Mental Health > Child Abuse—Behavioral Issues in Child Care and Schools

Mental Health

Child Abuse—Behavioral Issues in Child Care and Schools

Print, Share, or View Spanish version of this article


  • T74.02

  • T74.12

  • T74.22

  • T74.32

  • T74.52

  • T74.62

  • T74.92

  • T76.02

  • T76.12

  • T76.22

  • T76.32

  • T76.52

  • T76.62

  • T76.92

  • Z55

How can children who have experienced child abuse be identified?

Child abuse should be suspected or considered in children who

  • Show physical signs suggestive of abuse.

    • Have injuries on body parts that would be hard to injure accidentally, including bruises or scars on the back, buttocks, or the backs of the legs

    • Have unexplained injuries or injuries that don’t match the given explanation (eg, fractures reportedly from rolling off a bed, in an infant who cannot roll over yet)

    • Have recurrent, serious injuries that have not been evaluated by a medical professional

  • Show signs of possible sexual abuse.

    • Say someone touched them or made them perform sexual acts

    • Act out or talk about sexual acts in play or with others

    • Masturbate or touch themselves publicly even when redirected

    • Have any signs of injury or blood in the genital area

  • Show signs of possible neglect.

    • Show signs of inadequate physical caregiving, including not being bathed or having their diaper changed

    • Are not growing and are not under medical care for this problem

    • Hide food or stuff it into their mouths quickly

    • Are overly friendly with strangers and would go off with a stranger if given the opportunity

    • Have inconsistent school attendance

    • Have unmet medical needs and/or don’t seem to get adequate medical care or follow-up

  • Show emotional signs consistent with child maltreatment.

    • Sadness or lack of joy

    • Irritability, emotional reactivity, aggression, and low frustration tolerance

    • Developmental plateau or regression

    • Extreme distress with separations or other specific situations or kinds of people

    • Social withdrawal

    • Nightmares or avoidance of sleep

  • Have a parent showing some red flags.

    • Overly harsh, punitive, or irritable in interactions with the child

    • Not appearing to be concerned about a child’s feelings or safety

    • Blaming the child for things that are not related to the child or that are developmentally typical

    • Depends on the child to take care of him or her, emotionally or physically

    • Cannot explain injuries

How common is it?

About 9 in every 1,000 children have at least one legally confirmed child maltreatment experience, with most being neglect.1 However

  • 2.5% of all infants younger than 12 months have a legally confirmed child abuse experience.

  • 25% of children who experience maltreatment are younger than 3 years.

  • Most child maltreatment is not reported or identified.

What are the behaviors usually seen?

  • Fear with reminders of the trauma and avoidance of those reminders

    • Reminders may include talking about the trauma or the people involved, specific sounds (eg, tone of voice), smells, kinds of touch or closeness to others, specific kinds of people (based on their sex, race, or build), places, or thoughts

    • Signs of fear can be

      • Obvious emotional distress (eg, sadness, anger, fear, appearing frozen)

      • Body signals (eg, faster than usual breathing and heart rate, sweating, stomach distress, pupils enlarging)

  • Signs of repetitive, uncontrollable thoughts about the trauma

    • Older children may talk about the trauma or related topics, even when the conversation isn’t about that.

    • Younger children may play out the trauma with toys or people (including being aggressive toward others, if that was the event) or talk about the event or related topics, including aggressive acts or sexual topics.

    • Nightmares.

  • Negative emotions and social withdrawal

  • Emotional reactivity and being “on alert”

    • Keeping track of where everyone is and that they are safe and/or under control

    • Sleep problems

    • Irritability

    • Highly reactive “startle” response to sudden, unexpected noises or movements

    • Reduced concentration

When should a more concerning issue be suspected?

  • If a child has a known chronic or new exposure to traumatic events, monitoring for the patterns described herein is recommended.

  • It is not uncommon for child care or early education professionals to not be aware of a child’s exposure to trauma—and sometimes, parents are not aware of the trauma either. In these cases, red flags should include new development of the patterns described herein in a child who is new to the class or program.

  • If behavioral changes persist more than 2 weeks after a known event, especially without improvement, parents should be alerted that they may want to seek advice from a physical or mental health professional.

Posttraumatic stress disorder does not resolve on its own, so waiting for it to go away is not a reasonable plan.

What are typical management strategies in the behavioral support plan?

  • Child care and educational professionals’ number-1 priority is to keep children physically and emotionally safe when children are in their care. These strategies include ensuring that the physical space is safe, the adults and children are physically and emotionally safe toward each other, and there are no threats of violence, especially from adults to any children. Children who have been exposed to child abuse and neglect are at particularly high risk of emotional dangers from actual corporal punishment or threats of corporal punishment, as well as from forced seclusion and isolation or public shaming.

  • Children who have experienced maltreatment benefit from predictable routines and schedules, including expectations for their behaviors. This can include placing an emphasis on praise for positive behaviors, as well as setting routine expectations for their own safe behaviors.

  • When children are safe, adults can address distress by reminding the children that they are safe in this setting and that the adults are working together to keep them safe.

  • Understanding the specifics of the traumatic event can help child care and early education professionals avoid unintentional exposures. For example, if children’s maltreatment included exposure to emergency vehicles (eg, police, ambulances), hearing sirens or loud noises may be frightening to them. Children who experienced sexual abuse may have difficulty with diaper changes, bathroom time, or changing clothes.

  • It can be helpful to label children’s apparent feelings when they are distressed: “It looks like you got scared when the fire alarm went off. But you are OK. We are all safe. We are just practicing how to be safe. The grown-ups have a plan for keeping you safe when the alarm goes off.”

  • It is also useful to teach children relaxation strategies to manage mild distress and body reactions to stress, such as breathing or muscle relaxation.

  • Adults should monitor their own emotional reactions to learning about a child’s traumatic history, especially if they have had similar experiences that might lead them to overprotect children, withdraw from children, or feel angry around children.

When should I ask for additional support?

  • Child care and early educational professionals are mandated reporters of suspected child abuse and/or neglect. It is appropriate to discuss with supervisors the best way to file a report, but a report must be filed according to local laws.

  • A mental health consultant can help tailor expectations for children who have experienced child abuse and/or neglect and consider when recommendations for therapy or referral to a child’s pediatrician are warranted.

  • Children’s therapists, pediatricians, or clinicians who treat anxiety disorders may ask teachers to complete questionnaires that ask about a child’s symptoms. Questionnaires aid in assessment and help track effects of treatments. It is helpful to add written comments to expand on questionnaire responses. Responses can be returned to families without any formal, specific consent process and can be sent directly to the pediatrician or other clinician with the parent’s consent. Direct communication with a treating clinician can be invaluable. The more information that is made available to the child’s therapist, the more specific the treatment plan can be.

What training and/or policies may be needed?

  • Child care and early education staff members should be familiar with their obligations as mandated reporters.

  • Additionally, child care and early educational professionals may need training to learn to interpret the behavioral signs of child abuse and neglect, to avoid interpreting aggressive or sexual reenactment such as aggression, sexual acting out, or withdrawal as “bad” behaviors, rather than signs of what has happened in children’s lives.

  • Training may also need to focus on talking about safety with children and practicing coping or relaxation strategies, such as deep breathing, muscle relaxation, or meditation.

Where can I find additional resources?

  • American Academy of Pediatrics The Resilience Project: Child abuse and neglect (

  • National Child Traumatic Stress Network (

  • American Academy of Child and Adolescent Psychiatry: Trauma and child abuse resource center (


  • US Department of Health and Human Services; Administration for Children and Families; Administration on Children, Youth, and Families; Children’s Bureau. Children. In: Child Maltreatment 2017. Accessed December 19, 2019

Adapted from Managing Behavioral Issues in Child Care and Schools: A Quick Reference Guide.

Any websites, brand names, products, or manufacturers are mentioned for informational and identification purposes only and do not imply an endorsement by the American Academy of Pediatrics (AAP). The AAP is not responsible for the content of external resources. Information was current at the time of publication.

The information contained in this publication should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.

© 2020 American Academy of Pediatrics. All rights reserved.

Copyright © 2021 Kids Clinic. All rights reserved.