Full Resources List
Adriel Booker
Offers a book: Teaching kids body privacy, personal agency, and consent begins while they’re in diapers.
https://adrielbooker.com/teaching-kids-body-privacy-personal-agency-consent/
American Academy of Pediatrics
Practice Management Resources
American Academy of Pediatrics (AAP)
Professional Tools and Resources for Child Abuse and Neglect
American Association for the Study of Liver Diseases and the Infectious Diseases Society of America (AASLD-IDSA)
(Accessed June 2025)
HCV Guidance: Recommendations for Testing, Managing, and Treating Hepatitis C
American College of Obstetricians and Gynecologists. Emergency Contraception. Practice Bulletin No. 152, Reaffirmed 2022. 2010.
Emergency contraception, also known as postcoital contraception, is therapy …
Emergency contraception, also known as postcoital contraception, is therapy used to prevent pregnancy after an unprotected or inadequately protected act of sexual intercourse. Common indications for emergency contraception include contraceptive failure (eg, condom breakage or missed doses of oral contraceptives) and failure to use any form of contraception 1 2 3. Although oral emergency contraception was first described in the medical literature in the 1960s, the U.S. Food and Drug Administration (FDA) approved the first dedicated product for emergency contraception in 1998. Since then, several new products have been introduced. Methods of emergency contraception include oral administration of combined estrogen–progestin, progestin only, or selective progesterone receptor modulators and insertion of a copper intrauterine device (IUD). Many women are unaware of the existence of emergency contraception, misunderstand its use and safety, or do not use it when a need arises 4 5 6. The purpose of this Practice Bulletin is to review the evidence for the efficacy and safety of available methods of emergency contraception and to increase awareness of these methods among obstetrician–gynecologists and other gynecologic providers.
American College of Radiology and Society for Pediatric Radiology
Rev. 2021.
The ACR-SPR Practice Parameter for the Performance and Interpretation of Skeletal Surveys in Children
American Medical Association
Current Procedural Terminology (CPT)
Arrowhead Forensics
May 2019.
Proper Use of AFBO Scales
Association for the Treatment of Sexual Abusers
They offer: Information library, conferences and training, and referrals for treatment.
atsa.com
Breuner CC, Mattson G. Sexuality Education for Children and Adolescents. Pediatrics. 2016; 138 (2).
Keywords: Adolescent, Child, Health Personnel, Humans, Pediatrics, Schools, *Sex Education, Sexual Abstinence
The purpose of this clinical report is to provide pediatricians updated …
The purpose of this clinical report is to provide pediatricians updated research on evidence-based sexual and reproductive health education conducted since the original clinical report on the subject was published by the American Academy of Pediatrics in 2001. Sexuality education is defined as teaching about human sexuality, including intimate relationships, human sexual anatomy, sexual reproduction, sexually transmitted infections, sexual activity, sexual orientation, gender identity, abstinence, contraception, and reproductive rights and responsibilities. Developmentally appropriate and evidence-based education about human sexuality and sexual reproduction over time provided by pediatricians, schools, other professionals, and parents is important to help children and adolescents make informed, positive, and safe choices about healthy relationships, responsible sexual activity, and their reproductive health. Sexuality education has been shown to help to prevent and reduce the risks of adolescent pregnancy, HIV, and sexually transmitted infections for children and adolescents with and without chronic health conditions and disabilities in the United States.
Bright Futures
July 2022.
Promoting Healthy Development of Sexuality and Gender Identity
Bright Futures
Well-Child Care Toolkit, curriculum for pediatric providers
Tanner stage
CHAMP
Botash, AS. Decision Points 1-5 in the Evaluating Child Sexual Abuse course
CHAMP
Botash AS. The Medical History Points 71&72 in the Evaluating Child Sexual Abuse course
CHAMP
Botash AS. The Medical Examination in the Evaluating Child Sexual Abuse course
CHAMP
Botash AS. The Medical History in the Evaluating Child Sexual Abuse course
CHAMP
Handout for the CHAMP webcast by Blair Hammond, Striving to Promote Early Relational Health and Child Development in the Healthcare Space. A Primary Preventive Model
CHAMP
2024.
How to Make a Child Abuse Report in New York State
CHAMP
2024.
Triage in Suspected Child and Adolescent Sexual Abuse or Other Sexual Offenses
CHAMP
Evaluation Guidelines for Suspected Child Physical Abuse. 2022.
https://cha …
CHAMP
Evaluation Guidelines for Suspected Physical Abuse https://champprogram.com/pd …
Center for Health Care Strategies
Words Matter: Strategies to Reduce Bias in Electronic Health Records
Centers for Disease Control and Prevention (CDC). U.S. Medical Eligibility Criteria for Contraceptive Use, 2024. MMWR. Morbidity and mortality weekly report. 2024; 73 (4).
The 2024 U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) …
The 2024 U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) comprises recommendations for the use
of specific contraceptive methods by persons who have certain characteristics or medical conditions. These recommendations for
health care providers were updated by CDC after review of the scientific evidence and a meeting with national experts in Atlanta,
Georgia, during January 25–27, 2023. The information in this report replaces the 2016 U.S. MEC (CDC. U.S. Medical
Eligibility Criteria for Contraceptive Use, 2016. MMWR 2016:65[No. RR-3]:1–103). Notable updates include 1) the
addition of recommendations for persons with chronic kidney disease; 2) revisions to the recommendations for persons with certain
characteristics or medical conditions (i.e., breastfeeding, postpartum, postabortion, obesity, surgery, deep venous thrombosis or
pulmonary embolism with or without anticoagulant therapy, thrombophilia, superficial venous thrombosis, valvular heart disease,
peripartum cardiomyopathy, systemic lupus erythematosus, high risk for HIV infection, cirrhosis, liver tumor, sickle cell disease,
solid organ transplantation, and drug interactions with antiretrovirals used for prevention or treatment of HIV infection); and
3) inclusion of new contraceptive methods, including new doses or formulations of combined oral contraceptives, contraceptive
patches, vaginal rings, progestin-only pills, levonorgestrel intrauterine devices, and vaginal pH modulator. The recommendations
in this report are intended to serve as a source of evidence-based clinical practice guidance for health care providers. The goals
of these recommendations are to remove unnecessary medical barriers to accessing and using contraception and to support the
provision of person-centered contraceptive counseling and services in a noncoercive manner. Health care providers should always
consider the individual clinical circumstances of each person seeking contraceptive services. This report is not intended to be a
substitute for professional medical advice for individual patients; when needed, patients should seek advice from their health care
providers about contraceptive use.
Centers for Disease Control and Prevention (CDC). U.S. Selected Practice Recommendations for Contraceptive Use, 2024. MMWR. Morbidity and mortality weekly report. 2024; 73 (3).
The 2024 U.S. Selected Practice Recommendations for Contraceptive Use (U.S. SPR) …
The 2024 U.S. Selected Practice Recommendations for Contraceptive Use (U.S. SPR) addresses a selected group of common, yet sometimes complex, issues regarding initiation and use of specific contraceptive methods. These recommendations for health care providers were updated by CDC after review of the scientific evidence and a meeting with national experts in Atlanta, Georgia, during January 25–27, 2023. The information in this report replaces the 2016 U.S. SPR (CDC. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. MMWR 2016;65[No. RR-4]:1–66). Notable updates include 1) updated recommendations for provision of medications for intrauterine device placement, 2) updated recommendations for bleeding irregularities during implant use, 3) new recommendations for testosterone use and risk for pregnancy, and 4) new recommendations for self-administration of injectable contraception. The recommendations in this report are intended to serve as a source of evidence-based clinical practice guidance for health care providers. The goals of these recommendations are to remove unnecessary medical barriers to accessing and using contraception and to support the provision of person-centered contraceptive counseling and services in a noncoercive manner. Health care providers should always consider the individual clinical circumstances of each person seeking contraceptive services. This report is not intended to be a substitute for professional medical advice for individual patients; when needed, patients should seek advice from their health care providers about contraceptive use.
Centers for Disease Control and Prevention
About Adverse Childhood Experiences 2024
Centers for Disease Control and Prevention
Developmental Milestones
Centers for Disease Control and Prevention
National Center for Health Statistics, International Classification of Diseases, Tenth Revision (ICD-10)
Centers for Disease Control and Prevention
Sexually Transmitted Infections Treatment Guidelines, 2021
Sexual Assault and Abuse STIs, Adolescents and Adults
Centers for Disease Control and Prevention
Sexually Transmitted Infections (STI) Treatment Guidelines
Centers for Disease Control and Prevention
Summary Chart of U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC)
Centers for Medicare & Medicaid Services (CMS)
ICD-10 Codes
Child Abuse MD Appendices
Child Abuse MD Curbside Consults
Child Abuse MD
Directory of Child Abuse Agencies and Organizations. (n.d.)
Child Abuse MD
Child Abuse Evaluation & Treatment for Medical Providers
Chapter on …
Child Abuse Evaluation & Treatment for Medical Providers
- Chapter on Diagnosis: Physical Abuse
[NEED LINK]
- Appendix: Common Types of Diaphyseal Fractures
[NEED LINK]
- Curbside Consults
Child Abuse MD
Child Welfare Information Gateway
Forensic Interviewing: A Primer for Child Welfare Professionals. 2023
Child Welfare Information Gateway
Child Welfare Information Gateway. (2022). Definitions of child abuse and …
Child Welfare Information Gateway. (2022).
Definitions of child abuse and neglect. U.S. Department of Health and Human Services, Administration for Children and Families, Children's Bureau.
https://www.childwelfare.gov/topics/systemwide/laws-policies/statutes/define/.
State Statutes
Child Welfare Information Gateway
US Department of Health and Human Services, 2018
The Risk and Prevention of Maltreatment of Children with Disabilities
Child Welfare Information Gateway
Factsheet, April 2019, Washington, DC: U.S. Department of Health and Human
Services, Children’s Bureau.
Consent for medical care for those under age 18
A guide for New York State:
https://ocfs.ny.gov/programs/youth/rhy/assets/docs/ …
Cyberbullying Research Center
They offer: Sexting: Advice for Teens
Darkness to Light
They offer: Training for schools and community organizations to help adults recognize signs of potential sexual misconduct, including their flagship program Stewards of Children®.
d2l.org
Defend Young Minds
They offer: Books, curriculum, guides and a newsletter to help raise empowered, resilient, screen-smart kids. Kids can learn to reject pornography.
defendyoungminds.com
Disability & Abuse Project
disability-abuse.com
Disability Day of Mourning
disability-memorial.org
Drugs that facilitate sexual abuse
Rohypnol: https://www.justice.gov/archive/ndic/pubs6/6074/index.htm and …
Enough Abuse Campaign
They offer: Training for schools and community organizations to help adults recognize signs of potential sexual misconduct; on-line resources including guides for parents.
enoughabuse.org
Enough Abuse
They offer: A free, downloadable guide to prevention of child sexual abuse …
enoughabuse.org
Finkelhor D, Turner H, Colburn D. Prevalence of Online Sexual Offenses Against Children in the US. Jama Network Open. 2022; 5 (10) : e2234471.
Keywords: Adolescent, Child, *Child Abuse, Sexual, Erotica, Female, Humans, Male, Prevalence, Retrospective Studies, *Sexual Harassment, Young Adult
IMPORTANCE: Sexual abuse is increasingly facilitated by technology, but the …
IMPORTANCE: Sexual abuse is increasingly facilitated by technology, but the prevalence and dynamics of such offenses have not been well delineated, making it difficult to design prevention strategies. OBJECTIVE: To examine the frequency and characteristics of online and technology-facilitated sexual abuse against children and youth. DESIGN, SETTING, AND PARTICIPANTS: In this nationally representative online survey study performed from November 19 to December 29, 2021, young adults aged 18 to 28 years were asked retrospectively about their childhood (<18 years) experiences of online and technology-facilitated abuse. The 2639 participants were sampled from an online panel. MAIN OUTCOMES AND MEASURES: Participants were asked questions about 11 different kinds of online and technology-facilitated sexual abuse with follow-up questions about their dynamics and offenders. Prevalence rates were calculated for several cross-cutting concepts (online child sexual abuse, image-based sexual abuse, self-produced child sexual abuse images, nonconsensual sexting, online grooming by adults, revenge pornography, sextortion, and online commercial sexual exploitation). Survey weights were applied to obtain population prevalence estimates. RESULTS: A total of 2639 individuals (48.5% male, 49.8% female, and 1.8% other gender; 23.7% Hispanic, 12.6% non-Hispanic Black, 53.9% non-Hispanic White, 4.8% other race, and 5.0% ≥2 races) were surveyed. Childhood (before 18 years of age) prevalence rates were as follows: online child sexual abuse, 15.6% (SE, 1.0%); image-based sexual abuse, 11.0% (SE, 0.9%); self-produced child sexual abuse images, 7.2% (SE, 0.7%); nonconsensual sexting, 7.2% (SE, 0.7%); online grooming by adults, 5.4% (SE, 0.5%); revenge pornography, 3.1% (SE, 0.5%); sextortion, 3.5% (SE, 0.6%); and online commercial sexual exploitation, 1.7% (SE, 0.3%). The prime age of vulnerability across all categories was 13 to 17 years. Perpetrators in most categories were predominantly dating partners, friends, and acquaintances, not online strangers. CONCLUSIONS AND RELEVANCE: The results of this national survey study suggest that a considerable portion of youth have experienced online child sexual abuse. Professionals planning prevention and intervention strategies for online sexual abuse should understand that dynamics include diverse episodes that are often extensions of dating abuse, sexual bullying, and sexual harassment, not only events perpetrated by adult internet predators.
Gewirtz-Meydan A, Finkelhor D. Sexual Abuse and Assault in a Large National Sample of Children and Adolescents. Child Maltreatment. 2020; 25 (2) : 203-214.
Keywords: Adolescent, Age Distribution, Child, Child Abuse, Sexual/ethnology/psychology/*statistics & numerical data, Child, Preschool, Fear, Female, Humans, Infant, Infant, Newborn, Male, Sex Distribution, Socioeconomic Factors, United States/epidemiology
The present study sought to examine features of sexual abuse cases among a U.S. …
The present study sought to examine features of sexual abuse cases among a U.S. nationally representative sample of 13,052 children and adolescents, ages 0-17 years. The National Survey of Children's Exposure to Violence was collected in three different years (2008, 2011, and 2014) via telephone interviews. Information about sexual abuse and assault was obtained from youth themselves (ages 10-17) or caregivers (for children ages 0-9) using the Juvenile Victimization Questionnaire. Results indicate most offenses are at the hands of other juveniles (76.7% for males and 70.1% for females), primarily acquaintances, and occurring more frequently for adolescents aged 14-17. Whereas girls are mostly abused by males (88.4%), boys are abused by both males (45.6%) and females (54.4%). In 15% of cases, penetration is part of the abuse. Victims report being very afraid in 37.5% of episodes but not at all afraid in 19.8%. Among 10- to 17-year-olds, 66.3% of episodes are not reported to parents or any adult. Police reports occur for 19.1% of all cases. The results in the present study indicate that children and youth are exposed to sexual abuse and assault in varied ways, which require moving beyond conventional stereotypes of the problem.
Goldberg AP, Moore JL, Houck C, Kaplan DM, Barron CE. Domestic Minor Sex Trafficking Patients: A Retrospective Analysis of Medical Presentation.
Journal of Pediatric and Adolescent Gynecology. 2017; 30 (1) : 109-115.
Epub 2016
Keywords: Adolescent, *Attitude of Health Personnel, Awareness, Child, Child Abuse, Sexual/*diagnosis/psychology, Emergency Service, Hospital, Female, *Health Knowledge, Attitudes, Practice, Homeless Youth/psychology, Hospitals, Pediatric, Human Trafficking/*psycho
STUDY OBJECTIVE: To describe the clinical characteristics of patients …
STUDY OBJECTIVE: To describe the clinical characteristics of patients referredfor domestic minor sex trafficking (DMST) to improve identification andintervention. DESIGN: Retrospective cohort study. SETTING: The Lawrence A. Aubin,Sr Child Protection Center at Hasbro Children's Hospital where patients areevaluated by child abuse pediatricians in outpatient, emergency department, andinpatient settings. PARTICIPANTS: A total of 41 patients younger than the age of18 years referred for the evaluation of DMST involvement between August 1, 2013and March 30, 2015. INTERVENTIONS AND MAIN OUTCOME MEASURES: We collecteddemographic, social-environmental, medical, and psychiatric variables from themedical records of patients referred for evaluation who have self-disclosed, beenreported with evidence, and/or have histories that place them at high risk forDMST involvement. RESULTS: Children had frequent contact with medical providers,with 81% seen in the year before referral for DMST. Childhood maltreatment andfamily dysfunction were identified (sexual abuse, 21/37 or 57%; parentalsubstance abuse, 22/37 or 60%) in the 41 patients. Children had medical problems(eg, sexually transmitted infection, 13/41 or 32%), psychiatric needs (eg, acutesuicidality, 8/41 or 20%; at least 1 previous psychiatric admission, 19/41 or46%), and substance use (36/41 or 88%). Although 26/41 (63%) had runaway and17/41 (42%) lived in a group home placement, 28/41 (68%) currently lived at homeand 29/41 (71%) presented with a parent/guardian or relative. CONCLUSION:Children referred for DMST present frequently to physicians and have complexmedical and psychiatric needs. Medical providers' increased awareness of thishealth issue would inform victim identification and intervention.
Greenbaum J, Crawford-Jakubiak JE. Child sex trafficking and commercial sexual exploitation: health care needs ofvictims. Pediatrics. 2015; 135 (3) : 566-74.
Keywords: Child, Child Abuse, Sexual/*legislation & jurisprudence/statistics & numerical data, Health Services Needs and Demand/*legislation & jurisprudence, Human Trafficking/*legislation & jurisprudence, Humans, *Public Health, Sexual Behavior, United States
Child sex trafficking and commercial sexual exploitation of children (CSEC) …
Child sex trafficking and commercial sexual exploitation of children (CSEC) aremajor public health problems in the United States and throughout the world.Despite large numbers of American and foreign youth affected and a plethora ofserious physical and mental health problems associated with CSEC, there islimited information available to pediatricians regarding the nature and scope ofhuman trafficking and how pediatricians and other health care providers may helpprotect children. Knowledge of risk factors, recruitment practices, possibleindicators of CSEC, and common medical and behavioral health problems experiencedby victims will help pediatricians recognize potential victims and respondappropriately. As health care providers, educators, and leaders in childadvocacy, pediatricians play an essential role in addressing the public healthissues faced by child victims of CSEC. Their roles can include working toincrease recognition of CSEC, providing direct care and anticipatory guidancerelated to CSEC, engaging in collaborative efforts with medical and nonmedicalcolleagues to provide for the complex needs of youth, and educating child-servingprofessionals and the public.
HIV and PEP Laws and Guidelines
HIV
Public Health Law, Article 27-F New York State Confidentiality Law and …
HealthyChildren.org
Sexual Behaviors in Young Children: What’s Normal, What’s Not? 2023
Hong S, Lu N, Wu D, Jimenez DE, Milanaik RL. Digital sextortion: Internet predators and pediatric interventions. Current Opinion in Pediatrics. 2020; 32 (1) : 192-197.
Keywords: Child, Child Abuse, Sexual/legislation & jurisprudence/*psychology, Coercion, Correspondence as Topic, Crime Victims/legislation & jurisprudence/*psychology, Cyberbullying/*psychology, Humans, *Internet/legislation & jurisprudence, Minors/legislation & ju
PURPOSE OF REVIEW: Sextortion is defined as the act of coercing people into …
PURPOSE OF REVIEW: Sextortion is defined as the act of coercing people into sending explicit images of themselves and subsequently blackmailing victims with the public release of said images. Prosecutions of sextortion cases involving minors have increased almost two-fold in the past 5 years. The purpose of this review is to explore the literature regarding the behavior of both victims and perpetrators, the effects on victims, and the support resources available for clinicians, victims, and parents. RECENT FINDINGS: Sextortion begins as an unassuming request for personal pictures and quickly escalates. Minors targeted by predators fear both punishment by guardians and the social consequences that follow the release of their explicit pictures. This cycle of victimization endangers minors and may lead to mental health problems, such as anxiety and depression. Recently, sextortion cases have risen to the forefront of national attention through the mainstream media with celebrities revealed as both perpetrators and victims. This higher visibility of sextortion highlights the importance of reviewing recent research regarding minors and their online behavior and the tactics of perpetrators. SUMMARY: Sextortion, an extreme form of cyber abuse, endangers minors and may lead to anxiety and depression. Pediatricians should be familiar with the concept of sextortion and discuss its dangers and available resources with parents and minors.
Howell JO, Flowers D. Prepubertal Vaginal Bleeding: Etiology, Diagnostic Approach, and Management. Obstetrical & Gynecological Survey. 2016; 71 (4) : 231-42.
Keywords: Age Factors, Child, Child, Preschool, Disease Management, Female, Gynecological Examination, Humans, Infant, Uterine Hemorrhage/diagnosis/*etiology/therapy
IMPORTANCE: Prepubertal vaginal bleeding outside the neonatal period is always …
IMPORTANCE: Prepubertal vaginal bleeding outside the neonatal period is always abnormal and is very alarming to parents. A variety of practitioners, including obstetrician-gynecologists and pediatricians, may be asked to see patients with this presenting complaint, yet many do not receive adequate training in pediatric gynecology. EVIDENCE ACQUISITION: Review of the published literature in PubMed, focusing on the last 20 years, regarding the incidence, etiologies, diagnosis, and management strategies for the common causes of prepubertal vaginal bleeding. RESULTS: Careful history taking and pediatric-specific gynecological examination skills, including awareness of normal anatomy across the age spectrum and the ability to identify an estrogenized hymen, are keys to the appropriate assessment of this clinical problem. CONCLUSIONS AND RELEVANCE: Prepubertal vaginal bleeding has many causes and requires a thorough targeted history and pediatric genitourinary examination, requiring knowledge of the variants of normal pediatric genitourinary anatomy. Most causes can be easily treated and are less likely to be due to sexual abuse or malignancy.
Imaging Technology News
Pediatric Imaging. January 26, 2018.
FDA Releases New Guidance on Children's X-ray Exams
Internet Watch Foundation
They offer: An anonymous online reporting service for child sexual abuse images & videos. This organization works globally.
www.iwf.org.uk
It’s time we talked
They offer: Tip sheets to help parents support their young people navigate the influence of pornography.
itstimewetalked.podia.com/parent-resources
Kimberlin DW, Banerjee R, Barnett ED, Lynfield R, Sawyer MH.
Red Book: 2024–2027 Report of the Committee on Infectious Diseases. American Academy of Pediatrics. 2024; Chapter: Group A Streptococcal Infections
DOI.
ISBN: 978-1-61002-737-3
For more than 85 years, health care professionals have “referred to the Red …
For more than 85 years, health care professionals have “referred to the Red Book” for trustworthy guidance on pediatric infectious disease prevention, management, and control. The new 33rd edition continues this tradition of distinction with the latest clinical guidance on the manifestations, etiology, epidemiology, diagnosis, and treatment of more than 200 childhood infectious diseases.
Legal Information Institute, Cornell University
Emancipation of minors – laws:
Laws of the fifty states, District of Columbia and Puerto Rico governing the emancipation of minors. Cornell University
https://www.law.cornell.edu/wex/table_emancipation
Legality of Female Circumcision
In 2008, the World Health Assembly passed resolution WHA61.16 on the …
In 2008, the World Health Assembly passed resolution
WHA61.16 on the elimination of female genital mutilation. FGM is a crime under federal law except in circumstances where it is deemed necessary to the health of the person on whom it is performed and when performed by a medical practitioner (
18 USC §116: Female genital mutilation) In New York State, female genital mutilation is a felony Class E offense. According to
New York Penal Code §130.85, it is the excision, circumcision or infibulation of any part of the clitoris or labia of a girl who is younger than eighteen years of age.
Lobo M, Smith JA, Gall JA. Challenging the Myth That the Sexually Abused Female Child Must Have Genital Injuries. Journal of Law and Medicine. 2022; 29 (1) : 270-278.
Keywords: Child, *Child Abuse, *Child Abuse, Sexual/diagnosis, Female, Genitalia, Humans, Puberty
This article aims to define and describe female genital anatomy, the changes …
This article aims to define and describe female genital anatomy, the changes that occur in the genitalia during growth and puberty, and during sexual response and intercourse. It elaborates the reasons for normal genital examination findings in most female children who have been sexually abused and explains why the absence of findings of genital trauma should not be used to challenge the credibility of the child's history of sexual abuse.
Madigan S, Villani V, Azzopardi C, Laut D, Smith T, Temple JR, Browne D, Dimitropoulos G. The Prevalence of Unwanted Online Sexual Exposure and Solicitation Among Youth: A Meta-Analysis. The Journal of Adolescent Health : Official Publication of the Society for Adolescent Medicine. 2018; 63 (2) : 133-141.
Keywords: Adolescent, *Erotica, Humans, *Internet, Sex Factors, *Sexual Behavior
PURPOSE: The objective of this meta-analysis was to provide a synthesis of …
PURPOSE: The objective of this meta-analysis was to provide a synthesis of studies examining the prevalence of unwanted online exposure and solicitation of a sexual nature among youth, and to determine if prevalence varies by youth age, gender, year of study data collection, or study geographical location. METHOD: Eligible studies from January 1990 to January 2016 were identified utilizing a comprehensive search strategy. Included studies examined the prevalence of unwanted online exposure and solicitation in youth who ranged from 12 to 16.5 years. Two independent coders extracted all relevant data. Random-effects meta-analyses were used to derive mean prevalence rates. RESULTS: Thirty-one (37,649 participants) and nine (18,272 participants) samples were included in the syntheses on unwanted online sexual exposure and solicitation, respectively. For online exposure, the mean prevalence rate was 20.3% (95% confidence interval: 17.1-23.4). For online solicitation, the mean prevalence rate was 11.5% (95% confidence interval: 9.4-13.6). Moderator analyses indicated that prevalence rates for unwanted online exposure and solicitation have decreased over time. Prevalence varied as a function of gender (solicitations were higher for males), but not age or geographical location. CONCLUSIONS: Approximately one in five youth experience unwanted online exposure to sexually explicit material and one in nine youth experience online sexual solicitation. Educational campaigns to raise awareness of Internet risks and safety strategies are warranted.
Melmer MN, Gutovitz S. Child Sexual Abuse and Neglect. Treasure Island (FL): StatPearls Publishing; 2024. StatPearls [Internet]. 2023.
Sexual abuse of children is the involvement of children or adolescents in …
Sexual abuse of children is the involvement of children or adolescents in sexual activities that he or she does not fully understand and can include exhibitionism, fondling, oral-genital contact, and rectal or vaginal penetration. By adulthood, 26% of girls and 5% of boys experience sexual abuse. It is the healthcare provider's responsibility to advise the parents unless they are suspected of abuse and enlist help from other medical specialists or child protective services. A variety of nonspecific presenting symptoms including but not limited to pain, anogenital bleeding, vaginal/urethral discharge, dysuria, urinary tract infection, sexualized behavior, and suicidality are possible. It is also common for the initial presentation of suspected sexual abuse in the absence of any physical symptoms. In such cases, it is important to be mindful that the assailant is often an individual that is close to the victim, such as a close relative or even the parent. All patients presenting within 72 hours of the suspected abuse or presenting with any concerning symptoms should be evaluated emergently, preferably by a sexual assault nurse examiner or child abuse pediatrician if available. In those presenting without symptoms and greater than 72 hours following the suspected abuse, specialized outpatient follow-up should be arranged for further evaluation and treatment. A good understanding of state-specific legislation regarding consent and treatment of minors is essential when treating victims of child sexual abuse.
NC Detect - North Carolina Department of Health and Human Services
North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT)
What are E-codes and why are they important?
National Center for the Sexual Behavior of Youth
Your Guiding Principles
National Center for Missing and Exploited Children
They offer: A wide range of resources for parents as well as professionals. …
-
They offer: A wide range of resources for parents as well as professionals.
- Including, Net Smartz Kids, an activity site for kids about being safer online. https://www.netsmartzkids.org.
- In addition, a free service that helps victims remove or stop the online sharing of nude, partially or sexually explicit images taken of minors https://takeitdown.ncmec.org.
https://www.ncmec.org/
National Center for Missing and Exploited Children
-
They offer: Resources and materials for the public and professionals.
-
In addition, www.takeitdown.ncmec.org, a free service that helps victims remove or stop the online sharing of nude, partially or sexually explicit images taken of minors.
ncmec.org/
National Center on Sexual Behaviors of Youth
They offer: Information, resources, and support to help children move forward towards a healthier and happier future.
www.ncsby.org/parents-caregivers
National Child Traumatic Stress Network
They offer: Resources, information and training on multiple types of child traumatic stress, including violence and abuse.
nctsn.org
National Children’s Alliance
Standards for Accreditation of Child Advocacy Centers
National Coalition to Prevent Child Sexual Abuse and Exploitation
They offer: A National Plan to prevent child sexual abuse and exploitation; resources for professionals.
preventtogether.org
National Coordinator for Health IT
ONC’s Cures Act Final Rule (21st Century Cures Act). This rule supports seamless and secure access, exchange, and use of electronic health information.
https://www.healthit.gov/topic/oncs-cures-act-final-rule
New York City - Administration for Children's Services
What is Child Abuse/Neglect?
New York Civil Liberties Union
Reference card: Minors and rape crisis treatment 2006
New York Civil Liberties Union
Teenagers, healthcare and the law: A guide to the law on minors' rights in New York State. 3rd edition, 2018.
New York State Association of County Health Officials (NYSACHO)
Directory of County Health Offices
New York State Department of Health
The New York State Early Intervention Program (EIP) is part of the national Early Intervention Program for infants and toddlers with disabilities and their families.
Early Intervention Program
New York State Department of Health Aids Institute
HIV Testing and Acute HIV
New York State Division of Criminal Justice - Evidence Collection
for information about obtaining evidence collection kits and forms https://www.c …
New York State Initiative to Prevent Child Sexual Abuse
Main link. https://www.nypreventsexabuse.org/.
The Healthy Child Sexual …
New York State Initiative to Prevent Child Sexual Abuse
They offer: A downloadable brochure on healthy sexual development for kids of …
nypreventsexabuse.org
New York State Laws
NY State Sanitary Code Title 10 § 2.1
New York State Laws
Social Services Law - SOS § 412
New York State Laws
Family Court Law
Family Court Act - FCT §1024. Describes taking a …
New York State Laws - Hepatitis C
New York State Public Health Law §2171. Requires offering of hepatitis C …
New York State Office of Children and Family Services
2025 New York State Child Protective Services Manual, Chapter 14: Definitions of abuse and maltreatment. 2022, June.
2022-CPS-Manual-Ch14-2022Jun.pdf
New York State Office of Children and Family Services
Per the New York State Office of Children and Family Services Mandated Reporter …
Per the New York State Office of Children and Family Services Mandated Reporter definitions of neglect:
The minimum degree of care standard does not necessarily equate to optimal parenting.... When determining whether the minimum degree of care was taken, we must consider whether the parent was financially able to provide for the child or was offered financial or other means to do so. Remember, poverty in and of itself, is not maltreatment or abuse.
Downloaded March 25, 2025.
Definitions of Maltreatment and Abuse/Neglect
New York State Office of Children and Family Services
Mandated Reporter Resource Center
New York State Office of Children and Family Services
NYS-2025-CPS-Manual.pdf
New York State Resources on Drug-Assisted Sexual Assault
Drug facilitated sexual assault evidence collection kit https://www.templater …
Newlin C, Steele LC, Chamberlin A, Anderson J, Kenniston J, Russell A, Stewart H, Vaughan-Eden V. Child Forensic Interviewing: Best Practices. U.S. Department of Justice, Office of Justice Programs. Juvenile Justice Bulletin. 2015; (September).
This bulletin consolidates the current knowledge of professionals from several …
This bulletin consolidates the current knowledge of professionals from several
major forensic interview training programs on best practices for interviewing
children in cases of alleged abuse. The authors discuss the purpose of
the child forensic interview, provide historical context, review overall
considerations, and outline each stage of the interview in more detail.
Among the topics that the authors discuss are the following:
• No two children will relate their experiences in the same way or
with the same level of detail and clarity. Individual characteristics,
interviewer behavior, family relationships, community influences,
and cultural and societal attitudes determine whether, when, and
how they disclose abuse.
• The literature clearly explains the dangers of repeated questioning
and duplicative interviews; however, some children require more
time to become comfortable with the process and the interviewer.
• Encouraging children to give detailed responses early in the
interview enhances their responses later on.
• Forensic interviewers should use open-ended questions and should
allow for silence or hesitation without moving to more focused
prompts too quickly. Although such questions may encourage
greater detail, they may also elicit potentially erroneous responses if
the child feels compelled to reach beyond his or her stored memory.
Northeast Regional Children’s Advocacy Center
2023.
Minimal Facts Guidelines
Reading R, Hughes G, Hill J, Debelle G. Genital herpes in children under 11 years and investigations for sexual abuse. Archives of Disease in Childhood. 2011; 96 (8) : 752-7.
Keywords: Child, Child Abuse, Sexual/*diagnosis/statistics & numerical data, Child Welfare/statistics & numerical data, Child, Preschool, Female, Herpes Genitalis/epidemiology/*transmission/virology, Herpesvirus 1, Human/isolation & purification, Herpesvirus 2, Hum
OBJECTIVE: The implications for sexual abuse investigation of genital herpes in …
OBJECTIVE: The implications for sexual abuse investigation of genital herpes in a child are uncertain because of a lack of good quality research evidence. The incidence, presenting features, history of exposure, indicators of child maltreatment and outcomes of child protection investigations in children with genital herpes are described. PATIENTS AND METHODS: Ascertainment of all cases of genital herpes in children <11 years of age first presenting to paediatricians in the UK and Ireland from April 2007 to April 2009 conducted through the British Paediatric Surveillance Unit. RESULTS: 23 cases were notified. The incidence of confirmed and all reported cases was 0.091 and 0.13 per 100,000 children per year, respectively. Of the 16 virologically confirmed cases, 12 were female, 11 were <5 years of age, 14 had herpes simplex type 1, eight were tested for other sexually transmitted infections (STIs), and only one had a full STI screen. Three cases had other clinical features suggestive of sexual abuse. Six cases were referred for child protection investigation, but no sexual abuse was substantiated. CONCLUSIONS: Genital herpes in children under 11 years is rare. Almost a third of children diagnosed with genital herpes did not have appropriate virological investigation and few were screened for other STIs. Around a quarter of cases were referred to child protection agencies for further investigation, which limits any inferences in this study about mode of transmission in children. Sexual abuse guidance should emphasise the need for thorough assessment and investigation in cases of genital herpes in children.
Sege RD, Siegel BS. Effective Discipline to Raise Healthy Children. Pediatrics. 2018; 142 (6).
Keywords: Child, *Child Behavior, Child Behavior Disorders/*prevention & control/psychology, Child Rearing/*psychology, Humans, *Parent-Child Relations, Parenting/*psychology, Parents/*psychology, Reinforcement, Psychology, *Societies, Medical
Pediatricians are a source of advice for parents and guardians concerning the …
Pediatricians are a source of advice for parents and guardians concerning the management of child behavior, including discipline strategies that are used to teach appropriate behavior and protect their children and others from the adverse effects of challenging behavior. Aversive disciplinary strategies, including all forms of corporal punishment and yelling at or shaming children, are minimally effective in the short-term and not effective in the long-term. With new evidence, researchers link corporal punishment to an increased risk of negative behavioral, cognitive, psychosocial, and emotional outcomes for children. In this Policy Statement, the American Academy of Pediatrics provides guidance for pediatricians and other child health care providers on educating parents about positive and effective parenting strategies of discipline for children at each stage of development as well as references to educational materials. This statement supports the need for adults to avoid physical punishment and verbal abuse of children.
Sex Wise Parent
They offer: Resources for parents to help them communicate with their children about sex.
sexwiseparent.com
Stop It Now
They offer: Parent tip sheets on multiple aspects of prevention and …
stopitnow.org
The Image Gently Alliance
A coalition of healthcare organizations dedicated to providing safe, high-quality pediatric imaging worldwide.
imagegently.org
The Royal College of Radiologists and The Society and College of Radiographers
Radiological Investigation of Suspected Physical Abuse in Children. 2018
The SAFER Society
They offer: Publications and continuing education ‘rooted in the latest empirical research’ to equip professionals to address sexual and social violence.
safersociety.org
US Center for SafeSport
They offer: Free, short trainings for parents and guardians that provide information and tools to keep kids safe.
uscenterforsafesport.org/parents/
US Department of Health and Human Services - Office on Women's Health
Female Genital Cutting
US Department of Health & Human Services - Head Start
May 2025.
Individualized Family Service Plans (IFSPs) Tips
US Department of Health and Human Services
The Health Insurance Portability and Accountability Act (HIPAA)
What's OK?
They offer: The opportunity for a teen to text, chat or email questions about their own sexual thoughts and interests.
whatsok.org
Wolak J, Finkelhor D, Mitchell KJ, Ybarra ML. Online “Predators” and their Victims: Myths, Realities and Implications for Prevention and Treatment. The American Psychologist. 2008; 63 (2) : 111-28.
Keywords: Adolescent, Child, Child Abuse, Sexual/*prevention & control, Crime/*prevention & control, *Crime Victims, Humans, *Internet
The publicity about online "predators" who prey on naive children using …
The publicity about online "predators" who prey on naive children using trickery and violence is largely inaccurate. Internet sex crimes involving adults and juveniles more often fit a model of statutory rape--adult offenders who meet, develop relationships with, and openly seduce underage teenagers--than a model of forcible sexual assault or pedophilic child molesting. This is a serious problem, but one that requires approaches different from those in current prevention messages emphasizing parental control and the dangers of divulging personal information. Developmentally appropriate prevention strategies that target youths directly and acknowledge normal adolescent interests in romance and sex are needed. These should provide younger adolescents with awareness and avoidance skills while educating older youths about the pitfalls of sexual relationships with adults and their criminal nature. Particular attention should be paid to higher risk youths, including those with histories of sexual abuse, sexual orientation concerns, and patterns of off- and online risk taking. Mental health practitioners need information about the dynamics of this problem and the characteristics of victims and offenders because they are likely to encounter related issues in a variety of contexts.
World Health Organization
Traditional medicine has a long history of contributing to conventional medicine and continues to hold promise
Zuckerbrot RA, Cheung AH, Jensen PS, Stein RE, Laraque D. Guidelines for Adolescent Depression in Primary Care (GLAD-PC): I. Identification, assessment, and initial management. Pediatrics. 2007; 120 (5) : e1299-312.
Keywords: Adolescent, Adult, Child, Depressive Disorder/*diagnosis/psychology/*therapy, Disease Management, Humans, Primary Health Care/*methods/*standards
OBJECTIVES: To develop clinical practice guidelines to assist primary care …
OBJECTIVES: To develop clinical practice guidelines to assist primary care clinicians in the management of adolescent depression. This first part of the guidelines addresses identification, assessment, and initial management of adolescent depression in primary care settings. METHODS: By using a combination of evidence- and consensus-based methodologies, guidelines were developed by an expert steering committee in 5 phases, as informed by (1) current scientific evidence (published and unpublished), (2) a series of focus groups, (3) a formal survey, (4) an expert consensus workshop, and (5) draft revision and iteration among members of the steering committee. RESULTS: Guidelines were developed for youth aged 10 to 21 years and correspond to initial phases of adolescent depression management in primary care, including identification of at-risk youth, assessment and diagnosis, and initial management. The strength of each recommendation and its evidence base are summarized. The identification, assessment, and initial management section of the guidelines includes recommendations for (1) identification of depression in youth at high risk, (2) systematic assessment procedures using reliable depression scales, patient and caregiver interviews, and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria, (3) patient and family psychoeducation, (4) establishing relevant links in the community, and (5) the establishment of a safety plan. CONCLUSIONS: This part of the guidelines is intended to assist primary care clinicians in the identification and initial management of depressed adolescents in an era of great clinical need and a shortage of mental health specialists but cannot replace clinical judgment; these guidelines are not meant to be the sole source of guidance for adolescent depression management. Additional research that addresses the identification and initial management of depressed youth in primary care is needed, including empirical testing of these guidelines.
Full Reference List
Abdoo DC, Puls HT, Hall M, Lindberg DM, Anderst J, Wood JN, Parikh K, Tashijan M, Sills MR. Racial and ethnic disparities in diagnostic imaging for child physical abuse. Child Abuse & Neglect. 2024; 149 : 106648 Section on Radiology; Diagnostic Imaging of Child Abuse.
Keywords: Humans, Infant, Infant, Newborn, Black or African American, *Child Abuse/diagnosis, Hispanic or Latino, Physical Abuse, Radiography, Retrospective Studies, White, *White People
IMPORTANCE: Racial bias may affect occult injury testing decisions for children …
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.
Adams JA, Kellogg ND, Farst KJ, Harper NS, Palusci VJ, Frasier LD, Levitt CJ, Shapiro RA, Moles RL, Starling SP. Updated Guidelines for the Medical Assessment and Care of Children Who May Have Been Sexually Abused. Journal of Pediatric and Adolescent Gynecology. 2016; 29 (2) : 81-87 Review.
Keywords: Child sexual abuse,Differential diagnosis,Expert opinion,Expert testimony,Medical history taking,Peer review,Sexually transmitted infections
The medical evaluation is an important part of the clinical and legal process …
The medical evaluation is an important part of the clinical and legal process when child sexual abuse is suspected. Practitioners who examine children need to be up to date on current recommendations regarding when, how, and by whom these evaluations should be conducted, as well as how the medical findings should be interpreted. A previously published article on guidelines for medical care for sexually abused children has been widely used by physicians, nurses, and nurse practitioners to inform practice guidelines in this field. Since 2007, when the article was published, new research has suggested changes in some of the guidelines and in the table that lists medical and laboratory findings in children evaluated for suspected sexual abuse and suggests how these findings should be interpreted with respect to sexual abuse. A group of specialists in child abuse pediatrics met in person and via online communication from 2011 through 2014 to review published research as well as recommendations from the Centers for Disease Control and Prevention and the American Academy of Pediatrics and to reach consensus on if and how the guidelines and approach to interpretation table should be updated. The revisions are based, when possible, on data from well-designed, unbiased studies published in high-ranking, peer-reviewed, scientific journals that were reviewed and vetted by the authors. When such studies were not available, recommendations were based on expert consensus.
Adams JA, Harper K, Knudson S, Revilla J. Examination findings in legally confirmed child sexual abuse: it's normal to be normal. Pediatrics. 1994; 94 (3) : 310-7.
Keywords: Child, Child Abuse, Sexual/*diagnosis/legislation & jurisprudence, Colposcopy, Discriminant Analysis, Female, Genitalia, Female/anatomy & histology/*injuries, Humans, Photography, Physical Examination, Reference Values
BACKGROUND: Studies of alleged victims of child sexual abuse vary greatly in …
BACKGROUND: Studies of alleged victims of child sexual abuse vary greatly in the reported frequency of physical findings based on differences in definition of abuse and of "findings." This study was designed to determine the frequency of abnormal findings in a population of children with legal confirmation of sexual abuse, using a standardized classification system for colposcopic photographic findings. METHODS: Case files and colposcopic photographs of 236 children with perpetrator conviction for sexual abuse, were reviewed. The photos were reviewed blindly by a team member other than the examiner, and specific anatomical findings were noted and classified as normal to abnormal on a scale of 1 to 5. Historical and behavioral information, as well as legal outcome was recorded, and all data entered into a dBase III program. Correlations were sought between abnormal findings and other variables. RESULTS: The mean age of the patients was 9.0 years (range 8 months to 17 years, 11 months), with 63% reporting penile-genital contact. Genital examination findings in girls were normal in 28%, nonspecific in 49%, suspicious in 9%, and abnormal in 14% of cases. Abnormal anal findings were found in only 1% of patients. Using discriminant analysis, the two factors which significantly correlated with the presence of abnormal genital findings in girls were the time since the last incident, and a history of blood being reported at the time of the molest. CONCLUSIONS: Abnormal genital findings are not common in sexually abused girls, based on a standardized classification system. More emphasis should be placed on documenting the child's description of the molestation, and educating prosecutors that, for children alleging abuse: "It's normal to be normal."
Adams JA, Starling SP, Frasier LD, Palusci VJ, Shapiro RA, Finkel MA, Botash AS. Diagnostic accuracy in child sexual abuse medical evaluation: role of experience, training, and expert case review. Child Abuse & Neglect. 2012; 36 (5) : 383-92.
Keywords: Anal Canal, Child, Child Abuse, Sexual/*diagnosis, Clinical Competence/*standards, Diagnosis, Differential, Genitalia, Health Knowledge, Attitudes, Practice, Humans, Pediatric Nursing/*standards, Pediatrics/*standards, Photography, Physical Examination/*s
OBJECTIVES: (1) The purpose of this study was to assess the ability of …
OBJECTIVES: (1) The purpose of this study was to assess the ability of clinicians who examine children for suspected sexual abuse to recognize and interpret normal and abnormal ano-genital findings in magnified photographs using an online survey format. (2) Determine which factors in education, clinical practice, and case review correlate with correct responses to the survey questions. METHODS: Between July and December 2007, medical professionals participated in a web-based survey. Participants answered questions regarding their professional background, education, clinical experience, and participation in case review. After viewing photographs and clinical information from 20 cases, participants answered 41 questions regarding diagnosis and medical knowledge. Answers chosen by an expert panel were used as the correct answers for the survey. RESULTS: The mean number of correct answers among the 141 first-time survey respondents was 31.6 (SD 5.9, range 15-41). Child Abuse Pediatricians (CAP) had mean total scores which were significantly higher than Pediatricians (Ped) (34.8 vs. 30.1, p<0.05) and Sexual Assault Nurse Examiners (SANE) (34.8 vs. 29.3, p<0.05). The mean total scores for Ped, SANE, and Advanced Practice Nurses (APN) who examine fewer than 5 children monthly for possible CSA were all below 30. Total score was directly correlated with the number of examinations performed monthly (p=0.003). In multivariable regression analysis, higher total score was associated with self-identification as a CAP, reading The Quarterly Update newsletter (p<0.0001), and with quarterly or more frequent expert case reviews using photo-documentation (p=0.0008). CONCLUSIONS: Child Abuse Pediatricians, examiners who perform many CSA examinations on a regular basis, examiners who regularly review cases with an expert, and examiners who keep up to date with current research have higher total scores in this survey, suggesting greater knowledge and competence in interpreting medical and laboratory findings in children with CSA. Review of cases with an expert in CSA medical evaluation and staying up to date with the CSA literature are encouraged for non-specialist clinicians who examine fewer than 5 children monthly for suspected sexual abuse.
Adams JA. Sexual Abuse in Children: What the General Practice Ob/Gyn Needs to Know. Clinical Obstetrics and Gynecology. 2020; 63 (3) : 486-490.
Keywords: Adolescent, Child, *Child Abuse, Sexual/prevention & control/psychology/statistics & numerical data, Female, Genitalia, Female/*anatomy & histology/physiology, Gynecological Examination/*methods, Gynecology/*methods, Humans, Physical Examination/*methods,
The medical evaluation of a child who may have been sexually abused can be a …
The medical evaluation of a child who may have been sexually abused can be a challenge for physicians who are unfamiliar with the wide variation in normal genital anatomy in prepubertal girls. Signs of injury are rarely found, unless the child is examined within 72 hours of the event. This article will provide some history about how guidelines for medical care of these children have been developed, and list some of the findings that are normal or normal variants, caused by other conditions, or due to trauma or infection.
Alderman EM, Breuner CC. Unique Needs of the Adolescent. Pediatrics. 2019; 144 (6).
Keywords: Adolescent, Adolescent Behavior/*physiology/psychology, Adolescent Development/*physiology, Child, Female, *Health Policy/trends, Health Risk Behaviors/*physiology, *Health Services Needs and Demand/trends, Humans, Male, Pediatrics/methods/trends, Sexual
Adolescence is the transitional bridge between childhood and adulthood; it …
Adolescence is the transitional bridge between childhood and adulthood; it encompasses developmental milestones that are unique to this age group. Healthy cognitive, physical, sexual, and psychosocial development is both a right and a responsibility that must be guaranteed for all adolescents to successfully enter adulthood. There is consensus among national and international organizations that the unique needs of adolescents must be addressed and promoted to ensure the health of all adolescents. This policy statement outlines the special health challenges that adolescents face on their journey and transition to adulthood and provides recommendations for those who care for adolescents, their families, and the communities in which they live.
Ali-Panzarella AZ. A Diagnostic Approach to Conditions that Mimic Sexual Abuse. Pediatric Annals. 2020; 49 (8) : e334-e340.
Keywords: Anal Canal/injuries, Anus Diseases/*diagnosis/therapy, Child, Child Abuse, Sexual/*diagnosis, Child, Preschool, Diagnosis, Differential, Female, Genital Diseases, Female/*diagnosis/therapy, Genital Diseases, Male/*diagnosis/therapy, Genitalia/injuries, Hu
Primary care providers are often the first point of contact when there are …
Primary care providers are often the first point of contact when there are concerns of child sexual abuse. The history is the key factor in making the diagnosis as most children who have experienced child sexual abuse do not have an abnormal anogenital examination. When anogenital symptoms precipitate concerns for sexual abuse, especially in the absence of a history of sexual abuse, it is important to be aware of conditions that mimic sexual abuse. Being familiar with such conditions allows the provider to determine appropriate management, differentiate an anatomical variant or medical condition from abuse, and provide reassurance to the patient and family. Unnecessarily reporting these cases can have detrimental effects on the patient and family. If any doubt arises, patients can be referred for further evaluation by an expert in child abuse. This article presents many common medical conditions that can mimic sexual abuse, with a focus on history, examination findings, and management. [Pediatr Ann. 2020;49(8):e334-e340.].
American Academy of Pediatrics: Committee on Child Abuse and Neglect and Committee on Children With Disabilities. Assessment of maltreatment of children with disabilities. Pediatrics. 2001; 108 (2) : 508-12.
Keywords: Child, Child Abuse/legislation & jurisprudence/prevention & control/*statistics & numerical data, Child Advocacy, Children with Disabilities/classification/legislation & jurisprudence/*statistics & numerical data, Humans, Incidence, Organizational Policy,
Widespread efforts are continuously being made to increase awareness and …
Widespread efforts are continuously being made to increase awareness and provide education to pediatricians regarding risk factors of child abuse and neglect. The purpose of this statement is to ensure that children with disabilities are recognized as a population that is also at risk for maltreatment. The need for early recognition and intervention of child abuse and neglect in this population, as well as the ways that a medical home can facilitate the prevention and early detection of child maltreatment, should be acknowledged.
American Academy of Pediatrics Committee on Pediatric Workforce. Culturally effective pediatric care: education and training issues. Pediatrics. 1999; 103 (1) : 167-70.
Keywords: *Cultural Diversity, Culture, *Delivery of Health Care, Education, Medical, Continuing/methods, Education, Medical, Undergraduate/methods, Internship and Residency/methods, Pediatrics/*education, United States
This policy statement defines culturally effective health care and describes …
This policy statement defines culturally effective health care and describes its importance for pediatrics. The statement also defines cultural effectiveness, cultural sensitivity, and cultural competence and describes the importance of these concepts for training in medical school, residency, and continuing medical education. The statement is based on the premise that culturally effective health care is important and that the knowledge and skills necessary for providing culturally effective health care can be taught and acquired through 1) educational courses and other formats developed with the expressed purpose of addressing cultural competence and/or cultural sensitivity, and 2) educational components on cultural competence and/or cultural sensitivity that are incorporated into medical school, residency, and continuing medical education curricula.
American Academy of Pediatrics Committee on Child Abuse and Neglect. Guidelines for the evaluation of sexual abuse of children: subject review. Pediatrics. 1999; 103 (1) : 186-91.
Keywords: Child, Child Abuse, Sexual/*diagnosis/legislation & jurisprudence/therapy, Diagnostic Errors, Female, Humans, Male, *Mandatory Reporting, Medical History Taking, Medical Records, Physical Examination, Sexually Transmitted Diseases/diagnosis/etiology
This statement serves to update guidelines for the evaluation of child sexual …
This statement serves to update guidelines for the evaluation of child sexual abuse first published in 1991. The role of the physician is outlined with respect to obtaining a history, physical examination, and appropriate laboratory data and in determining the need to report sexual abuse.
American Academy of Pediatrics Committee on Bioethics. Religious objections to medical care. Pediatrics. 1997; 99 (2) : 279-81.
Keywords: Child, Child Advocacy, Child Welfare/*legislation & jurisprudence, Humans, Organizational Policy, Pediatrics, *Religion and Medicine, Societies, Medical, United States
Parents sometimes deny their children the benefits of medical care because of …
Parents sometimes deny their children the benefits of medical care because of religious beliefs. In some jurisdictions, exemptions to child abuse and neglect laws restrict government action to protect children or seek legal redress when the alleged abuse or neglect has occurred in the name of religion. The American Academy of Pediatrics (AAP) believes that all children deserve effective medical treatment that is likely to prevent substantial harm or suffering or death. In addition, the AAP advocates that all legal interventions apply equally whenever children are endangered or harmed, without exemptions based on parental religious beliefs. To these ends, the AAP calls for the repeal of religious exemption laws and supports additional efforts to educate the public about the medical needs of children.
American Academy of Pediatrics Council on Child Abuse and Neglect - healthychildren.org
Stirling J, & Gavril A.
Last updated 8/7/2024. Downloaded May 26, 2025.
Child Abuse and Neglect: AAP Policy Explained
Ammerman RT. Attention to the issues surrounding abuse and neglect of children with disabilities. Child Abuse & Neglect. 1998; 22 (7) : 661-2.
Keywords: Adolescent, Child, Child Abuse/prevention & control/*statistics & numerical data, Child Welfare, Child, Preschool, Cross-Sectional Studies, Children with Disabilities/*statistics & numerical data, Female, Humans, Infant, Male, Risk Factors, United States/
Anderst JD, Carpenter SL, Abshire TC. Evaluation for bleeding disorders in suspected child abuse. Pediatrics. 2013; 131 (4) : e1314-22.
Keywords: Blood Coagulation Disorders/blood/complications/*diagnosis, Blood Coagulation Tests, Child, Child Abuse/*diagnosis, Child, Preschool, Contusions/blood/*etiology, Decision Support Techniques, Diagnosis, Differential, Hemorrhage/blood/*etiology, Hemorrhagic
Bruising or bleeding in a child can raise the concern for child abuse. …
Bruising or bleeding in a child can raise the concern for child abuse. Assessing whether the findings are the result of trauma and/or whether the child has a bleeding disorder is critical. Many bleeding disorders are rare, and not every child with bruising/bleeding concerning for abuse requires an evaluation for bleeding disorders. In some instances, however, bleeding disorders can present in a manner similar to child abuse. The history and clinical evaluation can be used to determine the necessity of an evaluation for a possible bleeding disorder, and prevalence and known clinical presentations of individual bleeding disorders can be used to guide the extent of the laboratory testing. This clinical report provides guidance to pediatricians and other clinicians regarding the evaluation for bleeding disorders when child abuse is suspected.
Ashraf IJ, Faivus Ackley D, Razawich K, Botash A, Schafer M, Pekarsky A. Improving Follow-Up Skeletal Survey Completion in Children with Suspected Nonaccidental Trauma. Pediatric Quality & Safety. 2022; 7 (3) : e567.
INTRODUCTION: The skeletal survey (SS) is used to evaluate and diagnose bone …
INTRODUCTION: The skeletal survey (SS) is used to evaluate and diagnose bone abnormalities, including fractures caused by child abuse. The American Academy of Pediatrics recommends initial SS for all children younger than 24 months old who are suspected victims of abuse and a follow-up skeletal survey (FUSS) 2 weeks later. The latter can further characterize abnormal or equivocal findings, detect ongoing trauma, or fractures too acute for visualization upon initial assessment. METHODS: Preintervention review at our hospital for FUSS completion of children younger than 36 months old yielded a low 40% average monthly completion rate. We reviewed charts of children who underwent SS during the study period for FUSS completion. There were several barriers to FUSS completion, including lack of provider knowledge regarding FUSS importance, lack of an order for FUSS before hospital discharge, absent chart documentation regarding FUSS decision, loss to follow-up, and parental refusal. Interventions targeting the barriers included provider education, protocolizing FUSS scheduling, standardizing documentation, and community pediatrician outreach. The goal was to increase the average monthly FUSS completion rate from 40% to 90% over 1 year. RESULTS: After interventions implementation, the average monthly FUSS completion rate rapidly increased from 40% to 80%. There was sustained improvement over the subsequent 12 months. CONCLUSIONS: Interventions were implemented sequentially, targeting barriers at various levels of workflow. Provider education was key and helped increase the reliability of intervention implementation. The most effective intervention was protocol change. This approach led to significant improvement in FUSS completion and sustained improvement.
Asnes AG, Leventhal JM. Bruising in Infants: An Approach to the Recognition of Child Physical Abuse. Pediatrics in Review. 2022; 43 (7) : 361-370.
Keywords: Child, *Child Abuse/diagnosis, *Contusions/diagnosis/etiology, Humans, Incidence, Infant, Physical Abuse
Infants (children <12 months of age) are maltreated at more than twice the rate …
Infants (children <12 months of age) are maltreated at more than twice the rate of any other child age group, and infants die because of maltreatment at 3 times the rate of any other age group in childhood. The incidence of hospitalization for serious physical abuse in children also is highest for infants. Successful recognition of medically mild signs of physical abuse in infants, such as certain bruising patterns, can, therefore, lead to lifesaving interventions. The importance of the recognition of medically mild injuries due to physical abuse is underscored by the finding that a high percentage of infants (27.5%) hospitalized with serious physical abuse were found to have previously sustained milder injuries, such as bruising. Clinicians must be aware of patterns of bruising suggestive of abuse to distinguish between infants who have been abused and those who have been accidentally injured. To maximize the likelihood that abused infants will be identified and protected, as well to minimize the likelihood that an accidentally injured infant will be mischaracterized as abused, the application of an evidence-based approach to the evaluation of bruised infants should be applied. A consistent, evidence-based practice in this setting also may reduce the influence of racial and socioeconomic bias and decrease disparities in care.
BBC. Compassion over Chinese mother's 'mercy killing'. 2017.
Baren JM, Mace SE, Hendry PL. Children's mental health emergencies-part 3: special situations: child maltreatment, violence, and response to disasters. Pediatric Emergency Care. 2008; 24 (8) : 569-77.
Keywords: Adolescent, Child, Child Abuse/*psychology, Child, Preschool, *Disasters, Emergencies, Emergency Service, Hospital, Humans, Mass Casualty Incidents/psychology, Mental Disorders/*psychology, Residence Characteristics, Schools, Triage, Violence/*psychology
OBJECTIVE: Children may be exposed to or even be the victims of a violent …
OBJECTIVE: Children may be exposed to or even be the victims of a violent situation, or a disaster, and the likelihood of a child's exposure to a violent situation or a disaster is increasing. METHODS: A review of the literature was done to address key mental health issues occurring with child maltreatment, violence in the home, community, in the emergency department, and disasters. RESULTS: Although pediatric mental health issues regarding violence, disasters, and child maltreatment have often been overlooked or unrecognized, the consequences for the child in such situations can be devastating. However, recognition and appropriate treatment can favorably impact the child's recovery from exposure to such violent events or disasters. CONCLUSIONS: Recognition and early intervention to address the mental health issues of children in violent situations or disasters can help ameliorate the negative psychological sequelae of such events. The importance of providing mental health and social services to children exposed to disasters was recognized by the Pediatric Institute of Medicine Report.
Bennett CE, Christian CW. Clinical evaluation and management of children with suspected physical abuse. Pediatric Radiology. 2021; 51 (6) : 853-860.
Keywords: Child, *Child Abuse/diagnosis/prevention & control, Diagnosis, Differential, Humans, *Physical Abuse, Physical Examination
Evaluating and managing children with suspected physical abuse is challenging. …
Evaluating and managing children with suspected physical abuse is challenging. Few single injuries are pathognomonic for abuse and, as a result, child abuse is easily missed. As such, a healthy bit of skepticism is needed to recognize and protect abused children. The medical history and clinical presentation should guide evaluation. Medical providers must consider the differential diagnosis, epidemiology of injuries, and child development to inform the assessment. In this review, we address evidence-based recommendations to inform child physical abuse evaluations. We also discuss the role of medical providers in communicating with families, mandated reporting and interpreting medical information for investigative agencies and other non-medical colleagues entrusted with protecting children.
Berson NL, Herman-Giddens ME, Frothingham TE. Children's perceptions of genital examinations during sexual abuse evaluations. Child Welfare. 1993; 72 (1) : 41-9.
Keywords: *Attitude to Health, Child, Child Abuse, Sexual/diagnosis/*psychology, *Child Welfare, Child, Preschool, Female, Humans, Internal-External Control, *Patient Care Team, Patient Participation/psychology, Physical Examination/*psychology
Children's reactions to the medical evaluation of sexual abuse and the methods …
Children's reactions to the medical evaluation of sexual abuse and the methods that enhance their coping ability have not been well addressed in the literature. For many children, a genital examination can be highly stressful, and may even trigger memories of the sexual abuse itself. Stress can be reduced by preparing the child for the examination, by giving the child greater control, and by debriefing the child (and parents) afterward. Research is needed to develop the most effective techniques for reducing children's stress during a genital examination.
Boehnke M, Mirsky D, Stence N, Stanley RM, Lindberg DM. Occult head injury is common in children with concern for physical abuse. Pediatric Radiology. 2018; 48 (8) : 1123-1129.
Keywords: Child Abuse/*diagnosis/statistics & numerical data, Craniocerebral Trauma/*diagnostic imaging/epidemiology, Female, Humans, Infant, Infant, Newborn, Magnetic Resonance Imaging, Male, Neuroimaging/*methods, Prevalence, Retrospective Studies, Risk Factors,
BACKGROUND: Studies evaluating small patient cohorts have found a high, but …
BACKGROUND: Studies evaluating small patient cohorts have found a high, but variable, rate of occult head injury in children <2 years old with concern for physical abuse. The American College of Radiology (ACR) recommends clinicians have a low threshold to obtain neuroimaging in these patients. OBJECTIVES: Our aim was to determine the prevalence of occult head injury in a large patient cohort with suspected physical abuse using similar selection criteria from previous studies. Additionally, we evaluated proposed risk factors for associations with occult head injury. MATERIALS AND METHODS: This was a retrospective, secondary analysis of data collected by an observational study of 20 U.S. child abuse teams that evaluated children who underwent subspecialty evaluation for concern of abuse. We evaluated children <2 years old and excluded those with abnormal mental status, bulging fontanelle, seizure, respiratory arrest, underlying neurological condition, focal neurological deficit or scalp injury. RESULTS: One thousand one hundred forty-three subjects met inclusion criteria and 62.5% (714) underwent neuroimaging with either head computed tomography or magnetic resonance imaging. We found an occult head injury prevalence of 19.7% (141). Subjects with emesis (odds ratio [OR] 3.5, 95% confidence interval [CI] 1.8-6.8), macrocephaly (OR 8.5, 95% CI 3.7-20.2), and loss of consciousness (OR 5.1, 95% CI 1.2-22.9) had higher odds of occult head injury. CONCLUSION: Our results show a high prevalence of occult head injury in patients <2 years old with suspected physical abuse. Our data support the ACR recommendation that clinicians should have a low threshold to perform neuroimaging in patients <2 years of age.
Bradford R, Choudhary AK, Dias MS. Serial neuroimaging in infants with abusive head trauma: timing abusive injuries. Journal of Neurosurgery. Pediatrics. 2013; 12 (2) : 110-9.
Keywords: Brain/diagnostic imaging/pathology, *Child Abuse, Craniocerebral Trauma/complications/*diagnosis/diagnostic imaging/epidemiology/*etiology, Diffusion Magnetic Resonance Imaging, Female, Hematoma, Subdural/diagnosis/etiology, Humans, Infant, Infant, Newbor
OBJECT: The appearance and evolution of neuroimaging abnormalities following …
OBJECT: The appearance and evolution of neuroimaging abnormalities following abusive head trauma (AHT) is important for establishing the time frame over which these injuries might have occurred. From a legal perspective this frames the timing of the abuse and therefore identifies and excludes potential perpetrators. A previous pilot study involving 33 infants with AHT helped to refine the timing of these injuries but was limited by its small sample size. In the present study, the authors analyzed a larger group of 210 cases involving infants with AHT to chronicle the first appearance and evolution of radiological (CT, MRI) abnormalities. METHODS: All children younger than 24 months admitted to the Penn State Hershey Medical Center with AHT over a 10-year period were identified from a medical record review; the time of injury was determined through an evaluation of the clinical records. All imaging studies were analyzed, and the appearance and evolution of abnormalities were chronicled on serial neuroimaging studies obtained in the days and weeks after injury. RESULTS: One hundred five infants with specific injury dates and available imaging studies were identified; a subset of 43 children additionally had documented times of injury. In infants with homogeneously hyperdense subdural hematomas (SDHs) on initial CT scans, the first hypodense component appeared within the SDH between 0.3 and 16 days after injury, and the last hyperdense subdural component disappeared between 2 and 40 days after injury. In infants with mixed-density SDHs on initial scans, the last hyperdense component disappeared between 1 and 181 days. Parenchymal hypodensities appeared on CT scans performed as early as 1.2 hours, and all were visible within 27 hours after the injury. Rebleeding into SDHs was documented in 17 cases (16%) and was always asymptomatic. Magnetic resonance imaging of the brain was performed in 49 infants. Among those with SDH, 5 patterns were observed. Patterns I and II reflected homogeneous SDH; Pattern I (T1 hyperintensity and T2/FLAIR hypointensity, "early subacute") more commonly appeared on scans performed earlier after injury compared with Pattern II (T1 hyperintensity and T2/FLAIR hyperintensity, "late subacute"), although there was considerable overlap. Patterns III and IV reflected heterogeneous SDH; Pattern III contained relatively equal mixtures having different intensities, whereas Pattern IV had fluid that was predominantly T1 hypointense and T2/FLAIR hyperintense. Again, Pattern III more commonly appeared on scans performed earlier after injury compared with Pattern IV, although there was significant overlap. CONCLUSIONS: These data extend the preliminary data reported by Dias and colleagues and provide a framework upon which injuries in AHT can be timed as well as the limitations on such timing estimates.
Braverman PK, Alderman WP, Alderman EM, Breuner CC, Levine DA, Marcell AV, O’Brien RF; COMMITTEE ON ADOLESCENCE. Contraception for adolescents.
Pediatrics. 2014; 134 (4) : e1244-56.
Reaffirmed 2021
Keywords: Adolescent, *Adolescent Behavior/psychology, Contraception/*methods/psychology/*standards, Female, Health Insurance Portability and Accountability Act/*standards/trends, Health Policy/trends, Humans, Male, *Patient Compliance/psychology, Pediatrics/standa
Contraception is a pillar in reducing adolescent pregnancy rates. The American …
Contraception is a pillar in reducing adolescent pregnancy rates. The American Academy of Pediatrics recommends that pediatricians develop a working knowledge of contraception to help adolescents reduce risks of and negative health consequences related to unintended pregnancy. Over the past 10 years, a number of new contraceptive methods have become available to adolescents, newer guidance has been issued on existing contraceptive methods, and the evidence base for contraception for special populations (adolescents who have disabilities, are obese, are recipients of solid organ transplants, or are HIV infected) has expanded. The Academy has addressed contraception since 1980, and this policy statement updates the 2007 statement on contraception and adolescents. It provides the pediatrician with a description and rationale for best practices in counseling and prescribing contraception for adolescents. It is supported by an accompanying technical report.
Breeuwsma G, van Geert P. Developmental psychology and decision-making by minor patients. Brill / Nijhoff. Children's Rights in Healthcare. 2018; : 111-149.
Brink FW, Lo CB, Shi J, Stanley R, Lindberg DM. Diagnosis codes dramatically underestimate the burden of abuse. Child Abuse & Neglect. 2023; 135 : 105986.
Keywords: Child, Humans, Male, Child, Preschool, Female, Retrospective Studies, Cross-Sectional Studies, *Child Abuse/diagnosis, Emergency Service, Hospital, International Classification of Diseases
BACKGROUND: International Classification of Diseases (ICD) billing codes are …
BACKGROUND: International Classification of Diseases (ICD) billing codes are not well-suited to estimate physical abuse prevalence among hospitalized patients and may be even less accurate in emergency departments (EDs). The Centers for Disease Control and Prevention (CDC) has recently published a child abuse and neglect syndromic surveillance definition to more accurately examine national abuse trends among ED visits. OBJECTIVE: To retrospectively apply the CDC syndromic definition to a population of physically abused children and determine its sensitivity for abuse in an ED and at hospital discharge. PARTICIPANTS AND SETTING: All physically abused children <5 years seen in the ED and evaluated by the child protection team from 2016 to 2020 at a large Midwestern children's hospital. METHODS: Retrospective cross-sectional study utilizing the hospital's child protection team administrative database, the Pediatric Health Information System and the electronic health record to identify the study sample, chief complaint, and abuse-specific codes assigned in the ED and at hospital discharge. Abuse-specific codes were defined as all ICD-10-CM and Systematized Nomenclature of Medicine - Clinical Terms (SNOMED CT) codes included in the CDC syndromic definition, which was applied to the sample and its sensitivity determined. RESULTS: Among the 550 abused patients identified, most were male (58.4 %), white (65.1 %), <2 years old (80.4 %), and had public insurance (81.6 %). When applying the CDC syndromic definition, only 11.6 % were identified as abused in the ED and 65.3 % were identified at hospital discharge. CONCLUSIONS: The CDC syndrome surveillance definition lacks sensitivity in identifying abuse in the ED or at hospital discharge.
Brown SD. Ethical challenges in child abuse: what is the harm of a misdiagnosis?. Pediatric Radiology. 2021; 51 (6) : 1070-1075.
Keywords: Child, *Child Abuse/diagnosis, Diagnostic Errors, Expert Testimony, Humans, *Physicians, *Radiology
In this article the author examines ethical tensions inherent to balancing …
In this article the author examines ethical tensions inherent to balancing harms of false-negative and false-positive child abuse diagnoses, and he describes how such tensions manifest in courtroom proceedings. Child abuse physicians, including pediatric radiologists, shoulder heavy responsibilities weighing the potential consequences of not diagnosing child abuse when it could have been diagnosed (false negatives) against the consequences of making the diagnosis when it has not occurred (false positives). These physicians, who practice under ethical obligations to serve children's best interests and protect them from harm, make daily practice decisions knowing that, on balance, abuse is substantially more underdiagnosed than over diagnosed. Legal justice advocates, however, emphasize that clinical decision-making around abuse is not disassociated from endemic injustices that unduly incriminate individuals from socioeconomically underprivileged populations. Some defense advocates charge that child abuse physicians are insufficiently sensitive to harms of erroneous diagnoses, and they have characterized these clinicians as frankly biased. To support their claims in court, defense advocates have enlisted likeminded physician witnesses whose credentials as experts flout professional standards and who provide consistently flawed testimony based upon deficiently peer-reviewed literature. This article concludes that, to help mitigate these unhealthy circumstances, child abuse physicians might build trust with criminal defense advocates by instituting measures to alleviate perceptions of biases and by more explicitly acknowledging the potential harms of erroneous diagnoses. Professional societies representing these physicians, such as the Society for Pediatric Radiology, could take concurrent measures to help better prepare their constituent clinicians for expert testimony and make them more available to testify.
Brownell AD, Shapiro RA, Hammerschlag MR. Caution Is Required When Using Non-Food and Drug Administration-Cleared Assays to Diagnose Sexually Transmitted Infections in Children. The Journal of Pediatrics. 2019; 206 : 280-282.
Keywords: Child, Child Abuse, Sexual/diagnosis, Child, Preschool, Diagnostic Test Approval, Female, Humans, Male, Nucleic Acid Amplification Techniques, Sensitivity and Specificity, Sexually Transmitted Diseases/*diagnosis/*microbiology
Nucleic acid amplification testing is the gold-standard for Chlamydia …
Nucleic acid amplification testing is the gold-standard for Chlamydia trachomatis and Neisseria gonorrhoeae testing in adults. We present 3 pediatric cases in which testing resulted in probable false-positive results. Clinicians should avoid tests without clearance from a regulatory agency and should maintain consistent communication with laboratories.
Brunetti P, Giorgetti R, Tagliabracci A, Huestis MA, Busardò FP. Designer Benzodiazepines: A Review of Toxicology and Public Health Risks. Pharmaceuticals (Basel, Switzerland). 2021; 14 (6).
The rising use of designer benzodiazepines (DBZD) is a cat-and-mouse game …
The rising use of designer benzodiazepines (DBZD) is a cat-and-mouse game between organized crime and law enforcement. Non-prohibited benzodiazepines are introduced onto the global drug market and scheduled as rapidly as possible by international authorities. In response, DBZD are continuously modified to avoid legal sanctions and drug seizures and generally to increase the abuse potential of the DBZD. This results in an unpredictable fluctuation between the appearance and disappearance of DBZD in the illicit market. Thirty-one DBZD were considered for review after consulting the international early warning database, but only 3-hydroxyphenazepam, adinazolam, clonazolam, etizolam, deschloroetizolam, diclazepam, flualprazolam, flubromazepam, flubromazolam, meclonazepam, phenazepam and pyrazolam had sufficient data to contribute to this scoping review. A total of 49 reports describing 1 drug offense, 2 self-administration studies, 3 outpatient department admissions, 44 emergency department (ED) admissions, 63 driving under the influence of drugs (DUID) and 141 deaths reported between 2008 and 2021 are included in this study. Etizolam, flualprazolam flubromazolam and phenazepam were implicated in the majority of adverse-events, drug offenses and deaths. However, due to a general lack of knowledge of DBZD pharmacokinetics and toxicity, and due to a lack of validated analytical methods, total cases are much likely higher. Between 2019 and April 2020, DBZD were identified in 48% and 83% of postmortem and DUID cases reported to the UNODC, respectively, with flualprazolam, flubromazolam and etizolam as the most frequently detected substances. DBZD toxicology, public health risks and adverse events are reported.
Busardò FP, Jones AW. GHB pharmacology and toxicology: acute intoxication, concentrations in blood and urine in forensic cases and treatment of the withdrawal syndrome. Current Neuropharmacology. 2015; 13 (1) : 47-70.
Keywords: Animals, Drug Interactions, Humans, Sodium Oxybate/pharmacokinetics/*pharmacology/*toxicity, Substance Withdrawal Syndrome/psychology/*therapy, Substance-Related Disorders/epidemiology/therapy
The illicit recreational drug of abuse, γ-hydroxybutyrate (GHB) is a potent …
The illicit recreational drug of abuse, γ-hydroxybutyrate (GHB) is a potent central nervous system depressant and is often encountered during forensic investigations of living and deceased persons. The sodium salt of GHB is registered as a therapeutic agent (Xyrem®), approved in some countries for the treatment of narcolepsy-associated cataplexy and (Alcover®) is an adjuvant medication for detoxification and withdrawal in alcoholics. Trace amounts of GHB are produced endogenously (0.5-1.0 mg/L) in various tissues, including the brain, where it functions as both a precursor and a metabolite of the major inhibitory neurotransmitter γ-aminobutyric acid (GABA). Available information indicates that GHB serves as a neurotransmitter or neuromodulator in the GABAergic system, especially via binding to the GABA-B receptor subtype. Although GHB is listed as a controlled substance in many countries abuse still continues, owing to the availability of precursor drugs, γ-butyrolactone (GBL) and 1,4-butanediol (BD), which are not regulated. After ingestion both GBL and BD are rapidly converted into GHB (t½ ~1 min). The Cmax occurs after 20-40 min and GHB is then eliminated from plasma with a half-life of 30-50 min. Only about 1-5% of the dose of GHB is recoverable in urine and the window of detection is relatively short (3-10 h). This calls for expeditious sampling when evidence of drug use and/or abuse is required in forensic casework. The recreational dose of GHB is not easy to estimate and a concentration in plasma of ~100 mg/L produces euphoria and disinhibition, whereas 500 mg/L might cause death from cardiorespiratory depression. Effective antidotes to reverse the sedative and intoxicating effects of GHB do not exist. The poisoned patients require supportive care, vital signs should be monitored and the airways kept clear in case of emesis. After prolonged regular use of GHB tolerance and dependence develop and abrupt cessation of drug use leads to unpleasant withdrawal symptoms. There is no evidence-based protocol available to deal with GHB withdrawal, apart from administering benzodiazepines.
CBS News. 3 Nigerian men charged in sextortion death of Marquette teen. n.d.
Caldas SJ, Bensy ML. The sexual maltreatment of students with disabilities in American school settings. Journal of Child Sexual Abuse. 2014; 23 (4) : 345-66.
Keywords: Adolescent, Adolescent Behavior/psychology, Child, Child Abuse, Sexual/psychology/*statistics & numerical data, Child Behavior/psychology, Child Welfare/*statistics & numerical data, Crime Victims/psychology/*statistics & numerical data, Children with Dis
This study presents results from the first nationwide survey of students with …
This study presents results from the first nationwide survey of students with disabilities who were sexually maltreated in American schools. The Web survey results, which were mostly provided by caregivers, parents/guardians, and professional advocates, illuminate the types of sexual maltreatment committed, the characteristics of the victims and the abusers, where in the school setting the maltreatment occurred, the manner in which the maltreatment was reported, and the school's response to the maltreatment. More than two-thirds of the maltreated students experienced at least one form of contact sexual maltreatment, and fully 35% of all incidences of maltreatment occurred more than 10 times. The majority of the incidences of maltreatment were committed by school personnel.
Campbell KA, Olson LM, Keenan HT. Critical Elements in the Medical Evaluation of Suspected Child Physical Abuse. Pediatrics. 2015; 136 (1) : 35-43.
Keywords: Child, Child Abuse/*diagnosis, Child, Preschool, Consensus, Data Collection, Humans, Infant, Pediatrics, Reproducibility of Results
BACKGROUND: Previous research has described variability in medical evaluation …
BACKGROUND: Previous research has described variability in medical evaluation of suspected abuse. The objective of this study was to identify, through expert consensus, required and highly recommended elements of a child abuse pediatrics (CAP) evaluation for 3 common presentations of suspected physical abuse in children aged 0 to 60 months. METHODS: Twenty-eight CAPs recruited from 2 national organizations formed the expert panel for this modified Delphi Process. An initial survey was developed for each presentation based on demographics, history of present illness, past medical, family and social history, laboratory, radiology, and consultation elements present in at least 10% of CAP consultations collected for a larger study. CAPs ranked each element on a 9-point scale then reviewed and discussed summary results through a project blog over 3 rounds. Required and highly recommended elements were defined as elements ranked as 9 and 8, respectively, by ≥75% of experts after the final round. RESULTS: From 96 elements in the initial surveys, experts identified 30 Required elements and 37 Highly Recommended elements for CAP evaluation of intracranial hemorrhage, 21 Required and 33 Highly Recommended elements for CAP evaluation of long bone fracture, and 18 Required and 16 Highly Recommended elements for CAP evaluation of isolated skull fracture. CONCLUSIONS: This guideline reflects expert consensus and provides a starting point for development of child abuse assessment protocols for quality improvement or research. Additional research is required to determine whether this guideline can reduce variability and/or improve reliability in the evaluation and diagnosis of child physical abuse.
Centers for Disease Control and Prevention
Sexually Transmitted Infections (STI) Treatment Guidelines
Chen SY, Gao L, Imagawa KK, Roseman ER, Shin CE, Kim ES, Spurrier RG. Screening for Child Abuse in Children With Isolated Skull Fractures. Pediatric Emergency Care. 2023; 39 (6) : 374-377.
Keywords: Child, Humans, Infant, *Skull Fractures/diagnosis/epidemiology, *Child Abuse/diagnosis, *Craniocerebral Trauma, Emergency Service, Hospital, Social Work, Retrospective Studies
OBJECTIVE: Head trauma is the most common cause of death from child abuse, and …
OBJECTIVE: Head trauma is the most common cause of death from child abuse, and each encounter for recurrent abuse is associated with greater morbidity. Isolated skull fractures (ISF) are often treated conservatively in the emergency department (ED). We determined patterns of physical abuse screening in a children's hospital ED for children with ISF. METHODS: A retrospective review was performed for children aged 3 years and younger who presented to the ED with ISF from January 1, 2015 to December 31, 2019. Children were stratified by age (<12 mo, ≥12 mo) and witnessed versus unwitnessed injury. Primary outcome was social work (SW) assessment to prescreen for abuse. Secondary outcomes were suspicion for abuse based on Child Protective Services (CPS) referral and subsequent ED encounters within 1 year. RESULTS: Sixty-six ISF patients were identified. Of unwitnessed injury patients aged younger than 12 months (n = 17/22), 88.2% (n = 15/17) underwent SW assessment and 47.1% (n = 8/17) required CPS referral. Of witnessed injury patients aged younger than 12 months (n = 23/44), 60.9% (n = 14/23) underwent SW assessment, with no CPS referrals. Overall, 18.2% (n = 4/22) unwitnessed and 20.5% (n = 9/44) witnessed injury patients returned to our ED: 2 were aged younger than 12 months and had recurrent trauma. CONCLUSIONS: To decrease risk of missed physical abuse, SW consultation should be considered for all ISF patients.
Choudhary AK, Servaes S, Slovis TL, Palusci VJ, Hedlund GL, Narang SK, Moreno JA, Dias MS, Christian CW, Nelson MD Jr, Silvera VM, Palasis S, Raissaki M, Rossi A, Offiah AC. Consensus statement on abusive head trauma in infants and young children. Pediatric Radiology. 2018; 48 (8) : 1048-1065.
Keywords: Child, Child Abuse/*diagnosis/mortality, Child, Preschool, Consensus, Craniocerebral Trauma/*diagnosis/mortality, Hematoma, Subdural/diagnosis, Humans, Infant, Infant, Newborn, Retinal Hemorrhage/diagnosis, Rib Fractures/diagnosis, Societies, Medical,
Abusive head trauma (AHT) is the leading cause of fatal head injuries in …
Abusive head trauma (AHT) is the leading cause of fatal head injuries in children younger than 2 years. A multidisciplinary team bases this diagnosis on history, physical examination, imaging and laboratory findings. Because the etiology of the injury is multifactorial (shaking, shaking and impact, impact, etc.) the current best and inclusive term is AHT. There is no controversy concerning the medical validity of the existence of AHT, with multiple components including subdural hematoma, intracranial and spinal changes, complex retinal hemorrhages, and rib and other fractures that are inconsistent with the provided mechanism of trauma. The workup must exclude medical diseases that can mimic AHT. However, the courtroom has become a forum for speculative theories that cannot be reconciled with generally accepted medical literature. There is no reliable medical evidence that the following processes are causative in the constellation of injuries of AHT: cerebral sinovenous thrombosis, hypoxic-ischemic injury, lumbar puncture or dysphagic choking/vomiting. There is no substantiation, at a time remote from birth, that an asymptomatic birth-related subdural hemorrhage can result in rebleeding and sudden collapse. Further, a diagnosis of AHT is a medical conclusion, not a legal determination of the intent of the perpetrator or a diagnosis of murder. We hope that this consensus document reduces confusion by recommending to judges and jurors the tools necessary to distinguish genuine evidence-based opinions of the relevant medical community from legal arguments or etiological speculations that are unwarranted by the clinical findings, medical evidence and evidence-based literature.
Christian CW, Crawford-Jakubiak JE, Flaherty EG, Leventhal JM, Lukefahr JL, Sege RD. The evaluation of suspected child physical abuse. Pediatrics. 2015; 135 (5) : e1337-e1354.
Child physical abuse is an important cause of pediatric morbidity and mortality …
Child physical abuse is an important cause of pediatric morbidity and mortality and is associated with major physical and mental health problems that can extend into adulthood. Pediatricians are in a unique position to identify and prevent child abuse, and this clinical report provides guidance to the practitioner regarding indicators and evaluation of suspected physical abuse of children. The role of the physician may include identifying abused children with suspicious injuries who present for care, reporting suspected abuse to the child protection agency for investigation, supporting families who are affected by child abuse, coordinating with other professionals and community agencies to provide immediate and long-term treatment to victimized children, providing court testimony when necessary, providing preventive care and anticipatory guidance in the office, and advocating for policies and programs that support families and protect vulnerable children.
Christian CW, Levin AV. The Eye Examination in the Evaluation of Child Abuse. Pediatrics. 2018; 142 (2).
Keywords: Child, Child Abuse/*diagnosis/prevention & control, Craniocerebral Trauma/complications/diagnosis/prevention & control, *Diagnostic Techniques, Ophthalmological/standards, Eye Injuries/*diagnosis/*etiology/prevention & control, Humans, Physical Examinatio
Child abuse can cause injury to any part of the eye. The most common …
Child abuse can cause injury to any part of the eye. The most common manifestations are retinal hemorrhages (RHs) in infants and young children with abusive head trauma (AHT). Although RHs are an important indicator of possible AHT, they are also found in other conditions. Distinguishing the number, type, location, and pattern of RHs is important in evaluating a differential diagnosis. Eye trauma can be seen in cases of physical abuse or AHT and may prompt referral for ophthalmologic assessment. Physicians have a responsibility to consider abuse in the differential diagnosis of pediatric eye trauma. Identification and documentation of inflicted ocular trauma requires a thorough examination by an ophthalmologist, including indirect ophthalmoscopy, most optimally through a dilated pupil, especially for the evaluation of possible RHs. An eye examination is helpful in detecting abnormalities that can help identify a medical or traumatic etiology for previously well young children who experience unexpected and unexplained mental status changes with no obvious cause, children with head trauma that results in significant intracranial hemorrhage and brain injury, and children with unexplained death.
Clayton EW. Potential liability in cases of child abuse and neglect. Pediatric Annals. 1997; 26 (3) : 173-7.
Keywords: Child, Child Abuse/diagnosis/*legislation & jurisprudence, Child Welfare, Documentation, Humans, *Liability, Legal, *Mandatory Reporting, Pediatrics/*legislation & jurisprudence, Physician's Role, Professional-Family Relations, State Government, United St
Clever LH. Cross-cultural medicine (Special Issue). The Western Journal of Medicine. 1992; 157 (3) : 247-373.
Keywords: *Cross-Cultural Comparison, *Health Services Needs and Demand, Humans, United States
Collins JA, Maney JA, Livingstone A. Fifteen-minute consultation: Apparent vaginal bleeding in the pre-pubertal girl. Archives of Disease in Childhood. Education and Practice Edition. 2021; 106 (3) : 142-148.
Keywords: Child, Child Abuse, Sexual, Emergency Service, Hospital, Female, Humans, Puberty, Referral and Consultation, *Uterine Hemorrhage/diagnosis/etiology
A parent or carer's observation of blood in a child's nappy or underwear can be …
A parent or carer's observation of blood in a child's nappy or underwear can be quite alarming for both parent and child and may indicate vaginal bleeding. At first glance, it may be difficult to ascertain whether the bleeding is from the skin, genital tract, urinary tract or anus. Confirmed vaginal bleeding in a pre-pubertal girl is rare but always abnormal and requires comprehensive assessment to determine the cause. Recognition of normal female pre-pubertal anatomy is essential to detect any abnormalities. Appropriate action should be taken according to findings on initial inspection of the ano-genital area. The possibility of child sexual abuse and the need for specialist paediatric sexual offences medicine examination by an FME (Forensic Medical Examiner) or specialist paediatrician should always be considered. This article offers a systematic approach to assessment in pre-pubertal girls with apparent vaginal bleeding which will benefit general paediatricians, emergency department practitioners and GPs.
Cosgrave L, Bowie S, Walker C, Bird H, Bastin S. Abusive head trauma in children: radiographs of the skull do not provide additional information in the diagnosis of skull fracture when multiplanar computed tomography with three-dimensional reconstructions is available. Pediatric Radiology. 2022; 52 (5) : 924-931.
Keywords: Child, *Craniocerebral Trauma/diagnostic imaging, Humans, Imaging, Three-Dimensional/methods, Radiography, Retrospective Studies, Skull, *Skull Fractures/diagnostic imaging, Tomography, X-Ray Computed/methods
BACKGROUND: Some data suggest that CT is more accurate than skull radiographs …
BACKGROUND: Some data suggest that CT is more accurate than skull radiographs in diagnosing skull fractures in abusive head trauma. OBJECTIVES: We investigated whether multiplanar CT with three-dimensional (3-D) reconstructions alone is non-inferior to combination CT/skull radiography for the diagnosis of skull fracture in suspected physical abuse. MATERIALS AND METHODS: We identified children who had skull radiographs and concurrent multiplanar CT with 3-D reconstructions obtained during suspected physical abuse imaging between 2010 and 2019, and a fracture diagnosis in the formal report. We included all fracture cases and an equal number of randomly selected non-fracture controls in an anonymised dataset. This dataset was independently reviewed for skull fracture by two paediatric radiologists and one less-experienced trainee using either radiography alone, CT alone or CT/skull radiography. The primary outcome was discordance in diagnosis of skull fracture between CT alone and CT/skull radiography, with a result > 0.03 deemed to indicate inferiority of CT alone. The Fleiss kappa was used to assess interobserver agreement. RESULTS: We included 106 children, 53 with and 53 without skull fracture. A single case was discordant between CT alone and CT/skull radiography, resulting in discordance of 0.009, consistent with non-inferiority of CT alone. The sensitivity and specificity of CT alone and CT/skull radiography were 98% and 96-98%, respectively, whereas radiography alone was more inaccurate (81% sensitivity and 96% specificity). Interobserver agreement for all modalities was very high (kappa 0.86-0.95). CONCLUSION: Multiplanar CT with 3-D reconstructions alone is not inferior (and clinically equivalent) to CT/skull radiography for diagnosing skull fracture in suspected physical abuse imaging and was as accurate when reported by a less-experienced trainee. This suggests that skull radiography can be removed from suspected physical abuse imaging guidelines.
Costa-Silva M, Fernandes I, Rodrigues AG, Lisboa C. Anogenital warts in pediatric population. Anais Brasileiros De Dermatologia. 2017; 92 (5) : 675-681.
Keywords: Anus Diseases/diagnosis/etiology/therapy/virology, Child, *Child Abuse, Sexual, Child, Preschool, *Condylomata Acuminata/diagnosis/etiology/therapy/virology, Humans, Papillomavirus Infections/complications, Prognosis
The approach to children with anogenital warts in the context of sexual abuse …
The approach to children with anogenital warts in the context of sexual abuse is a challenge in clinical practice. This study aims to review the current knowledge of anogenital warts in children, the forms of transmission, and the association with sexual abuse and to propose a cross-sectional approach involving all medical specialties. A systematic review of the literature was conducted in Portuguese and English from January 2000 to June 2016 using the ISI Web of Knowledge and PubMed databases. Children aged 12 years or younger were included. The ethical and legal aspects were consulted in the Declaration and Convention on the Rights of Children and in the World Health Organization. Non-sexual and sexual transmission events of human papillomavirus in children have been well documented. The possibility of sexual transmission appears to be greater in children older than 4 years. In the case of anogenital warts in children younger than 4 years of age, the possibility of non-sexual transmission should be strongly considered in the absence of another sexually transmitted infection, clinical indicators, or history of sexual abuse. The importance of human papillomavirus genotyping in the evaluation of sexual abuse is controversial. A detailed medical history and physical examination of both the child and caregivers are critical during the course of the investigation. The likelihood of an association between human papillomavirus infection and sexual abuse increases directly with age. A multidisciplinary clinical approach improves the ability to identify sexual abuse in children with anogenital warts.
Crawford-Jakubiak JE, Alderman EM, Leventhal JM; COMMITTEE ON CHILD ABUSE AND NEGLECT; COMMITTEE ON ADOLESCENCE. Care of the Adolescent After an Acute Sexual Assault.
Pediatrics. 2017; 139 (3).
Erratum: https://doi.org/10.1542/peds.2016-4243
Keywords: Adolescent, Contraception, Postcoital, *Crime Victims, Persons with Disabilities, Female, Forensic Medicine, Forensic Toxicology, Humans, Mandatory Reporting, Physical Examination, Post-Exposure Prophylaxis, Pregnancy, Pregnancy, Unwanted, *Sex Offenses/l
Sexual violence is a broad term that encompasses a wide range of sexual …
Sexual violence is a broad term that encompasses a wide range of sexual victimizations. Since the American Academy of Pediatrics published its last policy statement on sexual assault in 2008, additional information and data have emerged about sexual violence affecting adolescents and the treatment and management of the adolescent who has been a victim of sexual assault. This report provides new information to update physicians and focuses on the acute assessment and care of adolescent victims who have experienced a recent sexual assault. Follow-up of the acute assault, as well as prevention of sexual assault, are also discussed.
Csorba R, Atas Elfrink Z, Tsikouras P. Diagnosis of Child Sexual Abuse. Journal of Clinical Medicine. 2024; 13 (23).
Child sexual abuse (CSA) is a widespread and alarming issue, with an estimated …
Child sexual abuse (CSA) is a widespread and alarming issue, with an estimated global prevalence of 12-13% (affecting 18% of girls and 8% of boys). Despite its prevalence, many physicians working with children have insufficient knowledge of the medical diagnosis of CSA. This lack of expertise, combined with the sensitive and complex nature of these cases, often hampers proper identification and management. Diagnosing CSA is particularly challenging and requires specialized skills. A majority of children assessed for suspected sexual abuse present with normal genital and anal findings, which complicates the diagnostic process. Barriers such as professional isolation, societal taboos, and the sensitive nature of the subject often result in diagnostic failures. Accurate medical history taking, diagnosis, and documentation of findings are essential for ensuring a precise diagnosis, safeguarding children, and supporting legal proceedings. However, achieving these goals remains elusive without standardized guidelines and adequately trained healthcare professionals. Training of professionals in observing and reporting child sexual abuse is badly needed. This review explores the current state of medical diagnosis in suspected cases of CSA. This article is based on a selective review of pertinent literature retrieved from various databases, including PubMed and the overall index of the Quarterly Update.
Darling SE, Done SL, Friedman SD, Feldman KW. Frequency of intrathoracic injuries in children younger than 3 years with rib fractures. Pediatric Radiology. 2014; 44 (10) : 1230-6.
Keywords: Causality, Child Abuse/*diagnosis/*statistics & numerical data, Child, Preschool, Female, Humans, Incidence, Infant, Infant, Newborn, Male, Multiple Trauma/diagnostic imaging/*epidemiology, Radiography, Rib Fractures/diagnostic imaging/*epidemiology, Risk
BACKGROUND: Research documents that among children admitted to trauma intensive …
BACKGROUND: Research documents that among children admitted to trauma intensive care units the number of rib fractures sustained indicates the child's likelihood of having and severity of intrathoracic injury. This has been misused in court to argue that children with multiple rib fractures who lack intrathoracic injury have abnormal bone fragility rather than inflicted injury. OBJECTIVE: To determine frequency of intrathoracic injuries in children younger than 3 years with rib fractures in cases of child abuse and accidental trauma. MATERIALS AND METHODS: We conducted a retrospective review of rib fractures caused by documented abuse or accidents from 2003 to 2010 in children treated at Seattle Children's Hospital and Harborview Medical Center. A senior pediatric radiologist and radiology fellow independently reviewed the imaging. Children with bone demineralization were excluded. Descriptive and simple comparative statistics were used. RESULTS: Seventy-two percent (47/65) of infants and toddlers with rib fractures were abused. Abused children had more rib fractures than accidentally injured children (5.55 vs. 3.11, P = 0.012). However intrathoracic injuries as a whole (55.6% vs. 12.8%, P < 0.001) and individual types of intrathoracic injuries were more common with accidents. Rates of other thoracic cage injuries did not differ substantially (27.8% accidents vs. 12.8% abuse, P = 0.064). Intracranial and intra-abdominal injuries and skull fractures were equally frequent, but other extrathoracic fractures were more common with abuse (70.2% vs. 16.7%, P < 0.001). CONCLUSIONS: Abused infants and toddlers have fewer intrathoracic injuries but more rib fractures than accidentally injured peers. This likely reflects different injury mechanics. Lack of intrathoracic injuries in abused children with rib fractures does not imply bone fragility.
Davis BJ, Voegtle KH. Culturally Competent Health Care for Adolescents: A Guide for Primary Care Providers. Chicago: Department of Adolescent Health, American Medical Association [AMA]. 1994.
Keywords: Adolescents; Health; Health Care; Cultural Pluralism; Health Care for Newborns and Minors;
Davis M, Fang A. Emancipated Minor. NCBI Bookshelf. StatPearls. 2023.
Adolescence is the critical transition from childhood to adulthood, …
Adolescence is the critical transition from childhood to adulthood, characterized by unique biological, cognitive, emotional, and social changes. In the United States, adolescence also marks the last stage in a minor's life before he or she transition's to legal adulthood at the age of 18 in most states. Minors legally cannot provide consent to their medical care and are not subject to the confidentiality protections under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Parents or legal guardians usually have the authority to make medical decisions on behalf of minors and access their confidential medical information under the "best-interests standard" since, under the law, minors lack the cognitive maturity to be considered competent like adults.
Deutsch SA, Benyo S, Xie S, Carlin E, Andalaro B, Clagg B, De Jong A. Addressing Human Papillomavirus Prevention During Pediatric Acute Sexual Assault Care. Journal of Forensic Nursing. 2018; 14 (3) : 154-161.
Keywords: Adolescent, Age Factors, Caregivers, Child, *Child Abuse, Sexual, Counseling/*statistics & numerical data, Delaware, Emergency Service, Hospital, Female, Humans, Male, Mental Recall, Papillomavirus Infections/*prevention & control, *Papillomavirus Vaccine
BACKGROUND/OBJECTIVES: Human papillomavirus (HPV) is the most common sexually …
BACKGROUND/OBJECTIVES: Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States. Pediatric sexual assault (SA) victims are a special population eligible for HPV vaccination at the age of 9 years. National clinical practice guidelines advise clinicians to address HPV during emergency department (ED)-based SA care and at follow-up. At our institution, addressing HPV among suspected SA victims was highly variable, and HPV counseling was subsequently recommended on an ED-based acute SA clinical pathway as standard care. The aim of this study was to determine the proportion of age-eligible SA victims who received HPV counseling, determine victim characteristics associated with addressing HPV during SA care, and identify barriers to addressing HPV in the ED. METHODS: This study used a retrospective chart review of 448 pediatric SA victims presenting to the ED for acute postassault care. RESULTS: HPV was discussed in 10 of 56 (18%) and 37 of 49 (76%) cases in the control versus intervention groups, respectively. To verify vaccination status, caregiver recall was relied upon for 32 of 56 patients in the control group (57%) and 24 of 49 patients in the intervention group (48.9%). Factors associated with failure to discuss HPV during postassault care were younger age at encounter (OR = 0.78, 95% CI [0.67, 0.90], p < 0.001), verbal report of vaccination status verification (OR = 2.98, 95% CI [1.51, 6.01]), and male gender of the victim (OR = 3.35, 95% CI [1.20, 11.94]). CONCLUSIONS: Significant barriers to addressing HPV in the ED setting exist, most significantly reliance on caregiver recall to guide vaccination administration, raising concern for overvaccination and undervaccination.
Doukrou M, Segal TY. Fifteen-minute consultation: Communicating with young people-how to use HEEADSSS, a psychosocial interview for adolescents. Archives of Disease in Childhood. Education and Practice Edition. 2018; 103 (1) : 15-19.
Keywords: Adolescent, Adolescent Behavior/*psychology, Adolescent Health Services/*standards, *Communication, Female, Humans, Male, Mental Health Services/*standards, *Practice Guidelines as Topic, Referral and Consultation/*standards
Adolescents undergo a period of biological, social and psychosocial development, …
Adolescents undergo a period of biological, social and psychosocial development, and each of these domains impacts each other. Psychosocial areas of concern often emerge over the adolescent period (such as mental health conditions, drug use and risky sexual behaviour); those with chronic illness being at higher risk. The paper aims to guide health practitioners on when and how to approach the psychosocial interview with young people and assess areas of risk or concern. This will include putting them at ease, developing rapport, seeing them alone and explaining confidentiality before commencing the assessment. Home, Education/Employment, Eating, Activities, Drugs, Sexuality, Suicidal ideation and Safety (HEEADSSS) is a recognised psychosocial interview framework that allows a better understanding of the young person's situation and what their specific needs may be. By exploring each section in turn briefly or more fully, it gives the professional an overall impression of the young person's life and any risky behaviours or concerns. This systematic structure should develop an easily accessible approach to adolescents as a group of patients whatever their developmental stage.
Driscoll SJ, Fidler KJ, Shears A, Whetham J, White A. Sexually transmitted infections in suspected child sexual abuse. Archives of Disease in Childhood. 2023; 108 (1) : 53-55.
Keywords: Child, Humans, *Child Abuse, Sexual/diagnosis, Retrospective Studies, *Sexually Transmitted Diseases/diagnosis/epidemiology, *Child Abuse, Prevalence, *HIV Infections/epidemiology
Making associations between sexually transmitted infections (STIs) and child …
Making associations between sexually transmitted infections (STIs) and child sexual abuse can be controversial. To contribute to the paucity of research in this field, this service evaluation aims to (1) define the prevalence of STIs in children aged 0-13 years seen at a regional Children's Sexual Assault Referral Centre, (2) determine whether sexual transmission is the most likely mode of transmission for diagnosed STIs, (3) identify factors affecting application of STI screening and (4) assess follow-up. Methods consisted of retrospective analysis of an anonymous database for all patients seen between 1 July 2016 and 1 July 2019. Of 241 children seen, 114/241 (47.3%) received STI screening and 10/114 (8.8%) tested positive (4.1% of children seen overall). No asymptomatic child was diagnosed with an STI. Sexual transmission was the most likely mode of transmission based on child disclosure and physical examination findings for 6/10 children diagnosed with an STI.
Drummond R, Gall JA. Evaluation of forensic medical history taking from the child in cases of child physical and sexual abuse and neglect. Journal of Forensic and Legal Medicine. 2017; 46 : 37-45.
Keywords: Adolescent, Age Factors, Australia, Child, Child Abuse/*diagnosis/*legislation & jurisprudence, Child, Preschool, Female, Forensic Medicine/*legislation & jurisprudence, Humans, Male, Medical History Taking/*statistics & numerical data, Retrospective S
BACKGROUND: Suspected child physical abuse, sexual abuse and neglect are not …
BACKGROUND: Suspected child physical abuse, sexual abuse and neglect are not uncommon presentations. As part of the assessment of these cases, a forensic medical history may be taken. This forensic history is used not only to determine the steps necessary to address the child's wellbeing but also to direct the forensic examination. Currently, there is no clear consensus on whether or not a forensic medical history should consistently be considered an integral element within the paediatric forensic evaluation. This study examines the value derived by the medical practitioner taking a forensic medical history rather than relying on hearsay evidence when a child presents for an assessment. METHODS: A retrospective review of paediatric cases seen by the Victorian Forensic Paediatric Medical Service (VFPMS) between 2014 and 2015 was undertaken. 274 forensic case reports were reviewed and the data was entered into an Excel spread sheet and analysed using chi squared tests within STATA(®). RESULTS: With increasing age of the child, a forensic medical history is significantly more likely to be taken. Additional information is made available to the medical practitioner what would otherwise have been provided if the medical practitioner relied only on the interview conducted by the police. Discrepancies observed between the official third parties (police or child protection) report of what a child has said and what the child says to the medical practitioner decrease with age, as do discrepancies observed between the child's version of events and a third party's (eg. parents, caregivers, friends) version of events. CONCLUSIONS: The study showed that by taking a forensic medical history from the child additional information can be obtained. Further, that there is a value in the examining medical practitioner taking a forensic medical history from children in cases of child physical and sexual abuse and neglect.
Dubowitz H, Finkel M, Feigelman S, Lyon T. Initial Medical Assessment of Possible Child Sexual Abuse: History, History, History. Academic Pediatrics. 2024; 24 (4) : 562-569.
Keywords: Humans, *Child Abuse, Sexual/diagnosis, *Medical History Taking, Child, Primary Health Care, Physical Examination
Primary care professionals (PCPs) can play a valuable role in the initial …
Primary care professionals (PCPs) can play a valuable role in the initial assessment of possible child sexual abuse (CSA), an all too prevalent problem. PCPs, however, are often reluctant to conduct these assessments. The goal of this paper is to help PCPs be more competent and comfortable playing a limited but key role. This is much needed as there may be no need for further assessment and also because of a relative paucity of medical experts in this area. While some children present with physical problems, the child's history is generally the critical information. This article therefore focuses on practical guidance regarding history-taking when CSA is suspected, incorporating evidence from research on forensic interviewing. We have been mindful of the practical constraints of a busy practice and the role of the public agencies in fully investigating possible CSA. The approach also enables PCPs to support children and their families.
Duhaime AC, Christian CW. Abusive head trauma: evidence, obfuscation, and informed management. Journal of Neurosurgery. Pediatrics. 2019; 24 (5) : 481-488.
Keywords: Brain Injuries, Traumatic/diagnosis/therapy, Child, Child Abuse/*diagnosis/legislation & jurisprudence, Child Protective Services, Child, Preschool, Craniocerebral Trauma/*diagnosis/therapy, Hematoma, Subdural, Intracranial/diagnosis/therapy, Humans, Infa
Abusive head trauma remains the major cause of serious head injury in infants …
Abusive head trauma remains the major cause of serious head injury in infants and young children. A great deal of research has been undertaken to inform the recognition, evaluation, differential diagnosis, management, and legal interventions when children present with findings suggestive of inflicted injury. This paper reviews the evolution of current practices and controversies, both with respect to medical management and to etiological determination of the variable constellations of signs, symptoms, and radiological findings that characterize young injured children presenting for neurosurgical care.
Dwiggins M, Gomez-Lobo V. Current review of prepubertal vaginal bleeding. Current Opinion in Obstetrics & Gynecology. 2017; 29 (5) : 322-327.
Keywords: Child, Child Abuse, Sexual/diagnosis, Child, Preschool, Female, Genital Neoplasms, Female/*complications, Humans, Infant, Infant, Newborn, Medical History Taking, Physical Examination, Puberty, Puberty, Precocious/complications, Skin Diseases/complication
PURPOSE OF REVIEW: Prepubertal vaginal bleeding raises many concerns and …
PURPOSE OF REVIEW: Prepubertal vaginal bleeding raises many concerns and evaluation and diagnosis may prove difficult for many providers. We aim to provide a comprehensive review and recent updates for those practitioners who care for these patients. RECENT FINDINGS: Prompt management in the case of prepubertal vaginal bleeding is indicated, especially to rule out malignancy or abuse. If a child is reluctant to undergo examination, or if the extent of injury or source of bleeding cannot be determined, examination under anesthesia and vaginoscopy is recommended. Use of vaginoscopy allows for clear visualization of the vagina and cervix without distorting hymenal anatomy, as well as diagnosis and removal of a foreign body and evaluation of mucosal damage caused. In the case of sexual abuse, providers specifically trained in pediatrics need to be present, and safety of the patient should always be ensured. SUMMARY: Careful history taking and targeted examination may lead to diagnosis in the case of prepubertal vaginal bleeding. However, in more difficult cases, practitioners should not hesitate to examine a patient in the operating room using general anesthesia to elicit the cause. Although sexual abuse and malignancy are always on the differential, most causes of bleeding are benign and easily treated.
Elvik SL, Berkowitz CD, Nicholas E, Lipman JL, Inkelis SH. Sexual abuse in the developmentally disabled: dilemmas of diagnosis. Child Abuse & Neglect. 1990; 14 (4) : 497-502.
Keywords: Activities of Daily Living/psychology, Adolescent, Adult, Child Abuse, Sexual/*diagnosis/psychology, Diagnosis, Differential, Female, Humans, Institutionalization, Intellectual Disability/*psychology, Middle Aged, Physical Examination/methods
Evaluation of developmentally disabled persons for physical signs of sexual …
Evaluation of developmentally disabled persons for physical signs of sexual abuse presents many challenges to the practitioner. This group is especially vulnerable to all types of abuse. A group of 35 mentally retarded females from a residential treatment facility was examined by the child abuse medical team at Harbor/UCLA Medical Center after one inpatient was found to be pregnant. Patients ranged in age from 13 to 55 years (median, 26 years; mean, 31.3 +/- 13.6 years). All of the women had some degree of disability, with 24 (69%) being categorized as profoundly retarded. No patient was able to provide a history. There were 13 (37%) patients who had genital findings we believe are consistent with prior vaginal penetration. Dilemmas which arose during evaluation included the significance of healed genital lesions in this population and the implications of the findings for the residential facility. While developmentally disabled persons need an advocate in the medical and legal systems, these patients can overwhelm the practitioner. Whenever possible, a team approach is recommended to decrease the work load and frustration and provide collegial support and affirmation of findings.
Family Practice Notebook
2005.
Moses S. Toxicology Screening, Urine Tox Screen
Findley PA, Plummer SB, McMahon S. Exploring the Experiences of Abuse of College Students With Disabilities. Journal of Interpersonal Violence. 2016; 31 (17) : 2801-23.
Keywords: Adolescent, Adult, Cross-Sectional Studies, Persons with Disabilities/psychology/*statistics & numerical data, Female, Humans, Intimate Partner Violence/statistics & numerical data, Male, Physical Abuse/statistics & numerical data, Sex Offenses/statistics
Intimate partner violence and sexual assault of college students has garnered …
Intimate partner violence and sexual assault of college students has garnered increased attention and publicity. Current studies have focused primarily on general campus populations with little to no attention to students with disabilities. While studies suggest the rate of abuse of individuals with disabilities is similar or higher compared to the general population, there remains a lack of focus on this issue. Individuals with disabilities are at particularly high risk for abuse, both through typical forms of violence (physical, sexual, emotional, and economic) and those that target one's disability. In an effort highlight and explore this issue further, an exploratory study was conducted to learn the rates of abuse among university students who have identified as having a disability. This is a cross-sectional survey of 101 students of students with disabilities from a large northeastern public university. Experiences of abuse were measured through the use of the Abuse Assessment Screen- Disability (AAS-D) scale. Students were asked about experiences of physical, sexual, psychological, and disability related abuse within the last year and help seeking behaviors when an incident of abuse occurred. We found that 22 % of participants reported some form of abuse over the last and nearly 62% (n= 63) had experienced some form of physical or sexual abuse before the age of 17. Those who were abused in the past year, 40% reported little or no knowledge of abuse-related resources and only 27% reported the incident. Authors discuss implications results have for programs and policies on campus for individuals with disabilities.
Fisher-Owens SA, Lukefahr JL, Tate AR. Oral and Dental Aspects of Child Abuse and Neglect. Pediatrics. 2017; 140 (2).
Keywords: Adolescent, Bites and Stings/complications/diagnosis, Bullying, Child, Child Abuse/*diagnosis/legislation & jurisprudence, Child Abuse, Sexual/*diagnosis/legislation & jurisprudence, Child, Preschool, Diagnosis, Differential, Female, Guideline Adherence,
In all 50 states, health care providers (including dentists) are mandated to …
In all 50 states, health care providers (including dentists) are mandated to report suspected cases of abuse and neglect to social service or law enforcement agencies. The purpose of this report is to review the oral and dental aspects of physical and sexual abuse and dental neglect in children and the role of pediatric care providers and dental providers in evaluating such conditions. This report addresses the evaluation of bite marks as well as perioral and intraoral injuries, infections, and diseases that may raise suspicion for child abuse or neglect. Oral health issues can also be associated with bullying and are commonly seen in human trafficking victims. Some medical providers may receive less education pertaining to oral health and dental injury and disease and may not detect the mouth and gum findings that are related to abuse or neglect as readily as they detect those involving other areas of the body. Therefore, pediatric care providers and dental providers are encouraged to collaborate to increase the prevention, detection, and treatment of these conditions in children.
Flaherty E, Legano L, Idzerda S. Ongoing Pediatric Health Care for the Child Who Has Been Maltreated. Pediatrics. 2019; 143 (4).
Keywords: Child, Child Abuse/*prevention & control/*therapy, *Child Welfare, Child, Preschool, Delivery of Health Care/*methods, Female, Humans, Male, Pediatricians, Pediatrics/*standards/trends, Physician's Role, Practice Patterns, Physicians', Societies, Medical,
Pediatricians provide continuous medical care and anticipatory guidance for …
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.
Flaherty EG, Perez-Rossello JM, Levine MA, Hennrikus WL, Christian CW, Crawford-Jakubiak JE, Leventhal JM, Lukefahr JL, Sege RD, MacMillan H, Nolan CM, Valley LA, Hurley TP, Cassady CI, Bulas DI, Cassese JA, Mehollin-Ray AR, Mercado-Deane MG, Milla SS, Thorne V, Sills IN, Blo. Evaluating children with fractures for child physical abuse. Pediatrics. 2014; 133 (2).
Keywords: Fractures
Fractures are common injuries caused by child abuse. Although the consequences …
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. Copyright \textcopyright 2014 by the American Academy of Pediatrics.
Focardi M, Gori V, Romanelli M, Santori F, Bianchi I, Rensi R, Defraia B, Grifoni R, Gualco B, Nanni L, Losi S. 'Mimics' of Injuries from Child Abuse: Case Series and Review of the Literature. Children (Basel, Switzerland). 2024; 11 (9).
The phenomenon of child abuse/maltreatment is underestimated and often …
The phenomenon of child abuse/maltreatment is underestimated and often represents a difficult challenge for healthcare professionals and forensic pathologists who must proceed with the differential diagnosis with accidental or self-induced events, or with lesions due to pathologies that overlap with that of mistreatment, defined as "Mimics". This study presents a case series with the aim of discussing lesions that may mimic signs of physical abuse in children but are due to a different etiology to raise awareness and train healthcare professionals and forensic pathologists on possible confounding factors in order to avoid diagnostic errors. Six cases of "Mimics" out of 418 cases of suspected mistreatment (1.43% of cases) were identified, presenting skin lesions initially classified as injuries of abuse due to their location and type and, in particular, sexual abuse for three cases. Then, the lesions and the subjects, in particular the anamnestic history, were examined by a multidisciplinary team and the diagnosis of genital lichen sclerosus et atrophicus in three cases, and the results of popular healing techniques (i.e., "cupping") in the other three cases were ascertained. These situations require specific skills and a forensic background from healthcare professionals to conduct a correct differential diagnosis and the intervention of a multidisciplinary team to investigate every possible pathology or alternative therapeutic practice that could simulate child abuse. In particular, when "mimics" are due to alternative medicine, it should not strictly be considered child abuse, but professionals must be aware of the hypothesis of mistreatment in case of non-medical indication or potential personal injuries from other crimes, such as illegal practice of the medicine. This awareness is also crucial to direct the child toward appropriate medical care, and it is essential to recognize that these conditions can coexist within the same clinical presentation.
Fortin K, Jenny C. Sexual abuse. Pediatrics in Review. 2012; 33 (1) : 19-32.
Keywords: Adolescent, Child, Child Abuse, Sexual/*diagnosis/psychology/therapy, Child, Preschool, Female, Humans, Male
Child sexual abuse is a common pediatric problem that concerns all pediatric …
Child sexual abuse is a common pediatric problem that concerns all pediatric health care providers. Management of child sexual abuse is multifaceted and multidisciplinary. Specialized health providers can provide consultation, but this availability does not minimize the role of the referring physician who often has ongoing contact with the family. Physicians are mandated to report cases of suspected or confirmed sexual abuse. In the majority of cases, a child’s statement about sexual abuse is the strongest evidence that abuse has occurred. Physical examination is normal in the majority of sexual abuse victims. Accurate, evidence-based interpretation of physical and laboratory findings is essential. Normal examinations, normal variants, and findings indicative of sexual contact must be differentiated. Forensic evidence collection and prophylactic treatments may be indicated when patients present within 72 hours of an abusive episode, and patients should be triaged accordingly. Potentially negative psychosocial outcomes should be addressed for patients and their families on initial evaluation and follow-up.
Frasier, LF. Child abuse or mimic: Vaginal bleeding in an infant. Cliggot Publications. Consultant for Pediatricians. 2003; 2 (1) : 30-33.
Frasier KM, Fritts HA, Li V, Dudzik C, Sobotka M, Click K, Loperfito A. Advancing Understanding of Dermatological Manifestations in Munchausen Syndrome by Proxy. Cureus. 2024; 16 (10) : e71616.
This comprehensive review critically examines the complex relationship between …
This comprehensive review critically examines the complex relationship between Munchausen Syndrome by Proxy (MSBP) and its dermatological manifestations, uncovering new insights into the relatively uncharted territory of this psychiatric disorder. By synthesizing existing literature, case studies, and clinical observations, this paper reveals the multifaceted spectrum of dermatological phenomena seen in individuals affected by MSBP, ranging from self-inflicted injuries to entirely fabricated skin conditions. Additionally, we explore the psychological and behavioral mechanisms driving caregivers to induce or stimulate dermatological symptoms, shedding light on underlying psychopathologies, the nuanced dynamics of the caregiver-patient relationship, and patterns of pathological attachment and dependency. This review confronts the significant obstacles healthcare providers encounter in accurately identifying dermatological symptoms related to MSBP amidst genuine dermatologic conditions, underscoring the indispensable role of a multidisciplinary strategy and heightened clinical vigilance in these complex cases. Future investigations call for the development of standardized assessment tools, the potential of biomarkers for early detection, the exploration of the neurobiological basis of MSBP, and the utilization of specific interventions to protect susceptible populations while improving the accuracy of MSBP diagnoses. This paper calls for a more informed, sensitive, and proactive approach to better understanding and treating the dermatological manifestations of MSBP.
Friedrich WN, Fisher J, Broughton D, Houston M, Shafran CR. Normative sexual behavior in children: a contemporary sample. Pediatrics. 1998; 101 (4) : E9.
Keywords: Age Factors, Child, *Child Behavior/ethnology, Child Day Care Centers, Child, Preschool, Domestic Violence, Family/psychology, Family Relations, Female, Humans, Male, Reference Values, Sex Factors, *Sexual Behavior/ethnology/statistics & numerical data, S
OBJECTIVE: Sexual behavior in children can cause uncertainty in the clinician …
OBJECTIVE: Sexual behavior in children can cause uncertainty in the clinician because of the relationship between sexual abuse and sexual behavior. Consequently, it is important to understand normative childhood sexual behavior. DESIGN: Sexual behavior in 1114 2- to 12-year-old children was rated by primary female caregivers. These children were screened for the absence of sexual abuse. A 38-item scale assessing a broad range of sexual behavior (Child Sexual Behavior Inventory, Third Version) was administered along with the Child Behavior Checklist and a questionnaire assessing family stress, family sexuality, social maturity of the child, maternal attitudes regarding child sexuality, and hours in day care. RESULTS: Sexual behavior was related to the child's age, maternal education, family sexuality, family stress, family violence, and hours/week in day care. Frequencies of sexual behaviors for 2- to 5-, 6- to 9-, and 10- to 12-year-old boys and girls are presented. CONCLUSIONS: A broad range of sexual behaviors are exhibited by children who there is no reason to believe have been sexually abused. Their relative frequency is similar to two earlier studies, and this reinforces the validity of these results.
Gallion HR, Milam LJ, Littrell LL. Genital Findings in Cases of Child Sexual Abuse: Genital vs Vaginal Penetration. Journal of Pediatric and Adolescent Gynecology. 2016; 29 (6) : 604-611.
Keywords: Adolescent sexual assault,Child sexual abuse,Genital injury,Penetration
Study Objective To (1) examine the prevalence of abnormal genital findings in a …
Study Objective To (1) examine the prevalence of abnormal genital findings in a large cohort of female children presenting with concerns of sexual abuse; and (2) explore how children use language when describing genital contact and genital anatomy. Design In this prospective study we documented medical histories and genital findings in all children who met inclusion criteria. Findings were categorized as normal, indeterminate, and diagnostic of trauma. Logistic regression analysis was used to determine the effects of key covariates on predicting diagnostic findings. Children older than 4 years of age were asked questions related to genital anatomy to assess their use of language. Setting A regional, university-affiliated sexual abuse clinic. Participants Female children (N = 1500) aged from birth to 17 years (inclusive) who received an anogenital examination with digital images. Interventions and Main Outcome Measures Physical exam findings, medical history, and the child's use of language were recorded. Results Physical findings were determined in 99% (n = 1491) of patients. Diagnostic findings were present in 7% (99 of 1491). After adjusting for age, acuity, and type of sexual contact reported by the adult, the estimated odds of diagnostic findings were 12.5 times higher for children reporting genital penetration compared with those who reported only contact (95% confidence interval, 3.46-45.34). Finally, children used the word “inside” to describe contact other than penetration of the vaginal canal (ie, labial penetration). Conclusion A history of penetration by the child was the primary predictor of diagnostic findings. Interpretation of children's use of “inside” might explain the low prevalence of diagnostic findings and warrants further study.
Gewirtz-Meydan A, Finkelhor D. Sexual Abuse and Assault in a Large National Sample of Children and Adolescents. Child Maltreatment. 2020; 25 (2) : 203-214.
Keywords: Adolescent, Age Distribution, Child, Child Abuse, Sexual/ethnology/psychology/*statistics & numerical data, Child, Preschool, Fear, Female, Humans, Infant, Infant, Newborn, Male, Sex Distribution, Socioeconomic Factors, United States/epidemiology
The present study sought to examine features of sexual abuse cases among a U.S. …
The present study sought to examine features of sexual abuse cases among a U.S. nationally representative sample of 13,052 children and adolescents, ages 0-17 years. The National Survey of Children's Exposure to Violence was collected in three different years (2008, 2011, and 2014) via telephone interviews. Information about sexual abuse and assault was obtained from youth themselves (ages 10-17) or caregivers (for children ages 0-9) using the Juvenile Victimization Questionnaire. Results indicate most offenses are at the hands of other juveniles (76.7% for males and 70.1% for females), primarily acquaintances, and occurring more frequently for adolescents aged 14-17. Whereas girls are mostly abused by males (88.4%), boys are abused by both males (45.6%) and females (54.4%). In 15% of cases, penetration is part of the abuse. Victims report being very afraid in 37.5% of episodes but not at all afraid in 19.8%. Among 10- to 17-year-olds, 66.3% of episodes are not reported to parents or any adult. Police reports occur for 19.1% of all cases. The results in the present study indicate that children and youth are exposed to sexual abuse and assault in varied ways, which require moving beyond conventional stereotypes of the problem.
Giardino AP, Finkel MA, Giardino ER, Seidl T, Ludwig S. Practical Guide to the Evaluation of Sexual Abuse in the Prepubertal Child. California: Sage Publications. 1992; 16-28.
Keywords: The purpose of this manual is to serve as a reference guide for health care professionals called upon to evaluate children suspected of being sexually abused.
The manual may be useful for various health care team members, including …
The manual may be useful for various health care team members, including clinical social workers, psychologists and psychiatrists, child protective service workers, and law enforcement personnel. It provides background information on child sexual abuse in order to increase the awareness of health care professionals; to facilitate their consideration of sexual abuse in differential diagnoses, given specific and nonspecific signs and symptoms; to reassure health professionals in their roles as care providers and child advocates; and to provide a reference on how to proceed with medical and psychological assessment. Sections of the manual cover the scope of child sexual abuse, sexual abuse evaluation, interview and history procedures, physical examinations and laboratory specimens, the differential diagnosis of anogenital findings, sexually transmitted diseases, and mental health evaluation. References, tables, figures, and photographs
Glenn K, Nickerson E, Bennett CV, Naughton A, Cowley LE, Morris E, Murtagh U, Kontos K, Kemp AM. Head computed tomography in suspected physical abuse: time to rethink?. Archives of Disease in Childhood. 2021; 106 (5) : 461-466.
Keywords: Humans, Infant, *Tomography, X-Ray Computed/methods/statistics & numerical data, *Child Abuse/diagnosis/statistics & numerical data, Retrospective Studies, Male, Female, *Craniocerebral Trauma/diagnostic imaging, Child, Preschool, Practice Guidelines as T
BACKGROUND: National guidance recommends CT-head for all children <1 year old …
BACKGROUND: National guidance recommends CT-head for all children <1 year old with suspected physical abuse, and to be considered for those <2 years old to exclude abusive head trauma. OBJECTIVES: To investigate whether this guidance is followed, and the associations between clinical presentation and CT findings, to determine whether guidance could be refined. MATERIALS AND METHODS: A retrospective case note review of all children <2 years old who underwent medical assessment for suspected abuse (2009-2017). Outcome measures were frequency of CT-head, and diagnostic yield of intracranial injury, skull fracture or both. RESULTS: CT-head was undertaken in 60.3% (152/252) of children <12 months old and 7.8% (13/167) of those aged 12-24 months. The diagnostic yield in children who had a CT-head was 27.1% in children <6 months old, 14.3% in those 6-12 months old (p=0.07) and 42.6% (6/13) in those 12-24 months old. For those with head swelling or neurological impairment, it was 84.2% (32/38). In children <12 months old without these clinical features, the estimated prevalence of occult head injury was 6.1% (7/115). The strongest predictors of an abnormal CT-head were swelling to the head (OR 46.7), neurological impairment (OR 20.6) and a low haemoglobin (OR 11.8). CONCLUSION: All children <2 years of age with suspected physical abuse and neurological impairment or head swelling should undergo CT-head. Where the technical skills and the requisite expertise to interpret MRI exist, an MRI scan may be the optimal first-line neuroimaging investigation in infants who are neurologically stable with injuries unrelated to the head to minimise cranial radiation exposure.
Glick JC, Lorand MA, Bilka KR. Physical Abuse of Children. Pediatrics in Review. 2016; 37 (4) : 146-56; quiz 157.
Keywords: Child Abuse/*diagnosis/prevention & control/statistics & numerical data, Humans, Infant, Mandatory Reporting, Medical History Taking, Pediatricians, Physical Examination, Physician's Role, Risk Factors
Gold MA. Emergency Contraception. Adolescent Medicine (Philadelphia, Pa.). 1997; 8 (3) : 455-462.
Emergency contraception uses oral contraceptives or postcoital insertion of an …
Emergency contraception uses oral contraceptives or postcoital insertion of an intrauterine device (IUD) to prevent pregnancy after an episode of unprotected intercourse. This chapter reviews the available data on the efficacy of emergency contraceptive pills (ECPs), indications and contraindications, availability, safety, and potential side effects. It also addresses the controversial issues that arise from equating ECPs with abortion, as well as the effects of ECPs on contraceptive practices of adolescents.
Golonka M, Liu Y, Rohrs R, Copeland J, Byrd J, Stilwell L, Crew C, Kuehn M, Snyder-Fickler E, Hurst JH, Evans KE, Terrell L, Gifford EJ. What Do Child Abuse and Neglect Medical Evaluation Consultation Notes Tell Researchers and Clinicians?. Child Maltreatment. 2024; 29 (1) : 117-128.
Keywords: Child, Humans, *Child Abuse/diagnosis/prevention & control, Referral and Consultation
Child abuse and neglect (CAN) medical experts provide specialized …
Child abuse and neglect (CAN) medical experts provide specialized multidisciplinary care to children when there is concern for maltreatment. Their clinical notes contain valuable information on child- and family-level factors, clinical concerns, and service placements that may inform the needed supports for the family. We created and implemented a coding system for data abstraction from these notes. Participants were 1,397 children ages 0-17 years referred for a consultation with a CAN medical provider at an urban teaching and research hospital between March 2013 and December 2017. Coding themes were developed using an interdisciplinary team-based approach to qualitative analysis, and descriptive results are presented using a developmental-contextual framework. This study demonstrates the potential value of developing a coding system to assess characteristics and patterns from CAN medical provider notes, which could be helpful in improving quality of care and prevention and detection of child abuse.
Gunja N. The clinical and forensic toxicology of Z-drugs. Journal of Medical Toxicology : Official Journal of the American College of Medical Toxicology. 2013; 9 (2) : 155-62.
Keywords: Acetamides/*adverse effects/pharmacokinetics/poisoning, Azabicyclo Compounds/*adverse effects/pharmacokinetics/poisoning, Coma/etiology/prevention & control, Drug Overdose/drug therapy/mortality/physiopathology, Flumazenil/therapeutic use, GABA Modulators
The Z-drugs zolpidem, zopiclone, and zaleplon were hailed as the innovative …
The Z-drugs zolpidem, zopiclone, and zaleplon were hailed as the innovative hypnotics of the new millennium, an improvement to traditional benzodiazepines in the management of insomnia. Increasing reports of adverse events including bizarre behavior and falls in the elderly have prompted calls for caution and regulation. Z-drugs have significant hypnotic effects by reducing sleep latency and improving sleep quality, though duration of sleep may not be significantly increased. Z-drugs exert their effects through increased γ-aminobutyric acid (GABA) transmission at the same GABA-type A receptor as benzodiazepines. Their pharmacokinetics approach those of the ideal hypnotic with rapid onset within 30 min and short half-life (1-7 h). Zopiclone with the longest duration of action has the greatest residual effect, similar to short-acting benzodiazepines. Neuropsychiatric adverse events have been reported with zolpidem including hallucinations, amnesia, and parasomnia. Poisoning with Z-drugs involves predominantly sedation and coma with supportive management being adequate in the majority. Flumazenil has been reported to reverse sedation from all three Z-drugs. Deaths from Z-drugs are rare and more likely to occur with polydrug overdose. Z-drugs can be detected in blood, urine, oral fluid, and postmortem specimens, predominantly with liquid chromatography-mass spectrometry techniques. Zolpidem and zaleplon exhibit significant postmortem redistribution. Zaleplon with its ultra-short half-life has been detected in few clinical or forensic cases possibly due to assay unavailability, low frequency of use, and short window of detection. Though Z-drugs have improved pharmacokinetic profiles, their adverse effects, neuropsychiatric sequelae, and incidence of poisoning and death may prove to be similar to older hypnotics.
Hadley J, Moore J, Goldberg A. Sexual Abuse as a Cause of Prepubertal Genital Bleeding: Understanding the Role of Routine Physical Examination. Journal of Pediatric and Adolescent Gynecology. 2021; 34 (3) : 288-290.
Keywords: Child, Child Abuse, Sexual/*diagnosis/psychology, Child, Preschool, Diagnosis, Differential, Disclosure, Female, Genitalia, Female/*injuries, Hemorrhage/diagnosis/*etiology, Humans, Pediatrics, Physical Examination
Although accidental trauma is the most common mechanism for genital bleeding, …
Although accidental trauma is the most common mechanism for genital bleeding, sexual abuse should be considered when the patient is prepubertal and/or a vague history of bleeding is provided. Prepubertal female genital exams should be completed routinely; this clinical technique is critical for pediatricians to assess pubertal progression, to identify pathologies or differences in sexual differentiation, and to narrow a broad differential diagnosis of bleeding. Physical evidence of sexual abuse on exam is rarely found, and therefore the diagnosis relies on a child's disclosure. Physicians should be cognizant of barriers to patient disclosure. In this commentary we aim to provide general pediatricians and trainees with a framework for evaluating genital/vaginal bleeding in prepubertal girls, by discussing the following: (1) the importance of a complete anogenital exam in generating a differential diagnosis; and (2) the possibility of sexual abuse as an etiology with recognition that the disclosure process is complex.
Haney S, Scherl S, DiMeglio L, Perez-Rossello J, Servaes S, Merchant N. Evaluating Young Children With Fractures for Child Abuse: Clinical Report. Pediatrics. 2025; 155 (2).
Keywords: Humans, *Child Abuse/diagnosis, *Fractures, Bone/diagnosis, Infant, Child, Preschool, Diagnosis, Differential, Child
Fractures are common injuries in childhood and can be caused by unintentional …
Fractures are common injuries in childhood and can be caused by unintentional injury, medical conditions, and child abuse. Although the consequences of failing to diagnose an abusive injury in a child can be grave, the consequences of incorrectly diagnosing child abuse in a child whose fractures have another etiology are also significant. This report aims to review recent advances in the understanding of fracture specificity, fracture mechanisms, and other medical conditions that predispose infants and children to fracture. This clinical report will aid pediatricians and pediatric care providers in developing an evidence-based differential diagnosis and performing appropriate evaluations when assessing a child with fractures.
Hartog J, Hartog EA. Cultural aspects of health and illness behavior in hospitals. Western Journal of Medicine. 1983; 139 (6) : 910-6.
Keywords: Communication, *Culture, Diet, Hospitals, Humans, Pain/psychology, Religion and Medicine, *Sick Role
Health care attitudes reflect the basic world view and values of a culture, …
Health care attitudes reflect the basic world view and values of a culture, such as how we relate to nature, other people, time, being, society versus community, children versus elders and independence versus dependence. Illness behavior determines who is vulnerable to illness and who agrees to become a patient-since only about one third of the ill will see a physician. Cultural values determine how one will behave as a patient and what it means to be ill and especially to be a hospital patient. They affect decisions about a patient's treatment and who makes the decisions. Cultural differences create problems in communication, rapport, physical examination and treatment compliance and follow through. The special meaning of medicines and diet requires particular attention. The perception of physical pain and psychologic distress varies from culture to culture and affects the attitudes and effectiveness of care-givers as much as of patients. Religious beliefs and attitudes about death, which have many cultural variations, are especially relevant to hospital-based treatment. Linguistic and cultural interpreters can be essential; they are more available than realized, though there are pitfalls in their use. Finally, one must recognize that individual characteristics may outweigh the ethnic and that a good caring relationship can compensate for many cultural missteps.
Hauschild MH, Omar HN, Bauer M, Sarkisova N, Lee CJ, Wren TAL, Goldstein RY. Investigating the Determinants of Nonaccidental Trauma Evaluation in Pediatric Femur Fractures. The Journal of the American Academy of Orthopaedic Surgeons. 2024; 32 (19) : 915-920.
Keywords: Humans, Retrospective Studies, Infant, *Child Abuse/diagnosis/statistics & numerical data, *Femoral Fractures/diagnosis/etiology, Male, Female, Child, Preschool, Infant, Newborn, Practice Guidelines as Topic
BACKGROUND: Femoral fractures in children have the highest probability for …
BACKGROUND: Femoral fractures in children have the highest probability for abuse after skull fractures and humeral shaft fractures. However, the reported proportion of pediatric femur fractures that result from nonaccidental trauma (NAT) varies in the literature from 2% to 60%. The purpose of this study was to determine the patient characteristics associated with a physician's decision to conduct a NAT workup and challenge universal clinical practice guidelines stating that all children younger than 3 years with a diaphyseal femur fracture be evaluated for NAT. METHODS: A retrospective review was conducted on patients aged 0 to 36 months diagnosed with a femur fracture between January 1, 2004, and April 9, 2019, at our institution. NAT was defined as a diagnosis of trauma that was nonaccidental in the medical chart after a positive workup by skeletal survey, ophthalmological examination, or other appropriate referral made by the institution's child abuse and neglect team. Patients with incomplete medical records were excluded. RESULTS: A total of 299 patients were identified, and 22 were excluded. 71% (197/277) were screened for NAT. Patients younger than 1 year were significantly more likely to undergo a NAT workup ( P = 0.009; Odds Ratio [OR], 2.3; 95% CI, 1.2 to 4.4) and receive a positive result from the NAT workup ( P < 0.0005; OR, 11.3; 95% CI, 4.6 to 27.4). Additional injuries were also a significant predictor of a positive NAT workup ( P < 0.001; OR, 5.3; 95% CI, 2.4 to 11.9). Patient race/ethnicity, sex, and fracture type were not markedly associated with the physician's decision to conduct a NAT workup. CONCLUSIONS: Infants younger than 1 year with a femur fracture and children younger than 3 years presenting with a femur fracture and another injury are at increased risk of possible NAT. While clinical practice guidelines may minimize racial bias in NAT evaluation, this study demonstrates that universal NAT workups for walking-age children in the absence of other evidence of abuse may be unnecessary. LEVEL OF EVIDENCE: This is a Level III retrospective cohort study.
Heger AH, Emans SJ, Muram D. Evaluation of the Sexually Abused Child: A Medical Textbook and Photographic Atlas. 2nd Edition. Oxford University Press. 2003; 41-55.
Physicians examining children for suspected sexual abuse often do not have the …
Physicians examining children for suspected sexual abuse often do not have the training they need to make a skilled diagnosis. This comprehensive resource provides step-by-step guidance on interviewing and clinically evaluating possible child sexual abuse cases, and includes sixty-three pages of color photographs that document sexual abuse injuries, and offer comparisons to accidental injuries as well as normal anatomical variations.
Henry MK, Bennett CE, Wood JN, Servaes S. Evaluation of the abdomen in the setting of suspected child abuse. Pediatric Radiology. 2021; 51 (6) : 1044-1050.
Keywords: Abdomen, *Abdominal Injuries/diagnostic imaging, Child, *Child Abuse/diagnosis, *Fractures, Bone, Humans, Infant, Mass Screening
Abusive intra-abdominal injuries are less common than other types of injuries, …
Abusive intra-abdominal injuries are less common than other types of injuries, such as fractures and bruises, identified in victims of child physical abuse, but they can be deadly. No single abdominal injury is pathognomonic for abuse, but some types and constellations of intra-abdominal injuries are seen more frequently in abused children. Identification of intra-abdominal injuries can be important clinically or forensically. Injuries that do not significantly change clinical management can still elevate a clinician's level of concern for abuse and thereby influence subsequent decisions affecting child protection efforts. Abusive intra-abdominal injuries can be clinically occult, necessitating screening laboratory evaluations to inform decisions regarding imaging. Once detected, consideration of developmental abilities of the child, type and constellation of injuries, and the forces involved in any provided mechanism of trauma are necessary to inform assessments of plausibility of injury mechanisms and level of concern for abuse. Here we describe the clinical, laboratory and imaging evaluation of the abdomen in the setting of suspected child abuse.
Herring A, Richens J. Lymphogranuloma venereum. Sexually Transmitted Infections. 2006; 82 Suppl 4 (Suppl 4) : iv23-5.
Keywords: Chlamydia trachomatis/*isolation & purification, DNA, Bacterial/analysis, Female, Humans, Immunoassay/methods, Lymphogranuloma Venereum/*diagnosis/microbiology, Male, Mass Screening/*methods, Nucleic Acid Amplification Techniques, Rectal Diseases/diagnosi
Hershkowitz I, Lamb ME, Horowitz D. Victimization of children with disabilities. The American Journal of Orthopsychiatry. 2007; 77 (4) : 629-35.
Keywords: Child, Child Abuse/statistics & numerical data, Child, Preschool, Crime Victims/*statistics & numerical data, Developmental Disabilities/*epidemiology, Children with Disabilities/*statistics & numerical data, Female, Humans, Male
Children with disabilities (CWDs) are more likely to be victims of child abuse …
Children with disabilities (CWDs) are more likely to be victims of child abuse but may have more difficulty than their typically developing (TD) peers reporting their experiences. In this study, the authors examined the characteristics of abuse reported by CWDs based on forensic statements made by 40430 alleged abuse victims, 11% categorized as children with minor disabilities, and 1.2% categorized as children with severe disabilities. Proportionally more of the CWDs than of the TD children were allegedly victims of sexual rather than physical abuse. CWDs failed to disclose abuse and delayed disclosure more often than TD suspected victims. CWDs were more likely than TD children to be abused by parent figures and to experience physical abuse resulting in body injury or serious sexual offenses, including those involving penetration, repeated abuse, use of force, and threats. Higher levels of disability were associated with increased risk of sexual abuse. Both the heightened incidence of severe abuse among and the failure to disclose abuse by CWDs should be sources of considerable concern to social welfare and criminal justice agencies.
Hetal B, Gor HB, Chief Editor: Rivlin, ME. Vaginitis. Medscape. 2024.
Vaginitis (inflammation of the vagina) is the most common gynecologic condition …
Vaginitis (inflammation of the vagina) is the most common gynecologic condition encountered in the office. It is a diagnosis based on the presence of symptoms of abnormal discharge, vulvovaginal discomfort, or both. Cervicitis may also cause a discharge and sometimes occurs with vaginitis.
Hibbard RA. Triage and referrals for child sexual abuse medical examinations from the sociolegal system. Child Abuse & Neglect. 1998; 22 (6) : 503-13.
Keywords: Child, Child Abuse, Sexual/*diagnosis/*legislation & jurisprudence, Child, Preschool, Humans, *Referral and Consultation, *Triage, United States
Hornor G. Medical Child Abuse: Essentials for Pediatric Health Care Providers. Journal of Pediatric Health Care : Official Publication of National Association of Pediatric Nurse Associates & Practitioners. 2021; 35 (6) : 644-650.
Keywords: Child, *Child Abuse/diagnosis/psychology, Humans, Pediatric Nurse Practitioners, Physical Examination
Medical child abuse (MCA) is a rare but potentially deadly variant of child …
Medical child abuse (MCA) is a rare but potentially deadly variant of child maltreatment. MCA results in unnecessary health care for a child because of a caregiver's exaggeration, fabrication, or induction of physical and/or psychological symptoms of illness. These unnecessary health care interventions result in a morbidity rate of 100% in the form of complications and disabilities and a mortality rate as high as 9%. Although MCA is relatively rare, it is estimated that pediatric health care professionals, including pediatric nurse practitioners, will most likely encounter at least one MCA victim in the course of their career. This continuing education article will discuss MCA in terms of definition and features, epidemiology, perpetrators, variants in presentation, consequences, and implications for practice.
House.Gov
Federal rules of evidence. Article VII-Opinions and Expert Testimony
Huff RA & Kline MV. Promoting Health in Multicultural Populations: A Handbook for Practitioners. London: Sage Publication. 1999.
Promoting Health in Multicultural Populations will prove an excellent shelf …
Promoting Health in Multicultural Populations will prove an excellent shelf reference for health and human service providers and scholars, and a valuable text for students in a wide variety of professional disciplines, including public health and other arenas of health care, social work, and medical sociology and anthropology.
Jansson LM, Patrick SW. Neonatal Abstinence Syndrome. Pediatric Clinics of North America. 2019; 66 (2) : 353-367.
Keywords: Aftercare/methods, Analgesics, Opioid/*adverse effects/blood, Breast Feeding/methods, Diagnosis, Differential, Female, Humans, Infant, Newborn, Male, Mothers, Neonatal Abstinence Syndrome/*diagnosis/therapy, Opioid-Related Disorders/*therapy, Pregnancy, P
This review examines the continuum of care of opioid-exposed infants, including …
This review examines the continuum of care of opioid-exposed infants, including the assessment of the neonate, diagnosis of neonatal abstinence syndrome, management of the syndrome including nonpharmacologic and pharmacologic care, approach to breastfeeding, pediatric follow-up care, and integration of care of the mother-infant dyad.
Jenny C, Crawford-Jakubiak JE. The evaluation of children in the primary care setting when sexual abuse is suspected. Pediatrics. 2013; 132 (2) : e558-67.
Keywords: Adolescent, Child, Child Abuse, Sexual/*diagnosis/legislation & jurisprudence/psychology/therapy, Cooperative Behavior, Cross-Sectional Studies, Female, Follow-Up Studies, Humans, Interdisciplinary Communication, Interview, Psychological, Male, *Mandat
This clinical report updates a 2005 report from the American Academy of …
This clinical report updates a 2005 report from the American Academy of Pediatrics on the evaluation of sexual abuse in children. The medical assessment of suspected child sexual abuse should include obtaining a history, performing a physical examination, and obtaining appropriate laboratory tests. The role of the physician includes determining the need to report suspected sexual abuse; assessing the physical, emotional, and behavioral consequences of sexual abuse; providing information to parents about how to support their child; and coordinating with other professionals to provide comprehensive treatment and follow-up of children exposed to child sexual abuse.
Jenny C, Metz JB. Medical Child Abuse and Medical Neglect. Pediatrics in Review. 2020; 41 (2) : 49-60.
Keywords: Child, Child Abuse/*diagnosis/prevention & control/statistics & numerical data/therapy, Child Protective Services, Complementary Therapies, Family/psychology, Health Services Accessibility, Humans, Mandatory Reporting, Munchausen Syndrome by Proxy/diagnos
Johnson KL, Brown ECB, Feldman KW, Qu P, Lindberg DM. Child Abuse Pediatricians Assess a Low Likelihood of Abuse in Half of 2890 Physical Abuse Consults. Child maltreatment. 2022; 27 (2) : 202-208.
Keywords: Child, *Child Abuse/diagnosis, Humans, Pediatricians, *Physical Abuse, Referral and Consultation, Retrospective Studies
The aim of this study was to examine the frequency with which child abuse …
The aim of this study was to examine the frequency with which child abuse pediatricians (CAPs) assess consultations as low versus high likelihood of abuse. In this retrospective secondary analysis of data from the Examining Siblings to Recognize Abuse (ExSTRA) study, the likelihood of abuse score for 2890 consultations at 20 medical centers was collected. Descriptive statistics were used to examine the percentage of cases representing low versus high likelihood of abuse (i.e., score of 1-4 vs. 5-7 on a 7-point scale). Linear and logistic regression analyses were used to examine score variability between medical centers. Overall, fifty-three percent of cases were assessed as low likelihood of abuse, suggesting that CAPs were equally as likely to assess a high versus low likelihood of abuse. The percentage of cases representing low likelihood of abuse differed significantly (P < .001) between medical centers after controlling for patient age, sex, race/ethnicity, twin/triplet status, injury types, and injury severity. The variability between CAP assessments at different medical centers is discussed, along with potential contributors to this variability and directions for future work.
Jones L, Bellis MA, Wood S, Hughes K, McCoy E, Eckley L, Bates G, Mikton C, Shakespeare T, Officer A. Prevalence and risk of violence against children with disabilities: a systematic review and meta-analysis of observational studies. Lancet (London, England). 2012; 380 (9845) : 899-907.
Keywords: Adolescent, Child, Child Abuse/*statistics & numerical data, Child Abuse, Sexual/statistics & numerical data, *Children with Disabilities, Humans, Prevalence, Violence/*statistics & numerical data
BACKGROUND: Globally, at least 93 million children have moderate or severe …
BACKGROUND: Globally, at least 93 million children have moderate or severe disability. Children with disabilities are thought to have a substantially greater risk of being victims of violence than are their non-disabled peers. Establishment of reliable estimates of the scale of the problem is an essential first step in the development of effective prevention programmes. We therefore undertook a systematic review and meta-analysis to synthesise evidence for the prevalence and risk of violence against children with disabilities. METHODS: For this systematic review and meta-analysis, we searched 12 electronic databases to identify cross-sectional, case-control, or cohort studies reported between Jan 1, 1990, and Aug 17, 2010, with estimates of prevalence of violence against children (aged ≤18 years) with disabilities or their risk of being victims of violence compared with children without disabilities. FINDINGS: 17 studies were selected from 10,663 references. Reports of 16 studies provided data suitable for meta-analysis of prevalence and 11 for risk. Pooled prevalence estimates were 26·7% (95% CI 13·8-42·1) for combined violence measures, 20·4% (13·4-28·5) for physical violence, and 13·7% (9·2-18·9) for sexual violence. Odds ratios for pooled risk estimates were 3·68 (2·56-5·29) for combined violence measures, 3·56 (2·80-4·52) for physical violence, and 2·88 (2·24-3·69) for sexual violence. Huge heterogeneity was identified across most estimates (I(2)>75%). Variations were not consistently explained with meta-regression analysis of the characteristics of the studies. INTERPRETATION: The results of this systematic review confirm that children with disabilities are more likely to be victims of violence than are their peers who are not disabled. However, the continued scarcity of robust evidence, due to a lack of well designed research studies, poor standards of measurement of disability and violence, and insufficient assessment of whether violence precedes the development of disability, leaves gaps in knowledge that need to be addressed. FUNDING: WHO Department of Violence and Injury Prevention and Disability.
Kaplan DM, Moore JL, Hirway P, Barron CE, Goldberg AP. A Comprehensive Pediatric Acute Sexual Assault Protocol: From Emergency Department to Outpatient Follow-up. Pediatric Emergency Care. 2021; 37 (2) : 62-69.
Keywords: Child, *Child Abuse, Sexual/diagnosis/therapy, Emergency Service, Hospital, Follow-Up Studies, Humans, *Outpatients, Retrospective Studies, *Sex Offenses
OBJECTIVE: Close medical follow-up after pediatric acute sexual assault is …
OBJECTIVE: Close medical follow-up after pediatric acute sexual assault is recommended and may mitigate adverse consequences and decrease long-term comorbidities. The objectives are to (1) examine adherence to a comprehensive outpatient medical follow-up protocol after evaluation in the emergency department in a pediatric population and (2) identify characteristics associated with patient adherence to inform the utilization of a medical follow-up protocol after pediatric acute sexual assault. METHODS: A retrospective medical record review was conducted of patients younger than 18 years presenting to the emergency department from January 1, 2010, to December 31, 2013, with a discharge diagnosis suggestive of sexual assault/abuse. We examined differences in demographics, assault characteristics, and medical/legal needs of patients who were evaluated in follow-up versus patients who were not. RESULTS: Of 182 patients, 60.4% completed follow-up appointments with the child protection center. Younger patients had follow-up rates higher than older patients (70.2% vs 50%; odds ratio [OR], 0.42). For patients where child protective services or law enforcement were called, follow-up rates were 74.2% and 64.7%, respectively (OR, 2.5; OR, 3.1). All patients with anogenital injuries on initial examination were seen in follow-up. The majority of patients who followed-up were accompanied by a caregiver/relative (95%). CONCLUSIONS: (1) Caregivers should be integrated into the evaluation to facilitate compliance with follow-up; (2) child abuse specialists may be consulted to facilitate specific interventions and recommendations; (3) professionals should work as a multidisciplinary team; and (4) the patient's psychological status should be evaluated, and mental health interventions recommended.
Karmazyn B, Marine MB, Wanner MR, Cooper ML, Delaney LR, Jennings SG, Eckert GJ, Hibbard RA. Chest CT in the evaluation of child abuse - When is it useful?. Child Abuse & Neglect. 2022; 133 : 105823.
Keywords: Child, *Child Abuse/diagnosis, Female, Humans, Infant, Radiography, Retrospective Studies, *Rib Fractures/diagnostic imaging, Tomography, X-Ray Computed
BACKGROUND: Indications for chest CT in evaluation of child abuse are unknown. …
BACKGROUND: Indications for chest CT in evaluation of child abuse are unknown. OBJECTIVE: Determine which groups of children can best benefit from chest CT. PARTICIPANTS AND SETTING: 10-year (1/2010 to 12/2019) retrospective study of children <3 years who had chest CT within 3 days of the initial skeletal survey. METHODS: Demographic and clinical information were obtained from medical records. Two pediatric radiologists reviewed, independently and blinded to clinical information, anonymized rib X-rays (initial and follow up when available) and chest CT. Disagreements were resolved by a third pediatric radiologist. Agreement was evaluated using kappa statistics. Number and percentage of fractures were analyzed by negative binomial models and chi-square tests, respectively. RESULTS: 50 children (21 females) with average age of 9.7 months, 27 of whom had follow-up radiography. Agreement on initial and follow-up X-rays was substantial (k = 0.72) and perfect (k = 1.00), respectively, and almost perfect (k = 0.82) for CT scans. Chest CT demonstrated more fractures than X-ray, both initially (112 vs. 42, p < 0.0001) and at follow-up (93 vs. 49, p < 0.0001). Significantly more additional fractures were found at CT (11/13, 84.6 %) in patients with positive than in those with negative initial surveys (7/37, 18.9 %, p < 0.001). Ten initial surveys had only indeterminate fractures; four of them had fractures and six had no fractures on CT. Chest CT missed one patient (1/27, 3.7 %) with acute nondisplaced anterior rib fractures. CONCLUSION: Chest CT can be considered in children with negative skeletal survey and high clinical suspicion for child abuse, and when the diagnosis of rib fractures is indeterminate.
Keenan HT, Campbell KA. Three models of child abuse consultations: A qualitative study of inpatient child abuse consultation notes. Child Abuse & Neglect. 2015; 43 : 53-60.
Keywords: *Child Abuse/diagnosis/psychology/therapy, Child, Preschool, Female, Humans, Infant, Inpatients, Male, *Models, Theoretical, Parents/psychology, Pediatrics/*methods, Qualitative Research
Child abuse pediatricians have multiple roles in caring for abused children, …
Child abuse pediatricians have multiple roles in caring for abused children, including prevention, diagnosis, treatment, and, when needed, expert legal opinion. The child physical abuse consultation differs from the traditional medical consultation in that it has medical, investigative and legal audiences, all of whom have different information needs. How child abuse pediatricians approach their cases and how they document their initial inpatient consultations that will be used by such a diverse audience is currently unexplored. We used content analysis to examine 37 child physical abuse consultation notes from a national sample of child abuse pediatricians in order to understand physicians' approaches to these consultations. Three commonly used models of child physical abuse consultation were identified in the data that we named the base model, the investigative model, and the family-dynamic model. While model types overlap, each is distinguished by key features including the approach used to gather information, the information recorded, and the language used in documentation. The base model most closely mirrors the traditional medical approach; the investigative model concentrates on triangulation of sources of information; and, the family-dynamic model concentrates on physician perceptions of family relationships. The three models of consultations for child physical abuse mirror the areas of child abuse pediatrics: diagnostic, forensic and therapeutic. These models are considered in relationship to best practice from other medical specialties with forensic components.
Kellogg ND, Baillargeon J, Lukefahr JL, Lawless K, Menard SW. Comparison of nucleic acid amplification tests and culture techniques in the detection of Neisseria gonorrhoeae and Chlamydia trachomatis in victims of suspected child sexual abuse. Journal of Pediatric and Adolescent Gynecology. 2004; 17 (5) : 331-339.
Keywords: Child abuse,Chlamydia,Gonorrhea,Ligase chain reaction,Polymerase chain reaction,Sexual abuse,Sexually transmitted diseases
(1) To identify factors predictive for gonorrhea and chlamydia positivity by …
(1) To identify factors predictive for gonorrhea and chlamydia positivity by LCR testing based on history and physical findings encountered during the sexual abuse evaluations. (2) To compare Ligase Chain Reaction (LCR), Polymerase Chain Reaction (PCR), and culture methods in the detection of chlamydia and gonorrhea infection among prepubertal and adolescent girls referred for sexual abuse evaluations. Prevalence odds ratios and logistic regression analysis were used to identify factors among patients' physical symptoms and signs, history of sexual activity, and abuse characteristics that were associated with positive test results for gonorrhea and chlamydia. The Kappa statistic was used to perform pairwise comparisons of LCR, PCR, and culture identification of gonorrhea and chlamydia infection. A specialized sexual abuse clinic in San Antonio, Texas. A consecutive sample of 229 girls between the ages of 6 and 20 who reported, or had indicators of, abusive genital-genital or genital-anal contact. Patients' history and physical findings predicting positive test results for gonorrhea and chlamydia infection; and relative sensitivity of testing sites (vaginal swab and urine) and methodologies (LCR, PCR, and culture) in identifying gonorrhea and chlamydia infection. (1) Gonorrhea infection: 3.2% of subjects were positive for gonorrhea by LCR at one or more sites; 2.4% had positive gonorrhea cultures. There was excellent agreement between vaginal swab LCR and PCR; agreement between urine samples was limited by the small number of positive tests. The sole factor that predicted gonorrhea positivity was increased number of white blood cells seen on wet mount. (2) Chlamydia infection: 11.1% of subjects were positive for chlamydia by at least one LCR test; only 0.8% had positive chlamydia cultures. Both urine and vaginal swab testing showed good agreement between PCR and LCR but not between culture and either of the newer methodologies. Factors that predicted chlamydia positivity were: patient history of consensual sexual contact, patient history of vaginal discharge, and the presence of concerning or definitive findings of genital trauma. While LCR, PCR, and culture techniques appeared comparable for detecting gonorrhea, LCR techniques detected significantly more patients with chlamydia infection when compared with the culture technique. PCR was comparable to LCR in detecting chlamydia infection. The LCR vaginal swab detected more patients with chlamydia and gonorrhea than the LCR urine sample. Risk factors for chlamydia and gonorrhea infection were present in most, but not all, of the children with positive LCR findings. LCR and PCR appear to detect more chlamydial and gonorrheal infections than do cultures.
Kellogg ND, Farst KJ, Adams JA. Interpretation of medical findings in suspected child sexual abuse: An update for 2023. Child Abuse & Neglect. 2023; 145 (3) : 106283.
Keywords: Humans, Child, *Child Abuse, Sexual/diagnosis, Sexual Behavior, Consensus, Health Personnel
Health care professionals who examine children who may have been sexually …
Health care professionals who examine children who may have been sexually abused need to be able to recognize, and photo-document any physical signs, and to have access to expert reviewers, particularly when signs concerning for sexual abuse are found. Although the general consensus among practitioners is that children will show few signs of sexual abuse on examination, there is considerable variability and rates of positive exam findings among practitioners of different professions, practice settings, and countries. This review will summarize new data and recommendations regarding the interpretation of medical findings and sexually transmitted infections (STIs); assessment and management of pediatric patients presenting with suspected sexual abuse or assault; and testing and treating patients for STIs. Updates to a table listing an approach to the interpretation of medical findings are presented, and reasons for changes are discussed.
Kellogg ND, Farst KJ, Adams JA. Interpretation of medical findings in suspected child sexual abuse: An update for 2023. Child Abuse & Neglect. 2023; 145 : 106283.
Keywords: Humans, Child, *Child Abuse, Sexual/diagnosis, Sexual Behavior, Consensus, Health Personnel
Health care professionals who examine children who may have been sexually …
Health care professionals who examine children who may have been sexually abused need to be able to recognize, and photo-document any physical signs, and to have access to expert reviewers, particularly when signs concerning for sexual abuse are found. Although the general consensus among practitioners is that children will show few signs of sexual abuse on examination, there is considerable variability and rates of positive exam findings among practitioners of different professions, practice settings, and countries. This review will summarize new data and recommendations regarding the interpretation of medical findings and sexually transmitted infections (STIs); assessment and management of pediatric patients presenting with suspected sexual abuse or assault; and testing and treating patients for STIs. Updates to a table listing an approach to the interpretation of medical findings are presented, and reasons for changes are discussed.
Kellogg ND, Lukefahr JL, Koek W. Medical assessments for abuse and neglect in contacts of maltreated children. Journal of Paediatrics and Child Health. 2024; 60 (8) : 349-354.
Keywords: Humans, *Child Abuse/diagnosis/statistics & numerical data, Child, Female, Male, Child, Preschool, Risk Factors, Infant, Prevalence, Adolescent, Retrospective Studies
AIM: Identifying abuse or neglect in one child (index) implicates risk to other …
AIM: Identifying abuse or neglect in one child (index) implicates risk to other children residing in the same home (contacts). While child protection investigators may interview and visually examine contacts, there is lack of consensus regarding when contacts should have a medical assessment. Our goal was to describe the prevalence, characteristics and predictors of abuse and neglect among contacts medically assessed by a child maltreatment evaluation centre over a 5-year period. METHODS: Records of 381 maltreated index children and their 588 contacts were reviewed. Abuse or neglect was diagnosed in 15% of contact children. RESULTS: When index children had more than one type of maltreatment or more than three risk factors, their contacts were more likely to be neglected or abused, respectively. Failure to thrive, patterned injuries, and unmet medical needs were the most common findings among maltreated contacts, and most were diagnosed with injuries or conditions that would not be evident to a child protection investigator. CONCLUSIONS: Clinicians should consider evaluating contacts of maltreated children who have multiple risk factors or maltreatment types. These evaluations should include a careful assessment for injuries, growth and unmet medical needs.
Kellogg ND, Melville JD, Lukefahr JL, Nienow SM, Russell EL. Genital and Extragenital Gonorrhea and Chlamydia in Children and Adolescents Evaluated for Sexual Abuse. Pediatric Emergency Care. 2018; 34 (11) : 761-766.
Keywords: Adolescent, Child, Child, Preschool, Chlamydia Infections/*diagnosis/epidemiology, Chlamydia trachomatis/genetics, Crime Victims, Female, Gonorrhea/*diagnosis/epidemiology, Humans, Infant, Male, Neisseria gonorrhoeae/genetics, Nucleic Acid Amplification T
OBJECTIVE: The aim of this study was to describe the use of a nucleic acid …
OBJECTIVE: The aim of this study was to describe the use of a nucleic acid amplification test in detecting genital and extragenital Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) in children and adolescents assessed for sexual abuse/assault. METHODS: The charts of children aged 0 to 17 years, consecutively evaluated for sexual victimization, in emergency department and outpatient settings were reviewed. Data extracted included age, sex, type of sexual contact, anogenital findings, previous sexual contact, toxicology results, and sites tested for NG and CT. RESULTS: Of the 1319 patients who were tested, 579 were tested at more than 1 site, and 120 had at least 1 infected site. Chlamydia trachomatis was identified in 104 patients, and NG was found in 33. In bivariate analysis, a positive test was associated with female sex, age older than 11 years, previous sexual contact, acute or healed genital injury, drug/alcohol intoxication, and examination within 72 hours of sexual contact. Fifty-one patients had positive anal tests, and 24 had positive oral tests. More than 75% of patients with positive extragenital tests had additional positive tests or anogenital injury. Most with a positive anal (59%) or oral (77%) test did not report that the assailant's genitals came into contact with that site. CONCLUSIONS: Positive tests for NG and CT in patients evaluated for sexual victimization may represent infection from sexual contact, contiguous spread of infection, or the presence of infected assailant secretions. Relying on patient reports of symptoms, or types of sexual contact, to determine need for testing may miss NG and CT infections in patients evaluated for sexual victimization.
Kellogg ND, Parra JM, Menard S. Children with anogenital symptoms and signs referred for sexual abuse evaluations. Archives of Pediatrics & Adolescent Medicine. 1998; 152 (7) : 634-41.
Keywords: Adolescent, Anus Diseases/etiology, Child, Child Abuse, Sexual/*diagnosis, Child, Preschool, Diagnosis, Differential, Female, Genital Diseases, Female/etiology, Humans, Infant, Lichen Sclerosus et Atrophicus/diagnosis, Male, Odds Ratio, Urinary Tract I
OBJECTIVE: To determine whether children referred to a sexual abuse clinic …
OBJECTIVE: To determine whether children referred to a sexual abuse clinic because of anogenital symptoms or signs have examination findings that are suggestive of or probable or definitive for sexual abuse. DESIGN: Case series of 157 patients. SETTING: Child and adolescent ambulatory care sexual abuse clinic. RESULTS: A medical records review of 3660 cases was done; 157 cases were identified for study. Most (75%) referrals were from medical clinics. Of 184 complaints, the most common presenting symptom or sign was anogenital bleeding or bruising (29.3%), followed by irritation or redness (21.7%), abnormal anogenital anatomy (20.7%), vaginal discharge (18.4%), lesions (6.5%), and "other" symptoms or signs (3.3%). We used a standardized classification system and determined that 25 patients (15%) had examination findings in the sexual abuse clinic that were suggestive of or probable or definitive for sexual abuse. Although 85 patients had examination findings that corroborated the presenting symptom(s), 70 had nonspecific examination findings or a diagnosis other than sexual abuse. Seventy-two patients had normal examination findings. Only patients with the presenting symptom of lesions had an increased likelihood of a sexual abuse diagnosis. Common examination findings included anogenital erythema, enhanced vascularity of the hymen or vestibule in prepubertal girls, labial adhesions, and culture-negative vaginitis. CONCLUSIONS: Few children are referred for sexual abuse evaluations based on physical signs or symptoms alone. Children with anogenital symptoms but without a disclosure or suspicion of sexual abuse are unlikely to have examination findings suggestive of abuse. The evaluation of children with anogenital symptoms and signs should include a consideration of alternative conditions and causes not directly related to sexual abuse.
Kellogg ND. Sexual behaviors in children: evaluation and management. American Family Physician. 2010; 82 (10) : 1233-8.
Keywords: Adolescent, *Adolescent Behavior, Adolescent Development/*physiology, Child, Child Abuse, Sexual/prevention & control, *Child Behavior, Child Development/*physiology, Family/psychology, Humans, *Sexual Behavior, Sexual Development/*physiology
Sexual behaviors in children are common, occurring in 42 to 73 percent of …
Sexual behaviors in children are common, occurring in 42 to 73 percent of children by the time they reach 13 years of age. Developmentally appropriate behavior that is common and frequently observed in children includes trying to view another person's genitals or breasts, standing too close to other persons, and touching their own genitals. Sexual behaviors become less common, less frequent, or more covert after five years of age. Sexual behavior problems are defined as developmentally inappropriate or intrusive sexual acts that typically involve coercion or distress. Such behaviors should be evaluated within the context of other emotional and behavior disorders, socialization difficulties, and family dysfunction, including violence, abuse, and neglect. Although many children with sexual behavior problems have a history of sexual abuse, most children who have been sexually abused do not develop sexual behavior problems. Children who have been sexually abused at a younger age, who have been abused by a family member, or whose abuse involved penetration are at greater risk of developing sexual behavior problems. Although age-appropriate behaviors are managed primarily through reassurance and education of the parent about appropriate behavior redirection, sexual behavior problems often require further assessment and may necessitate a referral to child protective services for suspected abuse or neglect.
Keogh A, Goldberg A, Schroeder C, Slingsby B, Hardy E, Michelow IC. Anogenital HSV in Children: Should Providers Be Concerned for Sexual Abuse?. Journal of Pediatric and Adolescent Gynecology. 2023; 36 (3) : 263-267.
Keywords: Female, Pregnancy, Child, Humans, Infant, Newborn, Infant, Child, Preschool, *Sex Offenses, *Sexually Transmitted Diseases/diagnosis/epidemiology, *Child Abuse, Colposcopy, Physical Examination, *Child Abuse, Sexual/diagnosis
OBJECTIVE: Anogenital herpes simplex virus (HSV) is most commonly acquired via …
OBJECTIVE: Anogenital herpes simplex virus (HSV) is most commonly acquired via sexual transmission, although other nonsexual modes of transmission have been proposed. When a child presents with a first-time outbreak of anogenital HSV, providers must consider sexual abuse. There are currently no evidence-based consensus guidelines to inform management of these patients. The purpose of this study was to describe how child abuse pediatricians (CAPs) evaluate children with anogenital HSV infection and determine whether any consistent practice patterns are followed. PARTICIPANTS AND SETTING: The patients included in this study were children between the ages of 0 and 12 years with a first-time outbreak of anogenital HSV who were medically evaluated by a CAP. METHODS: Patient charts were retroactively reviewed for the period of January 1 2004 to May 1 2020. RESULTS: Twenty-two cases were referred for evaluation by a CAP in the chosen time frame. Fifteen were seen in person. Ten of these patients were interviewed, 15 had an anogenital exam with colposcopy, and 14 were tested for at least one other sexually transmitted infection. A diagnosis of sexual abuse was made for 1 patient. CONCLUSION: This study demonstrates that although nonsexual transmission of anogenital HSV may be possible, providers must still consider sexual abuse. Children with a first-time outbreak of anogenital HSV should have a comprehensive evaluation for sexual abuse, including interview, physical exam, and testing for sexually transmitted infections. Evidence-based concerns for sexual abuse should be reported to child protective services.
Killough E, Spector L, Moffatt M, Wiebe J, Nielsen-Parker M, Anderst J. Diagnostic agreement when comparing still and video imaging for the medical evaluation of child sexual abuse. Child Abuse & Neglect. 2016; 52 : 102-9.
Keywords: Analysis of Variance, Child, Child Abuse, Sexual/*diagnosis, Clinical Competence/standards, Female, Forensic Psychiatry, Humans, Observer Variation, Pediatricians/standards, Photography, Physical Examination, Prospective Studies, Video Recording
Still photo imaging is often used in medical evaluations of child sexual abuse ( …
Still photo imaging is often used in medical evaluations of child sexual abuse (CSA) but video imaging may be superior. We aimed to compare still images to videos with respect to diagnostic agreement regarding hymenal deep notches and transections in post-pubertal females. Additionally, we evaluated the role of experience and expertise on agreement. We hypothesized that videos would result in improved diagnostic agreement of multiple evaluators as compared to still photos. This was a prospective quasi-experimental study using imaging modality as the quasi-independent variable. The dependent variable was diagnostic agreement of participants regarding presence/absence of findings indicating penetrative trauma on non-acute post-pubertal genital exams. Participants were medical personnel who regularly perform CSA exams. Diagnostic agreement was evaluated utilizing a retrospective selection of videos and still photos obtained directly from the videos. Videos and still photos were embedded into an on-line survey as sixteen cases. One-hundred sixteen participants completed the study. Participant diagnosis was more likely to agree with study center diagnosis when using video (p<0.01). Use of video resulted in statistically significant changes in diagnosis in four of eight cases. In two cases, the diagnosis of the majority of participants changed from no hymenal transection to transection present. No difference in agreement was found based on experience or expertise. Use of video vs. still images resulted in increased agreement with original examiner and changes in diagnostic impressions in review of CSA exams. Further study is warranted, as video imaging may have significant impacts on diagnosis.
Kimberlin DW, Banerjee R, Barnett ED, Lynfield R, Sawyer MH.
Red Book: 2024–2027 Report of the Committee on Infectious Diseases. American Academy of Pediatrics. 2024; Chapter: Sexual Assault and Abuse in Children and Adolescents/Young Adults DOI: 10.1542/9781610027373-S2_005_003.
ISBN: 978-1-61002-737-3
For more than 85 years, health care professionals have “referred to the Red …
For more than 85 years, health care professionals have “referred to the Red Book” for trustworthy guidance on pediatric infectious disease prevention, management, and control. The new 33rd edition continues this tradition of distinction with the latest clinical guidance on the manifestations, etiology, epidemiology, diagnosis, and treatment of more than 200 childhood infectious diseases.
Kleinman PK, ed. Diagnostic Imaging of Child Abuse, 3rd Ed. Cambridge University Press, Cambridge, United Kingdom. 2015.
Klika JB and Conte J, eds. The APSAC Handbook on Child Maltreatment, Fourth edition. SAGE Publications, Inc. 2017.
The Fourth Edition of this best-selling handbook provides readers with the most …
The Fourth Edition of this best-selling handbook provides readers with the most up-to-date theory, research, and best practices in the field of child abuse and neglect. Edited by leading experts, the book covers all aspects of child maltreatment, from physical abuse to sexual abuse and neglect, focusing on etiology, consequences, investigation, and treatment and systems. Updates include new content on assessment and mental health interventions, prevention, as well as global perspectives. Comprehensive and easy to read, the handbook will serve as an invaluable resource for students and professionals—both emerging and seasoned—across disciplines, but part of the same movement dedicated to improving the lives of maltreated children.
Kondis JS, Muenzer J, Luhmann JD. Missed Fractures in Infants Presenting to the Emergency Department With Fussiness. Pediatric Emergency Care. 2017; 33 (8) : 538-543.
Keywords: Child Abuse/*diagnosis/prevention & control/statistics & numerical data, Delayed Diagnosis/*statistics & numerical data, Diagnostic Errors/*statistics & numerical data, Emergency Service, Hospital/statistics & numerical data, Fractures, Bone/*diagnosis
OBJECTIVES: The aim of this study was to evaluate incidence of prior fussy …
OBJECTIVES: The aim of this study was to evaluate incidence of prior fussy emergency visits in infants with subsequently diagnosed fractures suggestive of abuse. METHODS: This was a retrospective chart review of infants younger than 6 months who presented to the pediatric emergency department (ED) between January 1, 2006, and December 31, 2011. Inclusion criteria included age 0 to 6 months, discharge diagnosis including "fracture," "broken" (or break), or "trauma" or any child abuse diagnosis or chief complaint of "fussy" or "crying" as documented in the electronic medical record by the triage nurse. RESULTS: Three thousand seven hundred thirty-two charts were reviewed, and 279 infants with fractures were identified. Eighteen (6.5%) of 279 infants had a prior ED visit for fussiness without an obvious source. Of these, 2 had a witnessed event causing their fracture, and therefore the fracture was not considered concerning for abuse. The remaining 16 had fractures concerning for abuse. Mean age was 2.5 (SD, 1.2) months. Fifteen (83%) of 18 infants were 3 months or younger at the time of the fussy visit. The mean interval between the first and second ED visits was 27 days (median, 20 days). Thirty-nine percent were evaluated by a pediatric emergency medicine-trained physician during their initial fussy visit, whereas 78% were evaluated by pediatric emergency medicine-trained physician during their subsequent visit. Most common injuries were multiple types of fractures followed by extremity and rib fractures. CONCLUSIONS: Fractures concerning for child abuse are an important cause of unexplained fussiness in infants presenting to the pediatric ED. A high index of suspicion is essential for prompt diagnosis and likely prevention of other abuse.
Kraut AM. Healers and strangers. Immigrant attitudes toward the physician in America--a relationship in historical perspective. JAMA. 1990; 263 (13) : 1807-11.
Keywords: *Attitude to Health, *Culture, Emigration and Immigration/*history, Ethnicity, History, 19th Century, History, 20th Century, Humans, Medicine, Chinese Traditional, Medicine, Traditional, *Physician-Patient Relations, Physicians/supply & distribution, Q
The current wave of immigration to the United States--mostly Asians and Latin …
The current wave of immigration to the United States--mostly Asians and Latin Americans--may well be the largest in the 20th century. Many newcomers practice habits of health and hygiene deficient by American standards. Some prefer the shaman to the physician and traditional herb remedies to modern medical therapies. Physicians find themselves practicing at an invisible border separating them from their foreign-born patients, where differences of language and culture can lead to misunderstanding and frustration, impeding a physician's ability to gain cooperation with prescribed therapy. Similar issues faced physicians at the turn of the century. Newly arrived Italians, East European Jews, and Chinese were often ambivalent toward physicians and their therapies. Quacks further undermined the physician's credibility among immigrants. Today, some physicians try collaborating with shamans and herbalists to accommodate patients' cultural preferences. Respect for the customs and taboos of immigrant patients pays dividends in physician effectiveness and efficiency.
Kriss S, Thompson A, Bertocci G, Currie M, Martich V. Characteristics of rib fractures in young abused children. Pediatric Radiology. 2020; 50 (5) : 726-733.
Keywords: Child Abuse/*diagnosis, Female, Humans, Infant, Infant, Newborn, Male, Radiography/*methods, Retrospective Studies, Rib Fractures/*diagnostic imaging, Ribs/diagnostic imaging
BACKGROUND: The presumed mechanism of rib fractures in abuse is violent …
BACKGROUND: The presumed mechanism of rib fractures in abuse is violent grasping of the torso causing anterior-posterior chest compression. We hypothesized an asymmetrical distribution of rib fractures in abused infants given the greater incidence of right-hand dominance within the general population. OBJECTIVE: The objective of this study was to characterize rib fractures in abused children, particularly sidedness; additionally, we evaluated the sidedness of other abusive skeletal fractures. MATERIALS AND METHODS: We reviewed medical records from abused children (0-18 months old) with rib fractures. We also retrospectively reviewed their radiographs to determine characteristics of rib fractures (number, side, rib region, level, acuity) and other skeletal fractures (number, side, location), as well as differences in the distribution of rib and other skeletal fractures. RESULTS: A total of 360 rib fractures were identified on 273 individual ribs involving 78 abused children. Sixty-three children (81%) had multiple rib fractures. There was a significantly greater number of left-side rib fractures (67%) than right-side fractures (P<0.001). Fractures were most often identified in the posterior and lateral regions and mid level of the ribcage (Ribs 5 through 8). Fifty-four percent of subjects had other skeletal fractures; these non-rib fractures were also predominantly on the left side (P=0.006). CONCLUSION: In our study of abused children, there was a higher incidence of rib fractures in the posterior, lateral and mid-level locations. Additionally, we found a predominance of left-side rib and other skeletal fractures. Further research is needed to understand whether factors such as perpetrator handedness are associated with these unequal distributions of fractures in abused children.
Kroese L, Port C, Hauda W 2nd. Improving the evaluation of non-accidental trauma across multiple specialties at a single institution. Bmj Open Quality. 2025; 14 (1).
Keywords: Humans, Infant, *Quality Improvement, *Child Abuse/statistics & numerical data/diagnosis, Child, Preschool, Child, Infant, Newborn, *Wounds and Injuries, Male, Female, Adolescent, Guideline Adherence/statistics & numerical data/standards
BACKGROUND: Based on the presenting injury, patients undergoing abuse …
BACKGROUND: Based on the presenting injury, patients undergoing abuse evaluation may be managed by different specialties. Our local child abuse specialist expressed concern over the variability in evaluation of patients presenting with injuries concerning for non-accidental trauma (NAT). The aim of this quality improvement project was to increase the percentage of patients for whom there is a concern for NAT who receive a guideline-adherent evaluation from 7.7% to 50% in 6 months' time. METHODS: A committee of physician stakeholders developed criteria for a complete NAT evaluation which were integrated into an order panel with built-in clinical guidance for test selection within our electronic medical record. Data on the completeness of NAT evaluation in paediatric patients 0-18 years of age were collected before and after the order panel release and analysed by admitting service, injury category and equity factors. RESULTS: This initiative increased the percentage of patients with a guideline-adherent evaluation from a mean of 7.7% to 25% within 6 months' time. The number of days between patients with complete evaluations decreased from 63 days to 35 days. Order panel utilisation increased to 55%, and the percentage of evaluation opportunities was more complete when the order panel was used (79% vs 92%). CONCLUSIONS: Standardisation of NAT evaluations through creation of an order panel with a clinical decision tool resulted in more guideline-adherent evaluations. The potential reduction of bias in such evaluations remains an area of interest.
Kudze T, Wheeler C. Common pediatric gynecological issues: a review. Current Opinion in Obstetrics & Gynecology. 2021; 33 (4) : 350-354 Review.
Keywords: Adult, Child, Female, *Gynecology, Humans
PURPOSE OF REVIEW: To provide clinicians with a review of recent research and …
PURPOSE OF REVIEW: To provide clinicians with a review of recent research and methods for evaluation of common pediatric gynecology complaints and problems. RECENT FINDINGS: The examination and history of a pediatric gynecologic patient involve information gathering in order to limit anxiety for the child and optimize the ability to diagnose and treat her. Child abuse recognition is increasing, and its management requires special expertise. The early management of disorders of sexual development (DSDs) has changed with a focus towards early identification and consideration of delayed surgical management. The multidisciplinary evaluation and management of the pelvic mass in the child involves careful preoperative evaluation to allow for conservative management. SUMMARY: Reproductive endocrinology and infertility (REI) providers are often called upon to evaluate children when a pediatric gynecologist is not immediately available. This review highlights valuable information for adult gynecologic providers who may encounter young girls with gynecologic issues in a variety of settings. Having some basic knowledge of the evaluation and management will allow the provider to either manage the child themselves or triage her to the appropriate consultant.
Lane WG, Dubowitz H, Langenberg P. Screening for occult abdominal trauma in children with suspected physical abuse. Pediatrics. 2009; 124 (6) : 1595-602.
Keywords: Abdominal Injuries/*diagnosis/*epidemiology, Alanine Transaminase/blood, Amylases/blood, Aspartate Aminotransferases/blood, Child Abuse/*diagnosis/*statistics & numerical data, Child Welfare/statistics & numerical data, Child, Preschool, Cross-Sectional S
OBJECTIVES: The goals were (1) to determine the prevalence of occult abdominal …
OBJECTIVES: The goals were (1) to determine the prevalence of occult abdominal trauma (OAT) in a sample of children with suspected physical abuse, (2) to assess the frequency of OAT screening, and (3) to assess factors associated with screening. METHODS: Charts of children evaluated for abusive injury were identified through a search of hospital discharge codes. Identified charts were reviewed to determine whether OAT screening occurred. Data on results of screening tests, abusive injuries identified, family demographic features, and characteristics of the emergency department visit were collected. RESULTS: Screening occurred for 51 (20%) of 244 eligible children. Positive results were identified for 41% of those screened and 9% of the total sample; 5% of children 12 to 23 months of age had OAT identified through imaging studies. Screening occurred more often in children presenting with probable abusive head trauma (odds ratio [OR]: 20.4 [95% confidence interval [CI]: 3.6-114.6]; P < .01), compared with those presenting with other injuries. Consultation with the child protection team (OR: 8.5 [95% CI: 3.5-20.7]; P < .01) and other subspecialists (OR: 24.3 [95% CI: 7.1-83.3]; P < .01) also increased the likelihood that OAT screening would occur. CONCLUSIONS: Our findings support OAT screening with liver and pancreatic enzyme measurements for physically abused children. This study also supports the importance of subspecialty input, especially that of a child protection team. Although many identified injuries may not require treatment, their role in confirming or demonstrating increased severity of maltreatment may be critical.
Lasiecka ZM, Pitot M, Chern BJ, Chern JJ, Kadom N. Skull Fracture Healing in Children Up to 36 Months - A Cohort Analysis. Current Problems in Diagnostic Radiology. 2023; 52 (4) : 253-256.
Keywords: Infant, Newborn, Child, Humans, Infant, Child, Preschool, Retrospective Studies, *Fracture Healing, *Skull Fractures/diagnostic imaging/complications, Cohort Studies, Skull
During medicolegal proceedings in cases of suspected child abuse it is …
During medicolegal proceedings in cases of suspected child abuse it is sometimes argued that skull fractures could be sequelae from complications at birth or resulted from a prior witnessed accidental trauma that may have preceded the suspected abusive event. There is paucity of scientific evidence indicating timing for skull fracture healing in children up to 36 months old. Objective of this study was to assess the average time to imaging documentation of skull fracture healing in children up to 36 months old. We performed retrospective chart review and image analysis in children with documented skull fractures after trauma between May 2009 and December 2014, excluding any patients who underwent cranial procedures related to the head injury, patients with pre-existing CSF shunts, patients who were referred for child abuse evaluation, and patients who were admitted to the General Surgery service for multi-organ trauma.We analyzed 185 skull fractures: 82 fractures were not healed, 49 fractures were partially healed, and 54 fractures were healed on follow-up imaging. The mean time to imaging evidence of healing among patients with healed fractures was 108 days (3.6 months), the median was 112 days (3.7 months), the minimum was 22 days, and the maximum was 225 days (7.5 months). Chi-square analysis showed a significant relationship between the skull fracture healed status and presence of bleed (P = 0.001) and with fracture characteristics of displaced, depressed, or dehiscent (P= 0.009). There was no significant association with the age group (P= 0.32) nor with involvement of multiple cranial plates (P= 0.73). This information may be useful during medicolegal proceedings in patients with suspected abusive head trauma mechanism.
Lazebnik R, Zimet GD, Ebert J, Anglin TM, Williams P, Bunch DL, Krowchuk DP. How children perceive the medical evaluation for suspected sexual abuse. Child Abuse & Neglect. 1994; 18 (9) : 739-45.
Keywords: Adolescent, *Attitude to Health, Child, Child Abuse, Sexual/*diagnosis/*psychology, Child, Preschool, Cross-Sectional Studies, Fear, Female, Humans, Male, Pain/etiology, Physical Examination/adverse effects/*psychology, Physician-Patient Relations, *Ps
This study investigated how 99 children who were examined for suspected sexual …
This study investigated how 99 children who were examined for suspected sexual abuse (SSA) perceived their own medical evaluation experiences. Each child was interviewed about the degree of pain and fear associated with the experience, the kindness of the doctor, general fear of doctor visits, and degree of fear associated with a hypothetical second examination. The majority of children did not perceive their SSA examination to be strongly negative. However children did report greater fear associated with the SSA evaluation compared to an ordinary doctor visit. Using multiple regression, general fear of doctor visits and fear and pain associated with the SSA examination contributed to the prediction of intensity of fear about a hypothetical second SSA evaluation. Perceived kindness of the doctor, patient sex and age, and physician sex and age did not contribute to the regression equation. The relatively low reported rate of intense distress associated with medical evaluation of SSA suggests that fear and pain can be minimized and effectively managed for many children. The results of the regression analysis suggest that previous negative medical experiences may play an important role in determining how a child interprets the experience of an SSA medical evaluation.
Lee JY, Coombs C, Clarke J, Berger R. Aspartate aminotransferase and alanine aminotransferase elevation in suspected physical abuse: Can the threshold to obtain an abdominal computed tomography be raised?. The Journal of Trauma and Acute Care Surgery. 2024; 97 (2) : 294-298.
Keywords: Humans, Retrospective Studies, *Alanine Transaminase/blood, Male, Female, Infant, Child, Preschool, *Tomography, X-Ray Computed/methods, *Aspartate Aminotransferases/blood, *Abdominal Injuries/diagnostic imaging/blood, *Child Abuse/diagnosis, Liver Functi
BACKGROUND: Identification of abdominal injury (AI) in children with concern …
BACKGROUND: Identification of abdominal injury (AI) in children with concern for physical abuse is important, as it can provide important medical and forensic information. Current recommendations are to obtain screening liver function tests (LFTs) in all children with suspected physical abuse and an abdominal computed tomography (CT) when the aspartate aminotransferase (AST) or alanine aminotransferase (ALT) is >80 IU/L. This threshold to obtain an abdominal CT is lower than general trauma guidelines, which use a cutoff of AST >200 IU/L or ALT >125 IU/L. METHODS: This was a retrospective review of children aged 0 to 60 months at a single pediatric tertiary care center who were evaluated for physical abuse and had AST or ALT >80 IU/L. Subjects were then stratified into two groups: midrange (AST ≤200 IU/L and ALT ≤125 IU/L) and high-range (AST >200 IU/L and/or ALT >125 IU/L) LFTs. RESULTS: Abdominal CTs were performed in 55% (131 of 237) of subjects, 38% (50 of 131) with midrange LFTs and 62% (81 of 131) with high-range LFTs. Abdominal injury was identified in 19.8% (26 of 131) of subjects. Subjects with AI were older than those without AI (mean [SD] age, 18.7 [12.5] vs. 11.6 [12.2] months; p = 0.009). The highest yield of abdominal CTs positive for AI was in the group with high-range LFTs with signs or symptoms of AI at 52.0% (13 of 25; 95% confidence interval, 31.3-72.2%). The negative predictive value of having midrange LFTs and no signs or symptoms of AI was 100% (95% confidence interval, 97.0-100%). CONCLUSION: Our data suggest that abdominal CT may not be necessary in children being evaluated for physical abuse who have AST ≤200 IU/L and ALT ≤125 IU/L and do not have signs or symptoms of AI. This could limit the number of abdominal CTs performed. LEVEL OF EVIDENCE: Diagnostic Test/Criteria; Level IV.
Legano LA, Desch LW, Messner SA, Idzerda S, Flaherty EG; COUNCIL ON CHILD ABUSE AND NEGLECT; COUNCIL ON CHILDREN WITH DISABILITIES. Maltreatment of children with disabilities. Pediatrics. 2021; 147 (5) : 401-411.
Over the past decade, there have been widespread efforts to raise awareness …
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.
Levitt CJ. The medical examination in child sexual abuse: A balance between history and exam. Journal of Child Sexual Abuse. 1992; 1 (4) : 113-121.
In many cases, children reporting sexual abuse will not present specific …
In many cases, children reporting sexual abuse will not present specific physical symptoms; where such findings are present, they are likely to be subtle bruises or abrasions. The efforts of professional medical groups to establish consensus on the range of possible findings and their meanings have been hampered by the difficulty of finding valid experimental populations for child sexual abuse. The colposcope has been instrumental in providing a basis for standardization of examinations and interpretation of findings. However, the quality of an examination is only as good as the practitioner and technique used, particularly with regard to hymenal findings. The physician must be aware that the ability of the State to prosecute a child sexual abuse case often rests upon the quality of the medical history and manner in which it is presented. Therefore, the examination must include a physical evaluation as well as an opportunity for the physician to question the child regarding possible experiences of abuse. 15 references
Li Q, Li Y, Zheng J, Yan X, Huang J, Xu Y, Zeng X, Shen T, Xing X, Chen Q, Yang W. Prevalence and trends of developmental disabilities among US children and adolescents aged 3 to 17 years, 2018-2021. Scientific Reports. 2023; 13 (1) : 17254.
Keywords: Humans, Child, Adolescent, Developmental Disabilities/epidemiology, *Autism Spectrum Disorder/epidemiology, Prevalence, *Learning Disabilities/epidemiology, *Attention Deficit Disorder with Hyperactivity/epidemiology, *Intellectual Disability/epidemiology
Developmental disabilities prevalence seem to be high in countries around the …
Developmental disabilities prevalence seem to be high in countries around the world. It's worth understanding the most recent prevalence and trends of developmental disabilities. The objective of this study is to examine the prevalence and trends of developmental disabilities of US children and adolescents. A total of 26,422 individuals aged 3-17 years were included. Annual data were examined from the National Health Interview Survey (2018-2021). Weighted prevalence for each of the selected developmental disabilities were calculated. The prevalence of any developmental disabilities in individuals was 16.65% (95% CI 16.03-17.26%), prevalence of attention deficit/hyperactivity disorder (ADHD), learning disability (LD), autism spectrum disorder (ASD), intellectual disability (ID), and other developmental delay were 9.57% (95% CI 9.09-10.06%), 7.45% (95% CI 7.00-7.89%), 2.94% (95% CI 2.67-3.21%), 1.72% (95% CI 1.51-1.93%), and 5.24% (95% CI 4.89-5.59%), respectively. Significant increases were observed for other developmental delay (4.02-6.05%) and co-occurring LD & ID (1.03-1.82%). Findings form this study highlight a high prevalence of any developmental disabilities, although no significant increase was observed. The prevalence of other developmental delay and co-occurring LD & ID were significantly increased. Further investigation is warranted to assess potentially modifiable risk factors and causes of developmental disabilities.
Lindberg D, Makoroff K, Harper N, Laskey A, Bechtel K, Deye K, Shapiro R. Utility of hepatic transaminases to recognize abuse in children. Pediatrics. 2009; 124 (2) : 509-16.
Keywords: Abdominal Injuries/*diagnosis/enzymology, Alanine Transaminase/*blood, Aspartate Aminotransferases/*blood, Child Abuse/*diagnosis, Child, Preschool, *Emergency Service, Hospital, Female, Humans, Infant, Infant, Newborn, Liver Function Tests/statistics & n
OBJECTIVE: Although experts recommend routine screening of hepatic …
OBJECTIVE: Although experts recommend routine screening of hepatic transaminases (aspartate aminotransferase [AST] and alanine aminotransferase [ALT]) in cases of potential child physical abuse, this practice is highly variable. Our objective was to determine the sensitivity and specificity of routine transaminase testing in young children who underwent consultation for physical abuse. PATIENTS AND METHODS: This was a prospective, multicenter, observational study of all children younger than 60 months referred for subspecialty evaluation of possible physical abuse. The child abuse team at each center recommended screening transaminases routinely as standard of care for all cases with a reasonable concern for physical abuse. Sensitivity and specificity for transaminases and clinical examination findings to detect identified abdominal injuries were determined, and receiver operating characteristic analysis was undertaken. RESULTS: Of 1676 consultations, 1272 (76%) patients underwent transaminase testing, and 54 (3.2% [95% confidence interval: 2.4-4.2]) had identified abdominal injuries. Area under the curve for the highest level of either transaminase was 0.85. Using a threshold level of 80 IU/L for either AST or ALT yielded a sensitivity of 77% and a specificity of 82% (positive likelihood ratio: 4.3; negative likelihood ratio: 0.3). Of injuries with elevated transaminase levels, 14 (26%) were clinically occult, lacking abdominal bruising, tenderness, and distention. Several clinical findings used to predict abdominal injury had high specificity but low sensitivity. CONCLUSIONS: In the population of children with concern for physical abuse, abdominal injury is an important cause of morbidity and mortality, but it is not so common as to warrant universal imaging. Abdominal imaging should be considered for potentially abused children when either the AST or ALT level is >80 IU/L or with abdominal bruising, distention, or tenderness.
Lindberg DM, Beaty B, Juarez-Colunga E, Wood JN, Runyan DK. Testing for abuse in children with sentinel injuries. Pediatrics. 2015; 136 (5) : 831-838.
OBJECTIVE: Child physical abuse is commonly missed, putting abused children at …
OBJECTIVE: Child physical abuse is commonly missed, putting abused children at risk for abstract repeated injury and death. Several so-called sentinel injuries have been suggested to be associated with high rates of abuse, and to imply the need for routine testing for other, occult traumatic injuries. Our objective was to determine rates of abuse evaluation and diagnosis among children evaluated at leading children's hospitals with these putative sentinel injuries. METHODS: This is a retrospective secondary analysis of the Pediatric Health Information System database. We identified 30 355 children with putative sentinel injuries. We measured rates of abuse diagnosis and rates of testing commonly used to identify occult injuries. RESULTS: Among all visits for children,24 months old to Pediatric Health Information System hospitals, the rate of abuse diagnosis was 0.17%. Rates of abuse diagnosis for children with at least 1 putative sentinel injury ranged from 3.5% for children,12 months old with burns to 56.1% for children,24 months with rib fractures. Rates of skeletal survey and other testing that can identify occult traumatic injury were highly variable between centers and for different injuries. CONCLUSIONS: Several putative sentinel injuries are associated with high rates of physical abuse. Among eligible children with rib fracture(s), abdominal trauma, or intracranial hemorrhage, rates of abuse were more than 20%. Future work is warranted to test whether routine testing for abuse in these children can improve early recognition of abuse.
Lindberg DM, Blood EA, Campbell KA, Laskey AL, Berger RP. Predictors of screening and injury in contacts of physically abused children. The Journal of Pediatrics. 2013; 163 (3) : 730-5.e1-3.
Keywords: Child, Child Abuse/*diagnosis/statistics & numerical data, Child Health Services/standards/*statistics & numerical data, Child, Preschool, *Family, Female, Guideline Adherence/*statistics & numerical data, Health Care Surveys, Humans, Infant, Infant, Newb
OBJECTIVE: To determine rates of screening in contacts of children evaluated …
OBJECTIVE: To determine rates of screening in contacts of children evaluated for physical abuse, and the relationship of clinical characteristics to screening recommendation and completion and injury identification. STUDY DESIGN: This is a planned secondary analysis of a prospective study of 1918 contacts of 1196 children referred for subspecialty abuse consultation in 20 US centers. We used multivariable logistic models to determine the relationship of index child characteristics, contact child characteristics, and shared characteristics to screening and injury identification. RESULTS: We identified injuries or disclosures of abuse in 180 (9.4%) contacts. Recommended screening was omitted in >20% of subjects for each screening modality. At least 1 screening test was more likely to be completed in contacts of index children of non-White race or Hispanic ethnicity (OR 1.45, 95% CI 1.13-1.87), with abuse-specific injuries (OR 2.15, 95% CI 1.63-2.83), with a confession (OR 2.18, 95% CI 1.17-4.07), when the history changed (OR 1.65, 95% CI 1.05-2.61), when an occult injury was found by imaging in the index child (OR 1.84, 95% CI 1.39-2.43), and when families lacked private insurance (OR 1.63, 95% CI 1.15-2.31). CONCLUSION: Completion of screening recommended for contacts of potentially abused children is relatively poor, despite high risk of injury. Several clinical and demographic factors were associated with increased contact screening.
Lindberg DM, Shapiro RA, Laskey AL, Pallin DJ, Blood EA, Berger RP. Prevalence of abusive injuries in siblings and household contacts of physically abused children. Pediatrics. 2012; 130 (2) : 193-201.
Keywords: Adolescent, Adult, Child, Child Abuse/psychology/*statistics & numerical data, Child, Preschool, Cross-Sectional Studies, Domestic Violence/psychology/statistics & numerical data, Ethnicity/psychology/statistics & numerical data, Female, Fractures, Bone/e
OBJECTIVE: Siblings and other children who share a home with a physically …
OBJECTIVE: Siblings and other children who share a home with a physically abused child are thought to be at high risk for abuse, but rates of injury in these contact children are unknown and screening of contacts is highly variable. Our objective was to determine the prevalence of abusive injuries identified by a common screening protocol among contacts of physically abused children. METHODS: This is an observational, multicenter cross-sectional study of children evaluated for physical abuse, and their contacts, by 20 US child abuse teams who used a common screening protocol for the contacts of physically abused children with serious injuries. Contacts underwent physical examination if they were <5 years old, physical examination and skeletal survey (SS) if they were <24 months old, and physical examination, SS, and neuroimaging if they were <6 months old. RESULTS: Protocol-indicated SS identified at least 1 abusive fracture in 16 of 134 contacts (11.9%, 95% confidence interval [CI] 7.5-18.5) <24 months of age. None of these fractures had associated findings on physical examination. No injuries were identified by neuroimaging in 19 of 25 eligible contacts (0.0%, 95% CI 0.0-13.7). Twins were at substantially increased risk of fracture relative to nontwin contacts (odds ratio 20.1, 95% CI 5.8-69.9). CONCLUSIONS: SS should be obtained in the contacts of injured, abused children for contacts who are <24 months old, regardless of physical examination findings. Twins are at higher risk of abusive fractures relative to nontwin contacts.
Lindberg DM, Stence NV, Grubenhoff JA, Lewis T, Mirsky DM, Miller AL, O'Neill BR, Grice K, Mourani PM, Runyan DK. Feasibility and Accuracy of Fast MRI Versus CT for Traumatic Brain Injury in Young Children. Pediatrics. 2019; 144 (4).
Keywords: Brain Injuries, Traumatic/*diagnostic imaging, Child, Preschool, Feasibility Studies, Female, Hematoma, Subdural/diagnostic imaging, Humans, Infant, Infant, Newborn, Intracranial Hemorrhages/diagnostic imaging, Magnetic Resonance Imaging/*methods/statisti
BACKGROUND: Computed tomography (CT) is commonly used for children when there …
BACKGROUND: Computed tomography (CT) is commonly used for children when there is concern for traumatic brain injury (TBI) and is a significant source of ionizing radiation. Our objective was to determine the feasibility and accuracy of fast MRI (motion-tolerant MRI sequences performed without sedation) in young children. METHODS: In this prospective cohort study, we attempted fast MRI in children <6 years old who had head CT performed and were seen in the emergency department of a single, level 1 pediatric trauma center. Fast MRI sequences included 3T axial and sagittal T2 single-shot turbo spin echo, axial T1 turbo field echo, axial fluid-attenuated inversion recovery, axial gradient echo, and axial diffusion-weighted single-shot turbo spin echo planar imaging. Feasibility was assessed by completion rate and imaging time. Fast MRI accuracy was measured against CT findings of TBI, including skull fracture, intracranial hemorrhage, or parenchymal injury. RESULTS: Among 299 participants, fast MRI was available and attempted in 225 (75%) and completed in 223 (99%). Median imaging time was 59 seconds (interquartile range 52-78) for CT and 365 seconds (interquartile range 340-392) for fast MRI. TBI was identified by CT in 111 (50%) participants, including 81 skull fractures, 27 subdural hematomas, 24 subarachnoid hemorrhages, and 35 other injuries. Fast MRI identified TBI in 103 of these (sensitivity 92.8%; 95% confidence interval 86.3-96.8), missing 6 participants with isolated skull fractures and 2 with subarachnoid hemorrhage. CONCLUSIONS: Fast MRI is feasible and accurate relative to CT in clinically stable children with concern for TBI.
Lindberg DM. Bias and Objectivity When Evaluating Social Risk Factors for Physical Abuse: of Babies and Bathwater. The Journal of Pediatrics. 2018; 198 : 13-15.
Keywords: *Accidents, Bias, Child, Humans, Infant, *Physical Abuse, Reproducibility of Results, Risk Factors
Lipson JG, Dibble S & Minarik PA. Culture & Nursing Care: A Pocket Guide. San Francisco, CA: UCSF Nursing Press. 1996.
Lorenc T, Lester S, Sutcliffe K, Stansfield C, Thomas J. Interventions to support people exposed to adverse childhood experiences: systematic review of systematic reviews. BMC Public Health. 2020; 20 (1) : 657.
Keywords: Adolescent, Adult, Adverse Childhood Experiences/*statistics & numerical data, Aged, Aged, 80 and over, Child, Child Abuse/*psychology/statistics & numerical data/*therapy, Child, Preschool, Female, Humans, Male, Middle Aged, *Resilience, Psychological
BACKGROUND: Adverse Childhood Experiences (ACEs) such as abuse, neglect or …
BACKGROUND: Adverse Childhood Experiences (ACEs) such as abuse, neglect or household adversity may have a range of serious negative impacts. There is a need to understand what interventions are effective to improve outcomes for people who have experienced ACEs. METHODS: Systematic review of systematic reviews. We searched 18 database sources from 2007 to 2018 for systematic reviews of effectiveness data on people who experienced ACEs aged 3-18, on any intervention and any outcome except incidence of ACEs. We included reviews with a summary quality score (AMSTAR) of 5.5 or above. RESULTS: Twenty-five reviews were included. Most reviews focus on psychological interventions and mental health outcomes. The strongest evidence is for cognitive-behavioural therapy for people exposed to abuse. For other interventions - including psychological therapies, parent training, and broader support interventions - the findings overall are inconclusive, although there are some positive results. CONCLUSIONS: There are significant gaps in the evidence on interventions for ACEs. Most approaches focus on mitigating individual psychological harms, and do not address the social pathways which may mediate the negative impacts of ACEs. Many negative impacts of ACEs (e.g. on health behaviours, social relationships and life circumstances) have also not been widely addressed by intervention studies.
Lorenz DJ, Pierce MC, Kaczor K, Berger RP, Bertocci G, Herman BE, Herr S, Hymel KP, Jenny C, Leventhal JM, Sheehan K, Zuckerbraun N. Classifying Injuries in Young Children as Abusive or Accidental: Reliability and Accuracy of an Expert Panel Approach. The Journal of Pediatrics. 2018; 198 : 144-150.e4.
Keywords: *Accidents, Child Abuse/*classification/*diagnosis, Child, Preschool, Emergency Service, Hospital, Female, Humans, Infant, Male, Prospective Studies, Reproducibility of Results, Wounds and Injuries/*classification/diagnosis/*etiology
OBJECTIVE: To assess interrater reliability and accuracy of an expert panel in …
OBJECTIVE: To assess interrater reliability and accuracy of an expert panel in classifying injuries of patients as abusive or accidental based on comprehensive case information. STUDY DESIGN: Data came from a prospective, observational, multicenter study investigating bruising characteristics of children younger than 4 years. We enrolled 2166 patients with broad ranges of illnesses and injuries presenting to one of 5 pediatric emergency departments in whom bruises were identified during examination. We collected comprehensive data regarding current and past injuries and illnesses, and provided deidentified, standardized case information to a 9-member multidisciplinary panel of experts with extensive experience in pediatric injury. Each panelist classified cases using a 5-level ordinal scale ranging from definite abuse to definite accident. Panelists also assessed whether report to child protective services (CPS) was warranted. We calculated reliability coefficients for likelihood of abuse and decision to report to CPS. RESULTS: The interrater reliability of the panelists was high. The Kendall coefficient (95% CI) for the likelihood of abuse was 0.89 (0.87, 0.91) and the kappa coefficient for the decision to report to CPS was 0.91 (0.87, 0.94). Reliability of pairs and subgroups of panelists were similarly high. A panel composite classification was nearly perfectly accurate in a subset of cases having definitive, corroborated injury status. CONCLUSIONS: A panel of experts with different backgrounds but common expertise in pediatric injury is a reliable and accurate criterion standard for classifying pediatric injuries as abusive or accidental in a sample of children presenting to a pediatric emergency department.
MacPherson SC, Golonka M, Liu Y, Terrell L, Evans KE, Hurst JH, Gifford EJ. Child Sexual Abuse Documentation in Primary Care Settings. Clinical Pediatrics. 2024; 63 (9) : 1247-1257.
Keywords: Humans, *Primary Health Care/statistics & numerical data, Retrospective Studies, *Child Abuse, Sexual/statistics & numerical data/diagnosis, Child, Adolescent, Female, Male, Child, Preschool, *Documentation/statistics & numerical data/methods/standards, R
Primary care providers (PCPs) can play an important role in the continuity of …
Primary care providers (PCPs) can play an important role in the continuity of care for children who experience sexual abuse (SA). We performed a retrospective, chart-based study of children 3 to 17 years old with SA history. Primary care medical records were reviewed for 2 years after a subspecialty SA evaluation. Descriptive statistics and logistic regression were used to assess factors associated with documentation of SA history and mental health management by the PCP. Of 131 included patients, 43% had PCP documentation of their SA history, which was associated with care from resident providers (P < .01). There was greater mental health management and mental health referrals by PCPs for the group with documentation compared with the group without documentation (52% vs 23%, P < .001). Overall, child SA history was poorly documented in primary care settings. Identifying mechanisms to improve communication about a child's SA history with PCPs is important for the child's ongoing care.
Mackenzie B, Jenny C. The use of alternate light sources in the clinical evaluation of child abuse and sexual assault. Pediatric Emergency Care. 2014; 30 (3) : 207-10.
Keywords: Child, Child Abuse, Sexual/*diagnosis, Fluorescence, Humans, *Light, Physical Examination/*methods, Rape/*diagnosis
Alternate light sources are devices that produce visible and invisible light at …
Alternate light sources are devices that produce visible and invisible light at specific wavelengths to allow for enhanced visualization of fluorescent substances. These devices (which include Wood's lamp and blue light) are often used in forensics for evidence collection and can be quite useful to physicians in the medical evaluation of suspected physical or sexual assault. An understanding of the proper applications, as well as the limitations, of each alternate light source is imperative to correctly performing and interpreting medical evaluations in the emergency department. This review discusses the evidence from prospective trials in children and adults on the ability of specific alternate light sources to identify evidence of physical or sexual assault and also highlights some promising new technological adjuncts to alternate light sources that may allow for accurate dating of bruising.
Madigan S, Villani V, Azzopardi C, Laut D, Smith T, Temple JR, Browne D, Dimitropoulos G. The Prevalence of Unwanted Online Sexual Exposure and Solicitation Among Youth: A Meta-Analysis. The Journal of Adolescent Health : Official Publication of the Society for Adolescent Medicine. 2018; 63 (2) : 133-141.
Keywords: Adolescent, *Erotica, Humans, *Internet, Sex Factors, *Sexual Behavior
PURPOSE: The objective of this meta-analysis was to provide a synthesis of …
PURPOSE: The objective of this meta-analysis was to provide a synthesis of studies examining the prevalence of unwanted online exposure and solicitation of a sexual nature among youth, and to determine if prevalence varies by youth age, gender, year of study data collection, or study geographical location. METHOD: Eligible studies from January 1990 to January 2016 were identified utilizing a comprehensive search strategy. Included studies examined the prevalence of unwanted online exposure and solicitation in youth who ranged from 12 to 16.5 years. Two independent coders extracted all relevant data. Random-effects meta-analyses were used to derive mean prevalence rates. RESULTS: Thirty-one (37,649 participants) and nine (18,272 participants) samples were included in the syntheses on unwanted online sexual exposure and solicitation, respectively. For online exposure, the mean prevalence rate was 20.3% (95% confidence interval: 17.1-23.4). For online solicitation, the mean prevalence rate was 11.5% (95% confidence interval: 9.4-13.6). Moderator analyses indicated that prevalence rates for unwanted online exposure and solicitation have decreased over time. Prevalence varied as a function of gender (solicitations were higher for males), but not age or geographical location. CONCLUSIONS: Approximately one in five youth experience unwanted online exposure to sexually explicit material and one in nine youth experience online sexual solicitation. Educational campaigns to raise awareness of Internet risks and safety strategies are warranted.
Mahajan A, Kadavigere R, Sripathi S, Rodrigues GS, Rao VR, Koteshwar P. Utility of serum pancreatic enzyme levels in diagnosing blunt trauma to the pancreas: a prospective study with systematic review. Injury. 2014; 45 (9) : 1384-93.
Keywords: Abdominal Injuries/blood/diagnostic imaging/*enzymology, Adolescent, Adult, Amylases/*blood, Biomarkers/blood, Child, Child, Preschool, Cohort Studies, Diagnostic Tests, Routine, Female, Humans, Lipase/*blood, Male, Middle Aged, Pancreas/diagnostic imagin
INTRODUCTION: Reliability of serum pancreatic enzyme levels in predicting …
INTRODUCTION: Reliability of serum pancreatic enzyme levels in predicting pancreatic injuries has been a parameter of interest and the present recommendations on its utility are based primarily on anecdotal observations. The aim of this study was to evaluate the utility of serum pancreatic enzyme assessment in predicting blunt pancreatic injury with imaging and surgical correlation and compare our results with a systematic review of literature till date. METHODS: A prospective cohort study conducted over 4 years in a tertiary care referral centre with 164 consecutive patients who presented to the emergency department with a history of blunt abdominal trauma and had serum pancreatic enzyme assessment, USG and subsequent diagnostic CECT were analyzed. The CT findings and AAST grade of pancreatic injury, various intra-abdominal injuries and time elapsed since injury and other associated factors were correlated with serum pancreatic enzyme levels. For systematic review of literature MEDLINE database was searched between 1940 and 2012, also the related citations and bibliographies of relevant articles were analyzed and 40 articles were included for review. We compared our results with the systematic critique of literature till date to formulate recommendations. RESULTS: 33(21%) patients had pancreatic injury documented on CT and were graded according to AAST. Statistically significant elevated serum amylase levels were observed in patients with pancreatic and bowel injuries. However, elevated serum lipase was observed specifically in patients with pancreatic injury with or without bowel injury. Combined serum amylase and lipase showed 100% specificity, 85% sensitivity in predicting pancreatic injury. Elevated (n=28, 85%) vs. normal (n=5, 15%) serum amylase and lipase levels showed sole statistically significant association with time elapse since injury to admission, with a cutoff of 3h. CONCLUSIONS: Based on our results and the systematic review of the literature till date we conclude, persistently elevated or rising combined estimation of serum amylase and lipase levels are reliable indicators of pancreatic injury and is time dependent, nondiagnostic within 6h or less after trauma. In resource constrained countries where CT is not available everywhere it may support a clinical suspicion of pancreatic injury and can be reliable and cost-effective as a screening tool.
Mankad K, Sidpra J, Mirsky DM, Oates AJ, Colleran GC, Lucato LT, Kan E, Kilborn T, Agrawal N, Teeuw AH, Kelly P, Zeitlin D, Carter J, Debelle GD, Berger RP, Christian CW, Lindberg DM, Raissaki M, Argyropoulou M, Adamsbaum C, Cain T, van Rijn RR, Silvera V. International Consensus Statement on the Radiological Screening of Contact Children in the Context of Suspected Child Physical Abuse. Jama Pediatrics. 2023; 177 (5) : 526-533.
Keywords: Child, Humans, Infant, *Physical Abuse, *Child Abuse, Physical Examination, Radiography, Siblings
IMPORTANCE: Physical abuse is a common but preventable cause of long-term …
IMPORTANCE: Physical abuse is a common but preventable cause of long-term childhood morbidity and mortality. Despite the strong association between abuse in an index child and abuse in contact children, there is no guidance outlining how to screen the latter, significantly more vulnerable group, for abusive injuries. Consequently, the radiological assessment of contact children is often omitted, or variably performed, allowing occult injuries to go undetected and increasing the risk of further abuse. OBJECTIVE: To report an evidence-based and consensus-derived set of best practices for the radiological screening of contact children in the context of suspected child physical abuse. EVIDENCE REVIEW: This consensus statement is supported by a systematic review of the literature and the clinical opinion of an internationally recognized group of 26 experts. The modified Delphi consensus process comprised 3 meetings of the International Consensus Group on Contact Screening in Suspected Child Physical Abuse held between February and June 2021. FINDINGS: Contacts are defined as the asymptomatic siblings, cohabiting children, or children under the same care as an index child with suspected child physical abuse. All contact children should undergo a thorough physical examination and a history elicited prior to imaging. Contact children younger than 12 months should have neuroimaging, the preferred modality for which is magnetic resonance imaging, and skeletal survey. Contact children aged 12 to 24 months should undergo skeletal survey. No routine imaging is indicated in asymptomatic children older than 24 months. Follow-up skeletal survey with limited views should be performed if abnormal or equivocal at presentation. Contacts with positive findings should be investigated as an index child. CONCLUSIONS AND RELEVANCE: This Special Communication reports consensus recommendations for the radiological screening of contact children in the context of suspected child physical abuse, establishing a recognized baseline for the stringent evaluation of these at-risk children and providing clinicians with a more resilient platform from which to advocate for them.
Mankad K, Sidpra J, Oates AJ, Calder A, Offiah AC, Choudhary A. Sibling screening in suspected abusive head trauma: a proposed guideline. Pediatric Radiology. 2021; 51 (6) : 872-875.
Keywords: Child, *Child Abuse/diagnosis, Consensus, *Craniocerebral Trauma/diagnostic imaging, Humans, Infant, Siblings
Abusive head trauma (AHT) is the leading cause of death from child abuse in …
Abusive head trauma (AHT) is the leading cause of death from child abuse in children younger than 5 years. It is well documented that the infant contacts of children presenting with suspected AHT are at an increased risk of abuse when compared to the general infant population. Despite this association, a paucity of literature stratifies this risk and translates it to the clinic such that this high-risk group is stringently screened for abusive injuries. In this light, the authors propose a standardised screening method for all contact children of the index case and call for further consensus on the subject.
Marine MB, Corea D, Steenburg SD, Wanner M, Eckert GJ, Jennings SG, Karmazyn B. Is the new ACR-SPR practice guideline for addition of oblique views of the ribs to the skeletal survey for child abuse justified?. Ajr. American Journal of Roentgenology. 2014; 202 (4) : 868-71.
Keywords: Child Abuse/*diagnosis, Female, Humans, Infant, Infant, Newborn, Male, *Practice Guidelines as Topic, Radiography, Thoracic/*standards, Rib Fractures/*diagnostic imaging, Ribs/*injuries, Sensitivity and Specificity, Specialty Boards, United States
OBJECTIVE: The purpose of our study was to determine whether adding oblique …
OBJECTIVE: The purpose of our study was to determine whether adding oblique bilateral rib radiography to the skeletal survey for child abuse significantly increases detection of the number of rib fractures. MATERIALS AND METHODS: We identified all patients under 2 years old who underwent a skeletal survey for suspected child abuse from January 2003 through July 2011 and who had at least one rib fracture. These patients were age-matched with control subjects without fractures. Two randomized radiographic series of the ribs were performed, one containing two views (anteroposterior and lateral) and another with four views (added right and left oblique). Three fellowship-trained radiologists (two in pediatrics and one in trauma) blinded to original reports independently evaluated the series using a Likert scale of 1 (no fracture) to 5 (definite fracture). We analyzed the following: sensitivity and specificity of the two-view series for detection of any rib fracture and for location (using the four-view series as the reference standard), interobserver variability, and confidence level. RESULTS: We identified 212 patients (106 with one or more fractures and 106 without). The sensitivity and specificity of the two-view series were 81% and 91%, respectively. Sensitivity and specificity for detection of posterior rib fractures were 74% and 92%, respectively. There was good agreement between observers for detection of rib fractures in both series (average kappa values of 0.70 and 0.78 for two-views and four-views, respectively). Confidence significantly increased for four-views. CONCLUSION: Adding bilateral oblique rib radiographs to the skeletal survey results in increased rib fracture detection and increased confidence of readers.
Martin NR, Claypool AL, Diyaolu M, Chan KS, A'Neals E, Iyer K, Stewart CC, Egge M, Bernacki K, Hallinan M, Zuo L, Gupta U, Naru N, Scheinker D, Morris AM, Brandeau ML, Chao S. SCAN for Abuse: Electronic Health Record-Based Universal Child Abuse Screening. Journal of Pediatric Surgery. 2024; 59 (2) : 337-341.
Keywords: Child, Humans, Child, Preschool, *Electronic Health Records, *Child Abuse/diagnosis, Physical Abuse, Child Protective Services, Hospitals
BACKGROUND: Identification of physical abuse at the point of care without a …
BACKGROUND: Identification of physical abuse at the point of care without a systematic approach remains inherently subjective and prone to judgement error. This study examines the implementation of an electronic health record (EHR)-based universal child injury screen (CIS) to improve detection rates of child abuse. METHODS: CIS was implemented in the EHR admission documentation for all patients age 5 or younger at a single medical center, with the following questions. 1) "Is this patient an injured/trauma patient?" 2) "If this is a trauma/injured patient, where did the injury occur?" A "Yes" response to Question 1 would alert a team of child abuse pediatricians and social workers to determine if a patient required formal child abuse clinical evaluation. Patients who received positive CIS responses, formal child abuse work-up, and/or reports to Child Protective Services (CPS) were reviewed for analysis. CPS rates from historical controls (2017-2018) were compared to post-implementation rates (2019-2021). RESULTS: Between 2019 and 2021, 14,150 patients were screened with CIS. 286 (2.0 %) patients screened received positive CIS responses. 166 (58.0 %) of these patients with positive CIS responses would not have otherwise been identified for child abuse evaluation by their treating teams. 18 (10.8 %) of the patients identified by the CIS and not by the treating team were later reported to CPS. Facility CPS reporting rates for physical abuse were 1.2 per 1000 admitted children age 5 or younger (pre-intervention) versus 4.2 per 1000 (post-intervention). CONCLUSIONS: Introduction of CIS led to increased detection suspected child abuse among children age 5 or younger. LEVEL OF EVIDENCE: Level II. TYPE OF STUDY: Study of Diagnostic Test.
McGuire L, Martin KD, Leventhal JM. Child abuse consultations initiated by child protective services: the role of expert opinions. Academic Pediatrics. 2011; 11 (6) : 467-73.
Keywords: Academic Medical Centers, Child Abuse/*diagnosis, Child Welfare, Child, Preschool, Connecticut/epidemiology, *Expert Testimony, Female, Humans, Infant, Logistic Models, Male, Pediatrics, Physicians/*statistics & numerical data, Referral and Consultatio
OBJECTIVE: To describe consultations provided by child abuse pediatricians for …
OBJECTIVE: To describe consultations provided by child abuse pediatricians for cases referred by child protective services (CPS); compare the opinions of the likelihood of child maltreatment of the initial physician, CPS, and the child abuse pediatrician; and examine predictors of the experts' opinions. METHODS: Cases were referred by CPS for consultations between March 1, 1998, and June 30, 2005, to 2 child abuse pediatricians at Yale-New Haven Children's Hospital. We abstracted demographic and clinical information and the opinions of the initial physician, CPS, and the child abuse expert, each coded using a 5-point scale from definite maltreatment to definite benign cause (eg, accident). RESULTS: Of 187 cases, 50.3% occurred in children younger than 1 year of age. Children's most serious injuries were fractures (50.8%), burns (16.6%), and bruises/abrasions (15.0%). The child abuse experts' opinions were 47.6% definite or probable maltreatment, 8.6% uncertain, and 43.9% definite or probable benign. Of the 119 cases with opinions from all 3 assessors, the expert agreed with the physician in 57.1% of cases (κ = 0.34) and with CPS in 64.7% (κ = 0.42). The best predictor of the expert's opinion that the injury was due to maltreatment was agreement between the physician and CPS that maltreatment had occurred. CONCLUSIONS: Levels of agreement were fair to poor between the child abuse expert and either the physician or CPS. Child abuse experts' opinions have important value in selected cases to confirm previous assessments by the physician and/or CPS, or to change the opinion of the case.
McNamara CR, Wood JN, Lindberg D, Campbell KA, Poston S, Valente M, Antonucci M, Wolford J, Coombs C, Sahud H, Clarke J, Brink FW, Bachim A, Frasier LD, Harper NS, Melville JD, Laub N, Anderst J, Berger RP. Yield of skeletal surveys in national network of child abuse pediatricians: Age is key. Child Abuse & Neglect. 2024; 157 : 106992.
Keywords: Humans, *Child Abuse/statistics & numerical data/diagnosis, Cross-Sectional Studies, Child, Preschool, Infant, Male, Female, United States/epidemiology, Age Factors, Fractures, Closed/diagnosis, Pediatricians/statistics & numerical data, Fractures, Bone/e
BACKGROUND: Skeletal surveys (SS) are recommended for the evaluation of …
BACKGROUND: Skeletal surveys (SS) are recommended for the evaluation of suspected physical abuse in children <2 years old. No guidelines exist for SS completion in children between 2 and 5 years old. OBJECTIVE: To determine rates of SS completion by age and examine variables associated with occult fracture identification in older children. PARTICIPANTS AND SETTING: Observational cross-sectional multi-center study of 10 US pediatric centers 2/2021-9/2022 including children <6 years old evaluated for physical child abuse. METHODS: The principal outcome is occult fracture identified on SS. Non-parametric tests were conducted from comparison between age groups and those with and without occult fractures. RESULTS: The rate of SS completion declined with increasing age from a high of 91 % in infants <6 months old to 7 % in children 5-5.9 years old. The proportion of SS with occult fractures also decreased with age. Of 450 children 2-5 years old with a SS, 20 [4 % (95 % CI: 3-8 %)] had an occult fracture. The rate of occult fractures among children 2-5 years old who were diagnosed with abuse and not admitted to the hospital was 0.3 % (95 % CI 0-0.6 %)]. Over 30 % of children 2-5 years old were diagnosed with child abuse by a child abuse pediatrician without completion of a SS. CONCLUSION: In children 2-5 years of age being evaluated for physical abuse, use of SS and the rate of occult fractures is low. The number of SS performed in children in this age group could potentially be decreased by up to 60 % by limiting SS to children admitted to the hospital.
Melville JD. Photodocumentation in Child Abuse: Medical Diagnosis and Management Ed. by Laskey and Sirotnak (4th edition). American Academy of Pediatrics. 2019; : 861-873.
Meyer JS, Gunderman R, Coley BD, Bulas D, Garber M, Karmazyn B, Keller MS, Kulkarni AV, Milla SS, Myseros JS, Paidas C, Pizzutillo PD, Podberesky DJ, Prince JS, Ragheb J. ACR Appropriateness Criteria(®) on suspected physical abuse-child. Journal of the American College of Radiology : Jacr. 2011; 8 (2) : 87-94.
Keywords: Child, Child Abuse/*classification/*prevention & control, Diagnostic Imaging/*standards, Expert Testimony/*standards, Forensic Medicine/*standards, Humans, Radiology/*standards, United States
The appropriate imaging for pediatric patients being evaluated for suspected …
The appropriate imaging for pediatric patients being evaluated for suspected physical abuse depends on the age of the child, the presence of neurologic signs and symptoms, evidence of thoracic or abdominopelvic injuries, and whether the injuries are discrepant with the clinical history. The clinical presentations reviewed consider these factors and provide evidence-based consensus recommendations by the ACR Appropriateness Criteria(®) Expert Panel on Pediatric Imaging.
Miller AJ, Narang S, Scribano P, Greeley C, Berkowitz C, Leventhal JM, Frasier L, Lindberg DM. Ethical Testimony in Cases of Suspected Child Maltreatment: The Ray E. Helfer Society Guidelines. Academic Pediatrics. 2020; 20 (6) : 742-745.
Keywords: Child, Child Abuse, Child, Preschool, *Expert Testimony, *Guidelines as Topic, Humans, *Physicians, Societies, Medical
New guidelines for ethical testimony were developed by the Ray E. Helfer …
New guidelines for ethical testimony were developed by the Ray E. Helfer Society, the largest medical professional society for physicians working in the field of child maltreatment. Building on the foundation of ethical guidelines set forth by the American Academy of Pediatrics, these new guidelines set detailed standards for testifying in cases of suspected child maltreatment and recommend that hospitals, medical practices, academic institutions, and professional societies hold their members accountable for court testimony related to child maltreatment as with other forms of medical practice and expert testimony.
Monteleone JA, Brodeur AE. Child Maltreatment: A Clinical Guide and Reference. St Louis, MO: GW Medical Publishing. 1994; 170-189.
Although the information is presented from a medical perspective, it can also …
Although the information is presented from a medical perspective, it can also be useful for social service workers, attorneys, law enforcement workers, State agencies, and others involved with abused children. The first volume is a clinical guide and reference. It begins with a discussion of the identification, interpretation, and reporting of injuries to children, followed by a chapter on the radiology of child abuse. A chapter addresses each of the following types of injuries: thoracoabdominal, ophthalmic, head injuries, and burns. Four chapters on sexual abuse include an overview of sexual abuse, the physical examination, the victim interview, and sexually transmitted diseases in abused children. Other chapters related to abuse injuries focus on multiple personality disorder, poisoning, the Munchausen syndrome by proxy, neglect and abandonment, emotional abuse, and the cycle of abuse. Other chapters address the review process, legal issues, the role of the medical examiner in fatal child abuse, expert medical testimony in child abuse cases, and the prevention of child abuse. The second volume is a comprehensive photographic reference for identifying potential child abuse. The photographs are presented under sections on physical abuse, radiologic investigations, sexual abuse cases, cases involving the police, forms of neglect, and drawings by victims of abuse.
Moore Y, Hopkinshaw B, Arrowsmith B, White C, Gabriel L. Genital bleeding in prepubertal girls: a systematic review. Archives of Disease in Childhood. 2025; 110 (5) : 358-362.
Keywords: Humans, Female, Child, *Child Abuse, Sexual/diagnosis, *Hemorrhage/etiology, Child, Preschool, *Genital Diseases, Female/etiology/diagnosis
INTRODUCTION: This systematic review aims to collate evidence of the causes of …
INTRODUCTION: This systematic review aims to collate evidence of the causes of genital bleeding, other than child sexual abuse and accidental injuries, presenting in prepubertal girls. It provides an update to the 2015 Royal College of Paediatrics and Child Health publication 'The Physical Signs of Child Sexual Abuse', an evidence-based review also known as the Purple Book. METHODS: MEDLINE, EMBASE and Scopus databases were searched for studies published between March 2014 and June 2023. Eligible studies were primary studies reporting on genital bleeding with extractable data for prepubertal girls. RESULTS: 99 studies, describing a total of 672 prepubertal girls, met the inclusion criteria. The most common medical conditions with genital bleeding as a presenting feature were lichen sclerosus, infections and infestations, hormonal causes, urethral prolapse, vaginal foreign bodies and tumours. Meta-analysis was not possible due to the large heterogeneity of the studies. CONCLUSION: This review added further evidence to the 2015 edition of the Purple Book, describing the multiple medical conditions that may present with genital bleeding. Several of these conditions can mimic the presentation of child sexual abuse or may coexist with child sexual abuse.
Murphy N. Maltreatment of children with disabilities: the breaking point. Journal of Child Neurology. 2011; 26 (8) : 1054-6.
Keywords: Child, Child Abuse/classification/*psychology, Children with Disabilities/*psychology, Family/*psychology, Humans, Prevalence, Risk Factors
The maltreatment of children with disabilities is a serious public health issue. …
The maltreatment of children with disabilities is a serious public health issue. Children with disabilities are 3 to 4 times more likely to be abused or neglected than are their typically developing peers. When maltreated, they are more likely to be seriously injured or harmed. As alarming as these numbers are, they likely underestimate the problem. Children with disabilities encounter all 4 types of abuse: physical, sexual, neglect, and emotional. Here, the author discusses risk factors associated with the maltreatment of children with disabilities, which, as expected, include both child and family factors.
Myers JEB, Berliner L, Briere C, Hendrix CT, Jenny C, Reid TA, American Professional Society on the Abuse of Children. APSAC Handbook on Child Maltreatment, Second Edition. Thousand Oaks (CA): Sage Publications. 2002.
Myers JEB. Role of physician in preserving verbal evidence of child abuse. Journal of Pediatrics. 1986; 109 (3) : 409-11.
Keywords: Child, *Child Abuse, Humans, Jurisprudence, *Physician's Role, *Role
Narang SK, Fingarson A, Lukefahr J, COUNCIL ON CHILD ABUSE AND NEGLECT, Sirotnak AP, Flaherty EG, Gavril AR, Hoffert Gilmartin AB, et al. Abusive Head Trauma in Infants and Children. Pediatrics. 2020; 145 (4).
Keywords: Biomechanical Phenomena, Child, Child Abuse/*diagnosis/prevention & control, Child, Preschool, Contusions/diagnosis/etiology, Craniocerebral Trauma/*diagnosis/etiology/prevention & control, Diagnosis, Differential, Humans, Infant, Mandatory Reporting,
Abusive head trauma (AHT) remains a significant cause of morbidity and …
Abusive head trauma (AHT) remains a significant cause of morbidity and mortality in the pediatric population, especially in young infants. In the past decade, advancements in research have refined medical understanding of the epidemiological, clinical, biomechanical, and pathologic factors comprising the diagnosis, thereby enhancing clinical detection of a challenging diagnostic entity. Failure to recognize AHT and respond appropriately at any step in the process, from medical diagnosis to child protection and legal decision-making, can place children at risk. The American Academy of Pediatrics revises the 2009 policy statement on AHT to incorporate the growing body of knowledge on the topic. Although this statement incorporates some of that growing body of knowledge, it is not a comprehensive exposition of the science. This statement aims to provide pediatric practitioners with general guidance on a complex subject. The Academy recommends that pediatric practitioners remain vigilant for the signs and symptoms of AHT, conduct thorough medical evaluations, consult with pediatric medical subspecialists when necessary, and embrace the challenges and need for strong advocacy on the subject.
National Center on Substance Abuse and Child Welfare
The Child Abuse Prevention and Treatment Act (CAPTA) Plan of Safe Care (POSC)
National Center on the Sexual Behavior of Youth
When is sexual behavior a problem? and What causes problematic sexual behavior?
Child sexual development
National Children’s Alliance.. National Standards of Accreditation for Children’s Advocacy Centers. n.d.; 2023 Edition.
New York State Laws
Obligations of persons required to report.
Social Services Law § 416.
Nguyen A, Hart R. Imaging of non-accidental injury; what is clinical best practice?. Journal of Medical Radiation Sciences. 2018; 65 (2) : 123-130.
Keywords: Child, *Child Abuse, Humans, Practice Guidelines as Topic, Wounds and Injuries/*diagnostic imaging/*etiology
Non-accidental injury (NAI) remains the leading cause of morbidity and …
Non-accidental injury (NAI) remains the leading cause of morbidity and mortality in children. Fractures are the second most common findings of NAI, after cutaneous lesions such as bruises and contusions. Imaging in NAI remains a controversial issue with little agreement concerning how, when and what imaging modalities should be used in the investigation of suspected cases. This review addresses the radiological investigations and findings of NAI, and the differential diagnoses of these findings. Adherence to the international guidelines for skeletal survey imaging is recommended. This ensures the content and quality of the radiographic series are of an optimal standard to improve the detection of occult fractures, and ensuring the accurate reporting of images. The involvement of a paediatric radiologist is important, if not essential in the diagnosis of NAI. In the evaluation of suspected cases, the role of the radiologist includes the detection of radiological findings suggestive of NAI, and the differentiation of these findings from normal variants and underlying pathologies. The diagnosis of NAI relies not only on radiological imaging, but also a combination of clinical and social findings. It is mandatory that all physicians work in close collaboration to improve diagnostic accuracy, as failure to diagnose NAI carries significant risk for morbidity.
O'Brien JS. Interviewing Techniques. In: Olshaker JS, ed. Forensic Emergency Medicine Philadelphia: Lippincott, Williams, & Wilkins. 2001; : 55-61.
O'Hara MA, Swerdin HR, Botash AS. Expanding Trauma-Informed Care to Telemedicine: Brief Report From Child Abuse Medical Professionals. Clinical Pediatrics. 2023; 62 (1) : 5-7.
Keywords: Child, Humans, *Child Abuse/diagnosis, *Telemedicine
Olson LM, Campbell KA, Cook L, Keenan HT. Social history: A qualitative analysis of child abuse pediatricians' consultation notes. Child Abuse & Neglect. 2018; 86 : 267-277.
Keywords: Brain Injuries, Traumatic/etiology, Child, Child Abuse/*diagnosis/statistics & numerical data, Child, Preschool, Female, Fractures, Bone/etiology, Humans, Inpatients, Male, *Medical History Taking, Parenting, Pediatricians/statistics & numerical data, Phy
BACKGROUND: Child abuse pediatricians (CAPs) are often consulted for injuries …
BACKGROUND: Child abuse pediatricians (CAPs) are often consulted for injuries when child physical abuse is suspected or when the etiology of a serious injury is unclear. CAPs carefully evaluate the reported mechanism of the child's injury and the medical findings in the context of the child's family and social setting to identify possible risk and protective factors for child abuse and the need for social services. It is unknown what population risk indicators along with other social cues CAPs record in the social history of the consultation notes when assessing families who are being evaluated for child physical abuse. PARTICIPANTS AND SETTING: Thirty-two CAPs representing 28 US child abuse programs. METHODS: Participants submitted 730 completed cases of inpatient medical consultation notes for three injury types: traumatic brain injury, long bone fracture, and skull fracture in hospitalized children 4 years of age and younger. We defined a priori 12 social cues using known population risk indicators (e.g., single mother) and identified de novo 13 negative (e.g., legal engagement) and ten positive social cues (e.g., competent parenting). Using content analysis, we systematically coded the social history for the social cues. RESULTS: We coded 3,543 cues resulting in a median of 7 coded cues per case. One quarter of the cues were population indicators while half of the cues were negative and one quarter positive. CONCLUSIONS: CAPs choose a wide variety of information, not always related to known population risk indicators, to include in their social histories.
Ostfeld-Johns S. Pre-natal and post-natal screening and testing in neonatal abstinence syndrome. Seminars in Perinatology. 2025; 49 (1) : 152009.
Keywords: Humans, *Neonatal Abstinence Syndrome/diagnosis, Infant, Newborn, Female, Pregnancy, *Neonatal Screening/methods, Substance Abuse Detection/methods, Pregnancy Complications/diagnosis, Substance-Related Disorders/diagnosis, Prenatal Care/methods, Prenatal
The way we enact screening for substance use during pregnancy within our …
The way we enact screening for substance use during pregnancy within our healthcare systems can work by decreasing stigma, promoting engagement, and supporting people with reaching the end of their pregnancy in a manner where the newborn can be well supported. The way we enact biochemical specimen toxicology testing for substance use during pregnancy and in newborns contributes to increased stigma, disengagement from care, and potential continuation of uncontrolled substance use up until delivery such that the newborn may not be able to be well supported in the family environment. These effects are inequitably distributed, leading to worse outcomes for families of color and families living in poverty. Serial screening with a validated questionnaire starting at the first prenatal visit and continuing through the delivery hospitalization should occur and be followed up with service connections and substance use disorder diagnosis and treatment. Newborn toxicology testing as a diagnostic tool for risk of withdrawal or the etiology of potential withdrawal symptoms represents a failure in the effectiveness of compassionate communication by healthcare providers with the birthing person. Given the current level of evidence of clinical utility and the inequitable consequences specific to these tests, they are rarely needed.
Otjen JP, Menashe SJ, Romberg EK, Brown ECB, Iyer RS. Pearls and Pitfalls of Thoracic Manifestations of Abuse in Children. Seminars in Ultrasound, Ct, and Mr. 2022; 43 (1) : 51-60.
Keywords: Child, *Child Abuse/diagnosis, Humans, Infant, *Rib Fractures/diagnostic imaging, United States
Child abuse is a broad term that includes, but is not limited to, physical or …
Child abuse is a broad term that includes, but is not limited to, physical or emotional harm, neglect, sexual abuse, and exploitation. In 2018 in the United States, there were nearly 700,000 victims of such maltreatment, of which 1700 children died. The majority of deaths occur in infants and toddlers under 3 years of age. While clinical signs and symptoms may raise suspicion for inflicted injury, such as bruising in young infants, imaging often plays a central role in identifying and characterizing nonaccidental trauma. The purpose of this article is to discuss the array of inflicted traumatic injuries to the thorax in children. Rib fractures are among the most common and telling features of physical abuse, especially in infants. The locations of such fractures and differences in appearance while healing will be presented, along with potential mimics and pitfalls. Less typical fractures seen in abuse will also be reviewed, including those of the sternum, clavicle, spine, and scapula. Finally, uncommon injuries to the lungs, heart and esophagus will also be considered.
Paine CW, Fakeye O, Christian CW, Wood JN. Prevalence of Abuse Among Young Children With Rib Fractures: A Systematic Review. Pediatric Emergency Care. 2019; 35 (2) : 96-103.
Keywords: Child Abuse/*statistics & numerical data, Child, Preschool, Female, Humans, Infant, Male, Prevalence, Rib Fractures/*etiology, Sensitivity and Specificity
OBJECTIVES: We aimed to estimate the prevalence of abuse in young children …
OBJECTIVES: We aimed to estimate the prevalence of abuse in young children presenting with rib fractures and to identify demographic, injury, and presentation-related characteristics that affect the probability that rib fractures are secondary to abuse. METHODS: We searched PubMed/MEDLINE and CINAHL databases for articles published in English between January 1, 1990, and June 30, 2014 on rib fracture etiology in children 5 years or younger. Two reviewers independently extracted predefined data elements and assigned quality ratings to included studies. Study-specific abuse prevalences and the sensitivities, specificities, and positive and negative likelihood ratios of patients' demographic and clinical characteristics for abuse were calculated with 95% confidence intervals. RESULTS: Data for 1396 children 48 months or younger with rib fractures were abstracted from 10 articles. Among infants younger than 12 months, abuse prevalence ranged from 67% to 82%, whereas children 12 to 23 and 24 to 35 months old had study-specific abuse prevalences of 29% and 28%, respectively. Age younger than 12 months was the only characteristic significantly associated with increased likelihood of abuse across multiple studies. Rib fracture location was not associated with likelihood of abuse. The retrospective design of the included studies and variations in ascertainment of cases, inclusion/exclusion criteria, and child abuse assessments prevented further meta-analysis. CONCLUSIONS: Abuse is the most common cause of rib fractures in infants younger than 12 months. Prospective studies with standardized methods are needed to improve accuracy in determining abuse prevalence among children with rib fractures and characteristics associated with abusive rib fractures.
Palusci VJ, Botash AS. Race and Bias in Child Maltreatment Diagnosis and Reporting. Pediatrics. 2021; 148 (1).
Keywords: Child, Child Abuse/*diagnosis/*ethnology, Humans, *Mandatory Reporting, Pediatricians/*psychology, *Race Factors, *Racism, United States
Pediatricians have implicit and explicit racial biases that impact the health …
Pediatricians have implicit and explicit racial biases that impact the health and well-being of children and their families.1,2 Similarly, effects of racism on diagnosis and reporting of suspected child abuse and neglect to child protective services (CPS) can have serious consequences. Although we and others are mandated to report suspected child abuse or neglect in all US states and territories, the threshold for reporting requires only “reasonable suspicion” of abuse or neglect.3 Pediatricians may also report families that they perceive need additional resources.
Palusci VJ, Nazer D, Greydanus DE, Merrick J. An Introduction to the Medical Evaluation of Child Maltreatment. Nova, Hauppauge, NY. 2024.
As educators as well as clinicians, we recognized the scarcity of specific …
As educators as well as clinicians, we recognized the scarcity of specific books designed to address the needs of the resident trainee in this important area of pediatric practice. The American Academy of Pediatrics (AAP) and others have published a number of texts on child abuse; but, this book specifically addresses the need for easily accessible materials outlining the medical approach to child abuse and neglect for pediatric and family medicine trainees as well as other professionals working with children. It is a collection of materials that covers a range of topics and serves as a repository for materials we have found helpful when teaching about child abuse and neglect. In addition, it provides information for more advanced students and trainees who want to learn more than can be learned during standard rotations and clinical experiences. Child abuse identification, treatment and prevention is the responsibility of us all, and our hope is that all practitioners will recognize their responsibility to use their unique skills to provide the best care and treatment possible for this important and vulnerable pediatric population.
Peer JW, Hillman SB. Stress and resilience for parents of children with intellectual and developmental disabilities: a review of key factors and recommendations for practitioners. JPolicy Pract Intell Disabil. 2014; 11 (2) : 92-98.
Keywords: developmental disabilities, intellectual disability, parenting, resilience, stress
Parents of children with intellectual and/or developmental disabilities …
Parents of children with intellectual and/or developmental disabilities experience more stress in comparison to parents of normally developing children. Chronic stress could negatively influence parents' health while also impacting their ability to meet their child's needs. Despite this, there is a subset of parents who remain resilient in the face of significant stress in their lives. Knowledge of the factors that promote parental resilience could positively impact the services these families receive. The authors conducted a systematic review of research article databases and found support for coping style, optimism, and social support as resilience factors for parents of children with intellectual and/or developmental disabilities. Awareness of variables that promote resilience for parents of children with intellectual and/or development disabilities is likely to inform clinical practice through offering new avenues for clinical focus in all phases of family-centered care.
Pfeifer CM, Henry MK, Caré MM, Christian CW, Servaes S, Milla SS, Strouse PJ. Debunking Fringe Beliefs in Child Abuse Imaging: AJR Expert Panel Narrative Review. Ajr. American Journal of Roentgenology. 2021; 217 (3) : 529-540.
Keywords: Child Abuse/*diagnosis, Denial, Psychological, Diagnostic Imaging/*methods, Female, Humans, Infant, Magnetic Resonance Imaging, Male, Radiology, Reproducibility of Results, Tomography, X-Ray Computed
Child abuse is a global public health concern. Injuries from physical abuse may …
Child abuse is a global public health concern. Injuries from physical abuse may be clinically occult and not appreciable on physical examination. Imaging is therefore critical in identifying and documenting such injuries. The radiologic approach for a child who has potentially been abused has received considerable attention and recommendations according to decades of experience and rigorous scientific study. Nonetheless, fringe beliefs describing alternative explanations for child abuse-related injuries have emerged and received mainstream attention. Subsequently, imaging findings identified in abused children have been attributed to poorly supported underlying medical conditions, clouding the evidence basis for radiologic findings indicative of nonaccidental trauma. Fringe beliefs that attribute findings seen in child abuse to alternate pathologies such as genetic disorders, birth trauma, metabolic imbalances, vitamin D deficiency, and short-distance falls typically have limited evidence basis and lack professional society support. Careful review of the scientific evidence and professional society consensus statements is important in differentiating findings attributable to child abuse from fringe beliefs used to discount the possibility that a child's constellation of injuries is consistent with abuse. This review refutes fringe beliefs used to provide alternative explanations in cases of suspected child abuse and reinforces the key literature and scientific consensus regarding child abuse imaging.
Pierce MC, Kaczor K, Lorenz DJ, Bertocci G, Fingarson AK, Makoroff K, Berger RP, Bennett B, Magana J, Staley S, Ramaiah V, Fortin K, Currie M, Herman BE, Herr S, Hymel KP, Jenny C, Sheehan K, Zuckerbraun N, Hickey S, Meyers G, Leventhal JM. Validation of a Clinical Decision Rule to Predict Abuse in Young Children Based on Bruising Characteristics. JAMA Network Open. 2021; 4 (4) : 1-12.
Importance: Bruising caused by physical abuse is the most common antecedent …
Importance: Bruising caused by physical abuse is the most common antecedent injury to be overlooked or misdiagnosed as nonabusive before an abuse-related fatality or near-fatality in a young child. Bruising occurs from both nonabuse and abuse, but differences identified by a clinical decision rule may allow improved and earlier recognition of the abused child. Objective: To refine and validate a previously derived bruising clinical decision rule (BCDR), the TEN-4 (bruising to torso, ear, or neck or any bruising on an infant <4.99 months of age), for identifying children at risk of having been physically abused. Design, Setting, and Participants: This prospective cross-sectional study was conducted from December 1, 2011, to March 31, 2016, at emergency departments of 5 urban children's hospitals. Children younger than 4 years with bruising were identified through deliberate examination. Statistical analysis was completed in June 2020. Exposures: Bruising characteristics in 34 discrete body regions, patterned bruising, cumulative bruise counts, and patient's age. The BCDR was refined and validated based on these variables using binary recursive partitioning analysis. Main Outcomes and Measures: Injury from abusive vs nonabusive trauma was determined by the consensus judgment of a multidisciplinary expert panel. Results: A total of 21123 children were consecutively screened for bruising, and 2161 patients (mean [SD] age, 2.1 [1.1] years; 1296 [60%] male; 1785 [83%] White; 1484 [69%] non-Hispanic/Latino) were enrolled. The expert panel achieved consensus on 2123 patients (98%), classifying 410 (19%) as abuse and 1713 (79%) as nonabuse. A classification tree was fit to refine the rule and validated via bootstrap resampling. The resulting BCDR was 95.6% (95% CI, 93.0%-97.3%) sensitive and 87.1% (95% CI, 85.4%-88.6%) specific for distinguishing abuse from nonabusive trauma based on body region bruised (torso, ear, neck, frenulum, angle of jaw, cheeks [fleshy], eyelids, and subconjunctivae), bruising anywhere on an infant 4.99 months and younger, or patterned bruising (TEN-4-FACESp). Conclusions and Relevance: In this study, an affirmative finding for any of the 3 BCDR TEN-4-FACESp components in children younger than 4 years indicated a potential risk for abuse; these results warrant further evaluation. Clinical application of this tool has the potential to improve recognition of abuse in young children with bruising.
Pirotte M. Pediatric Protective Custody. emDocs. 2017.
Consent for treatment has long been considered a cornerstone in ethical medical …
Consent for treatment has long been considered a cornerstone in ethical medical practice. Children are considered to lack capacity to consent under the law, and therefore consent for their treatment falls to their legal guardians. In 2011 the American Academic of Pediatrics issued a policy paper on emergency care for children which states that “a child’s legal guardian… is required to act in the best interests of the child. When a legal guardian refuses to consent to medical care or transport that is necessary to prevent death, disability, or serious harm to the child, law enforcement officers may intervene.”1 When an emergency physician (EP) is faced with a scenario in which he or she does not believe a legal guardian is acting in the best interests of the child, further investigation and possibly action is required. In cases where the child’s health or safety are in question, the EP may consider taking temporary protective custody of a minor under their care.
Piteau SJ, Ward MG, Barrowman NJ, Plint AC. Clinical and radiographic characteristics associated with abusive and nonabusive head trauma: a systematic review. Pediatrics. 2012; 130 (2) : 315-23.
Keywords: Brain Injuries/diagnosis/epidemiology, Child Abuse/*diagnosis/statistics & numerical data, Child, Preschool, Cohort Studies, Craniocerebral Trauma/*diagnosis/epidemiology, Cross-Sectional Studies, Diagnosis, Differential, Diagnostic Errors, Female, Hospit
BACKGROUND AND OBJECTIVE: To systematically review the literature to determine …
BACKGROUND AND OBJECTIVE: To systematically review the literature to determine which clinical and radiographic characteristics are associated with abusive head trauma (AHT) and nonabusive head trauma (nAHT) in children. METHODS: We searched MEDLINE, EMBASE, PubMed, conference proceedings, and reference lists to identify relevant studies. Two reviewers independently selected studies that compared clinical and/or radiographic characteristics including historical features, physical exam and imaging findings, and presenting signs or symptoms in hospitalized children ≤ 6 years old with AHT and nAHT. RESULTS: Twenty-four studies were included. Meta-analysis was complicated by inconsistencies in the reporting of characteristics and high statistical heterogeneity. Notwithstanding these limitations, there were 19 clinical and radiographic variables that could be meta-analyzed and odds ratios were determined for each variable. In examining only studies deemed to be high quality, we found that subdural hemorrhage(s), cerebral ischemia, retinal hemorrhage(s), skull fracture(s) plus intracranial injury, metaphyseal fracture(s), long bone fracture(s), rib fracture(s), seizure(s), apnea, and no adequate history given were significantly associated with AHT. Epidural hemorrhage(s), scalp swelling, and isolated skull fracture(s) were significantly associated with nAHT. Subarachnoid hemorrhage(s), diffuse axonal injury, cerebral edema, head and neck bruising, any bruising, and vomiting were not significantly associated with either type of trauma. CONCLUSIONS: Clinical and radiographic characteristics associated with AHT and nAHT were identified, despite limitations in the literature. This systematic review also highlights the need for consistent criteria in identifying and reporting clinical and radiographic characteristics associated with AHT and nAHT.
Pérez Orts M, van Asten A, Kohler I. The Evolution Toward Designer Benzodiazepines in Drug-Facilitated Sexual Assault Cases. Journal of Analytical Toxicology. 2023; 47 (1) : 1-25.
Keywords: *Ethanol/analysis, Benzodiazepines, *Sex Offenses, Crime, Half-Life
Drug-facilitated sexual assault (DFSA) is a crime where the victim is unable to …
Drug-facilitated sexual assault (DFSA) is a crime where the victim is unable to provide sexual consent due to incapacitation resulting from alcohol or drug consumption. Due to the large number of substances possibly used in DFSA, including illicit, prescription and over-the-counter drugs, DFSA faces many toxicological challenges. Benzodiazepines (BZDs) are ideal candidates for DFSA, as they are active at low doses, have a fast onset of action and can be easily administered orally. The last decade has seen the emergence of designer benzodiazepines (DBZDs), which show slight modifications compared with BZDs and similar pharmacological effects but are not controlled under the international drug control system. DBZDs represent an additional challenge due to the number of new entities regularly appearing in the market, their possibly higher potency and the limited knowledge available on their pharmacokinetic and pharmacodynamics properties. Many BZDs and DBZDs have a short half-life, leading to rapid metabolism and excretion. The low concentrations and short time windows for the detection of BZD in body fluids require the use of highly sensitive analysis methods to enable the detection of drugs and their respective metabolites. This review discusses the current state of the toxicological analysis of BZDs and DBZDs in forensic casework and their pharmacokinetic properties (i.e., absorption, distribution, metabolism, and elimination), as well as their analysis in biosamples typically encountered in DFSA (i.e., blood, urine and hair).
Rasooly IR, Khan AN, Aldana Sierra MC, Shankar M, Dang K, Cao L, Wood JN. Validating Use of ICD-10 Diagnosis Codes in Identifying Physical Abuse Among Young Children. Academic Pediatrics. 2023; 23 (2) : 396-401.
Keywords: Adult, Child, Humans, Child, Preschool, *Physical Abuse, International Classification of Diseases, *Child Abuse/diagnosis, Predictive Value of Tests, Emergency Service, Hospital
OBJECTIVE: Evaluate the positive predictive value of International …
OBJECTIVE: Evaluate the positive predictive value of International Classification of Disease, 10th Revision, Clinical Modification (ICD-10-CM) codes in identifying young children diagnosed with physical abuse. METHODS: We extracted 230 charts of children <24 months of age who had any emergency department, inpatient, or ambulatory care encounters between Oct 1, 2015 and Sept 30, 2020 coded using ICD-10-CM codes suggestive of physical abuse. Electronic health records were reviewed to determine if physical abuse was considered during the medical encounter and assess the level of diagnostic certainty for physical abuse. Positive predictive value of each ICD-10-CM code was assessed. RESULTS: Of 230 charts with ICD-10 codes concerning for physical abuse, 209 (91%) had documentation that a diagnosis of physical abuse was considered during an encounter. The majority of cases, 138 (60%), were rated as definitely or likely abuse, 36 cases (16%) were indeterminate, and 35 (15%) were likely or definitely accidental injury. Other forms of suspected maltreatment were discussed in 16 (7%) charts and 5 (2%) had no documented concerns for child maltreatment. The positive predictive values of the specific ICD-10 codes for encounters rated as definitely or likely abuse varied considerably, ranging from 0.89 (0.80-0.99) for T74.12 "Adult and child abuse, neglect, and other maltreatment, confirmed" to 0.24 (95% CI: 0.06-0.42) for Z04.72 "Encounter for examination and observation following alleged child physical abuse." CONCLUSIONS: ICD-10-CM codes identify young children who experience physical abuse, but certain codes have a higher positive predictive value than others.
Reece RM & Ludwig S, eds. Child Abuse: Medical Diagnosis and Management (2nd Ed.). Baltimore: Lippincott, Williams and Wilkins. 2001.
Reece RM. Child abuse. The Pediatric Clinics of North America. 1990; 37 (4) : 943-954.
Reece RM. What the literature tells us about rib fractures in infancy. National Conference on SBS. SBS Quarterly. 2002; (Fall) : 2-3,6.
Reece RM, Hanson RF, Sargent J. Treatment of Child Abuse: Common Ground for Mental Health, Medical, and Legal Practitioners. Baltimore, Md, Johns Hopkins University Press. 2015.
A single reference source that nudges the field of child abuse beyond diagnosis …
A single reference source that nudges the field of child abuse beyond diagnosis and into the relatively uncharted territory of treatment of the initial and later consequences of abuse. Robert Reece, MD, director of the Institute for Professional Education at the Massachusetts Society for the Prevention of Cruelty to Children, chairperson of the Section on Child Abuse and Neglect (American Academy of Pediatrics), and Clinical Professor of Pediatrics at Tufts University School of Medicine, has edited Treatment of Child Abuse: Common Ground for Mental Health, Medical, and Legal Practitioners. This book offers up-to-date and practical information for the primary care practitioner who cares for adults or children and for professionals who specialize in the treatment of child abuse victims.
Ricci LR. Photographing the physically abused child. Principles and practice. American Journal of Diseases of Children (1960). 1991; 145 (3) : 275-81.
Keywords: Child, *Child Abuse/legislation & jurisprudence, Child, Preschool, Humans, Infant, Photography/legislation & jurisprudence/*methods
Photographic documentation of significant findings is an important part of any …
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.
Ruiz-Maldonado TM, Alsanea Y, Coats B. Age-related skull fracture patterns in infants after low-height falls. Pediatric Research. 2023; 93 (7) : 1990-1998.
Keywords: Humans, Infant, Accidental Falls, *Skull Fractures/diagnostic imaging, *Craniocerebral Trauma, Tomography, X-Ray Computed, Head, Skull
BACKGROUND: Prior research and experience has increased physician understanding …
BACKGROUND: Prior research and experience has increased physician understanding of infant skull fracture prediction. However, patterns related to fracture length, nonlinearity, and features of complexity remain poorly understood, and differences across infant age groups have not been previously explored. METHODS: To determine how infant and low-height fall characteristics influence fracture patterns, we collected data from 231 head CT 3D reconstructions and quantified length and nonlinearity using a custom image processing code. Regression analysis was used to determine the effects of age and fall characteristics on nonlinearity, length, and features of fracture complexity. RESULTS: While impact surface had an important role in the number of cracks present in a fracture, younger infants and greater fall heights significantly affected most features of fracture complexity, including suture-to-suture spanning and biparietal involvement. In addition, increasing fracture length with increasing fall height supports trends identified by prior finite-element modeling. Finally, this study yielded results supporting the presence of soft tissue swelling as a function of fracture location rather than impact site. CONCLUSIONS: Age-related properties of the infant skull confer unique fracture patterns following head impact. Further characterization of these properties, particularly in infants <4 months of age, will improve our understanding of the infant skull's response to trauma. IMPACT: Younger infant age and greater fall heights have significant effects on many features of fracture complexity resulting from low-height falls. Incorporating multiple crack formation and multiple bone involvement into computational models of young infant skull fractures may result in increased biofidelity. Drivers of skull fracture complexity are not well understood, and skull fracture patterns in real-world data across infant age groups have not been previously described. Understanding fracture complexity relative to age in accidental falls will improve the understanding of accidental and abusive head trauma.
Sabzghabaei A, Shojaee M, Safari S, Hatamabadi HR, Shirvani R. The Accuracy of Urinalysis in Predicting Intra-Abdominal Injury Following Blunt Traumas. Emergency (Tehran, Iran). 2016; 4 (1) : 11-5.
INTRODUCTION: In cases of blunt abdominal traumas, predicting the possible …
INTRODUCTION: In cases of blunt abdominal traumas, predicting the possible intra-abdominal injuries is still a challenge for the physicians involved with these patients. Therefore, this study was designed, to evaluate the accuracy of urinalysis in predicting intra-abdominal injuries. METHODS: Patients aged 15 to 65 years with blunt abdominal trauma who were admitted to emergency departments were enrolled. Abdominopelvic computed tomography (CT) scan with intravenous contrast and urinalysis were requested for all the included patients. Demographic data, trauma mechanism, the results of urinalysis, and the results of abdominopelvic CT scan were gathered. Finally, the correlation between the results of abdominopelvic CT scan, and urinalysis was determined. Urinalysis was considered positive in case of at least one positive value in gross appearance, blood in dipstick, or red blood cell count. RESULTS: 325 patients with blunt abdominal trauma were admitted to the emergency departments (83% male with the mean age of 32.63±17.48 years). Sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios of urinalysis, were 77.9% (95% CI: 69.6-84.4), 58.5% (95% CI: 51.2-65.5), 56% (95% CI: 48.5-63.3), 79.6% (95% CI: 71.8-85.7), 1.27% (95% CI: 1.30-1.57), and 0.25% (95% CI: 0.18-0.36), respectively. CONCLUSION: The diagnostic value of urinalysis in prediction of blunt traumatic intra-abdominal injuries is low and it seems that it should be considered as an adjuvant diagnostic tool, in conjunction with other sources such as clinical findings and imaging.
Schaul M, Schwark T. Rare (uro-)genital pathologies in young girls mimicking sexual abuse. International Journal of Legal Medicine. 2022; 136 (2) : 623-627.
Keywords: Child, *Child Abuse, Sexual/diagnosis, Child, Preschool, Female, Hemorrhage/etiology, Humans, Perineum/injuries, *Sex Offenses, *Urethral Diseases/complications/diagnosis, Vagina
Examinations of young children for suspicions of sexual abuse are challenging …
Examinations of young children for suspicions of sexual abuse are challenging for the involved medical specialists because the consequences of the interpretation of the findings can be severe and dramatic. A broad knowledge of differential diagnoses including rare pathologies like urethral prolapse and failure of the midline fusion of the perineum, known as perineal groove, is essential in order to avoid unnecessary diagnostics and treatment, prejudgment, and to reduce patient family's anxiety. We report two independent cases of girls aged 7 months and 5 years suffering from these rare pathologies, one presenting with painless lower genital tract bleeding, the other showing a lesion of the perineum as random finding during a neuropediatrician's consultation. In both cases, the pathologies were initially misdiagnosed as injuries due to sexual assault, and judicial investigation procedures were initiated. In this paper, the characteristic symptoms and morphology of urethral prolapse and perineal groove are presented to enhance the awareness of these pathologies among forensic experts and help to establish the correct diagnosis.
Schulte AG, Ricci LR, Melville JD, Brown J. Emerging Trends in Smartphone Photo Documentation of Child Physical Abuse. Pediatric Emergency Care. 2022; 38 (9) : 464-468.
Keywords: Child, *Documentation/methods, Electronic Health Records, Humans, Photography, Physical Abuse, *Smartphone
Photo documentation of injuries on children is universally recommended in cases …
Photo documentation of injuries on children is universally recommended in cases of suspected child physical abuse. As technology improves, the ability to document physical examination findings through smartphone photography is increasingly accessible and practical. The quality of images captured on smartphones now rivals traditional photography and the integration of photo capture within the electronic medical record has led to a variety of fields adopting smartphone photo documentation for diagnosis, consult, and follow-up. However, in cases of child physical abuse, practitioners have been hesitant to adopt smartphones as a primary means of photo documentation because of concerns around image quality, privacy, and security. In this article, we discuss the technology of available smartphone cameras and current evidence regarding their use for photo documentation, use existing guidelines to propose a workflow to improve the yield of smartphone photo documentation in child physical abuse, and discuss common medicolegal concerns.
Seidl T. Special Interviewing Techniques. In: Ludwig S & Kornberg AE eds. Child Abuse: A Medical Reference (2nd ed.) New York: Churchill Livingstone. 1992; : 279-293.
Shakeshaft C. Educator Sexual Misconduct: A Synthesis of Existing Literature. US Department of Education. 2004.
Sharko M, Jameson R, Ancker JS, Krams L, Webber EC, Rosenbloom ST. State-by-State Variability in Adolescent Privacy Laws. Pediatrics. 2022; 149 (6).
Keywords: Adolescent, Child, Confidentiality, Contraceptive Agents, Female, *HIV Infections/prevention & control, Humans, Pregnancy, Privacy, *Substance-Related Disorders, United States
OBJECTIVES: Health care providers managing the complex health needs of …
OBJECTIVES: Health care providers managing the complex health needs of adolescents must comply with state laws governing adolescent consent and right to privacy. However, these laws vary. Our objectives were to summarize consent and privacy laws state-by-state and assess the implications of variation for compliance with the 21st Century Cures Act and with evidence-based guidance on adolescent care. METHODS: We summarized state laws and regulations on minor consent for the following: health services, substance abuse treatment, prenatal care, mental health care, contraceptive management, immunizations, sexually transmitted infection management, human immunodeficiency viruses testing and treatment, dental care, and sexual assault evaluation. We compared state laws and regulations with American Academy of Pediatrics' evidence-based guidelines to assess consistencies in guidance. RESULTS: We observed notable state-by-state variability in laws governing consent for adolescent patients. No states had identical policies for all services studied. For example, although all states had provisions for consent to management of sexually transmitted infections, there were variable specifications in the age and type of minor, whether this includes human immunodeficiency viruses, and whether confidentiality is protected. Providing confidential care to the adolescent patient has been set as a priority by medical societies; however, guidelines are limited by the need to comply with state laws and regulations. CONCLUSIONS: State laws on consent and privacy for adolescents are highly variable, and many do not reflect pediatric professional standards of care. This inconsistency is a barrier to operationalizing a consistent and equitable experience providing evidence-based medical care and ensuring adolescent privacy protection.
Sinclair KA, Woods CR, Sinal SH. Venereal warts in children. Pediatrics in Review. 2011; 32 (3) : 115-21; quiz 121.
Keywords: Adolescent, Age Factors, Child, Child Abuse, Sexual/diagnosis, Child, Preschool, *Condylomata Acuminata/diagnosis/epidemiology/prevention & control/therapy, Consensus, Dissent and Disputes, Humans, Mandatory Reporting, Papillomavirus Vaccines
Spriggs M. Children and bioethics: clarifying consent and assent in medical and research settings. British Medical Bulletin. 2023; 145 (1) : 110-119.
Keywords: Child, Humans, *Decision Making, *Informed Consent
INTRODUCTION: The concept of consent in the pediatric setting is complex and …
INTRODUCTION: The concept of consent in the pediatric setting is complex and confusing. Clinicians and researchers want to know whose consent they should obtain, when a child can provide independent consent and how that is determined. The aim of this article is to establish what produces the justification to proceed with medical or research interventions involving children and the role of consent in that. I clarify concepts such as consent, assent, capacity and competence. SOURCE OF DATA: Literature review. AREAS OF AGREEMENT: Engaging with children and involving them in decisions about matters that affect them is a good thing. AREAS OF CONTROVERSY: The role of competence or capacity and the question of when a child can provide sole consent. GROWING POINTS: Flawed assumptions around competence/capacity. AREAS FOR DEVELOPING RESEARCH: An account of children's well-being that accommodates children's interests during the transition to adulthood.
Stavas N, Shea J, Keddem S, Wood J, Orji W, Cullen C, Scribano P. Perceptions of caregivers and adolescents of the use of telemedicine for the child sexual abuse examination. Child Abuse & Neglect. 2018; 85 : 47-57.
Keywords: Adolescent, Adult, Caregivers/*psychology, Child, Child Abuse, Sexual/*diagnosis, Child Advocacy, Female, *Health Knowledge, Attitudes, Practice, Humans, Interviews as Topic, Male, Middle Aged, Qualitative Research, *Telemedicine
BACKGROUND: Childhood sexual abuse is a common cause of morbidity and mortality. …
BACKGROUND: Childhood sexual abuse is a common cause of morbidity and mortality. All victims should receive a timely comprehensive medical exam. Currently there is a critical shortage of child abuse pediatricians who can complete the comprehensive child sexual abuse examination. Telemedicine has emerged as an innovative way to provide subspecialty care to this population. Despite the growing popularity of telemedicine, no literature exists describing patient and caregiver perceptions of telemedicine for this sensitive exam. OBJECTIVE: To explore caregiver and adolescent perspectives of the use of telemedicine for the child sexual abuse examination and discover factors that drive satisfaction with the technology. PARTICIPANTS AND SETTING: Caregivers and adolescents who presented for a child sexual abuse medical evaluation at our county's child advocacy center. METHODS: We completed semi structured interviews of 17 caregivers and 10 adolescents. Guided by the Technology Acceptance Model interviews assessed perceptions about: general feelings with the exam, prior use of technology, feelings about telemedicine, and role of the medical team. Interviews were audio-recorded, transcribed, coded and analyzed using content analysis with constant comparative coding. Recruitment ended when thematic saturation was reached. RESULTS: There was an overwhelming positive response to telemedicine. Participants reported having a good experience with telemedicine regardless of severity of sexual abuse or prior experience with technology. Behaviors that helped patients and caregivers feel comfortable included a clear explanation from the medical team and professionalism demonstrated by those using the telemedicine system. CONCLUSION: Telemedicine was widely accepted by adolescents and caregivers when used for the child sexual abuse examination.
Steinmetz M. Interviewing children: Balancing forensic and therapeutic techniques. National Resource Center on Child Sexual Abuse News. 1995; 4 (3) : 1-4.
Strouse PJ, Owings CL. Fractures of the first rib in child abuse. Radiology. 1995; 197 (3) : 763-5.
Keywords: Academic Medical Centers, Biomechanical Phenomena, Bone Diseases, Metabolic/diagnostic imaging, Brain Injuries/complications/diagnosis, Child Abuse/*diagnosis, Child, Preschool, Female, Humans, Incidence, Infant, Infant, Newborn, Male, Osteogenesis Imperf
PURPOSE: To evaluate the incidence and specificity of fracture of the first rib …
PURPOSE: To evaluate the incidence and specificity of fracture of the first rib as an indicator of child abuse and to determine a mechanism of fracture. MATERIALS AND METHODS: All infants and young children with rib fractures who were seen at the radiology department of an academic medical center over a 2-year period were identified from the radiology data base. RESULTS: Rib fractures were attributed to child abuse in 12 of 35 children identified. Apart from a neonate with congenital osteogenesis imperfecta, only three children, all abused, had first-rib fracture, one bilaterally. Two additional children with first-rib fracture were identified from years prior to the study period. In four children, first-rib fractures were "isolated," without fractures of adjacent bones. CONCLUSION: Child abuse should be considered in cases of pediatric rib fracture, particularly fracture of the first rib. Possible mechanisms for first-rib fracture include impact force, compressive force, and shaking or acute axial load (slamming), which cause an indirect fracture.
Summit RC. The child sexual abuse accommodation syndrome. Child Abuse & Neglect. 1983; 7 (2) : 177-93.
Keywords: Adaptation, Psychological, Attitude, Child, *Child Abuse, Child Development, Child Reactive Disorders/*psychology, Cross-Sectional Studies, Female, Humans, Incest, Male, Rape, Set, Psychology, *Sex Offenses
Child victims of sexual abuse face secondary trauma in the crisis of discovery. …
Child victims of sexual abuse face secondary trauma in the crisis of discovery. Their attempts to reconcile their private experiences with the realities of the outer world are assaulted by the disbelief, blame and rejection they experience from adults. The normal coping behavior of the child contradicts the entrenched beliefs and expectations typically held by adults, stigmatizing the child with charges of lying, manipulating or imagining from parents, courts and clinicians. Such abandonment by the very adults most crucial to the child's protection and recovery drives the child deeper into self-blame, self-hate, alienation and revictimization. In contrast, the advocacy of an empathic clinician within a supportive treatment network can provide vital credibility and endorsement for the child. Evaluation of the responses of normal children to sexual assault provides clear evidence that societal definitions of "normal" victim behavior are inappropriate and procrustean, serving adults as mythic insulators against the child's pain. Within this climate of prejudice, the sequential survival options available to the victim further alienate the child from any hope of outside credibility or acceptance. Ironically, the child's inevitable choice of the "wrong" options reinforces and perpetuates the prejudicial myths. The most typical reactions of children are classified in this paper as the child sexual abuse accommodation syndrome. The syndrome is composed of five categories, of which two define basic childhood vulnerability and three are sequentially contingent on sexual assault: (1) secrecy, (2) helplessness, (3) entrapment and accommodation, (4) delayed, unconvincing disclosure, and (5) retraction. The accommodation syndrome is proposed as a simple and logical model for use by clinicians to improve understanding and acceptance of the child's position in the complex and controversial dynamics of sexual victimization. Application of the syndrome tends to challenge entrenched myths and prejudice, providing credibility and advocacy for the child within the home, the courts, and throughout the treatment process. The paper also provides discussion of the child's coping strategies as analogs for subsequent behavioral and psychological problems, including implications for specific modalities of treatment.
Suniega EA, Krenek L, Stewart G. Child Abuse: Approach and Management. American Family Physician. 2022; 105 (5) : 521-528.
Keywords: Adult, *Adverse Childhood Experiences, Child, *Child Abuse/diagnosis/prevention & control/psychology, Emotions, Female, Gender Identity, Humans, Male, Mass Screening, Surveys and Questionnaires
Child maltreatment is a devastating type of adverse childhood experience that …
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.
Tate AR, Fisher-Owens SA, Spiller L, Muhlbauer J, Lukefahr JL. Oral and Dental Aspects of Child Abuse and Neglect: Clinical Report. Pediatrics. 2024; 154 (3).
Keywords: Humans, *Child Abuse/diagnosis/prevention & control, Child, Mandatory Reporting, Tooth Injuries/diagnosis/therapy/etiology, Oral Health, Physician's Role, Bites, Human/diagnosis, Mouth Diseases/diagnosis/etiology, Child, Preschool
In all 50 states, the District of Columbia, and the Commonwealth of Puerto Rico, …
In all 50 states, the District of Columbia, and the Commonwealth of Puerto Rico, pediatricians, dental professionals, and other physicians are mandated to report suspected cases of abuse and neglect to social service or law enforcement agencies. The purpose of this clinical report is to review the oral aspects of abuse and dental neglect in children and the role of pediatricians, dental professionals, and other physicians in evaluating such conditions. This clinical report addresses recommendations on the evaluation of bite marks, as well as perioral and intraoral injuries, infections, and diseases that may raise suspicion for child abuse or neglect. Some physicians may have received less education pertaining to oral health, dental injury, and oral disease. These physicians may not detect the mouth and gum findings possibly related to abuse or neglect as readily as abuse injuries involving other areas of the body. Therefore, pediatricians, dental professionals, and other physicians are encouraged to collaborate to increase the prevention, detection, and treatment of these conditions in children.
Teeuw AH, Kraan RBJ, van Rijn RR, Bossuyt PMM, Heymans HSA. Screening for child abuse using a checklist and physical examinations in the emergency department led to the detection of more cases. Acta Paediatrica (Oslo, Norway : 1992). 2019; 108 (2) : 300-313.
Keywords: Adolescent, *Checklist, Child, Child Abuse/*diagnosis/statistics & numerical data, Child, Preschool, Emergency Service, Hospital/statistics & numerical data, Female, Humans, Infant, Male, *Mass Screening, Physical Examination
AIM: We studied the accuracy of a screening checklist (SPUTOVAMO), complete …
AIM: We studied the accuracy of a screening checklist (SPUTOVAMO), complete physical examination (top-to-toe inspection, TTI) and their combination in detecting child abuse in the emergency department (ED). METHODS: Consecutive patients admitted to the ED of the Academic Medical Center in Amsterdam between January 2011 and 1 July 2013 were included. An Expert Panel assigned a consensus diagnosis to positive cases. For all other and missed cases, the Child Abuse Counselling and Reporting Centre diagnosis was used. RESULTS: We included 17 229 admissions of 12 198 patients. In 46%, SPUTOVAMO was performed, in 33% TTI; 421 children (4.3%) tested positive on either or both, with 68 positive consensus diagnoses. In eight children not reported to the Expert Panel, the Child Abuse Counselling and Reporting Center diagnosis was positive. Ten of 3519 (0.3%) children testing negative on both were child abuse cases; 0.88% of the study group had a final child abuse diagnosis. The estimated PPV was 0.46 for SPUTOVAMO, 0.44 for TTI and 0.43 for the combination. CONCLUSION: Combining screening tests significantly increased the number of test positives and led to more child abuse cases detected. Combined screening for child abuse in all children less than 18 years old presenting to an ED is recommended.
Thomas A, Asnes A, Libby K, Hsiao A, Tiyyagura G. Developing and Testing the Usability of a Novel Child Abuse Clinical Decision Support System: Mixed Methods Study. Journal of Medical Internet Research. 2024; 26 : e51058.
Keywords: Infant, Humans, Child, *Decision Support Systems, Clinical, Ethnicity, Electronic Health Records, Minority Groups, *Child Abuse/diagnosis
BACKGROUND: Despite the impact of physical abuse on children, it is often …
BACKGROUND: Despite the impact of physical abuse on children, it is often underdiagnosed, especially among children evaluated in emergency departments (EDs). 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.
Thompson K, Svendsen S. Analysis of Cases Presenting With Concern of Child Abuse or Neglect to a Child Protection Team. Clinical Pediatrics. 2024; 63 (9) : 1269-1275.
Keywords: Humans, *Child Abuse/statistics & numerical data/diagnosis/prevention & control, Child, Preschool, Child, Female, Male, *Child Protective Services/statistics & numerical data, Infant, Triage/methods, Referral and Consultation/statistics & numerical dat
Limited data are available on cases presenting for triage by child abuse …
Limited data are available on cases presenting for triage by child abuse specialists, particularly data combining patient demographics with presenting concerns and outcomes. This study aims to provide a descriptive analysis of cases presenting to one child abuse medical subspecialty team. Data were collected for all referrals triaged by the Child Protection Program, a child abuse team located within an academic children's medical center. The program triaged a total of 928 cases and completed 345 in-person visits with a medical provider. Nearly, half of all provider visits were for evaluation of children aged 3 years and younger (51%) and for a concern of physical abuse (49%). Of these visits, 26% were determined to be consistent with an accident or medical condition. This descriptive analysis highlights the burden of child abuse cases presenting to one small hospital-based child abuse program, as well as the structural and financial challenges faced by these programs.
Thorn Partnership. Self-Generated Child Sexual Abuse Material: Youth Attitudes and Experiences in 2020. Findings from 2020 quantitative research among 9–17 year olds. 2021.
Trout AT, Strouse PJ, Mohr BA, Khalatbari S, Myles JD. Abdominal and pelvic CT in cases of suspected abuse: can clinical and laboratory findings guide its use?. Pediatric Radiology. 2011; 41 (1) : 92-8.
Keywords: Abdominal Injuries/*diagnostic imaging, Child Abuse/*diagnosis, Child, Preschool, Female, Humans, Infant, Infant, Newborn, Male, Pelvis/*diagnostic imaging, Physical Examination/methods, Retrospective Studies, Tomography, X-Ray Computed, Ultrasonography
BACKGROUND: Incomplete history and concern for occult injury in suspected child …
BACKGROUND: Incomplete history and concern for occult injury in suspected child abuse occasionally results in CT screenings of the abdomen and pelvis. At our institution, we noted that these exams were infrequently positive. OBJECTIVE: To identify clinical or laboratory criteria that may predict intra-abdominal injury and guide the use of abdominal and pelvic CT in this population. MATERIALS AND METHODS: This retrospective review involved 68 children older than 36 months who had a CT of the abdomen/pelvis for suspected abuse. CT results and patient charts were reviewed for physical exam and historical and laboratory variables. RESULTS: CTs were positive in 16% of patients (11/68). Hypoactive/absent bowel sounds (P = 0.01, specificity = 94.7%) and AST and ALT values greater than twice normal (P = 0.004 and P = 0.003 respectively, NPV = 93.6%) were significantly associated with positive CTs. Multiple abnormal physical exam or laboratory findings were also significantly associated with positive CTs (P = 0.03 and P = 0.002 respectively, specificity = 91.3% and NPV = 93.6% respectively). CONCLUSION: CTs of the abdomen and pelvis are infrequently positive in cases of suspected abuse. To reduce radiation exposure, CTs should only be ordered if there are findings indicating that they may be positive. In our population, these findings include absent/hypoactive bowel sounds, LFTs greater than twice normal and ≥2 abnormal labs or physical exam findings.
Trübner K, Schubries M, Beintker M, Bajanowski T. Genital findings in boys suspected for sexual abuse. International Journal of Legal Medicine. 2013; 127 (5) : 967-70.
Keywords: Balanitis/diagnosis, Child, Child Abuse/*diagnosis, Child Abuse, Sexual/*diagnosis, Child, Preschool, Constriction, Pathologic/etiology, Diagnosis, Differential, Edema/etiology/pathology, Hematoma/etiology/pathology, Humans, Hypospadias/diagnosis, Infant,
Injuries in the genital region of boys are mostly caused by accidents. In this …
Injuries in the genital region of boys are mostly caused by accidents. In this study, three cases of child abuse and one case suspicious for child abuse but explainable by a congenital undiscovered malformation are presented. Injuries or findings in the genital region are especially suspicious for child abuse, including sexual abuse. Because of the possible misinterpretation and the consequences of a false confirmation of a child abuse, an interdisciplinary cooperation between pediatrics, forensic experts, and pediatric urologist should be carried out in doubtful cases.
Tuddenham S, Hamill MM, Ghanem KG. Diagnosis and Treatment of Sexually Transmitted Infections: A Review. Jama. 2022; 327 (2) : 161-172.
Keywords: Asymptomatic Infections/epidemiology/therapy, Chlamydia Infections/diagnosis/drug therapy/epidemiology/ethnology, Contact Tracing, Drug Resistance, Microbial, Ethnic and Racial Minorities/statistics & numerical data, Female, Gonorrhea/diagnosis/drug thera
IMPORTANCE: Approximately 1 in 5 adults in the US had a sexually transmitted …
IMPORTANCE: Approximately 1 in 5 adults in the US had a sexually transmitted infection (STI) in 2018. This review provides an update on the epidemiology, diagnosis, and treatment of gonorrhea, chlamydia, syphilis, Mycoplasma genitalium, trichomoniasis, and genital herpes. OBSERVATIONS: From 2015 to 2019, the rates of gonorrhea, chlamydia, and syphilis increased in the US; from 1999 to 2016, while the rates of herpes simplex virus type 1 (HSV-1) and HSV-2 declined. Populations with higher rates of STIs include people younger than 25 years, sexual and gender minorities such as men and transgender women who have sex with men, and racial and ethnic minorities such as Black and Latinx people. Approximately 70% of infections with HSV and trichomoniasis and 53% to 100% of extragenital gonorrhea and chlamydia infections are asymptomatic or associated with few symptoms. STIs are associated with HIV acquisition and transmission and are the leading cause of tubal factor infertility in women. Nucleic acid amplification tests have high sensitivities (86.1%-100%) and specificities (97.1%-100%) for the diagnosis of gonorrhea, chlamydia, M genitalium, trichomoniasis, and symptomatic HSV-1 and HSV-2. Serology remains the recommended method to diagnose syphilis, typically using sequential testing to detect treponemal and nontreponemal (antiphospholipid) antibodies. Ceftriaxone, doxycycline, penicillin, moxifloxacin, and the nitroimidazoles, such as metronidazole, are effective treatments for gonorrhea, chlamydia, syphilis, M genitalium, and trichomoniasis, respectively, but antimicrobial resistance limits oral treatment options for gonorrhea and M genitalium. No cure is available for genital herpes. Effective STI prevention interventions include screening, contact tracing of sexual partners, and promoting effective barrier contraception. CONCLUSIONS AND RELEVANCE: Approximately 1 in 5 adults in the US had an STI in 2018. Rates of gonorrhea, chlamydia, and syphilis in the US have increased, while rates of HSV-1 and HSV-2 have declined. Ceftriaxone, doxycycline, penicillin, moxifloxacin, and the nitroimidazoles are effective treatments for gonorrhea, chlamydia, syphilis, Mycoplasma genitalium, and trichomoniasis, respectively, but antimicrobial resistance limits oral therapies for gonorrhea and Mycoplasma genitalium, and no cure is available for genital herpes.
Walker-Descartes I, Mineo M, Condado LV, Agrawal N. Domestic Violence and Its Effects on Women, Children, and Families. Pediatric Clinics of North America. 2021; 68 (2) : 455-464.
Keywords: Adolescent, Adult, Child, Child Abuse/*psychology, Child, Preschool, Domestic Violence/*psychology, Female, Humans, Infant, Intimate Partner Violence/psychology, Male, Mental Health
Men and women experience severe domestic violence (DV) and intimate partner …
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.
Webb T, Valvano T, Nugent M, Melzer-Lange M. Child abuse pediatric consults in the pediatric emergency department improve adherence to hospital guidelines. WMJ : official publication of the State Medical Society of Wisconsin. 2013; 112 (5) : 206-10.
Keywords: Child, Child Abuse/*diagnosis, Child, Preschool, *Emergency Service, Hospital, Female, Guideline Adherence, Humans, Infant, Injury Severity Score, Male, Pediatrics/*standards, Practice Guidelines as Topic, *Referral and Consultation, Retrospective Stud
BACKGROUND: Little data describes the role of child abuse pediatricians in …
BACKGROUND: Little data describes the role of child abuse pediatricians in consultation for physical abuse patients the pediatric emergency department. OBJECTIVES: To compare adherence in the emergency department to hospital physical abuse guidelines and need to return for testing between 2 groups: those receiving a child abuse consultation in the pediatric emergency department vs those who received standard emergency department care with subsequent child abuse review. METHODS: We reviewed 471 records of visits to the pediatric emergency department for physical abuse. Data collected included demographics, studies performed, whether patients need to return after child abuse review, child abuse subpoenas, child abuse testimony in court. RESULTS: Patients who received a child abuse consult in the emergency department or inpatient were more likely to be younger and to have more severe injuries. In cases where a consult was obtained, there was 100% adherence to emergency department clinical guidelines vs 66% when no consult was obtained. In addition, in cases that did not receive a child abuse consult, 8% had to return to the hospital for labs or radiographs after their emergency department visit. CONCLUSIONS: Child abuse consultation in the pediatric emergency department improves compliance with clinical guidelines and decreases the likelihood that patients will need to return for further testing.
Whitehouse C, McKenzie P, Hobbs C. The First 72 Hours After Child Sexual Assault: Reporting Children, Young People, and Mothers' Experiences of Police, Hospital, and Psychosocial Care in Victoria. Journal of Interpersonal Violence. 2025; : 8862605251324962.
In Victoria, Australia, children who are reported to authorities to have …
In Victoria, Australia, children who are reported to authorities to have experienced very recent sexual assault routinely undergo a forensic medical examination and receive psychosocial care. There is very little known about how children and their families experience this process and whether current practices are meeting their needs. This study seeks to understand these experiences by undertaking a thematic analysis of in-depth interviews with 10 children/young people (aged between 4 and 16) and 8 mothers (n = 18). The study draws on constructivist grounded theory methodology and incorporates the contextual-embedded perspective of the clinician/researcher. The study identified three stages participants navigated in the hours following the assault: (a) reaching out for help, (b) hospital processes and procedures, and (c) discharge. Nested within these stages, five key themes emerged: confusion, distress, and minimization when reporting; valuing a caring presence; feeling exposed, vulnerable, and ashamed; being lost in space and time; and going home alone. The need for a sensitive, trauma-informed, accessible, and consistent response to acute sexual assault is discussed; one that acknowledges the experiences and centralizes the priorities and psychosocial needs of the child and their family.
Wood JN, Fakeye O, Feudtner C, Mondestin V, Localio R, Rubin DM. Development of guidelines for skeletal survey in young children with fractures. Pediatrics. 2014; 134 (1) : 45-53.
Keywords: Child abuse,Child maltreatment,Fracture,Skeletal survey,Trauma
OBJECTIVE: To develop guidelines for performing initial skeletal survey (SS) in …
OBJECTIVE: To develop guidelines for performing initial skeletal survey (SS) in children <24 months old with fractures, based on available evidence and collective judgment of experts from diverse pediatric specialties. METHODS: Following the Rand/UCLA Method, a multispecialty panel of 13 experts applied evidence from a literature review combined with their own expertise in rating the appropriateness of performing an SS for 525 clinical scenarios involving fractures in children <24 months old. After discussion on the initial ratings, panelists rerated SS appropriateness for 240 revised scenarios and deemed that SSs were appropriate in 191 scenarios. The panelists then assessed in which of those 191 scenarios SSs were not only appropriate, but also necessary. RESULTS: Panelists agreed that SS is "appropriate" for 191 (80%) of 240 scenarios rated and "necessary" for 175 (92%) of the appropriate scenarios. Skeletal survey is necessary if a fracture is attributed to abuse, domestic violence, or being hit by a toy. With few exceptions, SS is necessary in children without a history of trauma. In children <12 months old, SS is necessary regardless of the fracture type or reported history, with rare exceptions. In children 12 to 23 months old, the necessity of obtaining SS is dependent on fracture type. CONCLUSIONS: A multispecialty panel reached agreement on multiple clinical scenarios for which initial SS is indicated in young children with fractures, allowing for synthesis of clinical guidelines with the potential to decrease disparities in care and increase detection of abuse. Copyright \textcopyright 2014 by the American Academy of Pediatrics.
Wootton-Gorges SL, Soares BP, Alazraki AL, Anupindi SA, Blount JP, Booth TN, Dempsey ME, Falcone RA Jr, Hayes LL, Kulkarni AV, Partap S, Rigsby CK, Ryan ME, Safdar NM, Trout AT, Widmann RF, Karmazyn BK, Palasis S. ACR Appropriateness Criteria(®) Suspected Physical Abuse-Child. Journal of the American College of Radiology : Jacr. 2017; 14 (5S) : S338-S349.
Keywords: Child Abuse/*diagnosis, Contrast Media, Craniocerebral Trauma/*diagnostic imaging, Fractures, Bone/*diagnostic imaging/etiology, Humans, Infant, Infant, Newborn, Radiology, Rib Fractures/diagnostic imaging/etiology, Societies, Medical, Tomography, X-Ray C
The youngest children, particularly in the first year of life, are the most …
The youngest children, particularly in the first year of life, are the most vulnerable to physical abuse. Skeletal survey is the universal screening examination in children 24 months of age and younger. Fractures occur in over half of abused children. Rib fractures may be the only abnormality in about 30%. A repeat limited skeletal survey after 2 weeks can detect additional fractures and can provide fracture dating information. The type and extent of additional imaging for pediatric patients being evaluated for suspected physical abuse depends on the age of the child, the presence of neurologic signs and symptoms, evidence of thoracic or abdominopelvic injuries, and social considerations. Unenhanced CT of the head is the initial study for suspected intracranial injury. Clinically occult abusive head trauma can occur, especially in young infants. Therefore, head CT should be performed in selected neurologically asymptomatic physical abuse patients. Contrast-enhanced CT of the abdomen/pelvis is utilized for suspected intra-abdominal or pelvic injury. Particular attention should be paid to discrepancies between the patterns of injury and the reported clinical history. Making the diagnosis of child abuse also requires differentiation from anatomical and developmental variants and possible underlying metabolic and genetic conditions. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
Workowski KA, Bachmann LH, Chan PA, Johnston CM, Muzny CA, Park I, Reno H, Zenilman JM, Bolan GA.. Sexually Transmitted Infections Treatment Guidelines, 2021.
Morbidity and Mortality Weekly Report. 2021; 70 (3).
The section on Sexual Assault and Abuse and STIs can be accessed directly at https://www.cdc.gov/std/treatment-guidelines/sexual-assault.htm.
These guidelines for the treatment of persons who have or are at risk for …
These guidelines for the treatment of persons who have or are at risk for sexually transmitted diseases (STDs) were updated by CDC after consultation with a group of professionals knowledgeable in the field of STDs who met in Atlanta on April 30-May 2, 2013. The information in this report updates the Sexually Transmitted Diseases Treatment Guidelines, 2010 (MMWR Recomm Rep 2010;59 [No. RR-12]). These updated guidelines discuss 1) alternative treatment regimens for Neisseria gonorrhoeae; 2) the use of nucleic acid amplification tests for the diagnosis of trichomoniasis; 3) alternative treatment options for genital warts; 4) the role of Mycoplasma genitalium in urethritis/cervicitis and treatment-related implications; 5) updated HPV vaccine recommendations and counseling messages; 6) the management of persons who are transgender; 7) annual testing for hepatitis C in persons with HIV infection; 8) updated recommendations for diagnostic evaluation of urethritis; and 9) retesting to detect repeat infection. Physicians and other health-care providers can use these guidelines to assist in the prevention and treatment of STDs.
Yeung F, Smith J, Mendoza-Londono R, O'Connor C, Howard A, Sorbara J, Schwartz S. Fracture prevalence in children diagnosed with Ehlers-Danlos Syndrome and Generalized Joint Hypermobility. Child Abuse & Neglect. 2024; 153 : 106828.
Keywords: Humans, *Ehlers-Danlos Syndrome/epidemiology/complications, *Joint Instability/epidemiology, Male, Female, Prevalence, Retrospective Studies, Child, Preschool, Child, Infant, *Fractures, Bone/epidemiology/etiology, Adolescent
BACKGROUND: There is limited understanding of the hypothesized association …
BACKGROUND: There is limited understanding of the hypothesized association between the Ehlers-Danlos Syndromes (EDS), hypermobility and fractures in children. Despite this, EDS and hypermobility continue to be raised in the legal setting as possible causes of unexplained fractures in infants where there is a concern for physical abuse. Further understanding is needed regarding fractures in children with EDS and hypermobility. OBJECTIVE: This study assessed fracture prevalence and characteristics in children diagnosed with EDS and Generalized Joint Hypermobility (GJH). The secondary outcome was fracture prevalence in infants <1 year of age. PARTICIPANTS AND SETTING: Children aged <18 years with EDS or GJH seen in a single-center EDS clinic from April 2017 to December 2021 were included. Diagnoses were based on the 2017 international classification. Exclusion criteria were concurrent medical conditions associated with bone fragility. METHODS: This retrospective descriptive study examined variables including fracture history, fracture location, fracture type, age of sustaining fracture, and injury mechanism. Descriptive statistics were used for analysis. RESULTS: Fracture prevalence was 34.6 % (9/26, 95 % CI [16.3, 52.9]) in the EDS population and 25.4 % (15/59, 95 % CI [14.3, 36.5]) in the GJH population. No fractures occurred in infancy. Most fractures occurred in the limbs. There were no rib or skull fractures. Most fractures were the result of an identifiable injury event. CONCLUSION: In a cohort of children with formally diagnosed EDS or GJH, fractures occurred commonly in ambulatory children and generally in the limbs from identifiable events. This study does not support EDS or GJH as a cause of fractures in infancy.
Zablotsky B, Ng AE, Black LI, Blumberg SJ. Diagnosed Developmental Disabilities in Children Aged 3-17 Years: United States, 2019-2021. Nchs Data Brief. 2023; (473) : 1-8.
Keywords: Child, Humans, *Autism Spectrum Disorder/diagnosis/epidemiology, Developmental Disabilities/epidemiology, *Intellectual Disability/diagnosis/epidemiology, Prevalence, United States/epidemiology, Child, Preschool, Adolescent
Developmental disabilities are common in children in the United States, and the …
Developmental disabilities are common in children in the United States, and the prevalence has increased in recent years (1). Timely estimates are necessary to assess the adequacy of services and interventions that children with developmental disabilities typically need (2). This report provides updated prevalence estimates for diagnosed autism spectrum disorder, intellectual disability, and other developmental delay among children aged 3-17 years from the 2019-2021 National Health Interview Survey (NHIS), with differences in prevalence examined between years and by sex, age group, and race and Hispanic origin. Estimates are also presented for any developmental disability, defined as having had one or more of these three diagnoses.
Zamalin D, Hamlin I, Shults J, Katherine Henry M, Campbell KA, Anderst JD, Bachim AN, Berger RP, Frasier LD, Harper NS, Letson MM, Melville JD, Lindberg DM, Wood JN. Predictors of Making a Referral to Child Protective Services Prior to Expert Consultation. Academic Pediatrics. 2024; 24 (1) : 78-86.
Keywords: Child, Humans, *Child Protective Services, *Child Abuse/diagnosis, Child Welfare, Pediatricians, Referral and Consultation
OBJECTIVE: Suspicion for child abuse is influenced by implicit biases. …
OBJECTIVE: Suspicion for child abuse is influenced by implicit biases. Evaluation by a Child Abuse Pediatrician (CAP) may reduce avoidable child protective services (CPS) referrals. Our objective was to investigate the association of patient demographic, social and clinical characteristics with CPS referral before consultation by a CAP (preconsultation referral). METHODS: Children<5years-old undergoing in-person CAP consultation for suspected physical abuse from February 2021 through April 2022 were identified in CAPNET, a multicenter child abuse research network. Marginal standardization implemented with logistic regression analysis examined hospital-level variation and identified demographic, social, and clinical factors associated with preconsultation referral adjusting for CAP's final assessment of abuse likelihood. RESULTS: Among the 61% (1005/1657) of cases with preconsultation referral, the CAP consultant had low concern for abuse in 38% (384/1005). Preconsultation referrals ranged from 25% to 78% of cases across 10 hospitals (P < .001). In multivariable analyses, preconsultation referral was associated with public insurance, caregiver history of CPS involvement, history of intimate partner violence, higher CAP level of concern for abuse, hospital transfer, and near-fatality (all P < .05). The difference in preconsultation referral prevalence for children with public versus private insurance was significant for children with low CAP concern for abuse (52% vs 38%) but not those with higher concern for abuse (73% vs 73%), (P = .023 for interaction of insurance and abuse likelihood category). There were no differences in preconsultation referral based on race or ethnicity. CONCLUSIONS: Biases based on socioeconomic status and social factors may impact decisions to refer to CPS before CAP consultation.
Zand DH, Pierce KJ, Nibras S, Maxim R. Parental risk for the maltreatment of developmentally delayed/disabled children. Clinical Pediatrics. 2015; 54 (3) : 290-2.
Keywords: Adult, Child Abuse/*statistics & numerical data, Child, Preschool, Children with Disabilities/*statistics & numerical data, Female, Humans, Infant, Male, *Parents, Risk, Young Adult
The US Department of Health and Human Services
(2012) has reported that 27.1% …
The US Department of Health and Human Services
(2012) has reported that 27.1% of children younger than 3 years comprise more than one quarter of all maltreatment cases.
' It has been widely reported that children
with developmental delays/disabilities are at higher risk for maltreatment than typically developing children.?' It has been documented that these children are at a 1.7 times greater risk than children without disabilities.' While the American Academy of Pediatrics has published multiple reports and guidelines on child maltreat-ment, little information is available on specific, modifiable areas of parental risk. Such information is critical when providing relevant anticipatory guidance to the parents of high-risk children. The present brief report begins to fill this gap by identifying parental risk areas for the maltreatment of their developmentally delayed/disabled child and making specific recommendations for pediatric anticipatory guidance to this unique group of parents.
Zeidan NA, Bukhamseen FM, Al-Qassab AT, Alsadah FZ, Menezes RG. Cutaneous mimickers of physical child abuse: A brief overview. The Medico-Legal Journal. 2023; 91 (1) : 26-29.
Keywords: Humans, Child, Female, Male, Diagnosis, Differential, *Child Abuse/diagnosis, Skin/injuries, *Burns/diagnosis, *Physicians
Child abuse is one of the medico-legal issues a physician may face during his/he …
Child abuse is one of the medico-legal issues a physician may face during his/her clinical practice. It has devastating effects on both the child and family, especially psychological. If falsely identified as a child abuse case, it could result in detrimental consequences. Therefore, physicians must recognise and be able to rule out child abuse mimickers, which are often conditions that are mistakenly confused with true physical child abuse. Injuries like bruises and burns are common presentations and therefore it is important to consider cutaneous abuse mimics to avoid incorrect diagnosis of child abuse. This review article sheds light on the most common cutaneous conditions that can mimic physical child abuse, where patients present with patterns of various skin lesions that raise a suspicion of child abuse.
