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.

Gender-related stigma toward individuals with a history of sexual or physical violence in childhood.

BACKGROUND: Stigma is a key barrier to disclosing traumatic experiences of violence in childhood with adverse consequences for help-seeking behaviour. Disclosing behavior differs by gender and the form of violence experienced. However, there is a lack of comprehensive studies that address societal perceptions of males and females with a history of sexual or physical violence in childhood. Therefore, our aim is to focus on the impact of gender on the perception of individuals who experienced sexual or physical violence in childhood. METHODS: We conducted a study on a representative sample of the German general population in terms of age and gender. Participants were randomly assigned to brief case vignettes addressing sexual or physical violence in childhood. Analyses base on a sample of n = 659 individuals (50.1% female). Stigma was assessed through examining respondents' readiness to address specific traumas in conversation and respondents' attitudes toward the individuals in the vignettes. Mann-Whitney U tests were applied to check for differences between female and male victims and survivors as well as female and male respondents. RESULTS: Our results reveal that male victims and survivors face higher negative stereotypes (harm, unpredictability) and evoke communication barriers more often when compared to female victims and survivors, especially in male respondents. Sexual violence is associated with more distinct gender differences than physical violence. CONCLUSIONS: Findings reflect greater stigma toward male victims and survivors of sexual violence than female ones. Men had a greater tendency to stigmatize - especially toward their same-gender peers. Socially ingrained gender roles may act as a basis for different communication cultures and the notion of victim-perpetrator constellations in which males are not envisaged as victims.

Abusive spinal injury: imaging and updates.

Child physical abuse has significant morbidity and mortality in the pediatric population. There is growing evidence that abusive spinal injury has been under-recognized, changing historical perceptions that these injuries are relatively uncommon. Increased utilization of MRI has been pivotal in recognizing that most abusive spinal injuries involve the soft tissues and ligaments or manifest as intrathecal blood products, which are often undetectable by radiography or CT. Detecting spinal injury in the work-up of non-accidental trauma improves management for abused children and their siblings (defined as siblings or other household members). This review highlights key points in the imaging literature of abusive spinal injury, describes typical patterns of injury, and addresses appropriate imaging practice for work-up.

Orofacial manifestations of child maltreatment: A review.

The recognition and reporting of child abuse and neglect continues to be a challenge in the healthcare setting. All healthcare providers, including dentists, should be aware of the high prevalence of orofacial injuries and conditions that are concerning for abuse and neglect. Sentinel injuries may appear trivial and do not require medical attention, but are unlikely caused by accidental mechanisms and, if not properly identified, often precede more severe abusive injuries. Concerning orofacial findings can manifest as bruising, eye injuries, intraoral injuries, pharyngeal perforations, facial bone fractures, and sexually transmitted infections. Abusive caregivers are likely to give inadequate explanations or no history at all to explain concerning findings. Medical providers' failure to make mandated reports about their concerns to the appropriate agencies can have significant long-term impacts on the physical and psychological well-being of children.

Child physical abuse screening in a pediatric ED; Does TRAIN(ing) Help?

BACKGROUND: Child maltreatment is distressingly prevalent yet remains under-recognized by healthcare providers. In 2015 the Ohio Children's Hospital Association developed the Timely Recognition of Abusive INjuries (TRAIN) collaborative in an effort to promote child physical abuse (CPA) screening. Our institution implemented the TRAIN initiative in 2019. The objective of this study was to examine the effects of the TRAIN initiative at this institution. METHODS: In this retrospective chart review we recorded the incidence of sentinel injuries (SIS) in children presenting to the Emergency Department (ED) of an independent level 2 pediatric trauma center. SIS were defined and identified by a diagnosis of ecchymosis, contusion, fracture, head injury, intracranial hemorrhage, abdominal trauma, open wound, laceration, abrasion, oropharyngeal injury, genital injury, intoxication, or burn in a child < 6.01 months of age. Patients were stratified into pre-TRAIN (PRE), 1/2017-9/2018, or post-TRAIN (POST), 10/2019-7/2020, periods. Repeat injury was defined as a subsequent visit for any of the previously mentioned diagnoses within 12 months of the initial visit. Demographics/visit characteristics were analyzed using Chi square analysis, Fischer's exact test, and student's paired t-test. RESULTS: In the PRE period, 12,812 ED visits were made by children < 6.01 months old; 2.8% of these visits were made by patients with SIS. In the POST period there were 5,372 ED visits, 2.6% involved SIS (p = .4). The rate of skeletal surveys performed on patients with SIS increased from 17.1% in the PRE period to 27.2% in the POST period (p = .01). The positivity rate of skeletal surveys in the PRE versus POST period was 18.9% and 26.3% respectively (p = .45). Repeat injury rates did not differ significantly in patients with SIS pre- versus post-TRAIN (p = .44). CONCLUSION: Implementation of TRAIN at this institution appears to be associated with increased skeletal survey rates.

Suboptimal care was frequent in severe child physical abuse cases and was mainly related to delayed diagnoses and ineffective secondary prevention.

AIM: Our aim was to assess suboptimal care before a diagnosis of severe child physical abuse in western France. METHODS: A confidential inquiry was carried out, based on children under 6 years of age who were hospitalised in the Nantes regional university hospital from 2016 to 2018. Two researchers retrospectively reviewed the medical records of all the children who were reported to the authorities for suspected severe child physical abuse. Two experts determined the optimality of care and identified the main categories of suboptimal care. RESULTS: The median age of the 94 children included in the study was 8 months. A fifth of them had intra-cranial injuries and a quarter had fractures. One child died and a third had severe sequelae at hospital discharge. Included children frequently (37%) received suboptimal care before the diagnosis of severe CPA and this fell into two categories: delayed diagnosis was experienced by 17% and ineffective secondary prevention by 22%. CONCLUSION: Suboptimal care for severe child physical abuse was frequent and fell into two categories: delayed diagnosis and ineffective secondary prevention. These results can help us to design corrective actions.

Childhood exposure to physical and emotional violence over a 57-year period in Sweden.

AIMS: The aim of the present study was to examine the prevalence of childhood experiences of physical violence (CPV) and emotional violence (CEV) at the hands of parents over a 57-year period among adults born between 1937 and 1993. METHODS: In 2012, a survey among women and men aged 18-74 years in Sweden was undertaken to examine the lifetime prevalence of physical, psychological and sexual violence and associations with current health in adulthood. Questionnaires were based on the Adverse Childhood Experiences study and a previous national survey of violence exposure. Descriptive statistics were used to analyse the frequency of exposure to CPV and CEV, and changes over time were analysed using analysis of variance and logistic regression. RESULTS: A total of 10,337 individuals participated (response rates: 56% for women and 48% for men). CPV decreased significantly over the time period studied, particularly for those born after 1983. This decrease was more evident for male respondents. Throughout the time period studied, the proportion of women reporting CEV was higher than for men. Among both genders there was a steady rise in CEV rates from those born in the late 1930s to those born in the mid-1980s, after which there was a decline that was more marked for men. CONCLUSIONS: A significant group of children in Sweden experience violence at the hands of parents. However, our data corroborate previous national studies that children's exposure to violence has decreased. Clear gender differences indicate that these changes have affected girls and boys differently.

Association between self-reported dental fear and exposure to violence among adolescents-A population-based study.

BACKGROUND: The etiology of dental fear (DF) is multifactorial and involves other contributing factors than dental traumatic experiences. AIM: To study, among adolescents, associations between DF and exposure to child physical abuse (CPA), intimate partner violence (IPV), and bullying. DESIGN: We extracted data from a population-based survey of 4977 adolescents who were 15-17 years old in 2017. The questionnaire queried socioeconomic background factors, DF, self-perceived oral health, general health, and exposure to child abuse. To estimate associations between DF and exposure to child abuse, we used multivariate logistic regression analysis. RESULTS: Overall, 8.2% reported DF, girls (10.5%) reported DF significantly more often than boys (5%), and adolescents not identifying themselves as girl or boy reported the highest prevalence of DF (25.5%; p < .001). 15.3% had been exposed to child physical abuse; 11.1%, to IPV; and 11.2%, to bullying. Experiences of IPV and bullying, but not physical abuse, were statistically significantly associated with DF. The odds of developing DF for adolescents exposed to any type of violence was 1.9 times the odds for adolescents with no exposure to child abuse. CONCLUSION: Exposure to violence is associated with dental fear in adolescents.

Factors influencing the perceived credibility of children alleging physical abuse.

Adults' assessments of the credibility of children's reports are affected by factors including the frequency of abuse, reporting delays and the child's age. The present study examined whether similar factors affect the perceived credibility of children reporting physical abuse, which is more common than sexual abuse. Two hundred and eight mock jurors read a simulated transcript of a child reporting physical abuse to police and made credibility ratings. Within each transcript, abuse frequency (once, repeated), reporting timing (recent, delayed), police question type (open, closed) and child age (6 or 10 years) were manipulated. The child was considered more credible when the abuse was only experienced once and reported shortly after it occurred, and when prompted with open questions. The child's age did not affect credibility judgments. Current findings support recommendations to prioritise open questions with children and provide evidence for extension of the benefits of open questions to children's credibility.

Brief resolved unexplained events vs. child maltreatment: a review of clinical overlap and evaluation.

Within their first year, a number of infants present for medical evaluation because of unexplained changes in color, tone, breathing, or level of responsiveness. This broad collection of symptoms has an accordingly large differential diagnosis that includes both brief resolved unexplained event (BRUE) and child maltreatment. The overlap between clinical presentation for BRUE and maltreatment can present a diagnostic challenge - especially given the significant consequences for infants and families for diagnostic error at that juncture. In this review, we provide overviews of the presenting features and findings in cases of BRUE and child maltreatment with a focus on areas of overlap and differentiation.

Genetic causes of fractures and subdural hematomas: fact versus fiction.

Genetic disorders are in the differential diagnosis when young children present with unexplained fractures or intracranial hemorrhage. For medical and legal reasons, it is imperative to make the correct diagnosis and provide clear, evidence-based explanations of how alternative diagnoses were ruled out. A genetics consultation in cases of suspected child physical abuse should synthesize the history of present illness, medical history, family history, physical examination, and radiologic and laboratory findings in consultation with other specialists. The medical geneticist highlights how these disorders truly present. When the natural history of a genetic disorder is understood, it becomes clear that genetic disorders are not mysterious or difficult to diagnose. As highlighted in this case-based review, mainstream medical practice allows for differentiation among the intracranial and skeletal manifestations of osteogenesis imperfecta, Menkes disease, glutaric acidemia type 1 and child physical abuse. This review also highlights how a genetic disorder, Ehlers-Danlos syndrome, can be misused in a courtroom. Finally, this review summarizes when genetic testing is appropriate in cases of suspected child physical abuse.

Palm Bruising in Infants: A Recognizable Pattern of Abuse.

BACKGROUND: Bruising in an infant is an important sentinel injury that should raise concern for child physical abuse, and should prompt a medical evaluation for occult injury. Hyperflexion during forceful squeezing of an infant's hand results in a distinct pattern of bruising along the palmar and interdigital creases, as well as the palmar eminences. Self-inflicted injury by the infant or injury resulting from benign handling should not be accepted as plausible explanations for this injury. The presence of concurrent occult injuries is common, and further supports concerns for abuse. However, when this distinct pattern of palm bruising is identified in an infant, the absence of occult injuries should not prevent the recognition of child physical abuse. CASE REPORT: We report 11 cases depicting this distinct pattern of palm bruising in infants. Additionally, we include a perpetrator's documented confession. To the best of our knowledge, this pattern of bruising has not been previously described in the medical literature. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians play a crucial role in recognizing and addressing child physical abuse. Prompt recognition of this finding can aid in the identification of child physical abuse, even in the absence of underlying occult injury. This, in turn, can potentially prevent further injury, and even death, of an infant.

Child physical abuse: awareness and practices of medical and dental doctors in Pakistan.

OBJECTIVE: To determine the awareness and practices of doctors and dentists in detecting and reporting suspected cases of child physical abuse. METHODS: The cross-sectional study was conducted from November 2017 to June 2018 at the Hamdard College of Medicine and Dentistry, Karachi, and comprised doctors and dentists practising in public and private hospitals across Pakistan. Data was collected using a predesigned questionnaire to assess knowledge of the social indicators of child physical abuse, response to child physical abuse, and actions taken by the professionals when they believed a child abuse case had been detected. Data was analysed using SPSS 22. RESULTS: Of the 575 healthcare professionals, 371(64.5%) were doctors and 204(35.5%) were dentists; 347(60.3%) were males; 446(77.6%) were working in private hospitals; 384(66.8%) had <10 years of experience; and 99(17.2%) had received formal training of child abuse. While 450(78.3%) subjects strongly agreed on the value of identifying and documenting child physical abuse, 336(58%) did not take any action in suspected cases. CONCLUSIONS: Although doctors and dentists had a positive attitude regarding child physical abuse, the majority preferred to remain silent in suspected cases.

[Facing Children Suffering From Physical Abuse: The Decision-Making Process of Non-Abusing Caregivers].

BACKGROUND: Physical abuse is the most common type of child maltreatment reported in Taiwan. The action of non-abusing caregivers is key to ending this maltreatment and to preventing future victimization in the home. PURPOSE: The purpose of this study was to explore the decision-making process used by non-abusing caregivers to take action after finding that children under their care were being physically abused at home. METHODS: A qualitative descriptive approach was adopted and purposive, snowball sampling was used to recruit 11 non-abusing caregivers of children less than 18 years of age who were experiencing physical abuse at home. Data were collected using semi-structured, in-depth interviews. Data analysis was performed using a constant comparison method that was based on grounded theory principles and techniques. RESULTS: The participants adopted a process that shifted over time from passive observation to active participation in dealing with children under their care being physically abused at home. The three main categories and five subcategories in this process are (1) inaction (shirking parental responsibility and rationalizing spouse's use of corporal punishment); (2) obscure action (family harmony first; strategic solutions); and (3) action (bottom line for asking for help). In this study, the decision-making process was influenced by personal, family, and sociocultural factors. CONCLUSIONS / IMPLICATIONS FOR PRACTICE: The decision of the non-abusing caregivers in this study whether or not to take action was influenced by situational factors, which led to various consequences for their children. Non-abusing caregivers should be provided with coping strategies and resources to help them make decisions that protect the best interests of the physically abused child.

Gender differences in pathways from child physical and sexual abuse to adolescent risky sexual behavior among high-risk youth.

This study investigated gender differences in the roles of internalizing and externalizing symptoms and substance use as pathways linking child physical and sexual abuse to risky sexual behavior among youth at risk of maltreatment. Path analysis was performed with 862 adolescents drawn from Longitudinal Studies of Child Abuse and Neglect. Four waves of data collected in the United States were used: childhood physical and sexual abuse experiences (from ages 0-12) were assessed by Child Protective Services reports, internalizing and externalizing symptoms were measured at age 14, substance use was measured at age 16, and risky sexual behavior was measured at age 18. Physical abuse was directly associated with risky sexual behavior in boys but not girls. For girls, physical abuse had a significant indirect effect on risky sexual behavior via externalizing symptoms. Gender-focused preventive intervention strategies may be effective in reducing risky sexual behavior among at-risk adolescents.

A Retrospective Study of Cervical Spine MRI Findings in Children with Abusive Head Trauma.

BACKGROUND/AIMS: Increasing attention has been given to the possible association of cervical spine (c-spine) injuries with abusive head trauma (AHT). The aims of this study were to describe c-spine MRI findings in hospitalized AHT patients. METHODS: This is a retrospective study of children under the age of 5 years with AHT admitted to hospital in 2004-2013. Those with c-spine MRI were identified, and the images were reviewed. RESULTS: 250 AHT cases were identified, with 34 (14%) undergoing c-spine MRI. Eleven patients (32%) had 25 findings, including hematoma in 2, occiput-C1-C2 edema in 3, prevertebral edema in 6, facet edema in 2, and interspinous and/or muscular edema in 10. No patients had a clinically evident c-spine injury, a clinically unstable c-spine, or required c-spine surgery. CONCLUSIONS: C-spine MRI may identify abnormalities not apparent upon physical examination and the procedure should therefore be considered in cases of suspected AHT.

Child Physical Abuse, Non-anemic Iron Deficiency and Behavior Problems.

PURPOSE: Child abuse is regarded as a life-course social determinant of health problems. However, little is known about the nutritional status of physically abused children and their cumulative effect on child behavior. The present study aimed to examine the non-anemic iron deficiency status of abused children and the combined effect of physical abuse and non-anemic iron deficiency on child behavior in China. METHODS: This cross-sectional study comprised 314 children aged 11-14 (12.30±0.57) years old from Jintan, China. Children self-reported their physical abuse experiences and behavior problems. Blood iron and hemoglobin concentrations were also measured. RESULTS: Thirty-eight percent of children reported physical abuse experience, 17.5% had non-anemic iron deficiency, and the two risk factors co-occurred in 8.0% children. Physically abused children were more likely to be affected by non-anemic iron deficiency than their non-abused counterparts. Children who had experienced both physical abuse and non-anemic iron deficiency reported more behavior problems than children with neither or either risk factors. CONCLUSIONS: Physically abused children are more likely to have non-anemic iron deficiency. Children with the presence of both physical abuse experience and non-anemic iron deficiency have more behavior problems. There is a need to prevent both child abuse and non-anemic iron deficiency simultaneously to maintain normal child behavior development.

Exploring the Impact of Childhood Abuse on HIV Social and Attitudinal Factors Among Adults With and Without this History in Sub-Saharan Africa: Findings from NIMH Project Accept (HPTN 043).

Using data from four sites in three African countries, this community randomized study examined the association between childhood sexual and/or physical abuse (CSA and/or CPA) and HIV disclosure, HIV-related stigma, stress, and social support among adults with and without a history of abuse. A history of abuse among men was associated with higher levels of adult-reported stress and HIV-related stigma, and with significantly lower rates of HIV test result disclosure to current partners. Women with a history of CSA and/or CPA had significantly higher perceived stigma, discrimination and stress. Although childhood abuse was significantly associated with adult stress and stigmatization, participants with histories of CSA and/or CPA also reported significantly higher perceived social support compared to people without such experiences. These findings may reflect support received in response to disclosure of CSA or CPA or emotional ambivalence in relationships that have been found to be associated with child abuse. We conclude that it is critical for HIV prevention interventions to advocate for the primary prevention of child abuse, for early identification of adolescents and adults who report experiencing childhood abuse, and to address stigma and stress-related attitudinal, behavioral and relationship difficulties experiences as an aftermath of early abuse that increase their risk of HIV.

Childhood maltreatment as a risk factor for diabetes: findings from a population-based survey of Canadian adults.

BACKGROUND: It is well established that childhood maltreatment (CM) is a risk factor for various mental and substance use disorders. To date, however, little research has focused on the possible long-term physical consequences of CM. Diabetes is a chronic disease, for which an association with CM has been postulated. METHODS: Based on data from a sample of 21,878 men and women from the 2012 Canadian Community Health Survey - Mental Health (CCHS - MH), this study examines associations between three types of CM (childhood physical abuse (CPA), childhood sexual abuse (CSA), and childhood exposure to intimate partner violence (CEIPV)) and diabetes in adulthood. Multiple logistic regression models were used to examine associations between CM and diabetes controlling for the effects of socio-demographic characteristics and risk factors for type 2 diabetes. RESULTS: When controlling socio-demographic characteristics, diabetes was significantly associated with reports of severe and frequent CPA (OR = 1.8) and severe and frequent CSA (OR = 2.2). A dose-response relationship was observed when co-occurrence of CSA and CPA was considered with the strongest association with diabetes being observed when both severe and frequent CSA and CPA were reported (OR = 2.6). Controlling for type 2 diabetes risk factors attenuated associations particularly for CPA. CEIPV was not significantly associated with having diabetes in adulthood. CONCLUSION: CPA and CSA are risk factors for diabetes. For the most part, associations between CPA and diabetes are mediated via risk factors for type 2 diabetes. Failure to consider severity and frequency of abuse may limit our understanding of the importance of CM as a risk factor for diabetes.