Robert D. Sege

From suspicion of physical child abuse to reporting: Primary care clinician decision-making

OBJECTIVES. The goals were to determine how frequently primary care clinicians reported suspected physical child abuse, the levels of suspicion associated with reporting, and what factors influenced reporting to child protective services. METHODS. In this prospective observational study, 434 clinicians collected data on 15003 child injury visits, including information about the injury, child, family, likelihood that the injury was caused by child abuse (5-point scale), and whether the injury was reported to child protective services. Data on 327 clinicians indicating some suspicion of child abuse for 1683 injuries were analyzed. RESULTS. Clinicians reported 95 (6%) of the 1683 patients to child protective services. Clinicians did not report 27% of injuries considered likely or very likely caused by child abuse and 76% of injuries considered possibly caused by child abuse. Reporting rates were increased if the clinician perceived the injury to be inconsistent with the history and if the patient was referred to the clinician for suspected child abuse. Patients who had an injury that was not a laceration, who had >1 family risk factor, who had a serious injury, who had a child risk factor other than an inconsistent injury, who were black, or who were unfamiliar to the clinician were more likely to be reported. Clinicians who had not reported all suspicious injuries during their career or who had lost families as patients because of previous reports were more likely to report suspicious injuries. CONCLUSIONS. Clinicians had some degree of suspicion that ∼10% of the injuries they evaluated were caused by child abuse. Clinicians did not report all suspicious injuries to child protective services, even if the level of suspicion was high (likely or very likely caused by child abuse). Child, family, and injury characteristics and clinician previous experiences influenced decisions to report.

Clinicians' description of factors influencing their reporting of suspected child abuse: Report of the child abuse reporting experience study research group

OBJECTIVES. Primary care clinicians participating in the Child Abuse Reporting Experience Study did not report all suspected physical child abuse to child protective services. This evaluation of study data seeks (1) to identify factors clinicians weighed when deciding whether to report injuries they suspected might have been caused by child abuse; (2) to describe clinicians’ management strategies for children with injuries from suspected child abuse that were not reported; and (3) to describe how clinicians explained not reporting high-suspicion injuries. METHODS. From the 434 pediatric primary care clinicians who participated in the Child Abuse Reporting Experience Study and who indicated they had provided care for a child with an injury they perceived as suspicious, a subsample of 75 of 81 clinicians completed a telephone interview. Interviewees included 36 clinicians who suspected child abuse but did not report the injury to child protective services (12 with high suspicion and 24 with some suspicion) and 39 who reported the suspicious injury. Interviews were analyzed for major themes and subthemes, including decision-making regarding reporting of suspected physical child abuse to child protective services and alternative management strategies. RESULTS. Four major themes emerged regarding the clinicians’ reporting decisions, that is, familiarity with the family, reference to elements of the case history, use of available resources, and perception of expected outcomes of reporting to child protective services. When they did not report, clinicians planned alternative management strategies, including active or informal case follow-up management. When interviewed, some clinicians modified their original opinion that an injury was likely or very likely caused by abuse, to explain why they did not report to child protective services. CONCLUSIONS. Decisions about reporting to child protective services are guided by injury circumstances and history, knowledge of and experiences with the family, consultation with others, and previous experiences with child protective services.

Policy Statement—Child Passenger Safety

Child passenger safety has dramatically evolved over the past decade; however, motor vehicle crashes continue to be the leading cause of death of children 4 years and older. This policy statement provides 4 evidence-based recommendations for best practices in the choice of a child restraint system to optimize safety in passenger vehicles for children from birth through adolescence: (1) rear-facing car safety seats for most infants up to 2 years of age; (2) forward-facing car safety seats for most children through 4 years of age; (3) belt-positioning booster seats for most children through 8 years of age; and (4) lap-and-shoulder seat belts for all who have outgrown booster seats. In addition, a fifth evidence-based recommendation is for all children younger than 13 years to ride in the rear seats of vehicles. It is important to note that every transition is associated with some decrease in protection; therefore, parents should be encouraged to delay these transitions for as long as possible. These recommendations are presented in the form of an algorithm that is intended to facilitate implementation of the recommendations by pediatricians to their patients and families and should cover most situations that pediatricians will encounter in practice. The American Academy of Pediatrics urges all pediatricians to know and promote these recommendations as part of child passenger safety anticipatory guidance at every health-supervision visit.

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.

PEDIATRICIAN CHARACTERISTICS ASSOCIATED WITH CHILD ABUSE IDENTIFICATION AND REPORTING: RESULTS FROM A NATIONAL SURVEY OF PEDIATRICIANS

Pediatrician experience with child protective services (CPS) and factors associated with identifying and reporting suspected child physical abuse were examined by a survey of members of the American Academy of Pediatrics (AAP). Respondents provided information about their demographics and experience, attitudes and practices with child abuse. They indicated their diagnosis and management of a child in a purposely ambiguous clinical vignette. Pediatricians who had received recent child abuse education were more confident in their ability to identify and manage child abuse. High confidence in ability to manage child abuse and positive attitude about domestic violence screening and value of anticipatory guidance predicted that pediatricians would have high suspicion that the child in the vignette was abused and that they would report the child to CPS. Future efforts to improve medical intervention in child abuse should focus on physician attitudes and experience, as well as cognitive factors.

Variation in the diagnosis of child abuse in severely injured infants.

OBJECTIVE. Diagnosis of child abuse is difficult and may reflect patient, practitioner, and system factors. Previous studies have demonstrated potential lethal consequences if cases of abuse are missed and suggested a role for continuing medical education in improving the accuracy of diagnosis of suspected abuse. Although the majority of injured American children are treated at general hospitals, most published studies of severe injury resulting from child abuse have been conducted at children’s hospitals. The objective of this study was to evaluate the role of hospital type in observed variations in the frequency of diagnosis of child physical abuse among children with high-risk injuries. METHODS. Hospital discharge data were evaluated, and adjusted rates of abuse diagnosis were reported according to hospital type. A regression model estimated the number of cases of abuse that would have been diagnosed if all hospitals identified abuse as frequently as observed at pediatric specialty hospitals. This study consisted of children who were <1 year old and admitted to US hospitals in 1997 for treatment of traumatic brain injury or femur fracture, excluding penetrating trauma or motor-vehicle–related injury. A total of 2253 weighted cases were analyzed. RESULTS. The proportion of patients with a medical diagnosis of child abuse varied widely between hospital types: 29% of the cases were diagnosed as abuse at children’s hospitals compared with 13% at general hospitals. An estimated 178 infants (39% of total) with these specific injuries would have been identified as abused had they been treated at children’s rather than general hospitals. CONCLUSIONS. Hospital type was associated with large variations in the frequency of diagnosis of child abuse. This variation was not related to observed differences in the patients or their injuries and may result from systematic underdiagnosis in general hospitals. This result has implications for quality-improvement programs at general hospitals, where the majority of injured children in the United States receive emergent medical care.

Abused Women Disclose Partner Interference with Health Care: An Unrecognized Form of Battering

BACKGROUNDSome providers observe that partners interfere with health care visits or treatment. There are no systematic investigations of the prevalence of or circumstances surrounding partner interference with health care and intimate partner violence (IPV).OBJECTIVETo determine whether abused women report partner interference with their health care and to describe the co-occurring risk factors and health impact of such interference.DESIGNA written survey of women attending health care clinics across 5 different medical departments (e.g., emergency, primary care, obstetrics–gynecology, pediatrics, addiction recovery) housed in 8 hospital and clinic sites in Metropolitan Boston.PARTICIPANTSWomen outpatients (N = 2,027) ranging in age, 59% White, 38% married, 22.6% born outside the U.S.MEASUREMENTQuestions from the Severity of Violence and Abuse Assessment Scale, the SF-36, and questions about demographics.RESULTSOne in 20 women outpatients (4.6%) reported that their partners prevented them from seeking or interfered with health care. Among women with past-year physical abuse (n = 276), 17% reported that a partner interfered with their health care in contrast to 2% of women without abuse (adjusted odds ratios [OR] = 7.5). Further adjusted risk markers for partner interference included having less than a high school education (OR = 3.2), being born outside the U.S. (OR = 2.0), and visiting the clinic with a man attending (OR = 1.9). Partner interference raised the odds of women having poor health (OR = 1.8).CONCLUSIONSPartner interference with health care is a significant problem for women who are in abusive relationships and poses an obstacle to health care. Health care providers should be alert to signs of patient noncompliance or missed appointments as stemming from abusive partner control tactics.

The teen driver

Motor vehicle–related injuries to adolescents continue to be of paramount importance to society. Since the original policy statement on the teenaged driver was published in 1996, there have been substantial changes in many state laws and much new research on this topic. There is a need to provide pediatricians with up-to-date information and materials to facilitate appropriate counseling and anticipatory guidance. This statement describes why teenagers are at greater risk of motor vehicle–related injuries, suggests topics suitable for office-based counseling, describes innovative programs, and proposes preventive interventions for pediatricians, parents, legislators, educators, and other child advocates.

Ten years after: examination of adolescent screening questions that predict future violence-related injury

PURPOSE To determine which screening questions used in routine adolescent health care maintenance visits correlate with subsequent violence-related injury. METHODS A prospective cohort study was undertaken of adolescents initially seen at the East Boston Neighborhood Health Center (EBNHC) in 1986. Risk factor data were collected based on the adolescent health intake form in the medical records. The primary outcome measure, time until first violence-related injury was determined through identification on chart review of the treatment of any such injuries at the urgent care center at EBNHC in the subsequent 10 years. Kaplan-Meier survival statistics and Cox proportional hazards models were used to account for loss of patients to follow-up. RESULTS Median follow-up for this sample was >5 five years. Male gender, cigarette smoking, alcohol use, other drug use, poor relationships with parents, not being in school or failing school, and history of fighting in the past year, predicted violence-related injury within the follow-up period. The number of fights in the past year appeared to have a dose-response effect on risk of subsequent violence-related injury. A simple screening instrument consisting of items concerning school status, drug use, and fighting history was used to stratify youth into low, moderate, and high risk of violence-related injury during the follow-up period. CONCLUSIONS These results suggest that a simple three-item screening instrument may be used to stratify the risk of future injury at the time of adolescent health maintenance visits. Further research is indicated to validate this finding in other populations. Interventions designed to assist adolescents who are not in school or who have drug use problems should also incorporate violence prevention strategies.

Evaluation for bleeding disorders in suspected child abuse

Bruising or bleeding in a child can raise the concern for child abuse. Assessing whether the findings are the result of trauma and/or whether the child has a bleeding disorder is critical. Many bleeding disorders are rare, and not every child with bruising/bleeding concerning for abuse requires an evaluation for bleeding disorders. In some instances, however, bleeding disorders can present in a manner similar to child abuse. The history and clinical evaluation can be used to determine the necessity of an evaluation for a possible bleeding disorder, and prevalence and known clinical presentations of individual bleeding disorders can be used to guide the extent of the laboratory testing. This clinical report provides guidance to pediatricians and other clinicians regarding the evaluation for bleeding disorders when child abuse is suspected.