Child abuse and pubertal timing: what is the role of child sex and identity of the perpetrator?

BACKGROUND: This study investigated the association between child abuse [child neglect (CN), emotional (CEA) and physical abuse (CPA)] and early puberty with special regard to sex-specific effects concerning child and parental perpetrator. METHODS: Data assessment took place within the framework of the LIFE Child Depression study, a longitudinal study on the development of depressive symptoms and disorders between child- and adulthood in Leipzig, Germany. A sample of 709 children (8-14 years) was recruited from the general population and via psychiatric hospitals. Data on pubertal status were assessed using an instrument for self-assessment of tanner stages (scales of physical pubertal development). Information on menarche was provided by parents. The Parent-Child Conflict Tactics Scales (CTS-PC) served for data on child abuse. RESULTS: Regarding physical puberty markers, significant correlations were found, especially with child neglect (CN) and child emotional abuse (CEA). Regression analyses, controlling for Body-Mass-Index (BMI) and Socioeconomic Status (SES), revealed that children affected by child neglect perpetrated by mother (CNm) and child emotional abuse (CEA) parent-non-specifically enter puberty significantly earlier. Sex-specific analyses identified child neglect perpetrated by mother (CNm) to be associated with early puberty in girls and child emotional abuse perpetrated by father (CEAf) with early puberty in boys. Concerning the onset of menstruation, there was a significant positive correlation between early menarche and parent-specific and non-specific child neglect (CN), as well as between early menarche and child emotional abuse perpetrated by the mother (CEAm). In regression models that controlled for Body-Mass-Index (BMI) and Socioeconomic Status (SES) no significant associations were maintained. Child physical abuse (CPA) was not associated with early puberty. CONCLUSION: Results outlined child neglect (CN) and child emotional abuse (CEA) to be sex- and perpetrator-specific risk factors for early pubertal development. Knowledge of sex- and perpetrator-specific effects could help clinicians to specify their diagnostic process and to define differential prevention and treatment goals for children with experiences of CN and CEA. Further research on the sex-specific impact of parental CN and CEA on girls' and boys' puberty is needed.

Knowledge and experience of pediatricians and pedodontists in identifying and managing child abuse and neglect cases.

Child abuse, by definition parents and other family members, caregivers, or any adult he does not know culturally inappropriate, harmful to the child described, inhibiting growth and development, or exposure to a restrictive behavior. This study aims to evaluate the capabilities of pediatricians and pedodontists in identifying and managing child abuse and neglect within healthcare settings, a crucial responsibility for professionals across various medical disciplines. Questionnaire was performed on 53 pediatricians and 89 pedodontists. Utilizing a 28-item expert-designed electronic questionnaire, the study solicited responses from pediatricians and pedodontists to assess their demographic characteristics, professional experience, and self-perceived competence in this critical area. The results indicate that 42% of the participating healthcare providers have encountered at least one case of child abuse and neglect. Notably, pedodontists displayed a higher level of uncertainty in identifying abuse and neglect cases compared to pediatricians. Furthermore, participants who had a higher level of self-perceived competence were significantly more willing to identify and manage cases, although this self-assessment did not correlate with their actual skills or level of willingness to intervene effectively. The study concludes that there is a pressing need for specialized training programs tailored to enhance the skill sets of healthcare providers in identifying and managing child abuse and neglect. These programs should encompass not only academic knowledge but also practical applications and psychosocial support techniques to ensure a holistic approach to combating this serious issue.

Developing and Testing the Usability of a Novel Child Abuse Clinical Decision Support System: Mixed Methods Study.

BACKGROUND: Despite the impact of physical abuse on children, it is often underdiagnosed, especially among children evaluated in general emergency departments (EDs) and those belonging to racial or ethnic minority groups. Electronic clinical decision support (CDS) can improve the recognition of child physical abuse. OBJECTIVE: We aimed to develop and test the usability of a natural language processing-based child abuse CDS system, known as the Child Abuse Clinical Decision Support (CA-CDS), to alert ED clinicians about high-risk injuries suggestive of abuse in infants' charts. METHODS: Informed by available evidence, a multidisciplinary team, including an expert in user design, developed the CA-CDS prototype that provided evidence-based recommendations for the evaluation and management of suspected child abuse when triggered by documentation of a high-risk injury. Content was customized for medical versus nursing providers and initial versus subsequent exposure to the alert. To assess the usability of and refine the CA-CDS, we interviewed 24 clinicians from 4 EDs about their interactions with the prototype. Interview transcripts were coded and analyzed using conventional content analysis. RESULTS: Overall, 5 main categories of themes emerged from the study. CA-CDS benefits included providing an extra layer of protection, providing evidence-based recommendations, and alerting the entire clinical ED team. The user-centered, workflow-compatible design included soft-stop alert configuration, editable and automatic documentation, and attention-grabbing formatting. Recommendations for improvement included consolidating content, clearer design elements, and adding a hyperlink with additional resources. Barriers to future implementation included alert fatigue, hesitancy to change, and concerns regarding documentation. Facilitators of future implementation included stakeholder buy-in, provider education, and sharing the test characteristics. On the basis of user feedback, iterative modifications were made to the prototype. CONCLUSIONS: With its user-centered design and evidence-based content, the CA-CDS can aid providers in the real-time recognition and evaluation of infant physical abuse and has the potential to reduce the number of missed cases.

Pilot study using machine learning to improve estimation of physical abuse prevalence.

BACKGROUND: International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes have been shown to underestimate physical abuse prevalence. Machine learning models are capable of efficiently processing a wide variety of data and may provide better estimates of abuse. OBJECTIVE: To achieve proof of concept applying machine learning to identify codes associated with abuse. PARTICIPANTS AND SETTING: Children <5 years, presenting to the emergency department with an injury or abuse-specific ICD-10-CM code and evaluated by the child protection team (CPT) from 2016 to 2020 at a large Midwestern children's hospital. METHODS: The Pediatric Health Information System (PHIS) and the CPT administrative databases were used to identify the study sample and injury and abuse-specific ICD-10-CM codes. Subjects were divided into abused and non-abused groups based on the CPT's evaluation. A LASSO logistic regression model was constructed using ICD-10-CM codes and patient age to identify children likely to be diagnosed by the CPT as abused. Performance was evaluated using repeated cross-validation (CV) and Reciever Operator Characteristic curve. RESULTS: We identified 2028 patients evaluated by the CPT with 512 diagnosed as abused. Using diagnosis codes and patient age, our model was able to accurately identify patients with confirmed PA (mean CV AUC = 0.87). Performance was still weaker for patients without existing ICD codes for abuse (mean CV AUC = 0.81). CONCLUSIONS: We built a model that employs injury ICD-10-CM codes and age to improve accuracy of distinguishing abusive from non-abusive injuries. This pilot modelling endeavor is a steppingstone towards improving population-level estimates of abuse.

The shifting trends in the epidemiology and risk factors of non-accidental fractures in children.

BACKGROUND: Fractures are a common presentation of non-accidental trauma (NAT) in the pediatric population. However, the presentation could be subtle, and a high degree of suspicion is needed not to miss NAT. OBJECTIVE: To analyze a comprehensive database, providing insights into the epidemiology of fractures associated with NAT. PARTICIPANTS AND SETTING: The TriNetX Research Network was utilized for this study, containing medical records from 55 healthcare organizations. TriNetX was queried for all visits in children under the age of 6 years from 2015 to 2022, resulting in a cohort of over 32 million. METHODS: All accidental and non-accidental fractures were extracted and analyzed to determine the incidence, fracture location, and demographics of NAT. Statistical analysis was done on a combination of Python and Epipy. RESULTS: Overall, 0.36 % of all pediatric patients had a diagnosis of NAT, and 4.93 % of fractures (34,038 out of 689,740 total fractures) were determined to be non-accidental. Skull and face fractures constituted 17.9 % of all NAT fractures, but rib/sternum fractures had an RR = 6.7 for NAT. Children with intellectual and developmental disability (IDD) or autism spectrum disorder (ASD) had a 9 times higher risk for non-accidental fractures. The number of non-accidental fractures significantly increased after 2019. CONCLUSIONS: The study findings suggest that nearly 1 out of all 20 fractures in children under age 6 are caused by NAT, and that rib/sternum fractures are most predictive of an inflicted nature. The study also showed a significant increase in the incidence of NAT, during and after the pandemic.

Dermatitis versus nonaccidental trauma: A systematic review of initial pediatric misdiagnoses.

BACKGROUND/OBJECTIVES: Pediatric dermatitis and nonaccidental trauma (NAT) may have overlapping cutaneous presentations, posing a risk of misdiagnosis and subsequent emotional distress and further harm. Through a systematic literature review, we reviewed pediatric (<18 years old) patients investigated for both dermatitis and NAT. METHODS: EMBASE and MEDLINE databases were searched. English publications with original data involving pediatric patients investigated for both dermatitis and NAT were included. Nonhuman studies and incomplete articles/conference abstracts were excluded. Data extracted included the first author, year of publication, study design, participant count, sex of the population, age of the population, cutaneous presentation, timing of presentation, Child Protective Services involvement, and case relation to dermatitis and NAT. RESULTS: This review included 21 case reports or series encompassing 29 patients. Among 26 patients initially investigated as NAT (26.9% involving Child Protective Services), final diagnoses included irritant contact dermatitis (53.8%), phytophotodermatitis (30.8%), allergic contact dermatitis (7.7%), perianal infectious dermatitis (3.8%), and atopic dermatitis (3.8%). Three patients initially diagnosed with nontraumatic dermatitis were later found to be victims of physical (2/3; 66.7%) or sexual abuse (1/3; 33.3%). CONCLUSIONS: Effective history-taking and physical examinations should encompass a history of laxative use, contact with furocoumarin-containing plants/fruit, parallel family/peer cutaneous presentations, caregiver involvement, financial burden, patient discomfort, birthmark assessment, and lesions aligning with diaper borders or toilet seats. Limitations of this review include potential underreporting and the inclusion of low-quality study designs and evidence.

Evaluating Outcomes of Nonaccidental Trauma in Military Children.

BACKGROUND: Nonaccidental trauma (NAT), or child abuse, is a leading cause of childhood injury and death in the US. Studies demonstrate that military-affiliated individuals are at greater risk of mental health complication and family violence, including child maltreatment. There is limited information about the outcomes of military children who experience NAT. This study compares the outcomes between military-dependent and civilian children diagnosed with NAT. STUDY DESIGN: A single-institution, retrospective review of children admitted with confirmed NAT at a Level I trauma center was performed. Data were collected from the institutional trauma registry and the Child Abuse Team's database. Military affiliation was identified using insurance status and parental or caregiver self-reported active-duty status. Demographic and clinical data including hospital length of stay (LOS), morbidity, specialty consult, and mortality were compared. RESULTS: Among 535 patients, 11.8% (n = 63) were military-affiliated. The median age of military-associated patients, 3 months (interquartile range [IQR] 1 to 7), was significantly younger than civilian patients, 7 months (IQR 3 to 18, p < 0.001). Military-affilif:ated patients had a longer LOS of 4 days (IQR 2 to 11) vs 2 days (IQR 1 to 7, p = 0.041), increased morbidity or complication (3 vs 2 counts, p = 0.002), and a higher mortality rate (10% vs 4%, p = 0.048). No significant difference was observed in the number of consults or injuries, trauma activation, or need for surgery. CONCLUSIONS: Military-affiliated children diagnosed with NAT experience more adverse outcomes than civilian patients. Increased LOS, morbidity or complication, and mortality suggest military-affiliated patients experience more life-threatening NAT at a younger age. Larger studies are required to further examine this population and better support at-risk families.

Child Health Needs and the Child Abuse Pediatrics Workforce: 2020-2040.

Child abuse pediatrics (CAP) subspecialists evaluate, diagnose, and treat children when abuse or neglect is suspected. Despite the high rates of child maltreatment across the United States, CAP remains the smallest pediatric subspecialty. The CAP workforce faces numerous challenges, including few fellows entering the field, decreased financial compensation compared with other fields of medicine, and threats to workforce retention, including secondary trauma and harmful exposure in the media. A microsimulation model that estimates the future of the US CAP workforce over the next 20 years shows that, although the number of child abuse pediatricians in the field is expected to increase, the growth is smaller than that of every other pediatric subspecialty. In addition to the low overall CAP workforce in the United States, other workforce issues include the need to increase CAP subspecialists who are underrepresented in medicine and unequal geographic distribution across the country. To meet the medical needs of suspected victims of maltreatment, especially in CAP-underserved areas, many children are evaluated by providers who are not board-certified in CAP, such as general pediatricians, family medicine physicians, emergency medicine physicians, and advanced practice providers, whose CAP experience and training may vary. Current child abuse pediatricians should continue introducing the field to medical students and residents, especially those who identify as underrepresented in medicine or are from CAP-underserved areas, and offer mentorship, continuing education, and oversight to non-CAP physicians meeting this population's medical needs.

Development of a rating scale for maladaptive symptoms by maltreatment: Perspectives of attachment and dissociation.

Child abuse has been increasing in Japan. Abused children's behavior may often be confused with neurodevelopmental disorders; therefore, specialized tools to identify these cases and specific care for maltreatment are crucial. This study aimed to develop an objective early screening scale for abuse-related maladaptive symptoms. To do this, two surveys were conducted. Survey 1 included 60 children attending public elementary schools, who had been admitted to orphanages due to abuse (maltreated group), and 154 children attending public elementary schools with no reported maltreatment (control group). In this survey, 40 existing scale items related to attachment behavior and dissociative symptoms were evaluated. Childcare staff and homeroom teachers evaluated children's behaviors. Receiver operating characteristic (ROC) curves were drawn to determine optimal cut-off values. In Survey 2, 39 children in the maltreatment group and 186 children in the control group were subjected to confirmatory factor analysis to examine the new scale's reliability and validity. Based on the results of an exploratory factor analysis, a two-factor, 20-item rating scale for maladaptive symptoms due to maltreatment (RS-MSM) was developed. The receiver operating characteristic curve indicated that cutoff values set in Survey 1 were appropriate for screening the general population and children in the clinical range. The results confirmed a two-factor structure with high reliability and convergent validity in the Survey 2 sample. Therefore, the developed RS-MSM scale is valid and will allow for easy screening of maltreated children at school.

Caffey's disease in disguise: a child abuse mimic.

A male infant was brought in a paediatric emergency with swelling in the right hand associated with restriction of wrist movements. Examination confirmed similar findings. The history of trauma was not forthcoming. Given the ambiguous history, the possibility of child abuse was kept. X-ray showed local soft tissue swelling with periosteal thickening and raised inflammatory markers in blood tests, which on review of the literature, was consistent with Caffey disease. Due to the self-limiting nature of the condition, the child was managed conservatively. Child abuse should be suspected in children with unexplained injuries, and before labelling abuse, its mimickers should be ruled out.

Evidence for the Association Between Adverse Childhood Family Environment, Child Abuse, and Caregiver Warmth and Cardiovascular Health Across the Lifespan: The Coronary Artery Risk Development in Young Adults (CARDIA) Study.

BACKGROUND: This study aimed to quantify the association between childhood family environment and longitudinal cardiovascular health (CVH) in adult CARDIA (Coronary Artery Risk Development in Young Adults) Study participants. We further investigated whether the association differs by adult income. METHODS: We applied the CVH framework from the American Heart Association including metrics for smoking, cholesterol, blood pressure, glucose, body mass index, physical activity, and diet. CVH scores (range, 0-14) were calculated at years 0, 7, and 20 of the study. Risky Family environment (range, 7-28) was assessed at year 15 retrospectively, for childhood experiences of abuse, caregiver warmth, and family or household challenges. Complete case ordinal logistic regression and mixed models associated risky family (exposure) with CVH (outcome), adjusting for age, sex, race, and alcohol use. RESULTS: The sample (n=2074) had a mean age of 25.3 (±3.5) years and 56% females at baseline. The median risky family was 10 with ideal CVH (≥12) met by 288 individuals at baseline (28.4%) and 165 (16.3%) at year 20. Longitudinally, for every 1-unit greater risky family, the odds of attaining high CVH (≥10) decreased by 3.6% (OR, 0.9645 [95% CI, 0.94-0.98]). Each unit greater child abuse and caregiver warmth score corresponded to 12.8% lower and 11.7% higher odds of ideal CVH (≥10), respectively (OR, 0.872 [95% CI, 0.77-0.99]; OR, 1.1165 [95% CI, 1.01-1.24]), across all 20 years of follow-up. Stratified analyses by income in adulthood demonstrated associations between risky family environment and CVH remained significant for those of the highest adult income (>$74k), but not the lowest (<$35k). CONCLUSIONS: Although risky family environmental factors in childhood increase the odds of poor longitudinal adult CVH, caregiver warmth may increase the odds of CVH, and socioeconomic attainment in adulthood may contextualize the level of risk. Toward a paradigm of primordial prevention of cardiovascular disease, childhood exposures and economic opportunity may play a crucial role in CVH across the life course.

Effects of child trauma screening on trauma-informed multidisciplinary evaluation and service planning in the child welfare system.

Despite the prevalence of exposure to potentially traumatic events (PTEs) among children involved with the child welfare system (CWS), trauma screening is not yet a common practice. The purpose of this study was to assess the impact of embedding a formal trauma screening process in statewide multidisciplinary evaluations for CWS-involved youth. A retrospective record review was conducted with two random samples of cases reflecting both pre- and postimplementation of formal screening procedures (n = 70 preimplementation, n = 100 postimplementation). Findings from the record review indicate statistically significant improvements in the documentation of general, χ2(1, N = 170) = 18.8, p < .001, and specific, χ2(1, N = 170) = 10.7, p = .001, details of children's reactions associated with PTE exposure, as well as increases in providers' recommendations, χ2(1, N = 170) = 18.1, p < .001, and referrals, χ2(1, N = 170) = 4.5, p = .034, for trauma-focused services. The early identification of trauma-related symptoms may help connect children more promptly to trauma-informed evidence-based interventions, which may avert or mitigate the long-term sequelae of child maltreatment and CWS involvement.

Congenital depressed skull fracture ("ping-pong" fracture) in newborn infants as a differential diagnosis of physical abuse. / Fractura craneal deprimida congénita ("fractura ping-pong") en neonatos como diagnóstico diferencial de maltrato físico.

Depressed skull fractures without a clear explanation as to their origin point to trauma with a blunt object and suspected child abuse. In the case of newborn infants, their young age is a vulnerability factor and requires an exhaustive assessment. When child abuse is suspected, an assessment of the differential diagnoses is required to make the most appropriate intervention possible. Both an excessive intervention and an omission of a necessary intervention should be avoided. Congenital depressed skull fractures, described as "ping-pong fractures", are rare (0.3 to 2/10 000 births). They may appear without any trauma history or in instrumentalized childbirth. Here we describe the case of a newborn infant with a ping-pong fracture as an example of an accidental fracture.

Las fracturas con hundimiento de cráneo sin una explicación clara sobre su origen orientan al traumatismo con un objeto romo y a la sospecha de maltrato infantil. En el caso de los bebés recién nacidos, su corta edad es un factor de vulnerabilidad y obliga a una exhaustiva evaluación. Ante la sospecha de maltrato infantil, resulta importante evaluar los diagnósticos diferenciales para realizar la intervención más adecuada posible. Es necesario evitar tanto intervenciones excesivas como omitir la intervención que sea necesaria. Las fracturas craneales deprimidas congénitas, descritas como "fracturas pingpong", son raras (0,3 a 2/10 000 partos). Pueden aparecer sin antecedentes traumáticos o en partos instrumentalizados. Se describe en este artículo el caso de un recién nacido con una fractura ping-pong como ejemplo de una fractura no intencional.

Racial and ethnic disparities in diagnostic imaging for child physical abuse.

IMPORTANCE: Racial bias may affect occult injury testing decisions for children with concern for abuse. OBJECTIVES: To determine the association of race on occult injury testing decisions at children's hospitals. DESIGN: In this retrospective study, we measured disparities in: (1) the proportion of visits for which indicated diagnostic imaging studies for child abuse were obtained; (2) the proportion of positive tests. SETTING: The Pediatric Health Information System (PHIS) administrative database encompassing 49 tertiary children's hospitals during 2017-2019. PARTICIPANTS: We built three cohorts based on guidelines for diagnostic testing for child abuse: infants with traumatic brain injury (TBI; n = 1952), children <2 years old with extremity fracture (n = 20,842), and children <2 years old who received a skeletal survey (SS; n = 13,081). MAIN OUTCOMES AND MEASURES: For each group we measured: (1) the odds of receiving a specific guideline-recommended diagnostic imaging study; (2) among those with the indicated imaging study, the odds of an abuse-related injury diagnosis. We calculated both unadjusted and adjusted odds ratios (AOR) by race and ethnicity, adjusting for sex, age in months, payor, and hospital. RESULTS: In infants with TBI, the odds of receiving a SS did not differ by racial group. Among those with a SS, the odds of rib fracture were higher for non-Hispanic Black than Hispanic (AOR 2.05 (CI 1.31, 3.2)) and non-Hispanic White (AOR 1.57 (CI 1.11, 2.32)) patients. In children with extremity fractures, the odds of receiving a SS were higher for non-Hispanic Black than Hispanic and non-Hispanic White patients (AOR 1.97 (CI 1.74, 2.23)); (AOR 1.17 (CI 1.05, 1.31)), respectively, and lower for Hispanic than non-Hispanic White patients (AOR 0.59 (CI 0.53, 0.67)). Among those receiving a SS, the rate of rib fractures did not differ by race. In children with skeletal surveys, the odds of receiving neuroimaging did not differ by race. Among those with neuroimaging, the odds of a non-fracture, non-concussion TBI were lower in non-Hispanic Black than Hispanic patients (AOR 0.7 (CI 0.57, 0.86)) and were higher among Hispanic than non-Hispanic White patients (AOR 1.23 (CI 1.02, 1.47)). CONCLUSIONS AND RELEVANCE: We did not identify a consistent pattern of race-based disparities in occult injury testing when considering the concurrent yield for abuse-related injuries.

A lucid interval in a victim of abusive head trauma with multiple parenchymal lacerations.

Abusive head trauma (AHT) is a leading cause of abusive deaths in children under age one. AHT can include intracranial hemorrhages, hypoxic ischemic injury, or parenchymal lacerations. Most infants with parenchymal lacerations present with acute neurological symptoms. There has been some published literature on lucid intervals in cases of AHT; however, there has not been a described lucid interval with parenchymal lacerations. Parenchymal lacerations typically present with acute symptomatology such as seizures, alteration in mental status, or increased fussiness/lethargy given the damage to neurons and brain structure. We present a case of a healthy 2-month-old who ultimately was diagnosed with AHT and three parenchymal lacerations and had a 2.5 hour period of normal neurological status prior to acute decompensation.

[Emotional Abuse in Childhood and Adolescence: Biological Embedding and Clinical Implications]. / Emotionaler Missbrauch in Kindheit und Jugend ­ Biologische Einbettung und klinische Implikationen.

Emotional abuse, defined as degrading, manipulative, or neglectful behaviors by caregivers, represents a common adverse experience for children and adolescents, often co-occurring with other maltreatment types. Exposure to emotional abuse significantly affects mental health across the lifespan and is particularly associated with elevated depression risk.This review examinesmechanisms, by which emotional abuse influences brain development and the neuroendocrine stress response system and discusses the roles of genetic vulnerability and epigenetic processes in contributing to an elevated mental health risk. Emotional abuse has similar effects on brain networks responsible for emotion processing and regulation as other maltreatment types.Moreover, it uniquely affects networks related to self-relevant information and socio-cognitive processes. Furthermore, emotional abuse is associated with an impaired recovery of the neuroendocrine response to acute stress. Similar to other maltreatment types, emotional abuse is associated with epigenetic changes in genes regulating the neuroendocrine stress response system that are implicated in increased mental health risk.These findings suggest that emotional abuse has equally detrimental effects on children'smental health as physical or sexual abuse, warranting broader societal awareness and enhanced early detection efforts. Early interventions should prioritize emotion regulation, social cognition, self-esteemenhancement, and relationship- oriented approaches for victims of emotional abuse.