Sometimes the fear shows in their eyes or in the way they hold their heads. At other times, it's not nearly so obvious. Children who are victims of child abuse may say more with their body language than with the words they speak. Whatever the case, health care providers are obligated by law to report suspected child abuse, which can pose real challenges.

"Although it isn't something we see often, potential abuse is something we always need to consider," said Joyce Ramsey-Coleman, RN, MS, MBA, chief nurse executive at Children's Healthcare of Atlanta. "We look for cues - both verbal and non-verbal - that things aren't right, like stories that don't match the degree of injury or repeated visits to the emergency department."

If abuse is suspected, social workers are called in to talk with the child and the person who brought the child to the hospital. The nurse may speak with the child while the adult meets in another room with a social worker. "The social workers really help us assess the situation," Ramsey-Coleman said. "They also can help follow-up with outside agencies that can provide family support and guidance."

Ramsey-Coleman said she thinks child abuse may be on the rise as families face more stress in their lives. Higher unemployment, a lack of good parenting skills, families that are more spread out than ever before and a larger number of single parents contribute to the challenges of raising children and coping with dayto- day stress.

"So many people don't have extended families nearby to help them deal with stressful situations," she said.

At Children's Healthcare of Atlanta, the Center for Advocacy and Protection sees child abuse patients from around the state, many who are referred from outlying areas through pediatricians, the Department of Family and Children Services or law enforcement agencies. They come to the center, one of many such facilities in the state, for evaluation.

"Our role is to give them a head-to-toe examination and to document their injuries," said Robbie Leinweber, RN, CPNP with the center, which takes five or six appointments each day Monday through Friday. The staff is on call on weekends for the emergency room. "It's more than just doing exams," she said. "We interview the children and develop an assessment as well. We can also reassure them and provide support."

Leinweber said most children are afraid that they look different to the rest of the world because they've been abused.

"The most rewarding thing is being able to tell them that everything is all right," she said. "It's great to tell them that they're healthy and that they look just like everyone else."