Unthinkable as it is to imagine someone intentionally hurting a child, about 1 million children are abused every year in the United States. And these are only the reported incidents - many more are unreported and undetected, often because children are afraid to tell.

When mistreatment becomes abuse, children are injured, neglected, and emotionally damaged. Approximately 1,000 to 1,300 U.S. children are known to die as a result of physical abuse, and those who survive suffer emotional trauma that lasts long after the bruises have healed.

Some studies report that in the United States, as many as one out of every eight boys and one out of every four girls is sexually abused before turning 18 years old. In 90% of these cases, sexual abuse occurs in the home, particularly when younger children are involved. A child who knows the abuser (about 90% of cases involve an abuser who was previously known to the child) usually senses that the abuse is wrong, but he may feel trapped by the affection he feels for the person or fearful of the power the abuser has over him, so he doesn't tell. Whatever the statistics, one thing we know is that child abuse is too frequent and too often hidden.

Emotional abuse can be just as damaging. The effects can last a lifetime, stripping a child of self-esteem and affecting his relationships, happiness, and success.

Four Types of Abuse
Abuse of a child can mean physical abuse, physical neglect, sexual abuse, or emotional abuse.

Physical abuse can include the following actions when they are continuous, pervasive, and extreme, and if they are done intentionally to harm a child:

• hitting
• throwing
• kicking
• choking
• biting
• shaking
• beating with an object
• burning with a match, cigar, or cigarette
• scalding with hot water
• pushing and holding a child underwater
• tying up a child
• starving or failing to provide food for a child

The following actions can be considered physical neglect if they interfere with a child's growth and development:

• not providing adequate housing or warm clothing in cold weather
• locking a child in a closet or room
• leaving a child alone for extended periods of time
• not providing medical care when a child is sick or injured
• placing a child in a physically dangerous situation

These actions can be considered sexual abuse:

• fondling, touching, or kissing a child's sex organs
• making a child touch someone else's sex organs
• having sex with a child
• showing a child pornographic material
• showing sex organs to a child
• forcing a child to undress
• forcing a child to have sex with someone
• making a child pose or perform for pornographic pictures or videos
• telling a child "dirty" stories

Emotional abuse occurs when a parent ignores, terrorizes, blames, belittles, or otherwise makes a child feel that he's worthless and incompetent.

Shaken baby/shaken impact syndrome is a specific form of child abuse. It's the leading cause of death in child abuse cases in the United States. Most incidents last just 5 to 20 seconds, but that's enough time to cause sufficient brain damage to kill the baby. In some cases, a blow to the head accompanies the shaking.

Signs of Abuse
Of course, all children get scratches, bruises, and cuts from time to time. That's the nature of childhood - a time that's full of tumbling, climbing, and adventures. That makes it difficult to tell what's normal and what may be a sign of abuse. Unfortunately, there's no one telltale sign that a child is being abused. Bruises, black eyes, and broken bones are certainly clues, but other signs are less obvious. Children who have been abused may behave differently. They may have nightmares or trouble sleeping. Their school performance may suddenly decline. In addition, they may:

• have a poor self-image
• be unable to love or trust others
• be aggressive or disruptive (become bullies)
• display intense anger or rage
• act out in the classroom
• act out sexually
• be self-destructive, self-abusive, or suicidal
• feel sad, passive, withdrawn, or depressed
• have difficulty forming new relationships
• use drugs or alcohol
• avoid going home after school
• show a fear of certain adults

Children who witness abuse but are not victims themselves may also display some or all of the above signs. It's important to note that these symptoms are all nonspecific, meaning they could result from a number of causes - not just child abuse. Children who are under stress from a variety of sources - including parental separation, divorce, and visitation and custody arrangements - may show similar symptoms.

Those who abuse children may show certain nonspecific signs as well. For example, parents who abuse their children may avoid other parents in the neighborhood, may not participate in school activities, and may be uncomfortable talking about their children's injuries or behavioral problems.

What to Do if You Suspect Abuse
Abuse is not a private family matter, although it most often occurs within families and often every attempt is made to keep it secret. Once you suspect child abuse, you need to act to protect the child from further possible harm. It doesn't matter if you're wrong: it's better to be wrong than sorry.

Here's what to do:

• If you suspect that a child is being abused, it's your responsibility to contact your local child protective services agency, police, hospital, or emergency hotline. If necessary, you may remain anonymous. The child's safety is the immediate issue: you could save his life.

• If you have abused your own child or think that you might, talk with a friend, relative, or your child's doctor, or other trusted adult immediately. These people can refer you to a mental health professional who can help.

• If you suspect that someone you know is abusing a child, such as a babysitter or child care provider, there are specific steps to take. "If parents have a reasonable suspicion that a caregiver is abusing their child, they should protect the child by limiting or supervising contact with that person. They should then talk to the child in a way that's not alarmist, at the child's developmental level," advises Paul Robins, PhD, a behavioral health specialist.

Your child should know about the different kinds of abuse and how to spot it. "The issue is helping kids identify what adults can and can't do, what's OK and not OK, and helping kids know who they can talk with once something happens," Dr. Robins says. They should be told that they don't have to do everything adults (such as teachers or babysitters) tell them to do, especially when they think it's wrong.

Dr. Robins continues, "Parents must educate their children at home, when children are cognitively able to understand, because this is when they begin to be on their own more. It's not too early to talk to a preschooler, in a very basic way. Pick up a book about the subject and read it with your child."

Adults who sexually abuse children often tell them that their relationship is a "secret" or that, if they tell anyone about what's happening, they will be hurt or get in trouble or that the person they tell will get hurt. Be sure your child knows that he can always come to you if he thinks someone is being abusive, even if that person has told him to keep it a secret.

A parent who learns that their spouse or close relative is committing child abuse may be in shock; it would be natural not to want to believe someone you love could be abusive of your child - and the reality can rock your world. Sometimes the facts may seem to horrible to face and the consequences to great, which can leave a parent confused and paralyzed. In some cases, a parent may choose to ignore or deny suspicions or even disbelieve a child sharing such information. While not all suspicions and accusations turn out to be true, all deserve serious attention and immediate action with the help of professionals. And your child always deserves to be heard, protected, and helped no matter what.

Helping Your Child Heal
If your child tells you about an abusive experience, remain calm and let him know that you believe him. Your reaction can either help him begin to recover or further traumatize him. Here are some tips:

• Listen carefully and calmly, no matter how upset you are. You'll need to remember what your child tells you, so pay attention. And let your child know that he's being heard.
• Assure your child that you're glad that he told you of the abuse, that it was in no way his fault, and that you will make sure it doesn't happen again. Encourage him to tell you everything, but avoid asking too many specific questions. Specific questions may mislead or confuse your child, or they may be asked in a way that prompts a particular answer. Later, this may seriously affect the ability of investigators to find out exactly what did or did not happen. If investigators can't determine that abuse has occurred, they can't protect your child.
• Don't say anything bad about the perpetrator. He or she may be someone the child truly cares for. If you make threats, your child may feel the need to protect the person and not be as forthcoming with details.
• If you think that your child wants to say more but is afraid, encourage him to tell his story to a favorite stuffed animal or doll while you listen. Or provide a tape recorder or telephone for the child to talk into. It may be easier for the child to talk to an inanimate object than to you or another person.

Your child will need medical care if he has been sexually molested or physically injured. Even if signs of abuse are not evident, it's best to err on the side of caution and take him to the doctor anyway. Above all, keep your child in safe environments and assume the allegation is true until proven otherwise.

The American Academy of Pediatrics' Committee on Hospital Care recommends that children who are suspected abuse victims be brought to a hospital, where the initial diagnosis can be made and treatment can be given. Hospitals are havens for abused children, especially battered children who may need imaging studies (X-rays) or cultures for a diagnosis to be made. Imaging can indicate broken bones, which are often the only sign that infants and young children have been abused, as they can't or won't speak of the abuse themselves.

Psychological help is also strongly recommended. Without it, children who have been abused tend to repeat the pattern of abuse with their own children. As adults, they have trouble establishing and maintaining close relationships and they are at greater risk for anxiety, depression, substance abuse, medical illness, and problems at work.

Reviewed by: Paul Robins, PhD
Date reviewed: August 2000