Barriers to medical consultation and strategies for enhancing the prevention and reporting of child abuse: A cross-sectional survey of caregivers of paediatric patients at a tertiary care center in Karachi, Pakistan.

Objective: To assess the knowledge of caregivers in a tertiary care setting about child abuse, their perception of potential barriers in the way of seeking medical advice for the victims, and to identify proposed solutions to ensure prevention and reporting of child abuse. METHODS: The cross-sectional study was conducted from June to December 2022 at the paediatric ward of the Aga Khan University Hospital, Karachi, and comprised caregivers who were attendants of inpatients. Data was collected using a predesigned anonymous questionnaire consisting of demographic information and 27 items that were scored on a 6-point Likert scale. Data was analysed using SPSS 20. RESULTS: Of the 144 caregivers, 96(66.6%) were females and 48(33.3%) were males. Overall, 86(59.7%) were aged <35 years, 132(91.7%) were married, and 120(83.3%) were the admitted child's parent. The majority of caregivers 110(76.4%) perceived themselves to possess a high level of knowledge about child abuse. Barriers identified included a lack of trust in police and medicolegal departments 136(94.4%), fear of repercussion from the suspect 120(83.3%) and lack of confidentiality of the victims' identity 116(80.6%). The proposed solutions included spreading awareness among teachers 136(94.4%) and caregivers 131(91.0%) about timely reporting and consultation, and developing proper mechanisms to follow-up on victims 133(92.4%). There were significant associations between some demographic characteristics of the respondents and their self-perceived knowledge and perceptions (p<0.05). Conclusion: There was found a need to enhance public trust, ensure confidentiality, and fostering awareness through targeted strategies for a safer and more facilitative environment for children.

Long term effects of childhood trauma and abuse: Narrative on functional neurological disorder.

Functional neurological disorder is a condition in which a person experiences physical symptoms that cannot be fully explained by a medical condition. In Pakistan, domestic violence as well as emotional, physical and sexual abuse in children are prevalent. Despite legal and social support for victims, stigmatisation regarding seeking psychological help complicates the challenge. Some of the research culminated that patients with neurological disorder reported high level of sexual abuse and trauma. The symptomatology of functional neurological disorder is being ignored in Asian countries due to indigenous factors like poverty, lack of information on reporting abuse, poor law-enforcement and victim blaming. Functional neurological disorder can be manifested in various ways in the human body, such as blindness, paralysis, dystonia, swallowing difficulties, difficulty walking, motor symptoms affecting limbs, voice production, problems in sensory functions, problems in cognitive function, psychogenic non-epileptic seizures and even dementia, whereas differential diagnosis is established after screening for organicity. The common risk factors of functional neurological disorder may include psychosocial stressors, family history of functional neurological disorder, and significant life changes. It is critical to understand the disorder in reference to predisposing risk factors, cultural context, comorbidities and gender specification to diagnose and treat functional neurological disorder in time so that better intervention protocols could be devised to treat it efficiently.

Are Differences Evident in the Ways Boys and Girls Appraise and Interpret Their Traumatic Experiences? A Qualitative Analysis of Youth Trauma Narratives.

The purpose of this study was to explore potential similarities and differences in the ways boys and girls appraise and interpret their traumatic experiences, and better understand how gender roles, performance, and socialization processes may impact trauma experiences, appraisals, and narratives within the context of trauma-focused treatment. We used thematic analysis to analyze the trauma narratives of youth (N = 16) ages 8-16 who had experienced multiple types (M = 5.38) of child maltreatment and who were receiving Trauma-focused Cognitive Behavioral Therapy to address clinically elevated posttraumatic stress symptoms. Four themes emerged: variations in the content of negative cognitions, differences in relational emotion, adoption of socially prescribed gender roles, and symptom differences. Although many similarities existed in youth's trauma narratives, differences emerged that point to the importance of social context and the ways gender role expectations and socialization processes influence youth's appraisal of and responses to traumatic events. Findings indicate the importance of considering distress tolerance, relational emotion, gender identity development, and role socialization within the treatment milieu.

Development and Evaluation of a Community Advisory Board for Family Violence.

Although intimate partner violence (IPV) is an important risk factor for child physical abuse, most IPV-exposed children are not evaluated for abusive injuries. A Community Advisory Board (CAB) was formed to (a) optimize a program to evaluate IPV-exposed children for abusive injuries and (b) inform research methods to engage IPV victims and their children. The objectives of this study were to implement and to evaluate the family violence CAB. Following best practices on CAB formation, we recruited local stakeholders with key roles as service providers, community leaders, and knowledge experts in IPV, child abuse, and emergency care. Fourteen members met bimonthly to develop a family-centered intervention and to inform research and advocacy activities. A shared memorandum of understanding outlined goals and objectives. One year after the CAB's implementation, a research assistant interviewed CAB members to understand their experiences, perceived benefits of participation, and desired improvements. Eleven CAB members, including an IPV survivor, participated. Emerging categories included (a) motivations to join the CAB (victim advocacy), (b) benefits of participation (development of relationships among members and increased acceptability of research methods), (c) facilitators of sustainability (program adaptability and development of trust), and (d) desired improvements (case-based follow-up). The CAB was successfully implemented and facilitated the development of collaborative relationships among stakeholders with key roles in IPV and child abuse. The CAB led to community member-proposed changes in research activities and clinical care for victims of IPV.

Factors associated with the recurrence of violence against children and adolescents. Mato Grosso-Brazil, 2013 to 2019. / Fatores associados à recorrência de violência em crianças e adolescentes. Mato Grosso-Brasil, 2013 a 2019.

This study examined factors associated with the recurrence of interpersonal violence against children and adolescents in Mato Grosso state, considering cases recorded in the Notifiable Diseases Information System, from 2013 to 2019. Associations between variables were estimated by logistic regression and stratified by age group (children and adolescents). The frequency of recurrent violence against children was 49.0% and, against adolescents, 42.9%. For both, recurrent violence was positively associated with occurrence at home, psychological or emotional violence, aggressors' being more than two, their being relatives and threats being the means of aggression. Neglect or abandonment and male or both-sex aggressors were positively associated with recurrent violence against children. Against adolescents, poor education, sexual violence and intimate-partner aggressors were positively associated with recurrent violence, while other aggressors and firearms or physical force were negatively associated. The findings offer significant contributions to knowledge of factors associated with recurrent violence, which is still little studied in the national and international literature. This is essential in order to inform strategies to reduce the recurrence of violence and protect children and adolescents.

O objetivo do estudo foi analisar os fatores associados à recorrência da violência interpessoal contra crianças e adolescentes em Mato Grosso. Estudo com casos registrados no Sistema Informação de Agravos de Notificação no período de 2013 a 2019. A associação entre as variáveis foi estimada pela regressão logística, estratificada por faixa etária (crianças e adolescentes). A frequência da violência recorrente em crianças foi de 49,0%, e de 42,9% em adolescentes. Para ambos, a violência recorrente associou-se positivamente com ocorrência em residência, violência psicológica/moral, com mais de dois agressores envolvidos, agressores familiares e meio de agressão, ameaça. Para as crianças, negligência/abandono, sexo do agressor masculino ou ambos associaram-se positivamente com a recorrência da violência. Para adolescentes, baixa escolaridade, violência sexual e agressor parceiro íntimo estiveram associados positivamente à recorrência da violência, enquanto outros agressores e arma de fogo ou força corporal associaram-se negativamente. Os resultados trazem contribuições relevantes para o conhecimento dos fatores associados à violência recorrente, ainda pouco estudada na literatura nacional e internacional, sendo fundamental para apoiar estratégias de redução da recorrência da violência e de proteção às crianças e adolescentes.

Social network of families involved in child neglect: building a multidimensional perspective. / Rede social de famílias envolvidas na negligência contra crianças e adolescentes: construindo um olhar multidimensional.

Neglect is one of the most frequently reported forms of violence against children and adolescents, although it has rarely been explored in national studies. In this light, the present study aimed to analyze the personal social network of families involved in negligence against children and adolescents. This work takes a qualitative approach, anchored in the Paradigm of Complexity, conducted with twenty families involved in negligence against children and adolescents in a municipality in the countryside of the state of São Paulo, Brazil. Data collection took place through minimal maps of the personal social network and semi-structured interviews in January 2021. The networks were limited, with little to no interaction among the different services and sectors, and were predominantly homogeneous. Because they have many weakened ties, they are relatively unsupportive, pointing out difficulties in access to work, education, and health. Due to the characteristics of the network, the complexity of the phenomenon of neglect was identified, in which elements condition and perpetuate experiences of absence and fragility. Interprofessional and intersectoral views and actions are requested and recommended.

A negligência constitui uma das violências contra crianças e adolescentes mais notificadas, entretanto ainda pouco explorada em estudos nacionais. O objetivo deste estudo foi analisar a rede pessoal social de famílias envolvidas na negligência contra crianças e adolescentes. Estudo qualitativo, ancorado no paradigma da complexidade, realizado junto a 20 familiares envolvidos na negligência contra crianças e adolescentes em município do interior de São Paulo, Brasil. A coleta de dados se deu por mapas mínimos da rede pessoal social e entrevistas semiestruturadas em janeiro de 2021. As redes se apresentaram reduzidas, com pouca ou nenhuma articulação entre os diferentes serviços e setores e predominantemente homogêneas. Por terem muitos vínculos fragilizados, mostrou-se pouco sustentadora, apontando dificuldades no acesso a trabalho, educação e saúde. Pelas características da rede, identificou-se a complexidade do fenômeno da negligência, em que elementos condicionam e perpetuam vivências de ausências e fragilidades. Olhares e ações interprofissionais e intersetoriais são pleiteadas e recomendadas.

A hybrid digital parenting programme to prevent abuse of adolescents in Tanzania: statistical analysis plan for a pragmatic cluster randomised controlled trial.

BACKGROUND: Globally, violence against children poses substantial health and economic challenges, with estimated costs nearing USD 7 trillion. This prompts the urgent call for effective evidence-based interventions in preventing and mitigating violence against children. ParentApp is a mobile, open-source application designed to offer a remote version of the Parenting for Lifelong Health (PLH) programme. ParentApp is the first digital parenting intervention for caregivers of adolescents aged 10-17 years to be tested in low- and middle-income settings. METHODS: This study is a pragmatic, two-arm, cluster-randomised trial in Mwanza, Tanzania's urban and peri-urban areas. Assessments are set for baseline, 1 month post-intervention, and 12 months post-intervention. We randomised 80 clusters, each with about 30 caregiver-adolescent dyads, with a 1:1 ratio stratified by urban or peri-urban location. Both arms receive an entry-level smartphone preloaded with Kiswahili apps-ParentApp for intervention and WashApp control. The primary method of analysis will be generalised linear mixed-effects models with adjustment for person-level characteristics and multiple imputation. In three-level models, measurement waves are nested within a person, nested within a sub-ward. Regressions will constrain groups to be equal at baseline and include covariates for stratification, percentage of male caregivers, and individual-level characteristics. DISCUSSIONS: Preparations for the trial began in December 2022, including community mobilisation and sensitisation. Rolling recruitment, baseline data collection, and implementation onboarding took place between April and September 2023. One-month post-test data collection began in August 2023 and thus far achieved 97% and 94% retention rates for caregivers and adolescents respectively. Final post-test data collection will begin in September 2024, anticipated to run until April 2025. This SAP was submitted to the journal before the interim analysis to preserve scientific integrity under a superiority hypothesis testing framework. TRIAL REGISTRATION: The trial was registered on the Open Science Framework on 14 March 2023: https://doi.org/10.17605/OSF.IO/T9FXZ . The trial protocol was published in Trials 25, 119 (2024): Baerecke, L., Ornellas, A., Wamoyi, J. et al. A hybrid digital parenting programme to prevent abuse of adolescents in Tanzania: study protocol for a pragmatic cluster-randomised controlled trial. Trials 25, 119 (2024). https://doi.org/10.1186/s13063-023-07893-x .

BEST FOR CAN - bringing empirically supported treatments to children and adolescents after child abuse and neglect: update to the study protocol.

Background: The implementation trial BESTFORCAN aims to evaluate the dissemination of Trauma-Focused Behavioural Therapy (TF-CBT) for children and adolescents in Germany with posttraumatic stress symptoms (PTSS) after child abuse and neglect (CAN) with a focus on supervision.Objective: This update to the study protocol outlines changes made due to practical reasons in the course of the ongoing trial while maintaining methodological quality.Method: The amendments to the original study protocol comprise (1) a more refined operationalisation of the primary outcome sufficiently adherent TF-CBT therapy (SATT), (2) changes in the study sites and (3) additional inclusion of one post-gradual psychotherapy training institute.Discussion: The adaptions to the original study protocol ensured high methodological quality through the transparent presentation of protocol modification: ensuring the recruitment of participating psychotherapists in training by including a further post-gradual training institute as well as an adaption of the measurement of SATT with high external validity. The objectives, diagnostic set, and secondary outcomes remained unimpaired by the amendment. Therefore, we expect the trial to provide evidence for the effect of model-specific trauma-focused supervision on the implementation outcomes of TF-CBT as compared to supervision as usual.Trial registration: German Clinical Trials Register identifier: DRKS00020516..

Update to the study protocol of the trial BESTFORCAN that investigates the implementation of trauma-focused behavioural therapy for children and adolescents with posttraumatic stress symptoms following abuse with a focus on the role of supervision.Adaptions have been made regarding the specification of the definition of sufficiently adherent intervention, relocation of the data-handling centre and the recruitment of one additional psychotherapy institute.The adaptions have no impact on the objectives, diagnostic set, secondary outcomes, or processes of data handling.

Evidence From the USPSTF and New Approaches to Evaluate Interventions to Prevent Child Maltreatment.

Importance: The United States Preventive Services Task Force (USPSTF) has considered the topic of prevention of child maltreatment multiple times over its nearly 40-year history, each time reaching the conclusion that the evidence is insufficient to recommend for or against interventions aimed at preventing this important health problem with significant negative sequelae before it occurs. In the most recent evidence review, which was conducted from August 2021 to November 2023 and published in March 2024, the USPSTF considered contextual questions on the evidence for bias in reporting and diagnosis of maltreatment in addition to key questions regarding effectiveness of interventions to prevent child maltreatment. Observations: A comprehensive literature review found evidence of inaccuracies in risk assessment and racial and ethnic bias in the reporting of child maltreatment and in the evaluation of injuries concerning for maltreatment, such as skull fractures. When children are incorrectly identified as being maltreated, harms, such as unnecessary family separation, may occur. Conversely, when children who are being maltreated are missed, harms, such as ongoing injury to the child, continue. Interventions focusing primarily on preventing child maltreatment did not demonstrate consistent benefit or information was insufficient. Additionally, the interventions may expose children to the risk of harm as a result of these inaccuracies and biases in reporting and evaluation. These inaccuracies and biases also complicate assessment of the evidence for making clinical prevention guidelines. Conclusions and Relevance: There are several potential strategies for consideration in future efforts to evaluate interventions aimed at the prevention of child maltreatment while minimizing the risk of exposing children to known biases in reporting and diagnosis. Promising strategies to explore might include a broader array of outcome measures for addressing child well-being, using population-level metrics for child maltreatment, and assessments of policy-level interventions aimed at improving child and family well-being. These future considerations for research in addressing child maltreatment complement the USPSTF's research considerations on this topic. Both can serve as guides to researchers seeking to study the ways in which we can help all children thrive.

Developmental outcomes in abusive head trauma.

Abusive head trauma (AHT) is associated with high mortality and poorer outcomes compared to accidental head injuries. The short and long-term developmental outcomes for AHT are not well identified. Variability in outcome measures, small sample sizes, difficulty in measuring domain-specific developmental skills, co-existence of comorbidities, genetic and environmental factors and high attrition rates all contribute to the challenges on providing data in this area. The objective of this article is to review the scientific literature on the developmental outcomes of AHT, highlighting factors that affect outcomes, the available assessment tools, and short and long-term developmental outcomes, recommended follow up, societal costs, and future opportunities for research. Authors searched OVID Medline and PubMed for articles published between 2013 and 2023 using the terms "abuse", "craniocerebral trauma" and "development". Fifty-five records were included for this review. The data shows that injuries sustained from AHT result in a spectrum of outcomes ranging from normal development to death. There are more than 100 outcome assessment tools limiting the ability to compare studies. More than half of patients are left with disabilities post discharge. Gross motor and cognition/academics are the 2 most common domains studied. Advancement in surgical and neurocritical care management has influenced AHT outcomes. Close long-term follow up is recommended to maximize each child's developmental potential, irrespective of the presence of disability at discharge. We suggest that future research should focus on adopting a consistent diagnostic and assessment approach and explore the social environmental factors that can affect recovery.

Identifying inflicted injuries in infants and young children.

Child physical abuse is a common cause of pediatric morbidity and mortality. Up to half of all children presenting with abusive injuries have a history of a prior suspicious injury, suggesting a pattern of repeated physical abuse. Medical providers are responsible for identifying children with suspicious injuries, completing mandated reporting to child protective services for investigation, and screening for occult injuries and underlying medical conditions that can predispose to injuries. Early identification of inflicted injuries appropriate evaluations may serve as an opportunity for life-saving intervention and prevent further escalation of abuse. However, identification of abuse can be challenging. This article will review both physical exam findings and injuries that suggest abuse as well as the evaluation and management of physical abuse.

Child maltreatment in children with medical complexity and disability.

Child maltreatment is common and pediatric healthcare providers are becoming increasingly aware of risk factors and signs of abuse.1-4 Children with disabilities and those with special medical needs are recognized as a population at increased risk of child maltreatment. Understanding this risk and recognizing that not all disabilities confer the same risks can provide deeper insight for pediatric providers regarding the supports these children and their families need to prevent maltreatment.

Acute presentation of abusive head trauma.

Child abuse is a major cause of morbidity and mortality in the United States. The leading cause of child physical abuse related deaths is abusive head trauma, formerly known as shaken baby syndrome, making the rapid identification and assessment of these children critical. The clinical presentation of cases of abusive head trauma ranges from neurological complaints, such as seizures, to vague or subtle symptoms, such as vomiting. This results in frequent missed diagnoses of abusive head trauma. The identification of abusive head trauma relies on a thorough medical history and physical examination, followed by lab evaluation and imaging. The goal of the evaluation is to discover further injury and identify possible underlying non-traumatic etiologies of the patient's symptoms. In this article we present a framework for the assessment of abusive head trauma and provide information on common presentations and injuries, as well as differential diagnoses. A strong foundational knowledge of abusive head trauma will lead to greater recognition and improved safety planning for victims of this unfortunate diagnosis.

Neuroimaging considerations in abusive head trauma.

This focused review on abusive head trauma describes the injuries to the head, brain and/or spine of an infant or young child from inflicted trauma and their neuroimaging correlates. Accurate recognition and diagnosis of abusive head trauma is paramount to prevent repeated injury, provide timely treatment, and ensure that accidental or underlying medical contributors have been considered. In this article, we aim to discuss the various findings on neuroimaging that have been associated with AHT, compared to those that are more consistent with accidental injuries or with underlying medical causes that may also be on the differential.

Seizures, medical child abuse, and the pediatric neurologist.

Previously known as Munchausen syndrome by proxy, medical child abuse is a form of child maltreatment whereby the caregiver creates an environment in which medical care harms or threatens the wellbeing of a child. Approximately 40-50 % of medical child abuse cases involve neurological symptoms, with fabricated or induced seizures accounting for a significant proportion. Identifying fictitious seizures is often difficult even for the most experienced clinicians. Therefore, having a low threshold for clinical suspicion is essential in the timely diagnosis of medical child abuse. This article provides a review of the epidemiology, diagnosis, and management of medical child abuse when it involves seizures.

Ophthalmologic findings in abusive head trauma.

A leading cause of death and disability in infancy is abusive head trauma (AHT) and there are common clinical signs that help to establish this diagnosis. Children diagnosed with AHT can have many ophthalmologic findings, including retinal hemorrhages, retinoschisis, subconjunctival hemorrhages, corneal injury, and globe rupture. If any such injuries are suspected, an ophthalmologic consultation, with indirect ophthalmoscopy, should be completed. In addition to a complete physical exam, a thorough history imaging, and lab work, should be obtained to investigate the etiology of ophthalmic pathology including accidental and systemic causes. In general, studies show that retinal hemorrhages that are multilayered, too numerous to count, and located from the posterior pole to the ora serrata are highly suspicious for abusive head trauma.

Applying the WHO-INTEGRATE evidence-to-decision framework in the development of WHO guidelines on parenting interventions: step-by-step process and lessons learnt.

BACKGROUND: Development of guidelines for public health, health system, and health policy interventions demands complex systems thinking to understand direct and indirect effects of interventions within dynamic systems. The WHO-INTEGRATE framework, an evidence-to-decision framework rooted in the norms and values of the World Health Organization (WHO), provides a structured method to assess complexities in guidelines systematically, such as the balance of an intervention's health benefits and harms and their human rights and socio-cultural acceptability. This paper provides a worked example of the application of the WHO-INTEGRATE framework in developing the WHO guidelines on parenting interventions to prevent child maltreatment, and shares reflective insights regarding the value added, challenges encountered, and lessons learnt. METHODS: The methodological approach comprised describing the intended step-by-step application of the WHO-INTEGRATE framework and gaining reflective insights from introspective sessions within the core team guiding the development of the WHO guidelines on parenting interventions and a methodological workshop. RESULTS: The WHO-INTEGRATE framework was used throughout the guideline development process. It facilitated reflective deliberation across a broad range of decision criteria and system-level aspects in the following steps: (1) scoping the guideline and defining stakeholder engagement, (2) prioritising WHO-INTEGRATE sub-criteria and guideline outcomes, (3) using research evidence to inform WHO-INTEGRATE criteria, and (4) developing and presenting recommendations informed by WHO-INTEGRATE criteria. Despite the value added, challenges, such as substantial time investment required, broad scope of prioritised sub-criteria, integration across diverse criteria, and sources of evidence and translation of insights into concise formats, were encountered. CONCLUSIONS: Application of the WHO-INTEGRATE framework was crucial in the integration of effectiveness evidence with insights into implementation and broader implications of parenting interventions, extending beyond health benefits and harms considerations and fostering a whole-of-society-perspective. The evidence reviews for prioritised WHO-INTEGRATE sub-criteria were instrumental in guiding guideline development group discussions, informing recommendations and clarifying uncertainties. This experience offers important lessons for future guideline panels and guideline methodologists using the WHO-INTEGRATE framework.

Violencia y maltrato infantil. El aporte del médico radiólogo al abordaje integral multidisciplinario / Child maltreatment and violence. Contributions from radiologists to a comprehensive multidisciplinary approach

El maltrato infantil es definido por la Organización Mundial de la Salud (OMS) como "el abuso y la desatención que sufren los niños menores de 18 años. Incluye todo tipo de maltrato físico y/o emocional […] que resulte en un daño real o potencial para la salud, la supervivencia, el desarrollo o la dignidad del niño". Al examinar los rastros corporales del maltrato físico, siguiendo los mecanismos de lesión más frecuentemente implicados, es posible detectar patrones radiológicos típicos. La evaluación imagenológica del hueso en reparación permite inferir cronologías para correlacionar con los datos obtenidos en la anamnesis. Los profesionales de la salud deben detectar oportunamente lesiones radiológicas sospechosas y activar de forma temprana el resguardo del menor. Nuestro propósito es realizar una revisión sobre las publicaciones recientes referidas al estudio imagenológico en niños de quienes se sospeche que puedan ser víctimas de violencia física.

The World Health Organization (WHO) defines child maltreatment as "the abuse and neglect that occurs to children under 18 years of age. It includes all types of physical and/or emotional ill-treatment [...], which results in actual or potential harm to the child's health, survival, development or dignity." By examining the bodily traces of physical abuse, following the most frequently involved mechanisms of injury, it is possible to identify typical radiological patterns. The imaging studies of the bone under repair allows inferring a timeline that may be correlated to the data obtained during history taking. Health care providers should detect suspicious radiological lesions in a timely manner and promptly activate the safeguarding of the child. Our objective was to review recent publications on the imaging studies of children suspected of being victims of physical violence.