Lori D. Frasier

Updated guidelines for the medical assessment and care of children who may have been sexually abused

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.

Neuroimaging of abusive head trauma

The diagnostic process for evaluating suspected abusive head trauma in infants and children has evolved with technological advances in neuroimaging. Since Caffey first described a series of children with chronic subdural hematomas and multiple long bone fractures, radiologists have played an important role, along with pediatricians and pathologists, in evaluating abused children. Neuroimaging modalities include ultrasound, CT scans, and MRI technology. Each has distinct clinical applications, as well as practical uses in the clinical diagnostic process of AHT. Importantly, neuroimaging assists in the process of differential diagnosis of other conditions which may mimic AHT. Collaboration between neuroradiologists, clinicians, and pathologists remains critical to making the appropriate diagnosis. Careful history, physical examination, and investigation by legal authorities form the components that result in accurate assessment of any case. This paper reviews pertinent neuroimaging modalities currently utilized in the diagnosis of AHT, describing clinical indications and a collaborative approach to this process.

Diagnostic accuracy in child sexual abuse medical evaluation: Role of experience, training, and expert case review

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.

Abusive head trauma in infants and young children: a unique contributor to developmental disabilities.

Abusive head trauma in infants and young children is the leading cause of death and disability from child abuse. This article discusses the history, epidemiology, clinical aspects, developmental outcomes, and associated injuries of this unique contributor to developmental disabilities. Prevention of abusive injuries and prevention of child abuse and neglect are also discussed.

The use of TeleCAM as a remote Web-based application for child maltreatment assessment, peer review, and case documentation.

Approximately 1 million children are physically or sexually abused each year in the United States. Accurate diagnosis of these children and subsequent extensive legal intervention requires a thorough clinical assessment as well as legal documentation. A Web-based application developed for the remote sharing of child maltreatment assessment among multiple child protection providers is presented. Usability data was collected from medical personnel at three remote Utah Childrens Advocacy Centers (CACs) and one urban tertiary childrens hospital. Qualitative findings are summarized and satisfaction differences are reported between remote sites and their referral tertiary center.

Inter-rater reliability in child sexual abuse diagnosis among expert reviewers

OBJECTIVES To determine how well experts agree when assessing child sexual abuse cases. METHODS A total of twelve physician subjects were recruited and voluntarily enrolled from an existing peer review network. Experts from the network had been chosen for their experience in the field and their affiliation with childrens advocacy centers. Each expert submitted three cases of prepubertal female genital examinations clearly demonstrable of the case findings. Submitted cases included demographics, history, physical and genital exam findings, photodocumentation, and diagnosis. Experts reviewed each submitted case and labeled the case negative for physical finding(s), positive for physical finding(s), or indeterminate. Cases were analyzed to determine the level of agreement. RESULTS Thirty-six cases were submitted for use in this study; one case was excluded prior to starting the review process. After all experts completed their reviews the authors reviewed the cases and results. Two additional cases were excluded, one due to poor quality photodocumentation and one for not meeting the study criteria. Thirty-three cases were used for data analysis. All 12 expert reviewers agreed in 15 of the cases. Overall, in 22 of 33 (67%) cases at least 11 of the 12 reviewers agreed with the original diagnosis. Six of 33 (18%) cases had variable agreement (8-10 reviewers agreed with original diagnosis) among reviewers; 5 of 33 (15%) cases had poor or mixed agreement (7 or less reviewers agreed with original diagnosis). CONCLUSIONS Experts exhibit consensus in cases where the findings clearly are normal and abnormal, but demonstrate much more variability in cases where the diagnostic decisions are less obvious. Most of the diagnostic variability is due to interpretation of the findings as normal, abnormal or indeterminate, not on the perception of the examination findings themselves. More research should be done to develop a national consensus on the accurate interpretation of anogenital examination findings. Photographic image quality plays an important role in this quality review process and universally needs to be improved.

Development of Standardized Clinical Training Cases for Diagnosis of Sexual Abuse using a Secure Telehealth Application.

OBJECTIVES The training of physicians, nurse examiners, social workers and other health professional on the evidentiary findings of sexual abuse in children is challenging. Our objective was to develop peer reviewed training cases for medical examiners of child sexual abuse, using a secure web based telehealth application (TeleCAM). METHODS Sixty de-identified cases developed by 2 child abuse pediatricians, were stratified by availability of information (minimal, moderate, comprehensive) for both positive and negative child sexual abuse findings. These cases were narrowed to a set of 30 cases through an expert peer review process using pediatricians with extensive expertise in the evaluation of child sexual abuse. A previously studied secure web-based telehealth application TeleCAM which contains a child abuse workflow, was used to develop, disseminate and review cases. A series of Free Margin agreement statistics are used to select those cases with the highest rates of agreement. A final set of 30 cases are stratified equally by availability of information and for both positive and negative findings. Mantel Haenszel Chi-square was used for trend analysis of the ordered categorical variables. RESULTS The highest degrees of inter-rater reliability was found in cases with moderate to comprehensive information. Cases with minimal data had poor kappa agreement indicating that availability of differing levels and types of information contribute to variability in diagnostic findings. CONCLUSION These final cases will be further studied with medical examiners in various settings utilizing TeleCAM as the application for dissemination.

An Image-Centric, Web-Based, Telehealth Information System for Multidisciplinary Clinical Collaboration

Web-based technologies are changing the face of traditional telehealth applications by providing cost-effective clinical data capture and sharing solutions. Access to medical images in coordination with clinical workflow and face-to-face technologies can integrate clinical service delivery, diagnosis, and treatment across geographic, disciplinary, and organizational boundaries. For example, medical images are used for a variety of purposes and range in their complexity from a simple digital photograph of a physical mass taken by a primary care provider to a magnetic resonance image (MRI) reviewed by a radiologist that might describe the details of the mass; to a histopathology slide that a pathologist might use to diagnose the malignancy of the mass. Each of these images is managed by separate domain-specific information systems which are often located in technology silos and are constrained by disciplinary, organizational, and geographic barriers.

Abusive head trauma: Clinical, biomechanical, and imaging considerations

Introduction Abusive head trauma (AHT) is a medical diagnosis that encompasses data from clinical and experimental studies. The neuroimaging evaluation is a critical piece of the diagnosis, but should not be considered separate from the biomechanical research, clinical history, laboratory testing, and any other investigative information that is felt to be clinically warranted. Furthermore, many clinical subspecialties in addition to pediatrics and medical imaging offer supportive diagnostic information that must be incorporated in the overall analysis of a case. The ophthalmologist, critical care specialist, emergency medicine physician, trauma surgeon, and neurosurgeon play vital roles in the clinical assessment. Investigative collaboration requires a close relationship with biomechanical engineering, law enforcement, Child Protective Services (CPS), and forensic pathology. Child abuse is unique compared with other diagnostic processes because there is no single or combined set of clinical indicators that proves a child has been abused. In fact, there are many medical conditions that can mimic some or all of the indicators seen in child abuse. Laboratory testing and clinical evaluation is essential in the identification of confounding medical conditions. However, in the context of a traumatic brain injury (TBI) in an infant or young child who, in the absence of other medical factors, does not have a sufficient history of trauma to account for the injuries, AHT leads the differential diagnosis.