Definite Abuse Research Articles

Evaluation of an Emergency Department High-risk Bruising Screening Protocol.

The objective of this study was to describe the outcomes of implementing a high-risk bruise screening pathway in a pediatric emergency department (ED). A retrospective observational study was performed of children aged 0 to <48 months who presented to the ED between December 1, 2016, and April 1, 2019, and had bruising that is high-risk for physical abuse on a nurse screening examination. A high-risk bruise was defined as any bruise if aged <6 months or a bruise to the torso, ears, or neck if aged 6 to <48 months. Records of children with provider-confirmed high-risk bruising were reviewed. Of the 49 726 age-eligible children presenting to the ED, 43 771 (88%) were screened for bruising. Seven hundred eighty-three (1.8%) of those children had positive screen results and 163 (0.4%) had provider-confirmed high-risk bruising. Of the 8635 infants aged <6 months who were screened, 48 (0.6%) had high-risk bruising and 24 of 48 (50%) were classified as cases of likely or definite abuse. Skeletal surveys were performed in 29 of 48 (60%) infants, and 11 of 29 (38%) had occult fracture. Of the 35 136 children aged 6 to <48 months who were screened, 115 of 35 136 (0.3%) had high-risk bruising and 32 of 115 (28%) were classified as cases of likely or definite abuse. High-risk bruising was rarely present. When infants aged <6 months were evaluated per recommendations, occult fracture was identified in one-third of patients. The screening pathway could help other institutions identify occult injuries in pediatric ED patients.

GPs' experience of safeguarding in care homes: what do they see and what do they do?

Abuse of older people in care homes is an on-going problem. GPs, as the most frequent practitioner group visiting care homes, have an important role in detecting and reporting abuse. However, there is little research about GPs' experiences of working in care homes and how they work to safeguard residents. To explore the challenges experienced by GPs working in this unique environment and how these impact on safeguarding. An online survey collected qualitative data about GPs' experiences as visiting professionals to care homes, with an emphasis on safeguarding. A thematic analysis identified key themes. In total, 58 completed surveys were returned, with a range of practitioner experience represented (1-30 years). Approximately 70% were GP partners, with the remainder salaried and locum doctors. Over one third reported they had witnessed signs of definite or possible abuse within care homes. Emerging themes related to the complex care home context, in which residents had multiple health needs and GPs had to build multiple relationships with managers, carers, families, and residents. Difficulties in accessing information were reported; residents could not always provide information, GPs had to rely on others for information, and rarely had access to electronic records. GP work in care homes is a complex and skilled role, in which GPs encounter evidence of poor care and abuse. Key themes in respect of barriers and facilitators of good care were highlighted. The reliance on others for information and the need to build relationships with staff/managers may raise tensions in respect of safeguarding practice.

Prevalence of Abuse and Additional Injury in Young Children With Rib Fractures as Their Presenting Injury.

The primary objective of this study was to determine the prevalence of (a) additional injuries, (b) abuse as determined by a standardized scale, and (c) reports to child protective services (CPS) among children younger than 5 years in whom a rib fracture was the first presenting injury concerning for abuse. A retrospective study of children younger than 5 years diagnosed with rib fractures at a tertiary pediatric hospital between 2007 and 2018 was performed. Children in motor vehicle crashes, hospitalized after birth, or with previously diagnosed metabolic bone disease were excluded. We included only those children whose rib fractures were the first presenting injury. Demographic and clinical information was abstracted from the records. Prevalence of additional injuries, a diagnosis of abuse, and a report to CPS were calculated. Associations between patient demographic and clinical characteristics and the outcomes of interest were examined. Of the 67 cases included, additional injuries concerning for abuse were identified in 40 (60%), and 58% were deemed likely or definite abuse. Reports to CPS were filed in 72% of cases. Posterior rib fractures, multiple rib fractures, and presence of rib fractures of multiple ages were all associated with presence of additional injuries and classification as definite or likely abuse (all P ≤ 0.05). The presence of a rib fracture in young children is associated with a high likelihood of additional concerning injuries and should prompt a thorough evaluation for child abuse.

Elder Abuse—The Current State of Research in South Africa

Objectives: The concern about elder abuse increases as the global population ages. Elder abuse is a global public health, human rights, and criminal justice problem that goes beyond socioeconomic classes and regions. It remains understudied, especially in developing countries with limited resources. It is therefore timely to do a review of the available research on elder abuse in South Africa, to be able to address the gaps in the research with future projects.Methods: Publications were identified from PubMed, MEDLINE, PsychINFO, Sabinet, Africa-Wide Information, CINAHL, E-Journals, Family and Society Studies Worldwide, PsycARTICLES, Criminal Justice s, and Social Work s. Fourteen articles on elder abuse in South Africa were selected for further review. This paper provides a narrative review of elder abuse in South Africa and is not a systematic review.Discussion: South Africa is a multicultural nation, plagued by HIV/AIDS, poverty, and the remaining effects of the legacy of apartheid. This background sets the stage for categories of abuse that are unique to the country that are highlighted in this review. The available research on elder abuse is very limited and no reliable data about the prevalence of elder abuse in South Africa could be found.Conclusions: There is a clear need for more longitudinal research about all aspects of elder abuse in South Africa. To improve future research efforts consensus has to be reached about a universal operational definition of abuse and an elder abuse instrument with a clear cut-off for definite elder abuse.

Index de contenu traumatique au Rorschach (TCI) et diagnostic de l’abus sexuel chez l’enfant

ObjectivesThe article has two aims. The first objective is to present to French clinicians working in forensic field a translation of an index built and validated using Rorschach Inkblot method by Armstrong and Loewenstein (1990), called Trauma Content Index (TCI). TCI was codified inside the Comprehensive System and integrated in recent R-PAS. The Rorschach indicators that constitute TCI, namely responses related to blood, anatomy, sex, aggressive movement and morbid content can be easily translated in French Parisian School system. For us, these indicators are highly relevant because they refer, according to our conception, to the attack of the image of the body and the representation of self which are the first indicators to be degraded in case of sexual abuse. The second objective is to study if American validated TCI cutoff to identify sexual abuse has the same usefulness when applied to a cohort of French children suspected of sexual abuse than in American sample and using Parisian School Rorschach codifying system. MethodsWe compared TCI of 50 children aged from 5 to 12 evaluated with Rorschach Inkblot A methodology in double-blinded-scoring where the two experts were both convinced of probability child sexual abuse diagnosis. We have obtained a high fidelity score of interrater agreement (0.92). These data were compared to TCI index of 50 children matched control group with samples stratified according to socio-economic level of parents as well as age. Chi square method was used to compare the two groups. ResultsA TCI cutoff of 0.25 allows us to differentiate statistically the two groups (Chi2: 19.01; P<0.001). Such a cutoff enables us to identify 72 % of the clinical group and only 6 % of the control group as false positives, showing the interest of TCI index applied to children suspected of sexual abuse. We agree with point of view issued from Kamphuis-Kugeares and Finn research (2000) upon adults in their own samples (n=100). That study compared Rorschach records of non-dissociative outpatients with histories of (a) definite sexual abuse, (b) suspected but unconfirmed sexual abuse or (c) non-sexual abuse. They conclude that, although TCI was strongly associated with the presence and severity of sexual abuse, the TCI is one factor among many that can be used to assess the validity of clients’ claims of past sexual abuse. French and South America studies on children with projective tests (Condamin 2006, Mazoyer-Roques, 2014, Scortegagna and de Villemor-Amoral 2012) are more qualitative oriented than Anglo–Saxons researches (Leifer et al., 1991, Kikuchi et al., 2010), but they end up at the same conclusion. That is the reason why we compared our two groups with as second projective tool: the ant's tales test (Royer 1978, de Tychey 2010) used to study child's body image whose usefulness was recently suggested to identify child sexual abuse (Kabuth et al., 2017). Joined use of TCI and indicators issued from that tool allow us to identify 94 % (instead of 72 % with TCI single use) of our clinical group. ConclusionTCI and projective tools are useful in forensic field to undertake child sexual abuse diagnosis. It would be important for future research to make comparative studies to approach TCI cutoff scores derived from subjects confronted to various post-traumatic situations and their psychiatric disorders forms. So it would perhaps possible to highlight specific cutoff values to child sexual abuse diagnosis.

Classifying Injuries in Young Children as Abusive or Accidental: Reliability and Accuracy of an Expert Panel Approach

To assess interrater reliability and accuracy of an expert panel in classifying injuries of patients as abusive or accidental based on comprehensive case information. Data came from a prospective, observational, multicenter study investigating bruising characteristics of children younger than 4 years. We enrolled 2166 patients with broad ranges of illnesses and injuries presenting to one of 5 pediatric emergency departments in whom bruises were identified during examination. We collected comprehensive data regarding current and past injuries and illnesses, and provided deidentified, standardized case information to a 9-member multidisciplinary panel of experts with extensive experience in pediatric injury. Each panelist classified cases using a 5-level ordinal scale ranging from definite abuse to definite accident. Panelists also assessed whether report to child protective services (CPS) was warranted. We calculated reliability coefficients for likelihood of abuse and decision to report to CPS. The interrater reliability of the panelists was high. The Kendall coefficient (95% CI) for the likelihood of abuse was 0.89 (0.87, 0.91) and the kappa coefficient for the decision to report to CPS was 0.91 (0.87, 0.94). Reliability of pairs and subgroups of panelists were similarly high. A panel composite classification was nearly perfectly accurate in a subset of cases having definitive, corroborated injury status. A panel of experts with different backgrounds but common expertise in pediatric injury is a reliable and accurate criterion standard for classifying pediatric injuries as abusive or accidental in a sample of children presenting to a pediatric emergency department.

Oral injuries and occult harm in children evaluated for abuse

ObjectiveTo determine the frequency of occult trauma in children with oral injury evaluated for physical abuse.DesignThis was a retrospectively planned secondary analysis of a prospective, observational study.SettingEmergency departments supported by...

Non-cutaneous conditions clinicians might mistake for abuse

ObjectiveTo determine the frequency of non-cutaneous mimics identified in a large, multicentre cohort of children evaluated for physical abuse.MethodsProspectively planned, secondary analysis of 2890 physical abuse consultations from the Examining...

Assessing the use of follow-up skeletal surveys in children with suspected physical abuse

Child physical abuse is an important cause of morbidity and mortality in young children. The skeletal survey (SS) is considered a mandatory part of the evaluation for suspected physical abuse in young children. Literature suggests that a follow-up SS performed 10 to 21 days after the initial SS can provide important additional information, but previous studies evaluating the follow-up SS have been small and included very selective patient populations. A retrospective descriptive study of a consecutive sample of children who underwent an initial SS and a follow-up SS at a single children's hospital during a 7-year period. Data on demographics, clinical presentation, results, and effect of the follow-up SS on clinical diagnosis were collected. Of the 1470 children who underwent an initial SS, 11% (169 of 1470 children) also underwent a follow-up SS. The mean age of the children who underwent both an initial SS and a follow-up SS was 5.8 months. Fourteen percent of the follow-up SS identified previously unrecognized fractures; all of which were healing. There were eight children in whom the information obtained from the follow-up SS resulted in a diagnosis of definite physical abuse; all eight children were younger than 12 months, and in six of these cases, the initial SS did not demonstrate any fractures. Only a small proportion of children who undergo an initial SS also undergo a follow-up SS. The relatively high proportion of follow-up SS that demonstrated previously unrecognized fracture(s), the young age of children undergoing the follow-up SS, and the high morbidity and mortality of unrecognized/missed child physical abuse in this age group suggest that the follow-up SS should be a routine part of the evaluation of child physical abuse. III, observational study.

Quality of child abuse information for measurement and surveillance: linking hospital and child welfare data

National estimates of the prevalence of child abuse-related injuries are obtained from a variety of sectors including welfare, justice and health resulting in inconsistent estimates across sectors. The International Classification...

Odds of abuse associated with retinal hemorrhages in children suspected of child abuse

To describe the prevalence of retinal hemorrhages in children being evaluated for abusive head trauma and quantify the association between the likelihood of abuse and the presence and severity of retinal hemorrhages. Retrospective cross-sectional study of 110 children aged 15 months or younger who were evaluated for abusive head trauma and received an ophthalmological examination. The child abuse specialist's diagnosis was categorized as definite accident, probable accident, probable abuse, or definite abuse, according to an algorithm that excluded eye findings. Retinal hemorrhage severity was scored on a 12-point scale (6 points per eye) based on type, size, location, and extent. Higher scores indicated greater severity of eye findings. Seventy-four percent of children were younger than 6 months old. Forty-five percent of cases were definite abuse and 37% were definite accident. The prevalence of retinal hemorrhages was 32%. Across all subjects, the presence of retinal hemorrhage was highly associated with definite or probable abuse versus definite or probable accident (age-adjusted odds ratio 5.4 [95% CI, 2.1-13.6]). The odds ratio in children younger than 6 months (n = 81) was 11.7 (95% CI, 2.9-66.8). Retinal hemorrhage severity was higher in abuse versus accident (p < 0.0001) and correlated positively with abuse (Spearman r = 0.406, p < 0.0001). Scores above 8 (n = 13) were only present in abused children. Retinal hemorrhages are highly associated with abusive head trauma, particularly in children younger than 6 months of age. Increasing retinal hemorrhage severity is correlated with increasing likelihood of abuse.

Variability in Expert Assessments of Child Physical Abuse Likelihood

In the absence of a gold standard, clinicians and researchers often categorize their opinions of the likelihood of inflicted injury using several ordinal scales. The objective of this protocol was to determine the reliability of expert ratings using several of these scales. Participants were pediatricians with substantial academic and clinical activity in the evaluation of children with concerns for physical abuse. The facts from several cases that were referred to 1 hospital's child abuse team were abstracted and recorded as in a multidisciplinary team conference. Participants viewed the recording and rated each case using several scales of child abuse likelihood. Participants (n = 22) showed broad variability for most cases on all scales. Variability was lowest for cases with the highest aggregate concern for abuse. One scale that included examples of cases fitting each category and standard reporting language to summarize results showed a modest (18%-23%) decrease in variability among participants. The interpretation of the categories used by the scales was more consistent. Cases were rarely rated as "definite abuse" when likelihood was estimated at < or = 95%. Only 7 of 156 cases rated < or = 15% likelihood were rated as "no reasonable concern for abuse." Only 9 of 858 cases rated > or = 35% likelihood were rated as "reasonable concern for abuse." Assessments of child abuse likelihood often show broad variability between experts. Although a rating scale with patient examples and standard reporting language may decrease variability, clinicians and researchers should be cautious when interpreting abuse likelihood assessments from a single expert. These data support the peer-review or multidisciplinary team approach to child abuse assessments.

Are abusive fractures in young children becoming less common?: Changes over 24 years

Objective To determine whether the proportion of fractures rated as abusive in children <36 months of age evaluated at a regional pediatric hospital increased over a 24-year period from 1979 to 2002. Fractures were chosen as an example of serious injuries in young children. Methods Medical records were abstracted for all children <36 months of age who were seen at a single pediatric hospital with a fracture during three time periods: 1979–1983, 1991–1994, and 1999–2002. After reviewing the abstracted and radiographic information, two clinicians (one an expert on child abuse) and two pediatric radiologists each rated the likelihood of abuse using explicit criteria and a seven-point scale from definite abuse to definite unintentional injury. Ratings were done independently; when disagreements occurred, the case was discussed, and a joint rating was agreed upon, if possible. The proportions of cases rated as abuse were compared over the three time periods, and logistic regression was used to calculate adjusted odds ratios (OR). Results In the early, middle, and late samples, there were 200, 240, and 232 children, respectively, with fractures. The proportion of cases rated as abuse decreased from 22.5% in the early period to 10.0% in the middle period and was 10.8% in the late period ( p < .001). When comparing the odds of abuse in the middle and late groups to the odds of abuse in the early group (controlling for age, gender, ethnicity, type of medical insurance, and site of pediatric care), the adjusted ORs were .31 (95% CI = .15, .62) for the middle group and .45 (95% CI = .23, .86) for the late group. Thus, the odds of a given case being rated as abuse decreased by over 50% from the early period to the middle and late time periods. No statistically significant difference was found when comparing the odds of abuse for the middle group to those of the late group, OR: 1.46 (95% CI = .69, 3.08). Conclusions The proportion of abusive fractures in young children decreased substantially from 1979–1983 to 1991–1994 and 1999–2002 at a major pediatric hospital. We speculate that this decrease may reflect early recognition of less serious forms of maltreatment and the availability of services to high-risk families.

Can the Initial History Predict Whether a Child With a Head Injury Has Been Abused?

Previous studies of child abuse have used the presenting history as part of the case definition of abuse. Thus, data from these studies cannot be used to determine the diagnostic utility of historical features for identifying cases of abuse. The objective of this study was to determine the diagnostic utility of certain historical features for identifying cases of abusive head trauma. We retrospectively studied all children, aged 0 to 3 years, who had acute traumatic intracranial injury and were admitted to a tertiary care pediatric hospital from 1993 to 2000. Cases were categorized as either "definite abuse" or "not definite abuse" on the basis of radiologic, ophthalmologic, and physical examination findings, without regard to the presenting history. Forty-nine (30%) of 163 children met the criteria for definite abuse. Having no history of trauma had a high specificity (0.97) and positive predictive value (PPV; 0.92) for abuse. Among the subgroup of patients with persistent neurologic abnormality at hospital discharge (n = 34), having a history of no or low-impact trauma had a specificity of 1.0 and a PPV of 1.0 for definite abuse. Injuries were blamed on home resuscitative efforts in 12% of definite abuse cases and 0% of not definite abuse cases. The initial history of trauma was changed in 9% of definite abuse cases, as compared with 0% of not definite abuse cases. Among young children with a head injury, certain historical features have high specificity and PPV for diagnosing child abuse.

Fractures in Children Younger Than Age 1 Year: Importance of Collaboration With Child Protection Services

The medical records of all children less than 1 year of age presenting to the Accident and Emergency Department over a 5-year period (1995-1999) with a fracture were retrospectively reviewed for possible abuse. Seventy-four children presented with fractures during the study period, with a mean age at presentation of 5 months (range 2 weeks to 1 year). Of these children, 46 had skull fractures and 28 had long bone fractures. Children were classified into one of seven categories: definite abuse, likely abuse, suspicious, likely accident, definite accident, neglect, or unknown cause. A three-tier system of grading for possible abuse was then used to analyze variance. The first tier consisted of the initial assessment by staff clinicians, the second retrospectively by an orthopaedic registrar, and the third retrospectively by a designated doctor in child protection (consultant pediatrician), all using the same information from the case notes. The use of the three-tier system of grading demonstrated a variance in the diagnosis of nonaccidental injury. The possibility of abuse was underestimated at the time of the original injury in over a quarter of cases (28.4%) when compared with the assessment by the consultant pediatrician. In 34 children (46%), there was no written documentation that nonaccidental injury was ever considered. While management depends on local guidelines and arrangements, the authors would advise that all children under 1 year of age with a fracture should be admitted to the hospital and referred to a pediatrician for child protection assessment.

Alcohol abuse, cognitive impairment, and mortality among older people.

To estimate the prevalence of alcohol abuse, the association of alcohol abuse with cognitive impairment, and the contribution of alcohol abuse to short-term mortality in a cohort of older people screened for dementia. Using the Canadian Study of Health and Aging (CSHA)--a representative, national cohort study of 10,268 older persons (> or = 65 years) from communities and long-term care institutions conducted in 1991--alcohol abuse and dementia were diagnosed during clinical examinations. Death was determined by telephone interview 18 months after baseline and verified by vital statistics records. 36 regional community and 17 regional institutional populations in Canada. The 2,873 individuals from the clinical sample of the CSHA. Diagnosis of alcohol abuse (questionable, definite, none), diagnosis of dementia. The prevalence of clinically detected definite alcohol abuse was 8.9% (95% confidence interval (CI) 7.9-9.9) and of questionable alcohol abuse was 3.7% (95% CI 3.0-4.4). Definite or questionable alcohol abuse was associated with a younger average age compared with no such abuse history, and men were significantly more likely than women to comprise definite and questionable diagnostic groups as compared with the group without alcohol abuse. The occurrence of all types of dementia except probable Alzheimer's disease was higher in those with definite or questionable alcohol abuse. Mortality at 18 months was higher among those with definite (14.8%, 95% CI 13.5-16.1) or questionable (20.0%, 95% CI 18.5-21.5) alcohol abuse, as compared with those with no alcohol abuse history (11.5%, 95% CI 10.3-12.7), and alcohol abuse (definite or questionable) conferred a 56% additional risk of short-term mortality (odds ratio (OR) 1.56, 95% CI 1.11-2.20) after adjusting for age, sex, and a diagnosis of dementia. Alcohol abuse among older people is common and occurs more frequently among men. It is associated with cognitive impairment and independently with short-term mortality. Physician screening for alcohol abuse can yield a group of older people at risk for adverse health outcomes.

Rorschach Correlates of Sexual Abuse: Trauma Content and Aggression Indexes

This study compared Rorschach records of nondissociative outpatients with histories of (a) definite sexual abuse (n = 22), (b) suspected but unconfirmed sexual abuse (n = 13), or (c) no sexual abuse (n = 43) on selected variables hypothesized to be associated with sexual abuse. As predicted, clients with definite sexual abuse scored significantly higher than clients known not to be sexually abused on Armstrong and Loewenstein's (1990) Trauma Content index (TC/R), with an effect size greater than 1 SD. Contrary to prediction, there was no significant difference in the frequency of their Aggressive Past (AgPast; Gacono & Meloy, 1994) scores. AgPast scores, however, did positively correlate with sexual abuse that was violent or sadistic. As a test of discriminant validity, we hypothesized that 2 Rorschach variables (PER and Sc) would be unrelated to sexual abuse. This was supported by our data. Although TC/R was strongly associated with the presence and severity of sexual abuse, it could not discriminate sexually abused from nonsexually abused clients with great accuracy. The TC/R score is 1 factor among many that can be used to assess the validity of clients' claims of past sexual abuse.

Physical abuse of urban Native Americans.

To ascertain the extent of, and risk factors for, physical abuse among older urban American Indian/Alaska Natives (AI/ANs), we conducted a chart review of 550 urban AI/AN primary care patients >/=50 years old seen during 1 year. Mistreatment was documented in 10%. A logistic regression found younger age (P <.001), female gender (P <.001), current depression (P <.001), and dependence on others for food (P <.05) to be significant correlates of physical abuse. In only 31% of instances of definite abuse were the authorities notified. We conclude that providers should be alert to the possibility of physical mistreatment among older urban AI/ANs. Improvements in detection and management are sorely needed.

Femur Shaft Fractures in Toddlers and Young Children: Rarely from Child Abuse

One hundred thirty-nine children younger than 4 years were identified retrospectively from the period of 1993 through 1997 to have an isolated fracture of the shaft of one or both femurs. Abuse was classified as group A (definite, likely, or questionable abuse) or group B (unknown cause, questionable accident, likely accident, or definite accident). The average age of the children was 2.3 +/- 1.1 years. Thirteen children, 9% of the total group, average age of 1.1 +/- 1.0 years, were likely to have been abused (group A). A total of 126 children, 91% of the total, average age 2.3 +/- 1.0 years, sustained their fracture most likely as a result of an accident (group B). Whether a child had not yet achieved walking age (toddler) was the strongest predictor of likely abuse. Ten (42%) of 24 of nonwalking children were in group A, whereas only three (2.6%) of 115 of walking children were in group A (p < 0.001). Child Protective Services may have been unnecessary in 42-63% of cases. Unless other evidence of abuse such as an inconsistent story, bruises, or other fractures are present, abuse is very unlikely to be involved in the walking-age child, analogous to the toddler fracture of the tibia.

Genital findings in adolescent girls with suspected sexual abuse

Background Sexual abuse is a common problem affecting adolescent girls, but the frequency of medical findings in this population has not been specifically described. The objective of this study was to describe the frequency of abnormal genital findings in a group of girls referred for sexual abuse evaluation. Methods Case records and photographs were reviewed on all female patients with Tanner Genital stages 3, 4, or 5, who had given a history of penile-vaginal penetration, had colposcopic photographs taken, and were determined to have experienced probable or definite abuse. Photos were reviewed prior to the review of the history, and findings were classified using a standard system. Results There were 204 girls who fit the selection criteria. The mean age was 13 years; 57% were Hispanic, 34% white. Normal or non-specific genital findings were found in 68% of subjects. The best predictor of abnormal findings was an examination within 72 hours of the last episode of abuse (Early, 69% abnormal vs. late, 24% abnormal, p = .0001). The most common abnormal finding was notching in the hymen, which was found in 25% of patients. Conclusions Normal genital examinations are usually found in adolescents who have experienced penile-vaginal penetration as a result of abuse, unless the abuse occurred within 72 hours of the examination. Medical examination cannot be used to determine whether or not an adolescent girl has had sexual intercourse.