Christopher J. Hobbs

Abuse of children in foster and residential care

OBJECTIVE There have recently been many debates in the UK about how to provide good care for children placed away from home. Professionals have realized that the level of child abuse in foster care and childrens homes is high. This research examines the characteristics of physical and sexual abuse of children in foster and residential care in a city in England. The number of cases of abuse reported by pediatricians in this group was compared to the number reported by the same pediatricians for the population of Leeds as a whole. METHOD This is a retrospective study of 158 children, fostered or in residential care who were involved in 191 episodes of alleged physical and/or sexual abuse assessed and reported by pediatricians over a 6 year period from 1990 to 1995 in Leeds, England. Details of the child including the reason for placement in care, their physical and mental health, abuse characteristics, including perpetrator and case management were studied. RESULTS (see Table 1): 158 incidents of abuse in 133 children in foster/residential care are described. In foster care, 42 children were physically abused, 76 were sexually abused, and 15 experienced both forms of abuse. In residential care, 12 children were physically abused, 6 were sexually abused, and 6 experienced both forms of abuse. In foster care 60% of sexual abuse involved girls and 60% of physical abuse involved boys. In residential care almost twice as many boys as girls were reported to be abused. Foster carers perpetrated the abuse for 41%, natural parents on contact for 23%, and children 20% of incidents. A significant proportion of abuse was severe with 1 death, 8 children with burns, 18 with genital, and 34 with anal penetration. Long-standing emotional, behavioral and learning difficulties were common. Most children (80%) had been abused prior to entry into care. Foster children were 7-8 times and children in residential care 6 times more likely to be assessed by a pediatrician for abuse than a child in the general population. CONCLUSIONS Children in foster or residential care form an at risk group for maltreatment. Their special needs include additional measures to protect them from abuse.

Subdural haematoma and effusion in infancy: an epidemiological study

Aim: To determine incidence, aetiology, and clinical features of subdural haematoma and effusion (SDH/E) in infancy throughout the British Isles. Methods: Cases were notified to the British Paediatric Surveillance Unit over 12 months by paediatricians, neurosurgeons, and paediatric and forensic pathologists. Results: A total of 186 infants (121 boys, 65 girls) aged 0–2 years were identified. Annual incidence of SDH/E for the UK and Republic of Ireland is 12.54/100 000 aged 0–2 (95% CI 10.3 to 14.62) and 24.1/100 000 aged 0–1 (95% CI 20.89 to 28.18). A total of 106 infants suffered non-accidental head injury (NAHI), 7 accidental head injury, 26 a perinatal cause, 7 a non-traumatic medical condition, 23 meningitis, and in 17 the cause was undetermined; 35 infants died. Significant differences were found in injury pattern, body weight, and Townsend score between NAHI and SDH/E from other cause. There were fewer diagnostic investigations in non-NAHI cases. Delay in diagnosis of greater than a week occurred in 48/181. Conclusion: SDH/E is a significant cause of morbidity and mortality in infancy. NAHI is the predominant cause of SDH/E. SDH/E can present in a non-specific and varied way and must be considered in any infant who is unwell. Determining the cause of the SDH/E in some cases continues to present a diagnostic challenge.

Sexual abuse of English boys and girls: the importance of anal examination.

Child sexual abuse is attracting increasing attention in the United Kingdom. In Leeds this is reflected in the work of two pediatricians who receive multiagency, direct referrals for children of all ages. Over two years 1,368 referrals were received for all kinds of abuse and neglect, including 608 for suspected sexual abuse (Hobbs & Wynne, 1987a), of which 337 (243 girls, 94 boys) were confirmed or probable cases. The abuses included genital touching, masturbation, oral, vaginal and anal penetration. Of these abuses, 30% (which were frequently multiple) involved and penetration by finger or penis; and 42% of 337 children exhibited one or more anal findings, rising to 60% of 115 children in the 0-5 years of age group. The diagnosis of abuse was made from results of multidisciplinary assessment including medical examination. Genital findings were present in 3% of boys and 50% of girls. Anal findings included erythema; swelling (tyre); laxity; shortening or eversion; reflex anal dilatation (dilatation); fissures; venous congestion; reversible and permanent skin changes; twitching; funnelling; hematoma and bruising; as well as signs of infection. The pattern of anal signs varied with the age of the child and chronicity of abuse, as judged from the history. Healing and resolution of anal physical findings on follow-up were observed from days to months after initial examination. The general absence of these findings in the group of children judged not to have been sexually abused supports a cause and effect hypothesis, but further research is required. Medical examination of every child where symptoms, signs, or situation raise the possibility of abuse or neglect must include anal inspection, but instrumental or digital examination is not recommended.

Nonaccidental trauma: clinical aspects and epidemiology of child abuse

Radiologists play a key role in the recognition of child abuse. In the last century, radiologists pioneered the identification of nonaccidental injuries, including fractures and brain injury, and together with colleagues in paediatrics advocated the protection of children from abuse. Prevalence studies in many countries have revealed the widespread and hidden nature of child maltreatment. New and complex forms of abuse, e.g. fabricated or induced illness, have been recognized. Physical abuse affects 7–9% of children in the UK, although fewer suffer the severe or life-threatening injuries seen by radiologists. A high index of suspicion of nonaccidental trauma is required where known patterns of injury or inconsistencies of presentation and history are detected. In many cases the diagnosis is readily made, although some cases remain contentious or controversial and consume much clinical time and energy. Differences of view between doctors are tested in the courts. Adverse publicity has made this work unpopular in the UK. Knowledge of the differential diagnosis of unexplained or apparent injury is essential for accurate diagnosis, vital where errors in either direction can be disastrous. New UK radiological guidelines will assist radiologists in achieving best evidence-based practice.

ABC of child abuse. Fractures.

In one study of physically abused children more than half of the children (58%) were under 3 years old and they sustained most of the fractures (94%). In contrast, accidental fractures occur more commonly in children of school age. The proportion of children presenting to hospital with fractures resulting from physical abuse rises to a maximum during the first year of life, when it may be as high as a half. A great deal of suspicion is required at this age. Most accidental fractures in infants and toddlers result from falls, although fractures are uncommon in falls of under a metre. As early detection improves the proportion of children with fractures who are identified as having been physically abused falls from 50% to 10% or less. Most children with serious injury have suffered minor injury or shown other signs ofabuse that have not been recognised or acted on by professionals in contact with the child.

Genital injuries in boys and abuse

Aims: To describe a cohort of boys with genital injuries in whom child abuse was suspected. Methods: Boys with genital injury (penile and/or scrotal) and referred to paediatricians in Leeds, population 750 000, with concerns regarding possible abuse from 1983 to 2003 were identified from medical reports. Results: 86 boys (average age 62.7 months, median age 48 months) were referred between 1983 and 2003. The injury was judged inflicted in 63, unexplained, suspicious or inconsistent with the history given in 17 and accidental in six. The number of discrete injuries ranged from one in 57, two in 15, three in 12, to more than three in two cases. Genital injuries included burns in seven boys, bruises in 27, incised wounds, lacerations or scars in 39, and other traumatic lesions in 27. Non-genital findings included anal findings in 28, >10 bruises in 17, fractures in three, burns in 12, mouth injuries in four, brain and retinal haemorrhages in one, and poor nourishment or underweight in 14. The categories of abuse were physical (eight), sexual (19), both physical and sexual (eight), physical and neglect (four), and physical, sexual and neglect (one). The category of abuse was unspecified in 39 children. Conclusions: Genital injury in boys may be the result of abuse which may be physical or sexual in nature.

Cutaneous Manifestations of Child Abuse and Their Differential Diagnosis

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Abdominal injury due to child abuse.

Diagnosis of abuse in children with internal abdominal injury is difficult because of limited published work. We aimed to ascertain the incidence of abdominal injury due to abuse in children age 0â??14 years. 20 children (identified via the British Paediatric Surveillance Unit) had abdominal injuries due to abuse and 164 (identified via the Trauma Audit and Research Network) had injuries to the abdomen due to accident (112 by road-traffic accidents, 52 by falls). 16 abused children were younger than 5 years. Incidence of abdominal injury due to abuse was 2·33 cases per million children per year (95% CI 1·43â??3·78) in children younger than 5 years. Six abused children died. 11 abused children had an injury to the gut (ten small bowel) compared with five (all age >5 years) who were injured by a fall (relative risk 5·72 [95% CI 2·27â??14·4]; p=0·0002). We have shown that small-bowel injuries can arise accidentally as a result of falls and road-traffic accidents but they are significantly more common in abused children. Therefore, injuries to the small bowel in young children need special consideration, particularly if a minor fall is the explanation.

Blunt-Force Trauma: Bruises

In humans, the skin is the most visible organ, and it is also the most frequently damaged organ when children sustain injuries. The injuries most commonly seen are bruises and abrasions. These injuries are usually the result of everyday activities at home, including play, sports, or during participating in traffic. In most cases, a skin injury is the only abnormality. However, sometimes an external injury is an indication for more serious internal damage (the “tip of the iceberg” phenomenon).

Blunt-Force Trauma: Other Cutaneous Manifestations

The most common traumatic skin lesions in accident-related blunt-force trauma and child abuse are bruises. In child abuse, blunt-force trauma may also lead to injuries such as erythema, abrasions, and lacerations, but these are less common than bruises.