Abusive Head Trauma: Historical and Current Perspectives of a Complex Diagnosis.

Abusive Head Trauma (AHT) results in more child fatalities than any other form of physical abuse and is associated with significant risk of morbidity for survivors. The diagnosis of AHT is made like any other complex medical condition and is based on a constellation of findings within the context of a reported history provided by the patient's caregiver(s). A standardized process with careful consideration of a differential diagnosis and utilization of a multidisciplinary team is essential. This article explores the history of the diagnosis of AHT, reviews the scientific basis for potential mechanisms, references the recommended medical evaluation, describes common findings, and the importance of early and accurate diagnosis.

Female Caregivers' Perception of their Child's Sexualized Behaviors: A Pilot Study at a Child Protection Clinic.

This pilot study explored female caregiver's perception of their child's behaviors during sexual abuse evaluations. We compared reports by caregivers with histories of their own child sexual abuse (PCSA) to caregivers with no prior history of child sexual abuse (NPCSA) regarding their 1) child's sexualized behaviors and (2) perceptions of whether their child had been sexually abused. Forty-four caregivers met inclusion criteria. Ninety-five percent of PCSA caregivers versus 21% of NPCSA caregivers reported at least one behavior from the Child Sexual Behavior Inventory. Our findings identified that PCSA caregivers reported more sexualized behaviors for their children overall, potentially contributing to their perception that their child had been sexually abused. This pilot study demonstrated that caregivers were able to tolerate answering questions about their own history of child abuse. Parents should be asked these questions as this may influence perceptions of their child's behaviors and possible sexual abuse.

A Unique Canine Comfort Therapy Program for Child Maltreatment Cases.

Research has shown that programs utilizing comfort therapy canines in cases of child maltreatment have been successful in providing valuable support to children and their families. To date these programs have made canine comfort therapy dogs available solely within one of the involved disciplines. Therefore, a unique canine comfort therapy program was established specifically to support this pediatric population by implementing a collaborative canine comfort therapy program within two separate disciplines. CALI (Cranston Police, Aubin Center, Leadership in Innovation) was the first official K-9 comfort therapy dog in a police department in Rhode Island (RI), and the first employed dog within the state's only children's hospital. This program provides a longitudinal experience that supports children and their families by fostering a sense of familiarity and trust throughout all the difficult components of a child maltreatment case (e.g., evaluation, treatment, investigation and prosecution).

A Comprehensive Pediatric Acute Sexual Assault Protocol: From Emergency Department to Outpatient Follow-up.

OBJECTIVE: Close medical follow-up after pediatric acute sexual assault is recommended and may mitigate adverse consequences and decrease long-term comorbidities. The objectives are to (1) examine adherence to a comprehensive outpatient medical follow-up protocol after evaluation in the emergency department in a pediatric population and (2) identify characteristics associated with patient adherence to inform the utilization of a medical follow-up protocol after pediatric acute sexual assault. METHODS: A retrospective medical record review was conducted of patients younger than 18 years presenting to the emergency department from January 1, 2010, to December 31, 2013, with a discharge diagnosis suggestive of sexual assault/abuse. We examined differences in demographics, assault characteristics, and medical/legal needs of patients who were evaluated in follow-up versus patients who were not. RESULTS: Of 182 patients, 60.4% completed follow-up appointments with the child protection center. Younger patients had follow-up rates higher than older patients (70.2% vs 50%; odds ratio [OR], 0.42). For patients where child protective services or law enforcement were called, follow-up rates were 74.2% and 64.7%, respectively (OR, 2.5; OR, 3.1). All patients with anogenital injuries on initial examination were seen in follow-up. The majority of patients who followed-up were accompanied by a caregiver/relative (95%). CONCLUSIONS: (1) Caregivers should be integrated into the evaluation to facilitate compliance with follow-up; (2) child abuse specialists may be consulted to facilitate specific interventions and recommendations; (3) professionals should work as a multidisciplinary team; and (4) the patient's psychological status should be evaluated, and mental health interventions recommended.

Trafficking Experiences and Psychosocial Features of Domestic Minor Sex Trafficking Victims.

Domestic minor sex trafficking (DMST) is an increasingly recognized traumatic crime premised upon the control, abuse, and exploitation of youth. By definition, DMST is the "recruitment, harboring, transportation, provision, or obtaining of a person for the purpose of a commercial sex act" within domestic borders, in which the person is a U.S. citizen or lawful permanent resident under the age of 18 years. The present study described the demographics, psychosocial features, and trafficking experiences (e.g., environments of recruitment, relationship to trafficker, solicitation) of DMST victims. A total of 25 medical records of patients under the age of 18 who disclosed their involvement in DMST to medical providers between August 1, 2013, and November 30, 2015, were retrospectively reviewed. The majority of patients were female, and the mean age was 15.4 years old. Most patients lived at home and/or were accompanied at the evaluation by a parent/guardian. High rates of alcohol or substance use/abuse (92%), being placed in a group home or child protective services (CPS) custody (28%), a history of runaway behavior (60%), and/or exposure to other child maltreatment (88%) were identified. Our data indicated variation in reported trafficking experiences; however, patients commonly reported an established relationship with their trafficker (60%) and recruitment occurred primarily as a result of financial motivation (52%). Patients were prevalently recruited in settings where there were face-to-face interactions (56%), whereas the solicitation of sex-buyers occurred primarily online (92%). Victims who disclosed involvement in DMST had complicated psychosocial histories that may have rendered them susceptible to their exploitation, and reported a variety of DMST experiences perpetuated by traffickers. Although preliminary in nature, this study provided empirical evidence of the predisposing factors, motivations, and experiences of victimized youth uniquely from the perspective of patients who sought medical care.

Patients Referred for Domestic Minor Sex Trafficking: A Comparison of Confirmed and Suspected Youth.

STUDY OBJECTIVE: To compare characteristics of patients with confirmatory evidence (eg, disclosure, found by law enforcement) of domestic minor sex trafficking (DMST) involvement with those without confirmatory evidence but who were suspected of involvement. DESIGN: A retrospective chart review was conducted of all patients referred for DMST involvement. Confirmed DMST patients were compared with suspected patients with regard to demographic, psychosocial, medical, and psychiatric variables. SETTING: A child protection program at a children's hospital where patients are evaluated by child abuse pediatricians in outpatient, emergency department, and inpatient settings. PARTICIPANTS: Patients 11-17 years old referred for concern of DMST involvement between August 1, 2013 and July 1, 2016 were included. Patients self-disclosed, had reported with evidence, and/or had histories that placed them at high risk for DMST involvement. INTERVENTIONS AND MAIN OUTCOME MEASURES: We collected data on demographic, psychosocial, medical, and psychiatric variables from the medical records of patients referred for evaluation. RESULTS: A total of 67 patients were included. No statistically significant differences were identified between the confirmed and suspected groups. CONCLUSION: Our preliminary data showed that confirmed and suspected patients presented with similar and high rates of concerning medical and psychosocial issues; therefore, medical providers should evaluate and treat all patients referred for DMST. Similar treatment includes referrals for psychological/substance abuse interventions, safety planning, and collaboration with a multidisciplinary team.

The Provision of HIV Post-Exposure Prophylaxis in the Context of Child Sex Trafficking.

Child sex trafficking (CST) victims are at risk for HIV infection due to a convergence of both social and biological factors. However, sparse recommendations and guidelines exist for providers on the provision of HIV non-occupational post-exposure prophylaxis (nPEP) for CST patients. We evaluated whether pediatricians would provide HIV nPEP in a clinical vignette where a patient disclosed ongoing involvement in CST. Participants were relatively divided regarding whether they would provide HIV nPEP; 58.8% responded yes and 41.2% responded no. This highlights the need for medical guidelines to address the complex and case specific considerations of providing nPEP to these victims.

Food Insecurity and Child Maltreatment: A Quality Improvement Project.

Food insecurity affects both children and adults in 8% of households in the United States and 12.8% of households in Rhode Island, negatively impacting childhood health and development. Children with a history of child abuse or neglect are at higher risk for food insecurity than other pediatric populations. Patients evaluated at a child protection clinic - which completes evaluations for all forms of suspected child maltreatment - were screened for food insecurity using a validated two-item questionnaire. Data were collected over a four-month period, with three quality improvement cycles. A quality improvement cycle is a planned sequence of systematic and documented activities aimed at improving a process. Prior to the implementation of this protocol, children in the clinic were not screened for food insecurity. With the initiation of food insecurity screening, 8% of all households eligible for screening were found to be food insecure. Pediatric providers should identify food insecurity in their patients, including in subspecialty care clinics, to optimize care for pediatric patients and their families. When food insecurity is identified, referral to resources and support services is important.

Domestic Minor Sex Trafficking: Medical Follow-up for Victimized and High-Risk Youth.

Domestic minor sex trafficking (DMST) has become an increasingly recognized issue associated with both immediate and long-term physical and mental health consequences. Guidelines have focused on potential risk factors, recruitment practices, and health consequences for these youth assisting in identification and intervention efforts. However, recommendations have not been established for continuous medical intervention and follow-up for this vulnerable patient population that includes both patients involved in and at high risk for DMST. Our goal is to highlight preliminary recommendations for and the importance of medical visits for these youth. A comprehensive physical examination, STI testing and treatment, and pregnancy prevention options are important to address the patients' concerns for their body and identify acute and chronic injuries. Further, collaborating with other medical and non-medical providers can provide essential resources for the multifaceted needs of DMST patients.

Sex Trafficking of Minors.

Sex trafficking is an increasingly recognized global health crisis affecting every country and region in the world. Domestic minor sex trafficking is a subset of commercial sexual exploitation of children, defined as engagement of minors (<18 years of age) in sexual acts for items of value (eg, food, shelter, drugs, money) involving children victimized within US borders. These involved youth are at risk for serious immediate and long-term physical and mental health consequences. Continued efforts are needed to improve preventive efforts, identification, screening, appropriate interventions, and subsequent resource provision for victimized and high-risk youth.

Domestic Minor Sex Trafficking Patients: A Retrospective Analysis of Medical Presentation.

STUDY OBJECTIVE: To describe the clinical characteristics of patients referred for domestic minor sex trafficking (DMST) to improve identification and intervention. DESIGN: Retrospective cohort study. SETTING: The Lawrence A. Aubin, Sr Child Protection Center at Hasbro Children's Hospital where patients are evaluated by child abuse pediatricians in outpatient, emergency department, and inpatient settings. PARTICIPANTS: A total of 41 patients younger than the age of 18 years referred for the evaluation of DMST involvement between August 1, 2013 and March 30, 2015. INTERVENTIONS AND MAIN OUTCOME MEASURES: We collected demographic, social-environmental, medical, and psychiatric variables from the medical records of patients referred for evaluation who have self-disclosed, been reported with evidence, and/or have histories that place them at high risk for DMST involvement. RESULTS: Children had frequent contact with medical providers, with 81% seen in the year before referral for DMST. Childhood maltreatment and family dysfunction were identified (sexual abuse, 21/37 or 57%; parental substance abuse, 22/37 or 60%) in the 41 patients. Children had medical problems (eg, sexually transmitted infection, 13/41 or 32%), psychiatric needs (eg, acute suicidality, 8/41 or 20%; at least 1 previous psychiatric admission, 19/41 or 46%), and substance use (36/41 or 88%). Although 26/41 (63%) had runaway and 17/41 (42%) lived in a group home placement, 28/41 (68%) currently lived at home and 29/41 (71%) presented with a parent/guardian or relative. CONCLUSION: Children referred for DMST present frequently to physicians and have complex medical and psychiatric needs. Medical providers' increased awareness of this health issue would inform victim identification and intervention.