20.1 Child Maltreatment Recognition, Reporting & Documentation

The CPNP-PC exam treats child maltreatment as a recognition, safety, and reporting skill, not a week in a child-abuse pediatrics fellowship. Clinical category #16 sits with Domain II (does this injury match the history and this child's motor skills?) and Domain III.D.5 (you report reasonable suspicion to child protective services). You are not the judge, the detective, or the person who needs a positive skeletal survey before you pick up the phone. You are the primary-care NP who documents what you saw, what was said, and why you were worried — then you keep the child safe.

Quick Answer: Bruises on the torso, ears, or neck in a child younger than 4, injury to the frenulum, angle of the jaw, cheeks, eyelids, or subconjunctival space, patterned marks, or any bruise in a nonmobile infant (TEN-4-FACESp and related screens) are concerning for physical abuse until a protection workup says otherwise. Fractures in a nonambulatory child, stocking-glove or cigarette burns, a sexual-abuse disclosure, and a sexually transmitted infection in a prepubertal child are the same class of item: protect first, report suspicion, do not demand courtroom proof in the exam room.

Clinic opening. A 10-week-old is "fussy after rolling off the couch." Ten-week-old infants do not roll. There is a bruise on the helix of the ear and a healing tear at the upper-lip frenulum. The caregiver laughs that she "bruises if you look at her." If you code this as a routine fall, skip a full skin exam, and send the family home, you missed category #16. That ear bruise is a sentinel injury — a small, poorly explained mark that, left unaddressed, is how worse injury happens next month.

Physical abuse: TEN-4-FACESp is a screen, not a verdict

Accidental bruises happen on bony prominences in mobile children: shins, knees, forehead, elbows. They are not a loop-shaped welt on the back of a 2-year-old who "fell on the rug," and they are not a bruise on the pinna of a pre-cruiser.

Those who don't cruise rarely bruise. A nonmobile infant should not have bruises. Cruising and walking change the map; they do not make ear, neck, or genital bruises "normal toddler life."

TEN-4-FACESp (and the related TEN-4 rule) is the high-yield recognition frame. It does not diagnose abuse by itself. It tells you this mark is in the wrong place for ordinary play and that a child-protection medical evaluation belongs on today's list.

History mismatch is the item hiding in the stem. The injury does not match the stated mechanism, the child's developmental age, or the timeline. The story changes between the front desk and the room. A toddler sibling is blamed for a femur fracture. Care is delayed without weather, money, or transportation as an explanation. You document the discrepancy in quotes. You do not cross-examine the caregiver into a confession in the hallway.

Fractures. Any fracture in a nonambulatory infant is concerning until a child-abuse evaluation — usually in a center that does this work — says otherwise. High-specificity patterns include classic metaphyseal lesions (corner or bucket-handle), posterior rib fractures, and fractures of the scapula, sternum, or spinous processes. A spiral tibial toddler's fracture in a newly walking child can be accidental. A femur fracture in a 2-month-old is not "he must have wiggled in the bouncy seat." You do not dismiss a concerning fracture because the baby "looks well" in a 15-minute slot.

Burns. Accidental splash burns have irregular edges and often involve the front of the body as a pulled cup lands. Concerning patterns: stocking or glove distribution, immersion burns with a sharp waterline and spared flexed creases, and cigarette burns — circular, uniform depth, often grouped. A story of a "sibling bath" that the injured infant's motor skills cannot support is a mismatch, not a closed case.

Abusive head trauma is not a clinic observation project. An infant with unexplained lethargy, seizures, apnea, or a short-fall story that does not match the neurologic exam goes to the emergency department. Retinal hemorrhages and subdural collections are found in the hospital evaluation; your job is to stop sending that infant home with "colic."

Sexual abuse, neglect, and emotional maltreatment

Sexual abuse. The child's disclosure is the clinical event. Many abused children have no acute anogenital findings. A normal exam never rules the concern out. In primary care you believe the report enough to protect, you stop a forensic interview from happening three times in one afternoon, and you refer to a child advocacy center or a trained forensic examiner (SANE or equivalent). You do not perform a repeated speculum exam you are not trained to document for court. If an acute assault is hours old, follow local CAC or ED protocol about clothing, bathing, and evidence; do not "clean the child up" first.

A sexually transmitted infection in a prepubertal child, after the perinatal transmission window has closed, is sexual abuse until a specialist evaluation says otherwise. Gonorrhea, syphilis, HIV, and genital chlamydia in that setting are reportable concerns, not "maybe they sat on a toilet seat." Anogenital warts in a young child are not automatically diagnostic of abuse, but they are also not a freeze-and-ignore dermatology visit — they need a thoughtful maltreatment history and, when suspicion is reasonable, the same report-and-refer path.

Adolescent sexual activity is a different item: confidential, developmentally appropriate history, and a mandated-report decision based on age, partner age, force, and state law. Do not use that adolescent script on a preschooler with an STI.

Neglect is the most common maltreatment type in U.S. child-welfare systems, and it is easy to miss because there is no bruise. The exam uses several flavors:

• Medical neglect — missed insulin, an untreated spreading abscess, no follow-up for a confirmed elevated lead level or a failed hearing screen after you arranged the ride twice
• Supervisory neglect — a toddler found in the parking lot, repeated ingestions, an unlocked firearm with a school-age child in the house
• Physical neglect / failure to thrive — severe undernutrition when calories were available and disease workup is negative or mixed. Chapter 16.1 is the growth math; this chapter is the safety question: is this child safe going home tonight?
• Emotional / psychological maltreatment — repeated terrorizing, isolation, or degradation. You will not photograph it. You will hear it in how the caregiver talks to the child in the room. A single sharp word is not a report. A pattern that is harming the child is.

Intimate-partner violence in the home is a child-safety issue even when the child has no bruise. Ask. Document. Report when the child is being harmed or is reasonably suspected to be at risk under your state's rules.

Mandated reporting: suspicion, not proof

Domain III.D.5 is operational. The CPNP-PC reports reasonable suspicion to child protective services. Many jurisdictions also dual-report to law enforcement when the case is an acute crime. You do not need a confession, a positive skeletal survey, photographic proof, or a lawyer's blessing. Waiting for "proof" is how children go home and return with a worse injury.

You may tell the family, calmly, that you are a mandated reporter and that you are required to notify CPS. You do not need the alleged perpetrator's permission. You do not delay the report so a caregiver can "explain it to their cousin who is a lawyer." You do not confront in a way that makes the family flee the parking lot with the child.

Report even while you work up mimics. Mimics are real. They are not a reason to skip the phone call when the history still does not fit.

Safety first. If you are not sure the child is safe going home with the presenting caregiver, do not discharge while you "think about a report tomorrow." Use the ED, hospital social work, and CPS. The primary-care NP does not run a child-protection unit. You initiate protection.

Documentation and interviews

Write as if a later reader was not in the room:

• Verbatim quotes — "He rolled off the couch," not "caregiver described a fall"
• A body map of every mark (photographs only if your protocol, consent rules, and chain of custody allow)
• Who was present, who gave history, and which developmental skills you observed (does this 10-week-old actually roll?)
• Size, location, pattern, and tenderness — without pretending bruise color is a precise clock
• What you reported, the CPS intake identifier, and the time

Do not interview the child repeatedly. One gentle, open, developmentally appropriate question — "What happened?" — is enough in clinic. Several adults asking "Did Daddy do this?" contaminates the forensic interview. Leave the protocol interview to the CAC.

Clinic close. Concerning location or pattern, a bruise in a nonmobile infant, a history that does not match development, a sexual disclosure, a prepubertal STI, or medical neglect that is harming the child: document, protect, report suspicion. Mimics get a workup. They do not get a silent discharge.