Maltreatment of Children With Disabilities.

Over the past decade, there have been widespread efforts to raise awareness about maltreatment of children. Pediatric providers have received education about factors that make a child more vulnerable to being abused and neglected. The purpose of this clinical report is to ensure that children with disabilities are recognized as a population at increased risk for maltreatment. This report updates the 2007 American Academy of Pediatrics clinical report "Maltreatment of Children With Disabilities." Since 2007, new information has expanded our understanding of the incidence of abuse in this vulnerable population. There is now information about which children with disabilities are at greatest risk for maltreatment because not all disabling conditions confer the same risks of abuse or neglect. This updated report will serve as a resource for pediatricians and others who care for children with disabilities and offers guidance on risks for subpopulations of children with disabilities who are at particularly high risk of abuse and neglect. The report will also discuss ways in which the medical home can aid in early identification and intervene when abuse and neglect are suspected. It will also describe community resources and preventive strategies that may reduce the risk of abuse and neglect.

Understanding humerus fractures in young children: Abuse or not abuse?

Fractures are the second most common abusive injury occurring in young children, particularly those under 2 years of age. The humerus is often affected. To better identify factors discriminating between abusive and non-abusive humerus fractures, this retrospective study examined the characteristics and mechanisms of injuries causing humerus fractures in children less than 18 months of age. Electronic medical records were reviewed for eligible patients evaluated between September 1, 2007 and January 1, 2012 at two children's hospitals in Chicago, IL. The main outcome measures were the type of fracture and the etiology of the fracture (abuse vs not abuse). The 97 eligible patients had 100 humerus fractures. The most common fracture location was the distal humerus (65%) and the most common fracture type was supracondylar (48%). Child Protection Teams evaluated 44 patients (45%) and determined that 24 of those had 25 fractures caused by abuse (25% of the total study population).Among children with fractures determined to have been caused by abuse, the most common location was the distal humerus (50%) and the most common types were transverse and oblique (25% each); however, transverse and oblique fractures were also seen in patients whose injuries were determined to have been non-abusive. A younger age, non-ambulatory developmental stage, and the presence of additional injuries were significantly associated with abusive fractures. Caregivers did not provide a mechanism of injury for half of children with abusive fractures, whereas caregivers provided some explanation for all children with non-abusive fractures.

Enlarged subarachnoid spaces and intracranial hemorrhage in children with accidental head trauma.

OBJECTIVE Benign external hydrocephalus (BEH) is an enlargement of the subarachnoid spaces (SASs) that can be seen in young children. It is controversial whether children with BEH are predisposed to developing subdural hemorrhage (SDH) with or without trauma. This issue is clinically relevant as a finding of unexplained SDH raises concerns about child abuse and often prompts child protection and law enforcement investigations. METHODS This retrospective study included children (1-24 months of age) who underwent head CT scanning after an accidental fall of less than 6 feet. Head CT scans were reviewed, cranial findings were documented, and the SAS was measured and qualitatively evaluated. Enlarged SAS was defined as an extraaxial space (EAS) greater than 4 mm on CT scans. Clinical measurements of head circumference (HC) were noted, and the head circumference percentile was calculated. The relationship between enlarged SAS and HC percentile, and enlarged SAS and intracranial hemorrhage (ICH), were investigated using bivariate analysis. RESULTS Of the 110 children included in this sample, 23 had EASs greater than 4 mm. The mean patient age was 6.8 months (median 6.0 months). Thirty-four patients (30.9%) had ICHs, including subarachnoid/subpial (6.2%), subdural (6.2%), epidural (5.0%), and unspecified extraaxial hemorrhage (16.5%). Enlarged SAS was positively associated with subarachnoid/subpial hemorrhage; there was no association between enlarged SASs and either SDH or epidural hemorrhage. A larger SAS was positively associated with larger HC percentile; however, HC percentile was not independently associated with ICH. CONCLUSIONS Enlarged SAS was not associated with SDH, but was associated with other ICHs. The authors' findings do not support the theory that BEH predisposes children to SDH with minor accidental trauma.

Effect of early childhood adversity on child health.

OBJECTIVE: To examine the effect of child abuse and other household dysfunction on child health outcomes. DESIGN: Data from the Longitudinal Studies of Child Abuse and Neglect collected through interviews and questionnaires administered when target children were 4 years old and 6 years old. SETTING: Children in the South, East, Midwest, Northwest, and Southwest United States. PARTICIPANTS: One thousand forty-one children at high risk for child abuse and neglect (3 cohorts derived primarily from among children recruited through social service mechanisms, 1 cohort recruited at birth from among high-risk infants, and 1 cohort recruited from a medical setting). MAIN OUTCOME MEASURES: (1) Association of 7 adverse exposures (3 categories of child abuse [physical abuse, sexual abuse, and psychological maltreatment] and 4 categories of household dysfunction [caregiver problem drinking, caregiver depression, caregiver treated violently, and criminal behavior in the household]) derived from data collected when the child was 4 years old. (2) Indexes of child physical health at age 6 years (caregiver overall assessment of child health and reports of illness requiring medical attention). RESULTS: Two thirds of the sample had experienced at least 1 adverse exposure. One adverse exposure almost doubled the risk of overall poor health (odds ratio, 1.89; 95% confidence interval, 1.02-3.48), and 4 adverse exposures or more almost tripled the risk of illness requiring medical attention (odds ratio, 2.83; 95% confidence interval, 1.10-7.31). CONCLUSION: Adverse environmental exposures, including child abuse and other household dysfunction, are associated with poor child health even at an early age, although our data do not support a dose-response relationship.

Analysis of caretaker histories in abuse: comparing initial histories with subsequent confessions.

OBJECTIVE: We hypothesize that perpetrators of abuse include elements of truth in their initial history and that an analysis of perpetrator confessions can teach professionals how to identify these initial truths. METHODS: The information from a consecutive sample of perpetrators' confessions concerning 41 children hospitalized because of injuries caused by child abuse was reviewed. The details about the injuries contained in the confessions were compared with the details provided when these children initially presented for medical care. Information about the perpetrator's gender and relationship to the child, the victim's age and gender, type of injury, family risk factors, the trigger of the abusive event, the circumstances surrounding the event, and the type of trauma were collected. RESULTS: A total of 45 perpetrators abused 41 children; 76% of perpetrators were male; 56% were the child's father; 34% were the child's mother. The perpetrators initially provided no explanation about how 68% of the children received an injury. In 91% of their initial histories, the perpetrators provided some element of truth about the circumstances or triggering event for the abuse. In 67% of confessions, crying was the circumstance that triggered the abuse. Mothers were more likely to describe the situation that triggered the abuse (85% of mothers versus 58% of fathers, p=ns), while fathers were more likely to describe accurately the circumstances surrounding the abuse (79% of fathers versus 62% of mothers, p=ns). CONCLUSIONS: Perpetrators of abuse provide initial truths in their presenting history. Child abuse professionals must take a careful history from all caretakers and "listen" for the "elements of truth." These truths are the child's behavior or circumstance that increased stress and triggered the abuse. Employing this method in a careful analysis of confessions can make a significant contribution to the capacity to identify child abuse. In addition, more information about the role of triggers may help to focus child abuse prevention strategies.

Pediatrician characteristics associated with child abuse identification and reporting: results from a national survey of pediatricians.

Pediatrician experience with child protective services (CPS) and factors associated with identifying and reporting suspected child physical abuse were examined by a survey of members of the American Academy of Pediatrics (AAP). Respondents provided information about their demographics and experience, attitudes and practices with child abuse. They indicated their diagnosis and management of a child in a purposely ambiguous clinical vignette. Pediatricians who had received recent child abuse education were more confident in their ability to identify and manage child abuse. High confidence in ability to manage child abuse and positive attitude about domestic violence screening and value of anticipatory guidance predicted that pediatricians would have high suspicion that the child in the vignette was abused and that they would report the child to CPS. Future efforts to improve medical intervention in child abuse should focus on physician attitudes and experience, as well as cognitive factors.

Barriers to physician identification and reporting of child abuse.

Physicians systematically underidentify and underreport cases of child abuse. These medical errors may result in continued abuse, leading to potentially severe consequences. We have reviewed a number of studies that attempt to explain the reasons for these errors. The findings of these various studies suggest several priorities for improving the identification and reporting of child maltreatment: Improve continuing education about child maltreatment. Continuing education should focus not only on the identification of maltreatment but also on management and outcomes. This education should include an explanation of the role of CPS investigator and the physician's role in an investigation. The education should provide physicians with a better understanding of the overall outcome for children reported to CPS to help physicians gain perspective on the small number of maltreated children they may care for in their practice. This education should emphasize that the majority of maltreated children will benefit from CPS involvement. New York is the only state that mandates all physicians, as well as certain other professionals, take a 2-hour course called Identification and Reporting of Child Abuse and Maltreatment prior to licensing. Cited studies in this article suggest that such a mandate might be expected to improve identification and reporting, thereby encouraging other states to adopt similar regulations. Give physicians the opportunity to debrief with a trained professional after detecting and reporting child abuse. The concept of child abuse and the gravity of the decision to report can be troubling to the reporter. The debriefing could include discussions of uncomfortable feelings physicians may experience related to their own countertransference reactions. Provide resources to assist physicians in making the difficult determination of suspected maltreatment. The role of accessible telephone consultation should be evaluated, along with formalized collaborations with local Emergency Departments with pediatric expertise. Improve the relationship between CPS and medical providers. For example, CPS workers should systematically inform the reporting physician about the progress of their investigation and the outcome for the child and family. Several past reports have made specific suggestions to improve the working relationship. Warner and Hanson recommended that positive outcomes be programmed into the reporting process. They suggested that CPS have special phone lines staffed by well-trained employees for mandated reporters to call. Finkelhor and Zellman proposed a more radical change to improve the working relationship between CPS and mandated reporters. They suggested that certain professionals, with demonstrated expertise in the recognition and treatment of child abuse and registered as such, should have "flexible reporting options." Options include the ability to defer reporting, if there are no immediate threats to a child, or to make a report in confidence and defer the investigation until necessary. Finkelhor and Zellman emphasized that this model would improve physician-reporting compliance and enhance the role of CPS while reducing the work burden for CPS. Improve interaction with the legal system. Child abuse pediatric experts who have courtroom experience could provide education and support to physicians who have little preexisting experience with the legal system. Reimbursement for time spent supporting legal proceedings should be equitable and may reduce physician concerns about lost patient revenue. Retrospective studies and vignette analyses provide much information about some of the barriers to child maltreatment reporting and describe many of the reasons why physicians do not identify and report all child maltreatment. Future prospective examinations of physician decision-making may further explain the physician's decision-making process and the barriers he or she faces when identifying and reporting child abuse.

Understanding forearm fractures in young children: Abuse or not abuse?

This retrospective study describes the characteristics and mechanisms of forearm fractures in children <18 months adding to the evidence-base about forearm fractures. It also examines which features of forearm fractures in young children may help discriminate between abusive and noninflicted injuries. Electronic medical records were reviewed for eligible patients evaluated between September 1, 2007 and January 1, 2012 at two children's hospitals in Chicago, IL. The main outcome measures were the type of fracture and the etiology of the fracture (abuse versus not abuse). The 135 included patients sustained 216 forearm fractures. Most were buckle (57%) or transverse (26%). Child protection teams evaluated 47 (35%) of the patients and diagnosed 11 (23%) as having fractures caused by abuse. Children with abusive versus non-inflicted injuries had significant differences in age (median age 7 versus 12 months), race, and presence of additional injuries. Children with abusive forearm fractures often presented without an explanation or a changing history for the injury. Children with non-inflicted forearm fractures often presented after a fall. No particular type of forearm fracture was specific for child abuse. Any forearm fracture in a young child should be evaluated with special attention to the details of the history and the presence of other injuries. Young age, additional injuries, and an absent or inconsistent explanation should increase concern that the fracture was caused by child abuse.

Trajectories of Adverse Childhood Experiences and Self-Reported Health at Age 18.

OBJECTIVE: Despite growing evidence of links between adverse childhood experiences (ACEs) and long-term health outcomes, there has been limited longitudinal investigation of such links in youth. The purpose of these analyses was to describe the patterns of exposure to ACEs over time and their links to youth health. METHODS: The current analyses used data from LONGSCAN, a prospective study of children at risk for or exposed to child maltreatment, who were followed from age 4 to age 18. The analyses focused on 802 youth with complete data. Cumulative exposure to ACEs between 4 and 16 was used to place participants in 3 trajectory-defined groups: chronic ACEs, early ACEs only, and limited ACEs. Links to self-reported health at age 18 were examined using linear mixed models after controlling for earlier health status and demographics. RESULTS: The chronic ACEs group had increased self-reported health concerns and use of medical care at 18 but not poorer self-rated health status. The early ACEs only group did not significantly differ from limited ACEs on outcomes. CONCLUSIONS: In addition to other negative outcomes, chronic ACEs appear to affect physical health in emerging adulthood. Interventions aimed at reducing exposure to ACEs and early mitigation of their effects may have lasting and widespread health benefits.

Telling their stories: primary care practitioners' experience evaluating and reporting injuries caused by child abuse.

OBJECTIVE: To learn about primary care physicians' experiences in identifying and reporting injuries caused by physical abuse. METHOD: Two qualitative analysts facilitated a focus group of six Chicago area, primary care physicians. Physicians representing diverse practice settings were selected to participate in the discussion. The analysts reviewed and analyzed the audiotape transcription of the focus group for common emergent themes. RESULTS: Two themes emerged: (1) the importance of the participants' own past experience identifying and reporting suspected child abuse and (2) the responsibility physicians experience as they strive to assess possible abuse within the time constraints of an office visit. Each physician described a sentinel event that continues to affect decision-making. The physicians described several obstacles to decision-making including a lack of knowledge about child abuse, their previous experience with child protective services (CPS), and the additional time required to evaluate and report suspected abuse. The discussion suggested that rapid availability of expert consultation improved participant comfort in decision-making when abuse or neglect is suspected. CONCLUSION: Primary care physicians reported being strongly influenced by their previous experiences with suspected abuse. A better understanding of office-based experiences with suspected abuse is needed to guide the development of tools and systems to enhance the ability of the primary care physician to provide the best care for children who may have been abused.

Evaluating children with fractures for child physical abuse.

Fractures are common injuries caused by child abuse. Although the consequences of failing to diagnose an abusive injury in a child can be grave, incorrectly diagnosing child abuse in a child whose fractures have another etiology can be distressing for a family. The aim of this report is to review recent advances in the understanding of fracture specificity, the mechanism of fractures, and other medical diseases that predispose to fractures in infants and children. This clinical report will aid physicians in developing an evidence-based differential diagnosis and performing the appropriate evaluation when assessing a child with fractures.

Caregiver-fabricated illness in a child: a manifestation of child maltreatment.

Caregiver-fabricated illness in a child is a form of child maltreatment caused by a caregiver who falsifies and/or induces a child's illness, leading to unnecessary and potentially harmful medical investigations and/or treatment. This condition can result in significant morbidity and mortality. Although caregiver-fabricated illness in a child has been widely known as Munchausen syndrome by proxy, there is ongoing discussion about alternative names, including pediatric condition falsification, factitious disorder (illness) by proxy, child abuse in the medical setting, and medical child abuse. Because it is a relatively uncommon form of maltreatment, pediatricians need to have a high index of suspicion when faced with a persistent or recurrent illness that cannot be explained and that results in multiple medical procedures or when there are discrepancies between the history, physical examination, and health of a child. This report updates the previous clinical report "Beyond Munchausen Syndrome by Proxy: Identification and Treatment of Child Abuse in the Medical Setting" The authors discuss the need to agree on appropriate terminology, provide an update on published reports of new manifestations of fabricated medical conditions, and discuss approaches to assessment, diagnosis, and management, including how best to protect the child from further harm.

Child abuse physicians: coping with challenges.

This article explores how child abuse physicians (CAPs) experience the unique challenges of the emerging field of child abuse pediatrics. Practicing CAPs completed a written survey about known challenges in their field. Fifty-six CAPs completed the written survey and reported experiencing many negative consequences including: threats to their personal safety (52%), formal complaints to supervisors (50%) and licensing bodies (13%), negative stories in the media (23%), and malpractice suits (16%). A purposeful sample of CAPs participated in telephone interviews about these challenges. The 19 physicians who were interviewed described the challenges, while they spontaneously expressed satisfaction with their career and described some strategies for coping with the stresses of child abuse pediatrics. The findings highlight the stressors and challenges that may affect the ability to maintain an adequate CAP workforce. Better understanding of the challenges should help prepare physicians to practice this subspecialty.

Adverse childhood experiences and child health in early adolescence.

IMPORTANCE: Child maltreatment and other adverse childhood experiences, especially when recent and ongoing, affect adolescent health. Efforts to intervene and prevent adverse childhood exposures should begin early in life but continue throughout childhood and adolescence. OBJECTIVES: To examine the relationship between previous adverse childhood experiences and somatic concerns and health problems in early adolescence, as well as the role of the timing of adverse exposures. DESIGN: Prospective analysis of the Longitudinal Studies of Child Abuse and Neglect interview and questionnaire data when target children were 4, 6, 8, 12, and 14 years old. SETTING: Children with reported or at risk for maltreatment in the South, East, Midwest, Northwest, and Southwest United States Longitudinal Studies of Child Abuse and Neglect sites. PARTICIPANTS: A total of 933 children who completed an interview at age 14 years, including health outcomes. EXPOSURES: Eight categories of adversity (psychological maltreatment, physical abuse, sexual abuse, neglect, caregiver's substance use/alcohol abuse, caregiver's depressive symptoms, caregiver treated violently, and criminal behavior in the household) experienced during the first 6 years of life, the second 6 years of life, the most recent 2 years, and overall adversity. MAIN OUTCOMES AND MEASURES: Child health problems including poor health, illness requiring a doctor, somatic concerns, and any health problem at age 14 years. RESULTS: More than 90% of the youth had experienced an adverse childhood event by age 14 years. There was a graded relationship between adverse childhood exposures and any health problem, while 2 and 3 or more adverse exposures were associated with somatic concerns. Recent adversity appeared to uniquely predict poor health, somatic concerns, and any health problem. CONCLUSIONS AND RELEVANCE: Childhood adversities, particularly recent adversities, already show an impact on health outcomes by early adolescence. Increased efforts to prevent and mitigate these experiences may improve the health outcome for adolescents and adults.

Adverse Experiences and Suicidal Ideation in Adolescence: Exploring the Link Using the LONGSCAN Samples.

OBJECTIVE: Although widely studied in adults, the link between lifetime adversities and suicidal ideation in youth is poorly understood. The purpose of this study was to explore this link in adolescents. METHODS: The analyses used a sample of 740 16-year-old youth in the LONGSCAN sample, and distinguished between childhood (before the age of 12) and adolescent (between age 12 and age 16) adversities. RESULTS: There was a significant link between cumulative lifetime adversities and suicidal ideation. There was no evidence that this link was moderated by gender. Childhood adversities moderated the effects of adolescent adversities on suicidal ideation; effects of adolescent adversities were strongest at low levels of childhood adversities. There was also some evidence supporting a specific cumulative model of the effects of adversities on suicidal ideation; the most predictive model included the sum of the following adversities: childhood physical abuse, childhood neglect, childhood family violence, childhood residential instability, adolescent physical abuse, adolescent sexual abuse, adolescent psychological maltreatment, and adolescent community violence. CONCLUSION: The timing and nature of adversities are important in understanding youth suicidal ideation risk; in particular, adolescent maltreatment and community violence appear to be strong predictors. Preventing and appropriately responding to the abuse of adolescents has the potential to reduce the risk of suicidal ideation.

Clinical report­the pediatrician's role in child maltreatment prevention.

It is the pediatrician's role to promote the child's well-being and to help parents raise healthy, well-adjusted children. Pediatricians, therefore, can play an important role in the prevention of child maltreatment. Previous clinical reports and policy statements from the American Academy of Pediatrics have focused on improving the identification and management of child maltreatment. This clinical report outlines how the pediatrician can help to strengthen families and promote safe, stable, nurturing relationships with the aim of preventing maltreatment. After describing some of the triggers and factors that place children at risk for maltreatment, the report describes how pediatricians can identify family strengths, recognize risk factors, provide helpful guidance, and refer families to programs and other resources with the goal of strengthening families, preventing child maltreatment, and enhancing child development.

Does bruising help determine which fractures are caused by abuse?

To determine whether the presence or absence of bruising can be used to differentiate between abusive and nonabusive fractures, a retrospective study was conducted of patients with acute fractures referred to a child abuse team. A bruise and fracture were considered associated if both occurred on the same body site. Chart summaries, excluding information on bruising, were reviewed by 2 abuse experts to assign cause of injury. Of the 150 participants, fractures of 93 (62%) were categorized as abusive and 57 (38%) as nonabusive. Bruising associated with a fracture was found for 26% of abused and 25% of nonabused children. Most children (61%) had no bruises anywhere on the body, and this did not differ significantly by cause of injury. The sensitivity of a bruise associated with a fracture to predict abuse was only 26%. The presence or absence of bruising was not useful to differentiate between abusive and nonabusive fractures.

Adverse childhood exposures and reported child health at age 12.

OBJECTIVE: The relationship between adverse childhood exposures and poor health, illness, and somatic complaints at age 12 was examined. METHODS: LONGSCAN (Consortium for Longitudinal Studies of Child Abuse and Neglect) tracks a group of children with variable risk for maltreatment. Of the participating child-caregiver dyads, 805 completed an interview when the child was age 4 or age 6, as well as interviews at age 8 and 12. The relationships between 8 categories of childhood adversity (psychological maltreatment, physical abuse, sexual abuse, child neglect, caregiver's substance/alcohol use, caregiver's depressive symptoms, caregiver's being treated violently, and criminal behavior in the household) and child health at age 12 were analyzed. The impact of adversity in the first 6 years of life and adversity in the second 6 years of life on child health were compared. RESULTS: Only 10% of the children had experienced no adversity, while more than 20% had experienced 5 or more types of childhood adversity. At age 12, 37% of the children sampled had some health complaint. Exposure to 5 or more adversities, particularly exposure in the second 6 years of life, was significantly associated with increased risks of any health complaint (odds ratio [OR] 2.24, 95% confidence interval [95% CI] 1.02-4.96), an illness requiring a doctor (OR 3.69, 95% CI 1.02-15.1), and caregivers' reports of child's somatic complaints (OR 3.37, 95% CI 1.14-1.0). There was no association between adverse exposures and self-rated poor health or self-rated somatic complaints. CONCLUSIONS: A comprehensive assessment of children's health should include a careful history of their past exposure to adverse conditions and maltreatment. Interventions aimed at reducing these exposures may result in better child health.

Strategies for saving and improving children's lives.

At the Child Abuse Recognition, Research, and Education Translation (CARRET) Conference, national child abuse experts representing different disciplines discussed and developed new strategies that would address the barriers to reporting suspected child abuse and improve the protection of children. This article describes the experts' analysis of the barriers to and strategies for improving the outcome for abused children, in addition to the steps planned to facilitate continued action.