Abuse & Neglect Recognition
Board-focused recognition of child abuse, elder abuse, and intimate partner violence: the red-flag injuries that don't fit the story, the pathognomonic findings, and the differing mandatory-reporting rules that drive NEXT-BEST-STEP decisions.
Why the Boards Test Abuse & Neglect
Abuse and neglect appear across all ages on Step 2 CK, and the exam rewards two skills: recognizing injuries that don't fit the story, and knowing your duty to report. Maltreatment falls into three tested buckets — child abuse/neglect, elder abuse, and intimate partner violence (IPV) — each with characteristic red flags and, critically, different reporting rules.
The unifying red flag is an injury inconsistent with the stated mechanism or the patient's developmental stage, often with delayed presentation and a changing history. Neglect (failure to provide food, hygiene, supervision, or medical care) is the most common form of maltreatment in both children and elders.
The board's favorite trap: you do not need proof to act — reasonable suspicion is the threshold to report child and (in most states) elder abuse, and good-faith reporting is legally protected. In contrast, a competent adult experiencing IPV controls whether police are involved. Master the red flags, then map each scenario to the correct next step: ensure safety, interview alone, and report to the right agency.
- Injury vs. story mismatch, delayed care, inconsistent/changing history, doctor-shopping
- "Those who don't cruise rarely bruise" — a bruise in a non-ambulatory infant is a sentinel red flag
- Highly specific fractures: posterior rib fractures, metaphyseal corner ("bucket-handle") fractures, a long-bone fracture in a non-ambulatory child, and fractures in various stages of healing
- Abusive head trauma (shaken baby): subdural hematoma + retinal hemorrhages + encephalopathy, often with no external injury
- Patterned burns: cigarette burns (round, punched-out); immersion burns with a sharp line of demarcation, stocking-glove distribution, and no splash marks
- Torn frenulum in an infant (forced feeding/bottle)
- STI or genital trauma in a prepubertal child (beyond the neonatal period) = sexual abuse until proven otherwise
- Neglect clues: failure to thrive, poor hygiene, unfilled prescriptions, missed appointments, rampant dental caries
Vignette: A 4-month-old boy is brought in for "fussiness." He is not yet rolling. Exam shows a swollen thigh; X-ray reveals a spiral fracture of the femur. The parents say he "rolled off the couch." A skeletal survey shows several healing posterior rib fractures.
Diagnosis: Physical child abuse — a femur fracture in a non-ambulatory infant plus rib fractures of different ages is incompatible with the stated history and highly specific for inflicted injury.
Next best step: Ensure the child's safety (admit) and complete the occult-injury workup: a skeletal survey (indicated in all children <2 yr with suspected physical abuse) and, in an infant this young, neuroimaging plus a dilated fundoscopic exam to evaluate for occult abusive head trauma (subdural blood, retinal hemorrhages). File a mandatory report to Child Protective Services (CPS) — reasonable suspicion, not proof, is required. Do not confront/accuse the caregivers, and do not discharge the infant home to "sort it out."
Vignette: An 82-year-old woman with dementia is brought from home by her son. She has stage IV sacral pressure ulcers, is dehydrated and malnourished, and has multiple missed appointments. Her son controls her finances, answers all questions for her, and bank records show large unexplained withdrawals.
Diagnosis: Elder abuse — neglect (the most common type) plus financial exploitation. Classic risk factors: cognitive impairment, functional dependence, caregiver stress, and social isolation.
Next best step: Interview the patient alone, assess her decision-making capacity, treat the acute medical problems, and report to Adult Protective Services (APS) (mandatory in most states). If a cognitively intact elder with capacity declines intervention, respect her autonomy regarding placement/care — but reporting suspected abuse is still required where the law mandates it.
Vignette: A 29-year-old pregnant woman presents with an isolated ulnar shaft ("nightstick") fracture and bruises in various stages of healing. Her partner insists on staying in the room and answers for her. She avoids eye contact and says she "fell."
Diagnosis: Intimate partner violence — a defensive forearm fracture, inconsistent injury, and a controlling partner who won't leave the room are classic. Pregnancy is a period of escalation (homicide is a leading cause of maternal death).
Next best step: Interview her alone — get the partner out of the room. Express concern nonjudgmentally, perform a safety assessment (weapons at home, escalating violence, a safe place to go), and offer resources (hotline, shelter, safety plan). For a competent adult, do not report to police against her wishes and do not force her to leave — respect autonomy. Document objectively and quote her words.
TEN-4-FACESp is a validated clinical decision rule (Pierce et al.) that flags bruising suspicious for physical abuse in young children. Bruising is a red flag when found on:
- T — Torso
- E — Ears
- N — Neck
…in any child ≤4 years old, OR
- 4 — ANY bruise in an infant <4 months old
The FACESp extension adds Frenulum, Angle of jaw, Cheeks, Eyelids, Subconjunctival hemorrhage, and patterned bruising. Contrast: accidental bruises in a mobile toddler cluster over bony prominences (shins, knees, forehead). A bruise in a pre-mobile infant, or at any TEN-4-FACESp site, should trigger an abuse evaluation.
Reporting & Management by Type
| Feature | Child abuse | Elder abuse | IPV (competent adult) |
|---|---|---|---|
| Report to | Child Protective Services | Adult Protective Services | Patient's choice (police) |
| Mandatory report? | Yes — all 50 states | Yes in most states | Generally no |
| Threshold to act | Reasonable suspicion | Reasonable suspicion | Patient autonomy |
| Most common type | Neglect | Neglect | Physical / emotional |
| Priority action | Ensure safety; skeletal survey (<2 yr); CPS report | Interview alone; assess capacity; APS report | Interview alone; safety plan; resources |
| Patient autonomy | Overridden (minor) | Overridden if lacks capacity | Respected |
- Reasonable suspicion — not proof — triggers a report; you are legally protected when reporting in good faith
- Child abuse is mandatory to report in all 50 states → CPS; ensure safety first, skeletal survey if <2 yr, add neuroimaging + fundoscopy in young infants for occult abusive head trauma
- Elder / vulnerable-adult abuse → APS (mandatory in most states)
- IPV in a competent adult is generally NOT mandatory to report — provide safety planning and resources and respect autonomy; exception: many states mandate reporting injuries from weapons (gunshot/stab wounds)
- Always interview the patient alone, away from the suspected abuser
- Do not confront/accuse the alleged perpetrator, and do not delay protective action to gather proof
- Document objectively — quote the patient, describe/photograph injuries; records may be used legally
- USPSTF recommends screening all women of reproductive age for IPV (universal, not only when suspected); pregnancy is a high-risk, escalation period
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