Evaluation Of Child Abuse Research Articles

Retrospective review to determine the utility of follow-up skeletal surveys in child abuse evaluations when the initial skeletal survey is normal.

ObjectiveThe AAP recommends that a follow-up skeletal survey be obtained for all children < 24 months of age who are strongly suspected to be victims of abuse. The objective of the current study was to evaluate the utility of a follow-up skeletal survey in suspected child physical abuse evaluations when the initial skeletal survey is normal.MethodsA retrospective review of radiology records from September 1, 1998 - January 31, 2007 was conducted. Suspected victims of child abuse who were < 24 months of age and received initial and follow-up skeletal surveys within 56 days were enrolled in the study. Children with a negative initial skeletal survey were included for further analysis.ResultsForty-seven children had a negative initial skeletal survey and were included for analysis. The mean age was 6.9 months (SD 5.7); the mean number of days between skeletal surveys was 18.7 (SD 10.1)Four children (8.5%) had signs of healing bone trauma on a follow-up skeletal survey. Three of these children (75%) had healing rib fractures and one child had a healing proximal humerus fracture. The findings on the follow-up skeletal survey yielded forensically important information in all 4 cases and strengthened the diagnosis of non-accidental trauma.Conclusion8.5 percent of children with negative initial skeletal surveys had forensically important findings on follow-up skeletal survey that increased the certainty of the diagnosis of non-accidental trauma. A follow-up skeletal survey can be useful even when the initial skeletal survey is negative.

Globe Rupture and Nonaccidental Trauma

The association of globe rupture and nonaccidental trauma is not established in the literature. We present 2 cases involving a 9-month-old infant girl and a 14-month-old girl who experienced inflicted traumatic globe rupture. In the first case, the infant had isolated eye findings on physical examination, but extensive injuries were revealed on the skeletal survey and computed tomography of the head. In the second case, the toddler had a prior history of abuse, so our index of suspicion for nonaccidental trauma was heightened. Despite isolated eye findings on physical examination, this toddler also had evidence of additional injury on skeletal survey. These cases illustrate the importance of considering nonaccidental trauma in infants and toddlers who present with globe rupture and performing a complete evaluation for child abuse if no history is given or if the history is inconsistent with the injury.

Nonaccidental Trauma in Children: Editorial Comment

Nonaccidental Trauma in Children: Editorial Comment

Disparities in the Evaluation and Diagnosis of Abuse Among Infants With Traumatic Brain Injury

To evaluate in a national database the association of race and socioeconomic status with radiographic evaluation and subsequent diagnosis of child abuse after traumatic brain injury (TBI) in infants. We conducted a retrospective study of infants with non-motor vehicle-associated TBI who were admitted to 39 pediatric hospitals from January 2004 to June 2008. Logistic regression controlling for age, type, and severity of TBI and the presence of other injuries was performed to examine the association of race and socioeconomic status with the principal outcomes of radiographic evaluation for suspected abuse and diagnosis of abuse. Regression coefficients were transformed to probabilities. After adjustment for type and severity of TBI, age, and other injuries, publicly insured/uninsured infants were more likely to have had skeletal surveys performed than were privately insured infants (81% vs 59%). The difference in skeletal survey performance for infants with public or no insurance versus private insurance was greater among white (82% vs 53%) infants than among black (85% vs 75%) or Hispanic (72% vs 55%) infants (P=.022). Although skeletal surveys were performed in a smaller proportion of white than black or Hispanic infants, the adjusted probability for diagnosis of abuse among infants evaluated with a skeletal survey was higher among white infants (61%) than among black (51%) or Hispanic (53%) infants (P=.009). National data suggest continued biases in the evaluation for abusive head trauma. The conflicting observations of fewer skeletal surveys among white infants and higher rates of diagnosis among those screened elicit concern for overevaluation in some infants (black or publicly insured/uninsured) or underevaluation in others (white or privately insured).

The Eye Examination in the Evaluation of Child Abuse

Retinal hemorrhage is an important indicator of possible abusive head trauma, but it is also found in a number of other conditions. Distinguishing the type, number, and pattern of retinal hemorrhages may be helpful in establishing a differential diagnosis. Identification of ocular abnormalities requires a full retinal examination by an ophthalmologist using indirect ophthalmoscopy through a pupil that has been pharmacologically dilated. At autopsy, removal of the eyes and orbital tissues may also reveal abnormalities not discovered before death. In previously well young children who experience unexpected apparent life-threatening events with no obvious cause, children with head trauma that results in significant intracranial hemorrhage and brain injury, victims of abusive head trauma, and children with unexplained death, premortem clinical eye examination and postmortem examination of the eyes and orbits may be helpful in detecting abnormalities that can help establish the underlying etiology.

PedsCases - A Learning Module for Evaluation of Suspected Child Abuse for Medical Students

Abstract This learning module features two podcasts that review the evaluation of child abuse for medical students, as well as the common and more serious causes of abuse. These podcasts are follow...

Incidence of Fractures Among Children With Burns With Concern Regarding Abuse

Consensus recommendations state that a radiographic skeletal survey is mandatory for all children <2 years of age with concern for physical abuse. It has been suggested that patients with burns may represent a special subgroup at lower risk for occult fractures, compared with other abused children. Our objective was to determine the prevalence of fractures in children referred for subspecialty abuse evaluations because of burns. We performed retrospective analyses of data collected as part of the Using Liver Transaminases to Recognize Abuse (ULTRA) research network. Data were collected for all children <5 years of age who were referred to 19 child protection teams for subspecialty child abuse evaluations over 1 year (N = 1676). We compared the rate of fractures in children presenting with burns with that in other children evaluated for abuse. Of 97 children <24 months of age with burns, 18 (18.6%) were also found to have fractures. Among all 1203 children <24 months of age, 649 (53.9%) had fractures. Eleven children had multiple fractures, and 12 children had fractures with radiographic evidence of healing. Two children were noted to have classic metaphyseal fractures. The rate of fractures in children who present with burns and concerns regarding physical abuse is sufficient to support the recommendation for routinely performing skeletal surveys for children <2 years of age.

The Future: Telemedicine

&lt;p&gt;This issue of &lt;cite&gt;Pediatric Annals&lt;/cite&gt;, edited by Dr. Bryan Burke, clearly presents something new and innovative. This issue is devoted to the topic of telemedicine, which covers an array of activities that potentially affect a spectrum of clinical, teaching, and other aspects of medicine. The current effect of these technologic advances on pediatrics (consultative activities, child abuse evaluations, international health, nursing education, student and physician education, neonatal care, pediatric critical care, and others) is impressive, and the future effects seem boundless.&lt;/p&gt;

Fluorine-18 NaF PET imaging of child abuse

We describe the use of 18F-NaF positron emission tomography (PET) whole-body imaging for the evaluation of skeletal trauma in a case of suspected child abuse. To our knowledge, 18F NaF PET has not been used in the past for the evaluation of child abuse. In our patient, this technique detected all sites of trauma shown by initial and follow-up skeletal surveys, including bilateral metaphyseal fractures of the proximal humeri. Fluorine-18 NaF PET has potential advantage over Tc-99m-labeled methylene diphosphonate (MDP) based upon superior image contrast and spatial resolution.

Diagnostic Evaluation of Physical Abuse in Children

Diagnostic Evaluation of Physical Abuse in Children

Inflicted skeletal trauma: The relationship of perpetrators to their victims

Objective Although inflicted skeletal trauma is a very common presentation of child abuse, little is known about the perpetrators of inflicted skeletal injuries. Studies exist describing perpetrators of inflicted traumatic brain injury, but no study has examined characteristics of perpetrators of inflicted skeletal trauma. Methods All cases of suspected child physical abuse evaluated by the child abuse evaluation teams at Vanderbilt University Medical Center (January 1996 to August 2000) and at the Children's Hospital at Denver (January 1996 to December 1999) were reviewed for the presence of fractures. All children with inflicted fractures were entered into the study, and demographic data, investigative data, and identity of perpetrators were collected. Results There were a total of 630 fractures for 194 patients. The median number of fractures per patient was 2, and the maximum was 31. Sixty-three percent of children presented with at least one additional abusive injury other than the fracture(s). Perpetrators were identified in 79% of the cases. Nearly 68% of the perpetrators were male; 45% were the biological fathers. The median age of the children abused by males (4.5 months) significantly differed from the median age of those abused by females (10 months) ( p = .003). Conclusion In the cases where a perpetrator of inflicted fractures could be identified, the majority were men, most commonly the biological fathers. Children injured by men were younger than those injured by women.

Hospital-based multidisciplinary teams can prevent unnecessary child abuse reports and out-of-home placements

Objective To determine how often and for what reasons a hospital-based multidisciplinary child abuse team concluded that a report of alleged or suspected child abuse was unnecessary in young children with fractures. Methods A retrospective review was completed of all children less than 12 months of age who, because of fractures, were referred to the hospital multidisciplinary child abuse team for consultation regarding the need to consider child abuse. Results The team received 99 consultations, reported 92 (93%) children as alleged or possible victims of physical abuse, and did not report 7 (7%). Age at presentation of those who were reported was 4.2 months compared to 3.0 months in the non-reported group. The average number of fractures in the reported group was 2.9 ( SD 3.53) compared to 3.4 ( SD 4.6) in the non-reported group. Factors that led to cases not being reported included: (a) a trauma history consistent with the fracture ( n = 4), (b) a diagnosis of bone fragility secondary to genetic, nutritional or medical therapy etiologies ( n = 2), and (c) iatrogenic fracture ( n = 1). Conclusions Seven percent of the children less than 12 months of age and with at least one fracture referred to the multidisciplinary team for evaluation of possible child abuse were not reported as alleged or suspected physical abuse. The involvement of the hospital multidisciplinary child abuse team may have prevented unnecessary investigation by the county social services agency and/or police, and possible out-of-home temporary placement.

Orijinal Article: Evaluation of child abuse in a Central Anatolian city of Turkey

Orijinal Article: Evaluation of child abuse in a Central Anatolian city of Turkey

The impact of a management protocol on the outcomes of child abuse in hospitalized children in Hong Kong

Objective To study the outcomes of children hospitalized for suspected child abuse before and after the implementation of a management protocol in a hospital in Hong Kong. Study period Two 2-year periods before (1994–1995) and after (2002–2003) the implementation of the protocol in 1998. Methods This is a retrospective hospital chart review in which the patients’ characteristics, the use of laboratory and radiological examination, abuse substantiation and official registrations are compared between the two study periods. Results There were 109 and 320 patients admitted for evaluation of child abuse for the periods 1994–1995 and 2002–2003, respectively. Children in both periods were similar in sex ratio, proportion of severe forms of child abuse, rates of abuse substantiation and inclusion in the Child Protection Registry. After the implementation of a management protocol, there has been a significant drop in the proportion of children subjected to investigations such as blood counts (86% vs. 16%, p < .001), clotting study (75% vs. 9%, p < .001), and skeletal survey (78% vs. 6%, p < .001). The average length of hospital stay also dropped from 15.3 days to 6.1 days ( p < .001). Conclusions There has been an almost threefold rise in the number of child abuse cases handled at the hospital during the 10-year interval. With the implementation of a management protocol, only a small proportion of children need laboratory investigations or skeletal survey without any drop in abuse substantiation and official registration. The length of hospital stay has also been significantly reduced.

How useful is the presence of petechiae in distinguishing non-accidental from accidental injury?

Child abuse and neglect remains a significant cause of morbidity and mortality in children. Dermatologists may not fully conceptualize their crucial role in the evaluation of child abuse and neglect as both mandated reporters and experts in skin pathology. This CME article summarizes the current information on cutaneous signs and clinical signs of abuse for dermatologists so that they gain more insight into the skin examination for child abuse and neglect, develop confidence in their ability to distinguish dermatologic signs of accidental versus inflicted trauma, and more frequently consider abuse and neglect in their differential diagnosis.

Funding of Child Abuse Evaluations: Survey of Child Abuse Evaluation Programs

This article delineates the current fiscal management and reimbursement for child abuse examinations. These financial issues are high priority for child abuse programs because most programs lack the revenues to meet the demands for service, education, advocacy and research. Programs may share medical protocols and standards but have yet to share management solutions. The authors present the administrative details of 75 child abuse evaluation programs and highlight innovative approaches to increase funding and stabilize the funding for the programs. They present information on billing, contracts, costs of care, and state-based initiatives that can be reproduced by other programs and states.

Imaging of head injuries in infants: temporal correlates and forensic implications for the diagnosis of child abuse

The dating of inflicted head injuries in infants is a recurrent and difficult problem in the forensic evaluation of child abuse. The dating of hemorrhagic lesions when using magnetic resonance (MR) imaging is delicate because many confusing factors interact. In particular, infants frequently develop subdural hematomas (SDHs), which are generally composed of a supernatant, similar to cerebrospinal fluid (CSF), and a sediment, similar to blood clots. In the absence of a validated theoretical model predicting the evolution of blood signal in head-injured infants, clinical data are much needed; however, reliably dated information regarding head injuries in infants is scarce. The authors prospectively studied infants who presented with dated and corroborated head injury to investigate the temporal modifications of computerized tomography (CT) and MR imaging in relation to the delay since trauma. In cases of SDH, the authors distinguished between sediment and supernatant based on their CT scanning appearance. They then studied the MR imaging signal of these two components in T1- and T2-weighted, fluid-attenuated inversion recovery (FLAIR), and gradient-echo sequences. Whereas the signal of the supernatant showed little difference from that of the CSF and did not yield information about the date of trauma, the signal in the sediment, especially on the T1-weighted and FLAIR sequences, showed time-related modifications that could be used to date the trauma. The authors propose a method by which to develop a time scale for the dating of head injuries in infants based on the modifications of signal and location of blood on CT and MR images.

Emergency medicine resident rotation in pediatric emergency medicine: what kind of experience are we providing?

To characterize emergency medicine (EM) residents' clinical experience during a pediatric emergency medicine (PEM) rotation. Prospective observational study of EM resident-patient encounters in a children's hospital emergency department (ED). Fifty-six residents participated in the study. The mean (+/-SD) patient age was 6.3 (+/-5.6) years. Ambulatory infectious disease, respiratory illness, and wound management represented almost 50% of final diagnoses. Six and a half procedures/resident were performed per rotation, mainly nonemergent procedures, whereas resuscitations and child abuse evaluations were rare. A minority of patients required data interpretation: 34.4% had laboratory testing, 24.6% had radiographic studies, and 2.3% had electrocardiograms. Analysis of patient encounters during a PEM rotation showed deficiencies in critical care procedures, resuscitations, child abuse evaluations, and neonatal evaluations. Quantitative data of skills utilized during rotations can be used by residency programs to identify and correct deficiencies in their residents' PEM education.

La souffrance des familles maltraitantes à l’épreuve de l’intervention : Vers une éthique de l’intervention médico-psycho-sociale

Although maltreatment (towards children) is an aspect of human violence in general, current clinical research in this field is aimed at establishing increasingly finer diagnostic criteria and more specific treatments. The abusive or vulnerable families are better ‘screened’, and treatment management is more case-specific. In Belgium, a multidisciplinary intervention unit has been set up: SOS Children-Families, consisting of teams specialized in the evaluation and treatment of child abuse which attempt to offer solutions that are better adapted to these particular families. The choice between a legal or a non-legal approach to managing maltreated children and their abusive families is not easy to make and each decision in this regard inevitably involves certain risks, but the multidisciplinary method described in this article is more flexible and opens up new avenues. With the sometimes exaggerated media coverage and collective anxiety aroused by publicity over extreme cases, the abusive families elicit reactions that are more frequently repressive than reconstructive. The new approach, however, seeks to avoid criticism or stigmatization and establish a therapeutic alliance with the families in question. Treatment management also tends to increasingly involve professionals from a wide range of disciplines, and collaboration depends on their pertinent intervention at different levels in the therapeutic process; although their approaches may not always be compatible and even sometimes contradictory, the protagonists are strongly committed towards treatment of the family unit. In spite of the official and institutionalized nature of treatment management of specific cases, the abusive families are exposed to numerous confrontational situations that require their commitment and involvement. In this particular and quite innovative context aimed at providing aid to abusive families, different propositions can be considered: a) the analysis of personal, institutional and familial reference systems; b) clarification (of the reasons for) the therapeutic intervention; c) the child’s corroborative observation; d) an active and respectful dialogue between the therapists and the parties concerned; e) the construction of a therapeutic bond with the family; f) the initiation of a project for change; g) learning to develop empathy; h) a tried and tested ethical approach to treatment. In conclusion, the treatment approach, which is more socio-political than psychological, underlines the context in which therapeutic management should take place, the sharing of ethical values between the professionals involved, and the possibilities available to maltreated children and their abusive families.

Providing culturally competent pediatric care: integrating pediatricians, institutions, families, and communities into the process

Rapid growth in the diversity of our nation and recent research indicate the importance of providing culturally competent pediatric care. By 2040, nonwhite children will outnumber white non-Latino children in the United States. The 2000 Census revealed that ;45 million people in the United States speak a language other than English at home, and ;19 million are limited in English proficiency (LEP). Over the past two decades, there has been an 85% increase in the number of LEP school-aged US children. The number of foreign-born Americans more than tripled during the last three decades, reaching 28.4 million in 2000. Cultural and linguistic issues affect multiple aspects of pediatric care, including outcomes, quality, costs, and satisfaction with care. Failure to appreciate the role of culture in pediatrics can result in a variety of adverse consequences, including difficulties with informed consent, miscommunication, inadequate understanding of diagnoses and treatment plans by families, dissatisfaction with care, preventable morbidity and mortality, unnecessary child abuse evaluations, and disparities in prescriptions, analgesia, and diagnostic evaluations. Cultural competency is the ability to identify and appropriately respond to cultural issues that affect the health care of patients and their families. The purpose of this article is to examine how academic departments of pediatrics, hospitals, health centers and other healthcare institutions can ensure that culturally competent health care is being delivered to children and their families. The approach presented attempts to integrate clinicians, institutions, families, and communities into a collaborative process. How can we ensure that clinicians and trainees deliver culturally competent pediatric care? In my experience as an educator and researcher, the critical first step is to achieve buy-