Siblings Are Also at Risk for Abuse

Approximately 9 of every 1000 children in the United States are identified as victims of maltreatment, including neglect, physical abuse, emotional abuse, or sexual abuse.¹  However, many cases of maltreatment are not identified,²  which has severe consequences for affected children.³  Although it is important to evaluate any child at risk for abuse, identifying risk can be challenging. In this issue of Pediatrics, Kisely et al⁴  evaluated whether siblings of children with suspected abuse are themselves at increased risk. These researchers followed a large cohort of sibling pairs in Australia. They found a 60-fold increase in abuse reports for siblings of children who had themselves been reported as abused previously. The risk was even greater when the mother was <20 years of age. The type of abuse (eg, physical, sexual, neglect) was often concordant between sibling pairs.

Sibling risk has previously been studied but not on the scale of this new publication. Lindberg et al⁵  collected data from almost 3000 children who were evaluated for physical abuse. Contacts, including siblings or others in the same environment (including day care) of physically abused children were at significantly increased risk for injury.⁵  This risk was even higher among twins.

Armed with the knowledge of the increased risk to siblings, medical providers and child welfare professionals should advocate for evaluations of these children at high risk. In cases of physical abuse, the evaluation by Lindberg et al⁵  included head imaging for contacts aged <6 months or those with mental status changes, skeletal surveys for contacts aged <2 years, and physical examinations for all contacts aged <5 years. This evaluation by Lindberg’s team parallels the recommended evaluation for any child when there is concern for physical abuse, although it may be reasonable to perform head imaging on any infant at high risk for abuse, such as siblings.^6,7  To conduct a thorough examination, providers should familiarize themselves with injuries that are most specific for abuse, such as facial bruises and frenular injuries.⁸ 

Siblings of sexual abuse victims should also be evaluated. Although the American Academy of Pediatrics policy statement on sexual abuse does not mention siblings or contacts, the National Children’s Alliance (the accrediting body for children’s advocacy centers) recognizes that siblings and other household contacts of abuse victims are themselves at risk.^9,10  Evaluations for possible sexual abuse typically involve a forensic interview (if a child is developmentally capable) and a sexual abuse evaluation performed by a provider with training in pediatric sexual abuse examinations.^9,10  Children’s advocacy centers are present throughout the country to assist in these evaluations of both suspected sexual abuse victims and their siblings.¹⁰ 

The finding that children are at increased risk for maltreatment if they live with a young mother can help inform prevention efforts. For example, some home visitation programs, such as Nurse-Family Partnership, which works with first-time mothers in poverty, can help target the risks seen with young mothers, including lack of support and lack of education, and may have some benefit to prevent physical abuse.¹¹ 

As pediatricians, we are advocates for children, so our evaluation for suspected child abuse or neglect should include asking about the presence of siblings or other children in that environment. Subsequently, we should follow-up to ensure that any siblings are appropriately evaluated for abuse themselves.