John M. Leventhal

Interventions to prevent child maltreatment and associated impairment

Although a broad range of programmes for prevention of child maltreatment exist, the effectiveness of most of the programmes is unknown. Two specific home-visiting programmes-the Nurse-Family Partnership (best evidence) and Early Start-have been shown to prevent child maltreatment and associated outcomes such as injuries. One population-level parenting programme has shown benefits, but requires further assessment and replication. Additional in-hospital and clinic strategies show promise in preventing physical abuse and neglect. However, whether school-based educational programmes prevent child sexual abuse is unknown, and there are currently no known approaches to prevent emotional abuse or exposure to intimate-partner violence. A specific parent-training programme has shown benefits in preventing recurrence of physical abuse; no intervention has yet been shown to be effective in preventing recurrence of neglect. A few interventions for neglected children and mother-child therapy for families with intimate-partner violence show promise in improving behavioural outcomes. Cognitive-behavioural therapy for sexually abused children with symptoms of post-traumatic stress shows the best evidence for reduction in mental-health conditions. For maltreated children, foster care placement can lead to benefits compared with young people who remain at home or those who reunify from foster care; enhanced foster care shows benefits for children. Future research should ensure that interventions are assessed in controlled trials, using actual outcomes of maltreatment and associated health measures.

Intergenerational continuity of child physical abuse: how good is the evidence?

BACKGROUND There is widespread belief that individuals who were physically abused during childhood are more likely to abuse their own children than those who were not abused, but the empirical studies examining this belief have not been systematically reviewed. The aim of this study was to evaluate systematically, based on eight methodological standards derived from a hypothetical randomised controlled trial, the design of studies investigating the intergenerational transmission of child physical abuse. METHODS We reviewed studies published between 1965 and 2000 in English that provided information about physical maltreatment in two generations and included a comparison group. Two investigators independently assessed whether each study met the methodological standards. FINDINGS In the ten studies identified (four cohort, one cross-sectional, and five case-control), the relative risks of maltreatment in the children of parents who were abused during childhood were significantly increased in four studies (relative risks 4.75-37.8), but in three other studies the relative risks were less than 2. Most study reports provided a clear description of abuse of parents during childhood and abuse of their children. Five studies failed to avoid recall and detection bias; five did not ensure that controls were not themselves maltreated; eight did not provide adequate follow-up; and in six the report did not state whether the enrolled parent was responsible for the maltreatment. Most studies did not control for intervening factors, such as sociodemographic characteristics during the time of abuse of the parent generation and at the time their children were abused. Only one study met all eight criteria (relative risk of abuse transmission 12.6 [95% CI 1.82-87.2]) and one met six (1.05 [0.53-2.06]). INTERPRETATION The one study that met all eight methodological standards provided evidence for the intergenerational continuity of child physical abuse, but that which met six standards did not support the hypothesis. Use of our model and methodological standards should improve the scientific quality of studies examining the effects of risk factors for adverse outcomes that may continue across generations.

The Prevalence of Confirmed Maltreatment Among US Children, 2004 to 2011

IMPORTANCE Child maltreatment is a risk factor for poor health throughout the life course. Existing estimates of the proportion of the US population maltreated during childhood are based on retrospective self-reports. Records of officially confirmed maltreatment have been used to produce annual rather than cumulative counts of maltreated individuals. OBJECTIVE To estimate the proportion of US children with a report of maltreatment (abuse or neglect) that was indicated or substantiated by Child Protective Services (referred to as confirmed maltreatment) by 18 years of age. DESIGN, SETTING, AND PARTICIPANTS The National Child Abuse and Neglect Data System (NCANDS) Child File includes information on all US children with a confirmed report of maltreatment, totaling 5,689,900 children (2004-2011). We developed synthetic cohort life tables to estimate the cumulative prevalence of confirmed childhood maltreatment by 18 years of age. MAIN OUTCOMES AND MEASURES The cumulative prevalence of confirmed child maltreatment by race/ethnicity, sex, and year. RESULTS At 2011 rates, 12.5% (95% CI, 12.5%-12.6%) of US children will experience a confirmed case of maltreatment by 18 years of age. Girls have a higher cumulative prevalence (13.0% [95% CI, 12.9%-13.0%]) than boys (12.0% [12.0%-12.1%]). Black (20.9% [95% CI, 20.8%-21.1%]), Native American (14.5% [14.2%-14.9%]), and Hispanic (13.0% [12.9%-13.1%]) children have higher prevalences than white (10.7% [10.6%-10.8%]) or Asian/Pacific Islander (3.8% [3.7%-3.8%]) children. The risk for maltreatment is highest in the first few years of life; 2.1% (95% CI, 2.1%-2.1%) of children have confirmed maltreatment by 1 year of age, and 5.8% (5.8%-5.9%), by 5 years of age. Estimates from 2011 were consistent with those from 2004 through 2010. CONCLUSIONS AND RELEVANCE Annual rates of confirmed child maltreatment dramatically understate the cumulative number of children confirmed to be maltreated during childhood. Our findings indicate that maltreatment will be confirmed for 1 in 8 US children by 18 years of age, far greater than the 1 in 100 children whose maltreatment is confirmed annually. For black children, the cumulative prevalence is 1 in 5; for Native American children, 1 in 7.

Clinical Predictors of Pneumonia As a Guide to Ordering Chest Roentgenograms

To develop criteria for a more efficient approach to the ordering of chest roentgenograms, patients with fever or respiratory symptoms who were being evaluated with this diagnostic test were prospectively monitored. During a six-month period, residents working in a pediatric emergency room collected data on 136 children, 3 months to 15 years of age. Pneumonia, defined by appropriate abnormal chest roentgenographic findings, occurred in 19 per cent. Of the 29 single symptoms or signs examined, the variable which was the best predictor of pneu monia was tachypnea. In addition, a cluster of pulmonary findings was also a good index for pneumonia. If these clinical criteria had been applied to the patients under investigation, the number of chest roentgenograms obtained would have been reduced by 30 per cent.

Predictors of recurrent febrile seizures: a metaanalytic review.

The 1980 National Institutes of Health Consensus Development Conference on Febrile Seizures identified five circumstances in which it might be appropriate to consider anticonvulsant prophylaxis after a first febrile seizure: (1) a focal or prolonged seizure, (2) neurologic abnormalities, (3) afebrile seizures in a first-degree relative, (4) age less than 1 year, and (5) multiple seizures occurring within 24 hours. We performed a metaanalysis of 14 published reports to evaluate the strength of association between each of these indications and recurrent febrile seizures. Young age at onset (less than or equal to 1 year) and a family history of febrile seizures (not listed in the recommendations) each distinguished between groups with approximately a 30% versus a 50% risk of recurrence. Family history of afebrile seizures was not consistently associated with an increased risk. Focal, prolonged, and multiple seizures were associated with only a small increment in risk of recurrence. The data were not adequate to assess the risk associated with neurologic abnormalities. By considering children with combinations of risk factors, some studies were able to distinguish between groups with very low and very high recurrence risks. Only age at onset was consistently predictive of having more than one recurrence. These results suggest that the great majority of children who have a febrile seizure do not need anticonvulsant treatment even if one of the factors listed in the Consensus Statement is present, and that the rationale and indications for treating febrile seizures need to be reconsidered.

Identification of inflicted traumatic brain injury in well-appearing infants using serum and cerebrospinal markers: a possible screening tool

OBJECTIVE. Inflicted traumatic brain injury (iTBI) is the leading cause of death from TBI in infants. Misdiagnosis of iTBI is common and results in increased morbidity and mortality. Biomarkers may be able to assist in screening infants who are at high risk for iTBI and whose injury might otherwise be missed. We investigated whether serum and/or cerebrospinal fluid (CSF) concentrations of neuron-specific enolase (NSE), S100B, and myelin-basic protein (MBP) are sensitive and specific for iTBI in high-risk infants. METHODS. A prospective case-control study was conducted of 98 well-appearing infants who presented with nonspecific symptoms and no history of trauma. Serum or CSF was collected. NSE, S100B, and MBP concentrations were measured by enzyme-linked immunosorbent assay. Abnormal marker concentrations were defined a priori. Patients were followed for 12 months to assess for subsequent abuse. RESULTS. Fourteen patients received a clinical diagnosis of iTBI. Using preestablished cutoffs, NSE was 77% sensitive and 66% specific and MBP was 36% sensitive and 100% specific for iTBI. S100B was neither sensitive nor specific for iTBI. Five patients who were not identified with iTBI at enrollment were identified at follow-up as being possible victims of abuse; 4 had an increased NSE concentration at enrollment. CONCLUSIONS. Serum and/or CSF concentrations of NSE and MBP may be useful as a screening test to identify infants who are at increased risk for iTBI and may benefit from additional evaluation with a head computed tomography scan. S100B is neither sensitive nor specific for iTBI in this study population. The ability to identify iTBI that might otherwise be missed has important implications for decreasing the morbidity and the mortality from iTBI.

EPIDEMIOLOGY OF SEXUAL ABUSE OF CHILDREN : OLD PROBLEMS, NEW DIRECTIONS

Over the last 2 decades, the science of epidemiology has made important contributions to the understanding of sexual abuse of children. Well-designed epidemiological studies conducted during the next two decades should help refine our knowledge of the frequency of the problem, as well as further our understanding of risk factors and consequences.

Evaluating children with fractures for child physical abuse

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.

Research strategies and methodologic standards in studies of risk factors for child abuse

A major focus of studies of child abuse has been the identification of children who are at high risk for abuse. Despite this emphasis, little has been written about the research methodology in such studies. This paper reviews the three major research strategies to investigate risk factors: (1) randomized controlled trials, (2) prospective or observational cohort studies, and (3) retrospective or case-control studies. In addition, eight methodological standards are presented that should help to minimize bias in studies of risk factors for child abuse. These standards are: (1) clear description of abuse, (2) choice of a specific control group, (3) equal demographic and clinical susceptibility, (4) clear definition of the risk factor or protective factor, (5) unbiased ascertainment of the risk factor, (6) clear temporal sequence between risk factor and abuser, (7) equal detection of child abuse, and (8) unequal review of abused and nonabused subjects. Most studies of risk factors for child abuse have used either a case-control or, less frequently, an observational cohort design, both of which are nonexperimental research strategies. In such studies, the use of comparable control groups (standards 2 and 3) and equal detection of abuse in exposed and nonexposed children (standard 7) are of major importance in minimizing bias.

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.