References

Infants are at greatest risk of severe and fatal physical abuse yet they sometimes present for medical care multiple times with abusive injuries prior to being diagnosed with abuse and having protective actions taken. Efforts to identify these infants in a timely manner are critical to prevent repeated, escalating abuse and subsequent harm. Increasing the identification and evaluation of sentinel injuries has been highlighted as a strategy for improving timely detection of abuse in infants. Sentinel injuries are visible, minor, poorly explained injuries in young infants that raise concern for abuse. These injuries include cutaneous injuries such as bruising, subconjunctival hemorrhages and intra-oral injuries. Sentinel injuries can signal concurrent clinically occult but more serious injuries or precede more significant trauma from abuse. As such, sentinel injuries offer an opportunity to intervene and protect infants from further harm. A thorough physical exam is critical for detecting sentinel injuries. Imaging with skeletal survey and, when appropriate, neuroimaging are key components of the medical evaluation of sentinel injuries in these high-risk infants.

Children often present to emergency departments for evaluation and treatment of injuries or conditions that result from abuse. When child abuse is suspected, the physician must document the history, examination, medical impression, and report those concerns to the appropriate agency. Although physicians are often the first identifiers of abuse, the literature confirms that there is inadequate medical documentation for suspected child abuse victims. What is written in the medical record for these children significantly contributes to the success or failure of investigations and litigation. More importantly, however, medical documentation can ultimately impact the future of children who have suffered abuse. Therefore, emergency physicians must know what to document and put it into practice.

Cognitive errors have been studied in a broad array of fields, including medicine. The more that is understood about how the human mind processes complex information, the more it becomes clear that certain situations are particularly susceptible to less than optimal outcomes because of these errors. This article explores how some of the known cognitive errors may influence the diagnosis of child abuse, resulting in both false-negative and false-positive diagnoses. Suggested remedies for these errors are offered.

OBJECTIVE: This exploratory study investigated the co-occurrence of domestic violence and three types of child maltreatment: physical child abuse, psychological child abuse, and child neglect. METHOD: A sample of 2544 at-risk mothers with first-born children participated in a home-visiting child abuse prevention program. A longitudinal design using multiple data collection methods investigated the effect of domestic violence during the first 6 months of child rearing on confirmed physical child abuse, psychological child abuse, and child neglect up to the child's first 5 years. RESULTS: Logistic regressions revealed significant relationships between domestic violence and physical child abuse, psychological child abuse, and child neglect. These effects were significant beyond the significant effects of known risks of maltreatment, as measured by the Kempe Family Stress Inventory (KFSI). Domestic violence occurred in 59 (38%) of the 155 cases of confirmed maltreatment. Domestic violence preceded child maltreatment in 46 (78%) of the 59 cases of co-occurrence, as indicated by independent home observations and child protective service records. CONCLUSIONS: The findings indicate that domestic violence during the first 6 months of child rearing is significantly related to all three types of child maltreatment up to the child's fifth year. Domestic violence and risks factors measured on the KFSI continue to contribute to all three types of maltreatment up to the child's fifth year. Prevention programs would be wise to provide services to at-risk families until the child is at least 5 years old. Addressing concurrent problems during treatment may enhance intervention.

Child Abuse Pediatrics is a small and geographically dispersed specialty. This article reports on an intervention to improve written and photodocumentation quality and uniformity in suspected child physical abuse cases, using a remote, de-identified case review system. METHODS: In each cycle, participants submitted de-identified medical reports and photographs for review by a child abuse pediatrics expert. Experts evaluated 3 cycles of 5 cases using a novel rubric and assigned quality interventions for the participants based on their scores. RESULTS: 15 of 16 participants improved scores between cycles 1 and 3 (78% versus 89%, P < 0.001). All participants rated the program as helpful and would recommend it to a colleague. CONCLUSION: A quality improvement project administered via the internet improves the quality and uniformity of written and photographic documentation in child physical abuse evaluations.

The purpose of the New York State Child Protective Services Manual is to provide a comprehensive resource that incorporates current law, regulation, relevant guidelines, and procedures in the area of child protective services.

When asked to provide an assessment of a patient for whom there are concerns of suspected maltreatment, the clinician may have uncertainty about how to best proceed for a number of reasons including the actual or potential involvement of a child welfare authority. Existing literature helps to define the role of the medical expert in child abuse assessments, but there is little published guidance targeted to the general practitioner. The present article offers practical advice about the approach to: documentation of a child abuse assessment; providing testimony and behaviour in the court system for the nonexpert; and, finally, guidance for individuals giving expert or opinion evidence for medicolegal purposes. In all cases, if the clinician has specific concerns or unanswered questions about their role and responsibilities, they can contact their professional medicolegal association for support.

Photographic documentation of significant findings is an important part of any child abuse evaluation. High-quality photographs of significant physical findings may be important in helping courts to adjudicate whether child abuse has taken place. The physician evaluating abused children should ensure adequate photographic documentation of visible lesions. Physicians who care for abused children should be familiar with the basic principles and techniques of clinical photography. These include good equipment, adequate lighting, and planned composition. Equally important is a working knowledge of camera equipment, film procedure, and medicolegal implications. This review outlines for the practicing physician the basic concepts and techniques of photographing abused children.

OBJECTIVE: Relatively minor abusive injuries can precede severe physical abuse in infants. Our objective was to determine how often abused infants have a previous history of "sentinel" injuries, compared with infants who were not abused. METHODS: Case-control, retrospective study of 401, <12-month-old infants evaluated for abuse in a hospital-based setting and found to have definite, intermediate concern for, or no abuse after evaluation by the hospital-based Child Protection Team. A sentinel injury was defined as a previous injury reported in the medical history that was suspicious for abuse because the infant could not cruise, or the explanation was implausible. RESULTS: Of the 200 definitely abused infants, 27.5% had a previous sentinel injury compared with 8% of the 100 infants with intermediate concern for abuse (odds ratio: 4.4, 95% confidence interval: 2.0-9.6; P < .001). None of the 101 nonabused infants (controls) had a previous sentinel injury (P < .001). The type of sentinel injury in the definitely abused cohort was bruising (80%), intraoral injury (11%), and other injury (7%). Sentinel injuries occurred in early infancy: 66% at <3 months of age and 95% at or before the age of 7 months. Medical providers were reportedly aware of the sentinel injury in 41.9% of cases. CONCLUSIONS: Previous sentinel injuries are common in infants with severe physical abuse and rare in infants evaluated for abuse and found to not be abused. Detection of sentinel injuries with appropriate interventions could prevent many cases of abuse.

Child maltreatment is a devastating type of adverse childhood experience that encompasses neglect and emotional, physical, and sexual abuse (including sex trafficking). Adverse childhood experiences are exposures to maltreatment or household dysfunction during crucial developmental periods that disrupt neurodevelopment and can result in lifelong physical and psychological harm, altering the child's behavior and disease risk into adulthood. Maltreatment can affect patients of any gender identity and from all racial and ethnic backgrounds, socioeconomic statuses, and community settings. Use of the validated five-item Pediatric Hurt-Insult-Threaten-Scream-Sex screening tool to identify victims of child abuse is recommended. All suspected cases of child abuse must be reported to Child Protective Services. A trauma-informed approach to care requires that team members be mindful of the potential for traumatic stress, recognize and appropriately respond to the symptoms and signs of trauma, and prevent retraumatization. Prevention through education and anticipatory guidance provided during routine well-child visits and community partnerships can foster awareness and resiliency in children. Although caring for victims of child maltreatment may be among the most challenging professional situations encountered by physicians, advocating for these endangered patients can save lives and help prevent revictimization and chronic sequelae associated with adverse childhood experiences.

Men and women experience severe domestic violence (DV) and intimate partner violence (IPV); however, women and children remain especially vulnerable. Violence along the DV/IPV continuum has been recognized as a type of child maltreatment and a child's awareness that a caregiver is being harmed or at risk of harm is sufficient to induce harmful sequelae. Consequences of these abusive behaviors are associated with mental and physical health consequences. Health care professionals can screen, identify, and manage this pathology in affected families while educating communities to these pernicious effects.

Exposure to intimate partner violence is increasingly being recognized as a form of child maltreatment; it is prevalent, and is associated with significant mental health impairment and other important consequences. The present article provides an evidence-based overview regarding children's exposure to intimate partner violence, including epidemiology, risks, consequences, assessment and interventions to identify and prevent both initial exposure and impairment after exposure. It concludes with specific guidance for the clinician.