Roberta A. Hibbard

The prevalence of uncommon fractures on skeletal surveys performed to evaluate for suspected abuse in 930 children: Should practice guidelines change?

OBJECTIVE The objective of our study was to evaluate the prevalence and site of fractures detected on skeletal surveys performed for suspected child abuse at a tertiary childrens hospital and to determine whether any survey images may be eliminated without affecting clinical care or the ability to make a diagnosis. MATERIALS AND METHODS We identified all skeletal surveys performed for suspected abuse from 2003 to 2009 of children younger than 2 years. Repeated studies were excluded, as were studies not performed to evaluate for suspected abuse. From the reports, we documented the sites of all the fractures. RESULTS. Nine hundred thirty children (515 boys and 415 girls) with a median age of 6 months met the entry criteria for the study. Fractures were detected in 317 children (34%), of whom 166 (18%) had multiple fractures. The most common sites for fractures were the long bones (21%), ribs (10%), skull (7%), and clavicle (2%). Ten children (1%) had fractures in the spine (n = 3), pelvis (n = 1), hands (n = 6), and feet (n = 2). All 10 children had other signs of physical abuse. CONCLUSION In skeletal surveys performed for suspected child abuse, fractures limited to sites other than the long bones, ribs, skull, and clavicles are rare. The additional radiation exposure and cost of obtaining radiographs of the spine, pelvis, hands, and feet may outweigh their potential benefit. Given the rarity of fractures of the spine, pelvis, hands, and feet, consideration may be given to eliminating those views from routine skeletal surveys performed to evaluate for suspected child abuse.

Behavioral problems in alleged sexual abuse victims

This study was conducted to compare the parental assessments of problem behaviors, using the Achenbach Child Behavior Checklist, among alleged sexual abuse victims (n = 81) and an age, race, and gender matched group of nonabused comparison subjects (n = 90). Alleged sexual abuse victims demonstrated significantly higher mean total behavior problem, internalizing and externalizing scores than the comparison sample. Subscale profiles were all in the direction consistent with withdrawal, impairment in social interaction, and sexual problems. Item comparison indicated that sexual abuse victims were more likely to be assessed as having some problem behaviors that have been reported as being indicative of sexual abuse. A significant difference was not obtained on several behaviors that have been previously reported as indicative of sexual abuse. These findings support concerns that sexual abuse victims do exhibit more problem behaviors, but caution must be exercised when interpreting individual behaviors because of their frequency in a nonabused sample.

Patterns of child sexual abuse knowledge among professionals

To better understand knowledge and perceptions of child sexual abuse, a survey was conducted of 902 professionals attending child sexual abuse educational programs during 1986-1987. About half (50.8%) of the group reported seeing at least two child sexual abuse cases a month, while 20.5% reported seeing five or more. Almost half (48.9%) of the respondents reported previous formal training regarding child sexual abuse. Professionals were generally knowledgeable about child sexual abuse; however, at least 20% of the professionals were not knowledgeable about some items that are important in the identification of child sexual abuse and that might hamper the legal and medical investigation of a case. Those with formal training, more years of professional practice, and who see five or more victims per month answered more questions correctly, but the differences were not always statistically significant. Further training for both medical and non-medical professionals is needed to ensure appropriate care of child sexual abuse victims and to improve communication and coordination of efforts between professions.

Attorney Attitudes Regarding Behaviors Associated with Child Sexual Abuse.

There appears to be a good deal of disagreement between professionals as to what constitutes child abuse. Attorneys as a group have been found to judge behaviors associated with child abuse more leniently than other abuse professionals. However, no one has discriminated between defense and prosecuting attorneys in these areas. It was hypothesized that because of divergent roles in child sexual abuse cases attitudes toward adult-child behaviors associated with sexual abuse would differ among attorney groups. Two prosecuting and two defense attorneys from every county in the state of Indiana were sent questionnaires. Participants were asked to indicate if a behavior was acceptable, inappropriate, or sexual abuse if it occurred on one or on multiple occasions. Prosecutors had more severe judgements than the defense attorneys on 32 of the 42 behaviors. They were more likely to indicate that a behavior was inappropriate or abuse. Cognitive dissonance theory is proposed as a possible explanation for these findings.

Genitalia in human figure drawings: childrearing practices and child sexual abuse.

To replicate and explore the associations of drawing genitalia on a human figure, child-rearing practices, and a history of alleged sexual abuse, we designed a cross-sectional study of 109 alleged child sexual abuse victims, ages 3 through 8 years, and a group of 109 comparison children matched for age, sex, race, and socioeconomic status but with no history of abuse. A standardized format was used to collect drawings, administer the Peabody Picture Vocabulary Test, and gather background data on medical, developmental, and child-rearing issues. Seven alleged sexual abuse victims and one comparison child spontaneously drew genitalia (p = 0.02, one-tailed Fisher Exact Test, estimated relative risk 7.96). No differences in drawing maturity (Draw-A-Man score) were identified, although Peabody Picture Vocabulary Test scores were higher in comparison children (82.1 vs. 91.0, p less than 0.01). Neither drawing genitalia nor history of alleged sexual abuse were significantly associated with histories of medical problems, enuresis, encopresis, urinary tract infection, or child-rearing practices related to sleeping, nudity, bathing, sexual abuse education, or exposure to sexually explicit materials. The similar patterns of child-rearing practices in both samples should make professionals cautious in attributing allegations of abuse to specific child-rearing practices. This study confirms our previous report that the presence of genitalia spontaneously drawn on a childs drawing of a human figure is associated with alleged sexual abuse.

Child abuse and mental health among adolescents in dependent care

Do adolescents in dependent care who have been abused or neglected demonstrate more mental health problems than their nonabused peers? This study examined relationships of child abuse, depression, and self-esteem among 82 adolescents (mean age 14.5 years, 52% male, 82.9% white) living in a dependent care facility. Of these, 32 adolescents were victims of child abuse or neglect. Upon admission, 54 adolescents were identified as depressed on the Beck Depression Inventory. Initial scores on the depression and self-esteem instruments did not differ by age, race, or history of maltreatment, though trends among subtypes of abuse were identified. Females had significantly lower self-esteem and tended toward more depression. Repeat evaluation 6 months after admission revealed significant improvement in both depression and self-esteem scores for the entire sample. As a group, however, the maltreated adolescents did not demonstrate significant improvement in depression, and a history of neglect was associated with less improvement. Depression in this dependent care sample was common, however, we did not identify the maltreated adolescents as having significantly more problems with self-esteem or depression. For some adolescents, dependent care may be an appropriate and helpful alternative.

More than words: The Emotional Maltreatment of Children

Emotional maltreatment may be the most complex, prevalent, and damaging form of child maltreatment and can occur simultaneously with other forms of abuse. Children in the first few years of life seem to be at the greatest risk of suffering the most negative outcomes. Medical professionals can help identify and protect victims of emotional maltreatment by carefully observing caregiver-child interactions, paying attention to a familys social history, making referrals to community or counseling programs when necessary, and reporting any suspicions of maltreatment to Child Protective Services. A well-coordinated, multidisciplinary response must be enacted whenever emotional maltreatment is suspected or reported.

Clinical Report—Intimate Partner Violence: The Role of the Pediatrician

The American Academy of Pediatrics and its members recognize the importance of improving the physicians ability to recognize intimate partner violence (IPV) and understand its effects on child health and development and its role in the continuum of family violence. Pediatricians are in a unique position to identify abused caregivers in pediatric settings and to evaluate and treat children raised in homes in which IPV may occur. Children exposed to IPV are at increased risk of being abused and neglected and are more likely to develop adverse health, behavioral, psychological, and social disorders later in life. Identifying IPV, therefore, may be one of the most effective means of preventing child abuse and identifying caregivers and children who may be in need of treatment and/or therapy. Pediatricians should be aware of the profound effects of exposure to IPV on children.American Academy of Pediatrics and its members recognize the importance of improving the physicians ability to recognize intimate partner violence (IPV) and understand its effects on child health and development and its role in the continuum of family violence. Pediatri- cians are in a unique position to identify abused caregivers in pediatric settings and to evaluate and treat children raised in homes in which IPV may occur. Children exposed to IPV are at increased risk of being abused and neglected and are more likely to develop adverse health, behavioral, psychological, and social disorders later in life. Identifying IPV, therefore, may be one of the most effective means of preventing child abuse and identifying caregivers and children who may be in need of treatment and/or therapy. Pediatricians should be aware of the profound effects of exposure to IPV on children. Pediatrics 2010;125:1094-1100

Clinical report - Intimate partner violence

The American Academy of Pediatrics and its members recognize the importance of improving the physicians ability to recognize intimate partner violence (IPV) and understand its effects on child health and development and its role in the continuum of family violence. Pediatricians are in a unique position to identify abused caregivers in pediatric settings and to evaluate and treat children raised in homes in which IPV may occur. Children exposed to IPV are at increased risk of being abused and neglected and are more likely to develop adverse health, behavioral, psychological, and social disorders later in life. Identifying IPV, therefore, may be one of the most effective means of preventing child abuse and identifying caregivers and children who may be in need of treatment and/or therapy. Pediatricians should be aware of the profound effects of exposure to IPV on children.American Academy of Pediatrics and its members recognize the importance of improving the physicians ability to recognize intimate partner violence (IPV) and understand its effects on child health and development and its role in the continuum of family violence. Pediatri- cians are in a unique position to identify abused caregivers in pediatric settings and to evaluate and treat children raised in homes in which IPV may occur. Children exposed to IPV are at increased risk of being abused and neglected and are more likely to develop adverse health, behavioral, psychological, and social disorders later in life. Identifying IPV, therefore, may be one of the most effective means of preventing child abuse and identifying caregivers and children who may be in need of treatment and/or therapy. Pediatricians should be aware of the profound effects of exposure to IPV on children. Pediatrics 2010;125:1094-1100

ABUSE AND HEALTH BEHAVIORS IN A STUDENT POPULATION

Behavioral sequellae of child abuse are frequently noted, however, there are few studies of nonclinical children examining the strength of such associations. As part of a health needs assessment, we surveyed 712 junior high students (7th-9th grade, mean age 13.5 years) for self-reports of abusive experiences and health behaviors. The sample was 50% male, 77% white and represented all socioeconomic levels. 18.3% students reported physical (PA) and/or sexual abuse (SA); 14.7% reported PA, 8.1% reported SA and 4.1% reported both. Reports did not differ by age or race, but more females (12.6%) than males (3.9%) reported SA (p=0.0, X2). Both PA and SA were associated with running away, considering hurting oneself, suicide attempts, and the use of drugs, pot, alcohol, cigarettes, and laxatives (all p<.01). Strength of associations (odds ratios) range from 1.8 for the risk of alcohol use to 4.7 for the risk of running away. No clinically significant relationships were found between SA/PA and anger, sadness or self-esteem. This data confirms some previous reports and indicates the need for studies of nonclinical populations.