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.

Ongoing Pediatric Health Care for the Child Who Has Been Maltreated.

Pediatricians provide continuous medical care and anticipatory guidance for children who have been reported to state child protection agencies, including tribal child protection agencies, because of suspected child maltreatment. Because families may continue their relationships with their pediatricians after these reports, these primary care providers are in a unique position to recognize and manage the physical, developmental, academic, and emotional consequences of maltreatment and exposure to childhood adversity. Substantial information is available to optimize follow-up medical care of maltreated children. This new clinical report will provide guidance to pediatricians about how they can best oversee and foster the optimal physical health, growth, and development of children who have been maltreated and remain in the care of their biological family or are returned to their care by Child Protective Services agencies. The report describes the pediatrician's role in helping to strengthen families' and caregivers' capabilities and competencies and in promoting and maximizing high-quality services for their families in their community. Pediatricians should refer to other reports and policies from the American Academy of Pediatrics for more information about the emotional and behavioral consequences of child maltreatment and the treatment of these consequences.

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.

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.

Sensitivity of the limited view follow-up skeletal survey.

BACKGROUND AND OBJECTIVE: Reducing radiation exposure to minimize risk has been emphasized in recent years. In child abuse, the risk of missing occult injuries is often believed to outweigh radiation risk associated with skeletal surveys. Our hypothesis was that there would be no clinically significant difference in results from a limited view, follow-up skeletal survey (SS2) protocol, which omits spine and pelvis views unless these views have findings on the initial skeletal survey (SS1), compared with a traditional SS2 protocol for radiographic evaluation of suspected physical abuse. METHODS: This study was a retrospective record review involving 5 child protection teams. Consultations for suspected physical abuse were reviewed to identify subjects <24 months of age who had an SS1 and a traditional SS2. The results of these studies were compared to identify subjects in which newly identified spine and pelvis fractures (fractures seen only on SS2 and not on SS1) would have been missed by using a limited view SS2 protocol. RESULTS: We identified 534 study subjects. Five subjects had newly identified spine fractures, and no subjects had newly identified pelvis fractures on traditional SS2 studies. Only 1 subject with a newly identified spine fracture would have been missed with the limited view SS2 protocol used in this study (0.2% [95% confidence interval: <0.005-1.0]). None of the newly identified fractures changed the abuse-related diagnosis. CONCLUSIONS: We found no clinically significant difference in the results of a limited view SS2 protocol versus a traditional SS2 protocol for radiographic evaluation of suspected abuse.

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.

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.

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 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.

To report or not to report: examination of the initial primary care management of suspicious childhood injuries.

OBJECTIVE: This study examined the validity of primary health care providers' (PHCPs) assessment of suspicion that an injury was caused by child abuse and their decision to report suspected child abuse to child protective services (CPS). METHODS: By using a subsample of injuries drawn from the 15,003 childhood injuries evaluated in the Child Abuse Recognition and Evaluation Study, PHCPs completed telephone interviews concerning a stratified sample (no suspicion of abuse; suspicious but not reported; and suspicious of abuse and reported) of 111 injury visits. Two techniques were used to validate the PHCPs' initial decision: expert review and provider retrospective self-assessment. Five child abuse experts reviewed clinical vignettes created by using data prospectively collected by PHCPs about the patient encounter. The PHCPs' opinions 6 weeks and 6 months after the injury-related visits were elicited and analyzed. RESULTS: PHCPs and experts agreed about the suspicion of abuse in 81% of the cases of physical injury. PHCPs did not report 21% of injuries that experts would have reported. Compared with expert reviewers, PHCPs had a 68% sensitivity and 96% specificity in reporting child abuse. A PHCP's decision to report suspected child abuse to CPS did not reduce the frequency of primary care follow-up in the 6 months after the index visit. PCHPs received information from their state CPS in 70% of the reported cases. CONCLUSIONS: Child abuse experts and PHCPs are in general agreement concerning the assessment of suspected child physical abuse, although experts would have reported suspected abuse to CPS more frequently than the PHCPs. Future training should focus on clear guidance for better recognition of injuries that are suspicious for child abuse and state laws that mandate reporting.

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.

Unexplained gastrointestinal symptoms after abuse in a prospective study of children at risk for abuse and neglect.

PURPOSE: Unexplained gastrointestinal symptoms are more common in adults who recall abuse as a child; however, data available on children are limited. The aim of this study was to investigate the association of childhood maltreatment and early development of gastrointestinal symptoms and whether this relation was mediated by psychological distress. METHODS: Data were obtained from the Longitudinal Studies of Child Abuse and Neglect, a consortium of 5 prospective studies of child maltreatment. The 845 children who were observed from the age of 4 through 12 years were the subjects of this study. Every 2 years information on gastrointestinal symptoms was obtained from parents, and maltreatment allegations were obtained from Child Protective Services (CPS). At the age of 12 years children reported gastrointestinal symptoms, life-time maltreatment, and psychological distress. Data were analyzed by logistic regression. RESULTS: Lifetime CPS allegations of sexual abuse were associated with abdominal pain at age 12 years (odds ratio [OR] = 1.75; 95% confidence interval [CI] = 1.1-2.47). Sexual abuse preceded or coincided with abdominal pain in 91% of cases. Youth recall of ever having been psychologically, physically, or sexually abused was significantly associated with both abdominal pain and nausea/vomiting (range, OR = 1.5 [95% CI, 1.1-2.0] to 2.1 [95% CI, 1.5-2.9]). When adjusting for psychological distress, most effects became insignificant except for the relation between physical abuse and nausea/vomiting (OR = 1.5; 95% CI, 1.1-2.2). CONCLUSION: Youth who have been maltreated are at increased risk for unexplained gastrointestinal symptoms, and this relation is partially mediated by psychological distress. These findings are relevant to the clinical care for children who complain of unexplained gastrointestinal symptoms.

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.

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.

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.

From suspicion of physical child abuse to reporting: primary care clinician decision-making.

OBJECTIVES: The goals were to determine how frequently primary care clinicians reported suspected physical child abuse, the levels of suspicion associated with reporting, and what factors influenced reporting to child protective services. METHODS: In this prospective observational study, 434 clinicians collected data on 15003 child injury visits, including information about the injury, child, family, likelihood that the injury was caused by child abuse (5-point scale), and whether the injury was reported to child protective services. Data on 327 clinicians indicating some suspicion of child abuse for 1683 injuries were analyzed. RESULTS: Clinicians reported 95 (6%) of the 1683 patients to child protective services. Clinicians did not report 27% of injuries considered likely or very likely caused by child abuse and 76% of injuries considered possibly caused by child abuse. Reporting rates were increased if the clinician perceived the injury to be inconsistent with the history and if the patient was referred to the clinician for suspected child abuse. Patients who had an injury that was not a laceration, who had >1 family risk factor, who had a serious injury, who had a child risk factor other than an inconsistent injury, who were black, or who were unfamiliar to the clinician were more likely to be reported. Clinicians who had not reported all suspicious injuries during their career or who had lost families as patients because of previous reports were more likely to report suspicious injuries. CONCLUSIONS: Clinicians had some degree of suspicion that approximately 10% of the injuries they evaluated were caused by child abuse. Clinicians did not report all suspicious injuries to child protective services, even if the level of suspicion was high (likely or very likely caused by child abuse). Child, family, and injury characteristics and clinician previous experiences influenced decisions to report.