpersonal relationships, including dating relationships.⁵

REFERENCES

1. Alwan, R.M., Atigapramoj, N.S. (2021). Child maltreatment and neglect. Emergency Medicine Clinics of North America, 39(3), 589-603. doi:10.1016/j.emc.2021.04.009
2. American College of Surgeons (ACS). (2019). Trauma quality programs: Best practices guidelines for trauma center recognition of child abuse, elder abuse, and intimate partner violence. Retrieved June 17, 2025, from https://www.facs.org/media/o0wdimys/abuse_guidelines.pdf
3. Duffy, E.A. (2024). Chapter 14: Health problems of early childhood. In M.J. Hockenberry, E.A. Duffy, K.D. Gibbs (Eds.), Wong’s nursing care of infants and children (12th ed., pp. 442-462). St. Louis: Elsevier.
4. Hornor, G. (2022). Child maltreatment prevention: Essentials for the pediatric nurse practitioner. Journal of Pediatric Health Care, 36(2), 193-201. doi:10.1016/j.pedhc.2021.09.006
5. Hunt, K.E. and others. (2022). Teen dating violence victimization: Associations among peer justification, attitudes toward gender inequality, sexual activity, and peer victimization. Journal of Interpersonal Violence, 37(9-10), 5914-5936. doi:10.1177/08862605221085015
6. Ruiz-Maldonado, T.M., Russell, M., Giardino, A.P. (2025). Child abuse/treatment. In S.R. Quah (Ed.), International encyclopedia of public health (3rd ed., vol. 4, pp. 708-719). Waltham, MA: Elsevier.
7. Suniega, E.A., Krenek, L., Stewart, G. (2022). Child abuse: Approach and management. American Family Physician, 105(5), 521-528B. Retrieved June 17, 2025, from https://www.aafp.org/pubs/afp/issues/2022/0500/p521.pdf
8. Tolliver, D.G., He, Y., Kistin, C.J. (2023). Child maltreatment. Pediatric Clinics of North America, 70(6), 1143-1152. doi:10.1016/j.pcl.2023.06.013
9. Zhang, X. and others. (2023). Child maltreatment. In H.S. Friedman, C.H. Markey (Eds.), Encyclopedia of mental health (3rd ed., vol. 1, pp. 355-364). San Diego: Elsevier.

ADDITIONAL READINGS

Forkey, H. and others. (2021). Trauma-informed care. Pediatrics, 148(2), e2021052580. doi:10.1542/peds.2021-052580

Clinical Review: Marlene L. Bokholdt, MS, RN, CPEN, TCRN

Published: August 2025