Resmiye Oral

Fractures in young children: Are physicians in the emergency department and orthopedic clinics adequately screening for possible abuse?

Objectives: 1) To determine whether physicians are sufficiently investigating the cause of fractures in children younger than 3 years and 2) to find out what influences physicians quality of history taking and documentation necessary to rule out inflicted trauma. Design: Descriptive, retrospective chart review. Setting: Pediatric emergency department and orthopedic clinic of an urban teaching hospital. Subjects: Children younger than 3 years treated between January 1, 1995, and December 31, 1998, presenting with a fracture. Results: A total of 653 charts met entry criteria. Information that was significantly lacking in the recorded history included witness presence, history of previous injury, review of past medical record, other injury description, and whether the injury was consistent with the development of the child. It was not possible to rule out inflicted injury in 42% of the patients. Four groups emerged from the entire cohort: group 1, accidental trauma, which made up 63% of the entire group (n = 413); group 2, inflicted trauma, which made up 13% (n = 85); group 3, missed inflicted trauma, which made up 23% (n = 151); and group 4, missed accidental trauma, which made up 0.6% (n = 4). Younger age of the child, multiple fractures, need for hospital admission, and the examining physician being a pediatrician positively influenced physicians propensity to accurately report inflicted trauma. Conclusions: A large percentage of the charts reviewed contained inadequate documentation to explain the cause of fractures and thereby rule out inflicted trauma. Information in 23% of the charts reviewed aroused suspicion of inflicted trauma. There is a need to ensure that adequate information is obtained and documented in hospital records to rule out inflicted injury. This will require changes in the knowledge, skills, and attitudes of physicians. The use of forms, protocols, and periodic chart review will help to ensure compliance.

Child abuse in Turkey: an experience in overcoming denial and a description of 50 cases

OBJECTIVEnTo share the experiences of the first clinical multidisciplinary child abuse and neglect (CAN) team in Turkey with international child abuse community.nnnMETHODSnThe authors established the first Turkish CAN follow-up team at Dr. Behcet Uz Childrens Hospital. Following a training program in five teaching hospitals in Izmir, the authors kept a record of every case diagnosed with CAN from these hospitals between 1996 and 1998. The demographic, epidemiologic, and medical features of this case series are summarized.nnnRESULTSnFifty cases were diagnosed and followed-up. Seventy-six percent of patients were reported from Dr. Behcet Uz Childrens Hospital. Age and sex distribution was 9.2 +/- 6.7 years and 46% male, 54% female, respectively. The offenders were only father in 38%, only mother in 28%, and multiple in 34%. More than three CAN risk factors were present in 94%. Of the children reported 44% survived, 14% died, and 42% were lost to follow-up. Sixteen percent were free of reabuse, and 42% survived with handicaps.nnnCONCLUSIONSnChild abuse and neglect is a reality in Turkey. The teams work increased pediatricians awareness of CAN. Reporting these cases to Social Affairs Bureau was established for the first time in Turkey. Physicians in Turkey need training to diagnose and properly report CAN. The implemen tation of a national CAN prevention program is an urgent need for Turkey.

Adverse childhood experiences and trauma informed care: the future of health care

Adverse childhood experiences (ACEs) are related to short- and long-term negative physical and mental health consequences among children and adults. Studies of the last three decades on ACEs and traumatic stress have emphasized their impact and the importance of preventing and addressing trauma across all service systems utilizing universal systemic approaches. Current developments on the implementation of trauma informed care (TIC) in a variety of service systems call for the surveillance of trauma, resiliency, functional capacity, and health impact of ACEs. Despite such efforts in adult medical care, early identification of childhood trauma in children still remains a significant public health need. This article reviews childhood adversity and traumatic toxic stress, presents epidemiologic data on the prevalence of ACEs and their physical and mental health impacts, and discusses intervention modalities for prevention.

Illicit drug exposure in patients evaluated for alleged child abuse and neglect.

Background: Substantiation of drug exposure in cases with alleged maltreatment is important to provide proper treatment and services to these children and their families. A study performed at University of Iowa Hospitals and Clinics showed that 30% of pediatric patients with burn injuries, which were due to child maltreatment, were also exposed to illicit drugs. Objective: The children presenting to the University of Iowa Hospitals and Clinics with alleged maltreatment have been tested for illicit substances since 2004. The objective of this study was to analyze the presence of illicit drug exposure in the pediatric subpopulation admitted to pediatric inpatient and outpatient units for an evaluation for abuse/neglect. Design and Methods: The study design is a retrospective chart review. Using hospital databases, every pediatric chart with a child abuse/neglect allegation was retrieved. The association between risk factors and clinical presentation and illicit drug test result was assessed. Excel and SAS were used for statistical analysis. Institutional review board approval was obtained to conduct this study. Results: Six hundred sixty-five charts met study inclusion criteria for child abuse/neglect allegation. Of those, 232 cases were tested for illicit drugs between 2004 and 2008 per the testing protocol. Thirty-four cases (14.7%) tested positive on a drug test. Positive test rates based on clinical presentation were 28.6% (18/63) in neglect cases, 16.1% (5/31) in cases with soft tissue injuries, 14.3% (4/28) in burn injuries, 10.0% (2/20) in cases with sexual abuse, 7.1% (2/28) in cases with fractures, and 4.8% (3/62) in abusive head trauma cases. There were long-term abuse findings in 129 children (55.6%). Logistic regression analysis revealed that positive drug testing was most significantly associated with clinical symptoms suggesting physical abuse or neglect versus sexual abuse (odds ratio [OR] = 6.70; 95% confidence interval [CI], 1.26-35.49; P = 0.026), no or public health insurance versus those with private insurance (OR = 4.49; 95% CI, 1.47-13.66; P = 0.008), history of parental drug abuse versus those without parental history of drug abuse (OR = 3.42; 95% CI, 1.38-8.46; P = 0.008), and history of domestic violence versus those without a history of domestic violence (OR = 2.81; 95% CI, 1.08-7.30; P = 0.034). Conclusions: The results of this study showed that an illicit drug screening protocol used in the assessment of children evaluated for child abuse identified almost 15% of the population of allegedly abused and neglected children who were tested according to a protocol being exposed to illicit drugs. Thus, routine drug testing of at least children assessed for neglect and nonaccidental burn and soft tissue injuries, children with a history of either parental drug use or domestic violence is recommended.

Establishment of interdisciplinary child protection teams in Turkey 2002–2006: Identifying the strongest link can make a difference!

OBJECTIVESnThe University of Iowa Child Protection Program collaborated with Turkish professionals to develop a training program on child abuse and neglect during 2002-2006 with the goals of increasing professional awareness and number of multidisciplinary teams (MDT), regional collaborations, and assessed cases. This paper summarizes the 5-year outcome.nnnMETHODSnA team of instructors evaluated needs and held training activities in Turkey annually, and provided consultation when needed. Descriptive analysis was done via Excel and SPSS software.nnnRESULTSnEighteen training activities were held with 3,570 attendees. Over the study period, the number of MDTs increased from 4 to 14. The MDTs got involved in organizing training activities in their institutions and communities. The number of medical curriculum lectures taught by MDTs to medical students/residents, conferences organized by the MDTs, and lectures to non-medical professional audiences increased significantly (R(2)=91.4%, 83.8%, and 69.2%, respectively). The number of abuse cases assessed by the MDTs increased by five times compared to pre-training period.nnnCONCLUSIONSnA culturally competent training program had a positive impact on professional attitudes and behaviors toward recognition and management of child abuse and neglect in Turkey. The need to partner with policy makers to revise current law in favor of a greater human services orientation became clear.nnnPRACTICE IMPLICATIONSnPioneers in developing countries may benefit from collaborating with culturally competent instructors from countries with more developed child protection systems to develop training programs so that professional development can improve recognition and management of child abuse and neglect.

The Efficacy of Hair and Urine Toxicology Screening on the Detection of Child Abuse by Burning

Abuse by burning is estimated to occur in 1 to 25% of children admitted with burn injuries annually. Hair and urine toxicology for illicit drug exposure may provide additional confirmatory evidence for abuse. To determine the impact of hair and urine toxicology on the identification of child abuse, we performed a retrospective chart review of all pediatric patients admitted to our burn unit. The medical records of 263 children aged 0 to 16 years of age who were admitted to our burn unit from January 2002 to December 2007 were reviewed. Sixty-five children had suspected abuse. Of those with suspected abuse, 33 were confirmed by the Department of Health and Human Services and comprised the study group. Each of the 33 cases was randomly matched to three pediatric (0–16 years of age) control patients (99). The average annual incidence of abuse in pediatric burn patients was 13.7 ± 8.4% of total annual pediatric admissions (range, 0–25.6%). Age younger than 5 years, hot tap water cause, bilateral, and posterior location of injury were significantly associated with nonaccidental burn injury on multivariate analysis. Thirteen (39.4%) abused children had positive ancillary tests. These included four (16%) skeletal surveys positive for fractures and 10 (45%) hair samples positive for drugs of abuse (one patient had a fracture and a positive hair screen). In three (9.1%) patients who were not initially suspected of abuse but later confirmed, positive hair test for illicit drugs was the only indicator of abuse. Nonaccidental injury can be difficult to confirm. Although inconsistent injury history and burn injury pattern remain central to the diagnosis of abuse by burning, hair and urine toxicology offers a further means to facilitate confirmation of abuse.

Factors Related to Child Maltreatment in Children Presenting With Burn Injuries

The underpinnings of maltreatment in children presenting with burn injuries are necessary to discern as detection and prevention rest on a clear delineation of factors associated with maltreatment. Inaccurate identification of child victims can result in perpetuation of the maltreatment and its attendant neuropsychological sequela. The authors sought to determine factors associated with maltreatment in children presenting with burn injuries, which would guide the burn team in assessing the likelihood of maltreatment. All consenting children admitted with burn injuries were surveyed regarding their injury mechanism and current sociodemographic status. Suspicious injuries were referred by the burn team to the multidisciplinary review team (MRT). The MRT reported injuries with signs of physical abuse, supervision neglect, neglect of other basic needs, or sexual abuse. These children constituted the cases in our study. Variables related to maltreatment were entered into stepwise logistic regression to identify independent predicting variables. P< .05 was considered significant. MRT identified 16 children (24%) admitted with burn injuries with suspicions of maltreatment. Risk factors related to suspicions of maltreatment included: young age, large burns, tap water injury, immersion lines, delay in care, absence of a two-parent family (unconventional family structure), young parents, inconsistent history, and injury pattern. In this single-center prospective study, the authors identified several factors that, when present in injuries with initial suspicion of maltreatment, should trigger a child maltreatment workup. Burn clinicians have an important role as advocates for children and their families. It is important to continue to further the knowledge of maltreatment detection and prevention among children presenting with burn injuries.

Documentation of torture and cruel, inhuman or degrading treatment of children: A review of existing guidelines and tools

The documentation of individual cases of child torture is of paramount importance to bring justice to, and help heal, individuals and sensitize societies. Our objective is to systematically review medical guidelines for the recording of individual cases of child torture or cruel, inhuman or degrading treatment (CIDT). We searched CINAHL, Embase, the Guidelines International Network, Lilacs, Medline, the National Guideline Clearinghouse, PsychInfo and all websites of the organizations participating in the updating of the Istanbul Protocol for guidelines or studies on how to document torture, CIDT or abuse in persons under 18 years. We did not find a comprehensive guideline that encompassed all aspects of the documentation of child torture, as does the Istanbul Protocol for adults. An expert opinion guideline on how to document sexual torture in children was found, and in addition we identified 13 consensus-based guidelines for the evaluation of abuse in children or specific aspects thereof. We strongly recommend a child specific, comprehensive guideline on the documentation of torture and CIDT in children.

Quantitative measurement of retinal hemorrhages in suspected victims of child abuse

PURPOSEnChild abuse is one of the leading causes of death in early childhood. The presence of retinal hemorrhages often supports the diagnosis. The purpose of this study was to determine whether the specific measurement of retinal hemorrhages when present on fundus photography correlates with other clinical findings typically seen in children suspected of having been abused.nnnMETHODSnThe medical records of children with retinal hemorrhages who were suspected of being victims of abusive head trauma from June 2003 to June 2013 and who had widefield retinal photography performed were retrospectively reviewed. Data collected included hemorrhage-covered percentage (HCP) of the central retina (posterior pole or 40° circle centered on fovea) measured by ImageJ in relation to death, length of hospital stay, presence of abnormal findings on neuroimaging or skeletal survey, and definite versus possible abuse.nnnRESULTSnSignificant difference in retinal hemorrhage measured on fundus photography was found in patients with axial skeletal fracture (P = 0.016), signs of severe brain trauma on neuroimaging (P = 0.014) and definite versus possible abuse (P = 0.023). No correlation of quantitative measurement of the retinal hemorrhage to length of hospital stay, death, or the presence of skull fracture was found in this cohort.nnnCONCLUSIONSnThe quantitative measurement of total retinal hemorrhage when present on fundus photography centered on posterior pole in children suspected of having been abused correlated with some but not all findings typically seen in abused children.

Child abuse and neglect in Turkey: professional, governmental and non-governmental achievements in improving the national child protection system

Abstract Since ratification of the United Nations Convention on the Rights of the Child in 1995, significant efforts were made in Turkey to improve protection of children from abuse and neglect. The government took steps to amend relevant laws. Several state departments recognized the need for professional in-service training of relevant governmental agency staff. University hospitals established numerous hospital-based multidisciplinary child protection centres. The government established an Interministerial Higher Council, which has been overseeing the foundation of 13 child advocacy centres for a multidisciplinary and interagency response to child sexual abuse. In addition to undertaking research, non-governmental organizations contributed to this process by instituting professional and public education. These ground-breaking developments in the last decade give promise of even further improvement in the national child protection system from investigative, child protective and rehabilitative perspectives.