Andrea G. Asnes

Children's disclosures of sexual abuse: Learning from direct inquiry

OBJECTIVES Published protocols for forensic interviewing for child sexual abuse do not include specific questions about what prompted children to tell about sexual abuse or what made them wait to tell. We, therefore, aimed to: (1) add direct inquiry about the process of a childs disclosure to a forensic interview protocol; (2) determine if children will, in fact, discuss the process that led them to tell about sexual abuse; and (3) describe the factors that children identify as either having led them to tell about sexual abuse or caused them to delay a disclosure. METHODS Forensic interviewers were asked to incorporate questions about telling into an existing forensic interview protocol. Over a 1-year period, 191 consecutive forensic interviews of child sexual abuse victims aged 3-18 years old in which children spoke about the reasons they told about abuse or waited to tell about abuse were reviewed. Interview content related to the childrens reasons for telling or for waiting to tell about abuse was extracted and analyzed using a qualitative methodology in order to capture themes directly from the childrens words. RESULTS Forensic interviewers asked children about how they came to tell about sexual abuse and if children waited to tell about abuse, and the children gave specific answers to these questions. The reasons children identified for why they chose to tell were classified into three domains: (1) disclosure as a result of internal stimuli (e.g., the child had nightmares), (2) disclosure facilitated by outside influences (e.g., the child was questioned), and (3) disclosure due to direct evidence of abuse (e.g., the childs abuse was witnessed). The barriers to disclosure identified by the children were categorized into five groups: (1) threats made by the perpetrator (e.g., the child was told (s)he would get in trouble if (s)he told), (2) fears (e.g., the child was afraid something bad would happen if (s)he told), (3) lack of opportunity (e.g., the child felt the opportunity to disclose never presented), (4) lack of understanding (e.g., the child failed to recognize abusive behavior as unacceptable), and (5) relationship with the perpetrator (e.g., the child thought the perpetrator was a friend). CONCLUSIONS Specific reasons that individual children identify for why they told and why they waited to tell about sexual abuse can be obtained by direct inquiry during forensic interviews for suspected child sexual abuse. PRACTICE IMPLICATIONS When asked, children identified the first person they told and offered varied and specific reasons for why they told and why they waited to tell about sexual abuse. Understanding why children disclose their abuse and why they wait to disclose will assist both professionals and families. Investigators and those who care for sexually abused children will gain insight into the specific barrier that the sexually abused child overcame to disclose. Prosecutors will be able to use this information to explain to juries why the child may have delayed his or her disclosure. Parents who struggle to understand why their child disclosed to someone else or waited to disclose will have a better understanding of their childs decisions.

Managing child abuse: general principles

1. Andrea G. Asnes, MD, MSW* 2. John M. Leventhal, MD† 1. *Associate Medical Director. 2. †Medical Director, Child Abuse Programs, Department of Pediatrics, Yale University School of Medicine, New Haven, Conn. After completing this article, readers should be able to: 1. Identify their roles as mandated reporters of child abuse. 2. Discuss the approach to evaluating cases of suspected child maltreatment. 3. Know when to become concerned about possible child maltreatment and when and how to seek help in evaluating cases. 4. Recognize the role of the pediatric practitioner in ongoing care of and advocacy on the behalf of maltreated children. Child abuse is common. In 2007, the year for which the most recent child protective services (CPS) data are available, 3.2 million reports were filed concerning approximately 5.8 million children younger than 18 years of age who were suspected victims of abuse, neglect, or sexual abuse. Also in 2007, 1,760 child deaths were attributed to abuse or neglect. Neglect constituted 59% of all cases of child maltreatment, more than all other forms of substantiated child maltreatment combined. Most maltreatment occurs in childrens homes. In 2007, nearly 80% of the perpetrators of child maltreatment were parents. State laws mandate that pediatric practitioners report suspected cases of child abuse or neglect to local CPS. The process that begins when the clinician first feels concern about a childs welfare and ends when he or she makes a report to CPS is one of the most challenging and disturbing that practitioners must undertake. Because child maltreatment is common, it is likely that all pediatric clinicians will care for abused or neglected children and, therefore, will be obliged to report such children to CPS. For this reason, pediatric practitioners should know and employ a careful, systematic, and thoughtful approach to evaluating all suspected cases of child maltreatment to …

Implementation of newly adopted technology in acute care settings: a qualitative analysis of clinical staff

Abstract Technologies are not always successfully implemented into practice. This study elicited experiences of acute care providers with the introduction of technology and identified barriers and facilitators in the implementation process. A qualitative study using one-on-one interviews among a purposeful sample of 19 physicians and nurses within 10 emergency departments and intensive care units was performed. Grounded theory, iterative data analysis and the constant comparative method were used to inductively generate ideas and build theories. Five major categories emerged: decision-making factors, the impact on practice, technology’s perceived value, facilitators and barriers to implementation. Barriers included negative experiences, age, infrequent use and access difficulties. A positive outlook, sufficient training, support staff and user friendliness were facilitators. This study describes strategies implicated in the successful implementation of newly adopted technology in acute care settings. Improved implementation methods and evaluation of implementation processes are necessary for successful adoption of new technology.

Experiences with capnography in acute care settings: A mixed-methods analysis of clinical staff

PURPOSE Although capnography is being incorporated into clinical guidelines, it is not used to its full potential. We investigated reasons for limited implementation of capnography in acute care areas and explored facilitators and barriers to its implementation. METHODS A purposeful sample of physicians and nurses in emergency departments and intensive care units participated in semistructured interviews. Grounded theory, iterative data analysis, and the constant comparative method were used to analyze the data to inductively generate ideas and build theories. RESULTS Nineteen providers were interviewed from 5 hospitals. Six themes were identified: variability in use of capnography among acute care units, availability and accessibility of capnography equipment, the evidence behind capnography use, the impact of capnography on patient care, personal experiences impacting use of capnography, and variable knowledge about capnography. Barriers and facilitators to use were found within each theme. CONCLUSIONS We observed varied responsiveness to capnography and identified factors that work to foster or discourage its use. These data can guide future implementation strategies. A deliberate strategy to foster utilization, mitigate barriers, and broadly accelerate implementation has the potential to profoundly impact use of capnography in acute care areas with the goal of improving patient care.

Child maltreatment and risk patterns among participants in a child abuse prevention program

The relationship between risk factors and Child Protective Services (CPS) outcomes in families who participate in home visiting programs to prevent abuse and neglect and who are reported to CPS is largely unknown. We examined the relationship between parental risk factors and the substantiation status and number of CPS reports in families in a statewide prevention program. We reviewed CPS reports from 2006 to 2008 for families in Connecticuts child abuse prevention program. Six risk factors (histories of CPS, domestic violence [DV], mental health, sexual abuse, substance abuse, and criminal involvement) and the number of caregivers were abstracted to create risk scores for each family member. Maltreatment type, substantiation, and number of reports were recorded. Odds ratios were calculated. Of 1,125 families, 171 (15.6%) had at least one CPS report, and reports of 131 families were available for review. Families with a substantiated (25.2%) versus unsubstantiated (74.8%) first report had a high number of paternal risk factors (OR=6.13, 95% CI [1.89, 20.00]) and were more likely to have a history of maternal DV (OR=8.47, 95% CI [2.96, 24.39]), paternal DV (OR=11.23, 95% CI [3.33, 38.46]), and maternal criminal history (OR=4.55; 95% CI [1.32, 15.60]). Families with >1 report (34.4%) versus 1 report (65.6%) were more likely to have >3 caregivers, but this was not statistically significant (OR=2.53, 95% CI [0.98, 6.54]). In a prevention program for first-time families, DV, paternal risk, maternal criminal history, and an increased number of caregivers were associated with maltreatment outcomes. Targeting parental violence may impact child abuse prevention.

Has This Child Been Abused?: Exploring Uncertainty in the Diagnosis of Maltreatment

Uncertainty in the diagnosis of abuse can have profound implications for the health and safety of the child, the emotional burden of a family, and investigative and criminal proceedings. A logical algorithm for addressing physical and sexual abuse cases that details aspects contributing to the uncertainty may aid the clinician in making a diagnosis and in communicating the crucial details to the relevant investigative agencies. This article defines and discusses uncertainty in the realms of physical and sexual abuse, and suggests an approach to managing uncertainty while still providing valuable information for the medical and child protective service systems.

Diagnosing abusive head trauma: the challenges faced by clinicians

This article highlights five important aspects of the clinical problem of evaluating young children who are suspected of having abusive head trauma: 1) the clinical questions to be addressed, 2) challenges when evaluating young children with suspected abuse, 3) key aspects of clinical practice and data collection, 4) a framework for decision-making and 5) key articles in the literature that can help inform a sound clinical decision about the likelihood of abuse.

What Do Pediatricians Tell Parents About Bed-Sharing?

Background and objectives Despite the risks of bed-sharing, little is known about what pediatricians tell parents about bed-sharing with infants and whether pediatricians provide specific recommendations outlined by the American Academy of Pediatrics (AAP). This study aimed to understand pediatricians’ opinions about bed-sharing and the advice pediatricians provide to parents about bed sharing. Methods The study employed a qualitative study design and the conceptual framework of the Theory of Planned Behavior. 24 primary care pediatricians from a variety of practice settings were interviewed about the anticipatory guidance they provide to families whose infants are in the at-risk age group for SIDS. Results Pediatricians’ opinions about bed-sharing differed widely both with respect to identifying bed-sharing as a topic they routinely address in anticipatory guidance as well as in what they tell parents about bed sharing. Some strongly and routinely advise against bed-sharing and identify bed-sharing as a clear risk to infants. Others believe bed-sharing to be both safe and useful. A third group allow the content of anticipatory guidance to be driven by parental concerns. Most pediatricians are clearer in their recommendation to place infants supine to sleep than in their recommendation to avoid bed-sharing. Conclusions Overall, there is considerable variation among pediatricians in the advice they provide about bed-sharing, and most advice is not congruent with the AAP recommendations. Additional efforts to educate pediatricians may be necessary to change attitudes and behaviors with respect to anticipatory guidance about safe sleep.

Prevention of Pediatric Abusive Head Trauma: Time to Rethink Interventions and Reframe Messages

approved the voluntary fortification of corn masa flour in an effort to increase folic acid intake,13 particularly among Hispanic women,furthereffortstoaddressdisparitiesintheuseoffolicacid supplementsarewarranted.However,evenwithinthesubgroups of women who have the highest rates of supplementation, the proportion of women who follow the recommendation is relatively low. For example, among women with intended pregnancies, less than half took a daily folic acid supplement in the month prior to pregnancy.12 Hence, there is considerable room for improvement in the use of folic acid supplements across the population of reproductive-age women. The major challenges to increasing the proportion of women who take a daily folic acid supplement are not new: behavioral change is hard; the reproductive period is long; and messages about the health of hypothetical future child often do not resonate with the target audience. However, there have been changes since the initial folic acid awareness campaigns of the 1990s that provide new opportunities to address these challenges. For example,wearabledevicesandsmartphone-basedself-trackersprovide new approaches for disseminating information on folic acid supplementation (eg, as a component of menstruation and ovulation trackers) as well as for self-monitoring of supplement use (eg, using pill reminders and medication trackers) and are well suited to the development of messages and approaches that are targeted to specific subgroups of women. In addition, a national effort to promote preconception health, the National Preconception Health and Healthcare Initiative,14 has the potential to drive broad system changes that will increase women’s awareness of and receptiveness to health-related information, including the USPSTF recommendation on folic acid supplements. While identification of the causal link between folic acid and neural tube defects and the subsequent reduction in the prevalence of these conditions via folic acid fortification are remarkable public health successes, the current USPSTF recommendation provides an important reminder that we have yet to achieve the full benefit of these successes. Consequently, the current recommendation statement should serve as a catalyst for renewed efforts to develop and deliver folic acid messages that will translate into further reductions in the population prevalence of neural tube defects.

The Difficult Pediatric Encounter: Insights and Strategies for the Pediatric Practitioner

1. Andrea Gottsegen Asnes, MD, MSW* 2. Ambika Shenoy, MD* 1. *The Department of Pediatrics, Yale University School of Medicine, New Haven, Conn All pediatric practitioners are familiar with the concept of the “difficult” encounter with a family. Such encounters can range from those that leave clinicians with a slightly uneasy feeling once the family has left the office to those in which actual disputes occur. Barbara Korsch, MD, wrote, “There are certain names on the days schedule that make the practitioners heart sink and feel fatigued in advance.” (1) Although the responsibility of an effective partnership between pediatric practitioner and parent is shared, the larger part of the task falls to the clinician. A recent policy statement published by the American Academy of Pediatrics (AAP) refers to pediatric clinicians as “privileged and trusted advocates for the well-being of children.” (2) With privilege and trust comes the responsibility to foster relationships with families and to fortify such relationships when they are threatened. The AAP states that “communication and collaboration” are principles of professionalism in pediatric practice to be upheld. In addition, the statement says that pediatric practitioners must recognize that “patients’ families and the health care team must work cooperatively with each other and communicate effectively to provide the best patient care.” (2) Our own experience leads us to believe that although not all difficult encounters with families can be overcome or smoothed over, many can. Recognizing patterns of interaction that can lead to conflict with parents and addressing them early can be highly effective in preventing escalation. Many conflicts, once understood, even can lead to an enhancement of the partnership between clinician and family. The following case vignettes illustrate several types of difficult interactions with families that we have had in our pediatric practices. Each is followed by suggestions that the pediatric practitioner may find useful. Although it can feel awkward, even false, to try these responses when faced with …