Physicians' recognition of and response to child abuse: Northern Ireland and the U.S.A

There is a long history of professional and public concern with the problems of recognizing and reporting child abuse. The research reported here compares recognition of and response to potential abuse by physicians in Northern Ireland and the United States. An experimental study using vignettes in the USA and hospital data, showed that physicians' judgments were moderately affected by ethnic status (black-white) and socioeconomic status of the family, in addition to level of injury to the child. We conducted a comparative study to test whether the social cleavage based on religion (Protestant-Catholic in North Ireland), would affect the recognition of and response to child abuse by medical practitioners in North Ireland. While there was a slight tendency for responses to be affected by socioeconomic status and religion, the results were not statistically significant, as was true for the level of injury to the child. We also compared "diagnostic behavior," signs used to diagnose abuse and causal notions concerning abuse. Medical practitioners in the two countries differ with respect to (1) the amount and type of information desired about a case, and (2) the factors believed to "cause" abuse, but are in general agreement about the "signs" of abuse.     

Genital examinations for alleged sexual abuse of prepubertal girls: findings by pediatric emergency medicine physicians compared with child abuse trained physicians

OBJECTIVE: This study compares abnormal genital examination findings made by pediatric emergency medicine (PEM) physicians to examinations by physicians with training in child sexual abuse in the evaluation of prepubertal girls for suspected sexual abuse. METHOD: A prospective study was performed following the genital examination by a PEM physician of prepubertal girls suspected of being sexually abused. A physician with training in child sexual abuse re-examined those girls whose examinations were interpreted as abnormal by the PEM physicians. The findings and interpretations of the PEM physician were then compared to those by the physicians with training in child abuse. RESULTS: Between October 1994 and October 1998, 46 patients diagnosed by PEM physicians with nonacute genital findings indicative of sexual abuse were re-examined by a physician with training in child abuse. The follow-up examinations were done 2 days-16 weeks (mean 2.1 weeks) after the emergency department visit. The physicians with training in child abuse concluded that only eight of these children (17%) showed clear evidence of abuse. Normal findings were noted in 32 children (70%), nonspecific changes were noted in 4 children (9%), and 2 children (4%) had findings that are more commonly seen in abused children than nonabused children but are not diagnostic for abuse (concerning for abuse). CONCLUSIONS: There was poor agreement between the pediatric emergency medicine physicians and the physicians with training in child sexual abuse. This study suggests that emergency medicine physicians should consider additional training in this area. In addition, all children with abnormal ED examinations should have follow-up examinations by a child abuse trained physician.     

Referrals to a hospital-based child abuse committee: a comparison of the 1960s and 1990s

OBJECTIVE: Although reports of child maltreatment have increased yearly since national data were first collected in 1976, little information is available about changes in the characteristics of children reported. Therefore, to examine changes over time in recognition and reporting in a medical setting, we compared referrals to a hospital-based child abuse committee in the late 1960s and early 1990s. DESIGN: Retrospective, cross-sectional review of medical records and logs of the hospital's child abuse committee. SETTINGS: Ambulatory, emergency, and inpatient services at Yale-New Haven Hospital. Patients: Medical records were reviewed for 101 of the 165 children referred to the child abuse committee in 1968-1969 (early group) and 107 of the 843 children referred in 1990-1991 (late group). Cases of sexual abuse were excluded. RESULTS: Referrals for nonsexual abuse cases increased from 80 children per year in the early group to 181.5 per year in the late group; the late group was characterized by a larger number of newborn referrals (1% vs. 52%, p < .001). When non-newborns were compared, the two groups were similar with respect to gender and race, but the late group had fewer patients with private insurance (31% vs. 12%, p < .05). The late group also had more female-headed households (32% vs. 67%, p < .05) and more parents with a history of substance abuse (4% vs. 49%, p < .001). Excluding newborns, who were all classified as "at-risk," the types of problems were classified as abuse (41% early vs. 29% late), neglect (41% vs. 35%), and "at-risk" (16% vs. 35%). Although the types of injuries were similar: superficial injuries (20% vs. 16%), burns (9% vs. 8%), and fractures (6% vs. 4%), fewer maltreated children suffered physical injuries in the late group (71% vs. 49%, p < .05). CONCLUSIONS: A substantial change has occurred in referrals to the hospital's child abuse committee for abuse or neglect. Most referrals have become socially high-risk newborns and children or children with minimal injuries. This shift is likely due to broader definitions of maltreatment and earlier recognition of troubled families.     

Interpretations of colposcopic photographs: evidence for competence in assessing sexual abuse?

Accurate assessment of physical findings for child sexual abuse is medically and legally important. This study evaluated (1) interobserver reliability of clinicians rating colposcopic photographs, and (2) correlates of reliable interpretations. Seventy physicians and two nurse practitioners, divided by professional levels, assessed colposcopic photographs and completed a questionnaire. Ratings by a professional with extensive experience in this field were used as an accuracy standard. Leaders in the field of child sexual abuse assessment made significantly more "accurate" assessments than pediatricians, pediatric and family practice residents, and intern physicians. Leaders made fewer "inaccurate" interpretations than interns. Predictors of agreement with standard assessments, although weak, were knowledge of female perineal anatomy and professional level. Total number of sexual abuse examinations conducted and knowledge of sexually transmitted diseases as acquired by children were not significant predictors of accurate assessment. The findings are interpreted as to their potential relevance to actual sexual abuse evaluations of children.     

The sexual victimization of male children: a review of previous research

The evidence available at this time indicates that male children are more likely to be abused by nonfamily rather than family members. Residing in a neglectful home or a mother-headed household and having previous homosexual contact tend to heighten risk for sexual abuse by nonfamily members. Familial sexual abuse appears related to residence in a home where other siblings are being abused, where the father was a victim of sexual abuse as a child, and where parents suffer myriad personal and social adjustment difficulties. Effects of male child sexual abuse appear to be serious and long lasting. The scant writings available at this time imply that the sexually abused male child experiences a range of adjustment and self-esteem problems as an adult and may be at heightened risk to become a child sexual abuser.     

Counseling in the area of child sexual abuse within the family

This paper considers the recent recognition in Ireland of the problem of child sexual abuse. In 1983, the Government Department of Health, for the first time, allocated a separate category for it in its statistics. Treatment to date has been one of localised and ad hoc arrangements.Counseling approaches follow broadly the divisions that exist in the theoretical models that seek to explain the aetiology of abuse. These can be characterised as (1) those programs that derive from the family systems model and that emphasise dysfunctional family dynamics and (2) programs established for the counseling of a wide range of sex offenders, including intrafamily abusers, and which emphasise traits or aspects of individual perpetrator functioning. Both approaches, however, share fundamental prerequisites. These prerequisites are considered.Three issues are of particular relevance during counseling. The first relates to the child victim at the time of the discovery or disclosure of the abuse, and prior to entry into a family counseling program. The second looks at counseling programs that emphasise the family dimension. The third deals with counseling approaches for perpetrators of abuse. Each of these three topics will be discussed.     

Is the diagnosis of physical abuse changed when Child Protective Services consults a Child Abuse Pediatrics subspecialty group as a second opinion?

ObjectivesTo characterize the changes regarding the diagnosis of physical abuse provided to Child Protective Services (CPS) when CPS asks a Child Abuse Pediatrics (CAP) specialty group for a second opinion and works in concert with that CAP group.MethodsSubjects were reported to CPS for suspected physical abuse and were first evaluated by a physician without specialized training in Child Abuse Pediatrics (non-CAP physician). Subjects were then referred to the area's only Child Abuse Pediatrics (CAP physician) group, located in a large metropolitan pediatrics center in the United States, for further evaluation. The diagnoses regarding abuse provided by CAP physicians working in concert with CPS were compared to those provided to CPS by other physicians.ResultsTwo hundred consecutive patients were included in the study. In 85 (42.5%) cases, non-CAP physicians did not provide a diagnosis regarding abuse, despite initiating the abuse report to CPS or being asked by CPS to evaluate the child for physical abuse. Of the remaining 115 cases, the diagnosis regarding abuse differed between non-CAP physicians and CAP physicians working in concert with CPS in 49 cases (42.6%; κ = .14; 95% CI, ?.02, .29). In 40 of the 49 cases (81.6%), CAP assessments indicated less concern for abuse when compared to non-CAP assessments. Differences in diagnosis were three times more likely in children from a nonurban location (OR 3.24; 95% CI, 1.01, 11.36).ConclusionsIn many cases of possible child physical abuse, non-CAP providers do not provide CPS with a diagnosis regarding abuse despite initiating the abuse investigation or being consulted by CPS for an abuse evaluation. CPS consultation with a CAP specialty group as a second opinion, along with continued information exchange and team collaboration, frequently results in a different diagnosis regarding abuse. Non-CAP providers may not have time, resources, or expertise to provide CPS with appropriate abuse evaluations in all cases.Practice implicationsThough non-CAP providers may appropriately evaluate many cases of physical abuse, the diagnosis regarding abuse provided to CPS may be changed in some cases when CAP physicians are consulted and actively collaborate with CPS investigators. Availability of Child Abuse Pediatrics subspecialty services to investigators is warranted.     

Whiplash shaking syndrome: retinal hemorrhages and computerized axial tomography of the brain

Three cases of whiplash shaking injury of infants are presented. All children presented with seizures and had minimal signs of external injury. Examination of the retina revealed extensive retinal hemorrhages. These were missed on initial examination and were only discovered after pupillary dilatation. The presence of these palecentered retinal hemorrhages suggested the diagnosis of child abuse and skeletal surveys and thorough social histories confirmed the diagnosis. Despite extensive retinal hemorrhages, computerized axial tomography (C.T.) scan showed minimal inter-hemispheric bleeding. In contrast to the "Battered Child Syndrome," all the findings in whiplash shaking syndrome of infants are subtle and demand an awareness, an index of suspicion and a thorough examination which may include extensive retinal examination following dilatation of the pupils. This latter examination is frequently not performed by family physicians and residents so that the syndrome may be missed. A fourth case is also discussed where shaking is admitted on initial presentation but said to be done for resuscitation. This poses an immense diagnostic dilemma to the pediatrician since in this case the child presented later with all the signs of physical abuse.     

Expert medical assessment in determining probability of alleged child sexual abuse

The purpose of this paper is to describe the role of the physician as part of the investigative team in child sexual abuse both in corroborating previously obtained disclosures and in determining the level of probability of sexual abuse where there has been no disclosure. At retrospective chart audit, history of physical and behavioral symptoms and physical and laboratory findings suggestive of child sexual abuse were correlated with allegations where known in order to classify 63 patients as to probability of sexual abuse. In this study 14.3% of cases were "unfounded" based on available evidence while 65% were "probable" or "determined." The remainder were "uncertain." Of 16 patients with physical signs, in 11 cases physical findings corroborated suspicion of child sexual abuse. The need for a systematic approach to the "directed medical interview" and examination, preferably videotaped, is discussed.     

The utility and challenges of using ICD codes in child maltreatment research: A review of existing literature

ObjectiveThe objectives of this article are to explore the extent to which the International Statistical Classification of Diseases and Related Health Problems (ICD) has been used in child abuse research, to describe how the ICD system has been applied, and to assess factors affecting the reliability of ICD coded data in child abuse research.MethodsPubMed, CINAHL, PsychInfo and Google Scholar were searched for peer reviewed articles written since 1989 that used ICD as the classification system to identify cases and research child abuse using health databases. Snowballing strategies were also employed by searching the bibliographies of retrieved references to identify relevant associated articles. The papers identified through the search were independently screened by two authors for inclusion, resulting in 47 studies selected for the review. Due to heterogeneity of studies meta-analysis was not performed.ResultsThis paper highlights both utility and limitations of ICD coded data. ICD codes have been widely used to conduct research into child maltreatment in health data systems. The codes appear to be used primarily to determine child maltreatment patterns within identified diagnoses or to identify child maltreatment cases for research.ConclusionsA significant impediment to the use of ICD codes in child maltreatment research is the under ascertainment of child maltreatment by using coded data alone. This is most clearly identified and, to some degree, quantified, in research where data linkage is used.Practice implicationsThe importance of improved child maltreatment identification will assist in identifying risk factors and creating programs that can prevent and treat child maltreatment and assist in meeting reporting obligations under the CRC.     

The idealization of women: its role in the minimization of child sexual abuse by females

OBJECTIVE: The aim was to review the literature on female perpetrated child sexual abuse by highlighting how cultural myths about women inhibit recognition of this much hidden phenomenon. METHOD: Three sections are presented. Part 1 evaluates evidence concerning beliefs about child sexual abuse by women which minimize the problem. Part 2 provides a theoretical account of psychological processes that are hypothesized to maintain these beliefs. Part 3 illustrates that professionals working in the area of child sexual abuse are not immune to these processes. As a result, recommendations for future professional practices are made. RESULT: The paper demonstrates that in the context of what is known about child sexual abuse, cultural beliefs which serve to idealize women and minimize their potential harm to children are largely invalid. CONCLUSION: Individuals are urged to suspend their disbelief about female perpetrated child sexual abuse. Denial of the phenomenon may result in it continuing to be under-reported and trivialized. As this persists the price will ultimately be paid by victims of on-going abuse and survivors of past victimization whose suffering will be compounded by disparagement of the issue.     

Infant mental health and biological risk

Parents seldom seek help directly for infant mental health problems. Parents enter the health care system seeking advice for identified or presumed biological problems in their infants. Many of these biological problems, however, have major psychosocial components of importance to infant mental health. It is important that physicians deal directly with the psychosocial issues and avoid converting them into biological medical problems unintentionally. Three common types of problems and appropriate methods of management are discussed to ensure special recognition and effective handling by the physician of psychosocial problems and the promotion of mental health. The problems discussed are the following: Infants seen with defined medical conditions that generally have associated psychosocial problems including child abuse. Infants seen who have fully recovered from critical illnesses but are considered "at risk" for later developmental disability. Infants seen with normal variations of behavior that are misinterpreted by their parents or physicians as due to a medical problem. In infancy medical and psychosocial issues are so closely interwoven that it is critical that physicians learn to recognize the major psychosocial consequences of primary medical problems and the medical manifestations of primary psychosocial problems and their management.     

Dimensions of child sexual abuse before age 15 in three Central American countries: Honduras, El Salvador, and Guatemala

OBJECTIVE: The prevalence of sexual abuse during childhood or adolescence varies depending on the definitions and age categories used. This study examines the first national, population-based data available on child sexual abuse that occurs before age 15 in three countries: El Salvador, Guatemala, and Honduras. This study uses comparable indicators and measures of sexual abuse for the three countries to document the prevalence of abuse, types of perpetrators, and the association of child sexual abuse with recent intimate partner violence. METHODS: Child sexual abuse was defined as sexual abuse that first occurs before age 15. Nationally representative data from El Salvador, Guatemala, and Honduras were used. In El Salvador, separate questions on forced intercourse and non-penetrative sexual abuse were asked. Bivariate and multivariate analyses were performed using STATA Version 8SE. RESULTS: The prevalence of child sexual abuse varied from 7.8% in Honduras to 6.4% in El Salvador and 4.7% in Guatemala. In all three countries, the overwhelming majority of women who reported child sexual abuse first experienced the abuse before age 11. Perpetrators tended to be a family member, a neighbor, or an acquaintance. Bivariate and multivariate analyses indicated that women who experienced child sexual abuse in Guatemala and Honduras were about two times more likely to be in violent relationships as women who did not experience abuse. This relationship was not significant in multivariate analyses for El Salvador where the prevalence of intimate partner violence was the lowest. CONCLUSIONS: Child sexual abuse in Central America is clearly a problem with the prevalence between 5% and 8%. Child sexual abuse can have long-term negative health impacts including exposure to intimate partner violence in adulthood. Programs to prevent abuse and treat victims of child sexual abuse are needed in Central America.     

Teachers' recognition and reporting of child abuse: a factorial survey

OBJECTIVE: The major aim of this study was to determine the effect of characteristics of the case, the teacher, and the organizational setting on recognition and reporting of child abuse. METHOD: A factorial survey design was employed in which a probability sample of teachers (N = 480) responded to vignettes in which case characteristics were systematically manipulated. RESULTS: Analysis using OLS regression showed that case characteristics alone accounted for 50.30% of the variance in recognition and 51.08% of the variance in reporting: the strongest effects were from type and seriousness of abuse, positive behavior of the victim and positive psychology of the perpetrator. The inclusion of variables describing the teachers and the school explained only a very small additional proportion of the variance in teacher's responses. CONCLUSIONS: Teachers responses to child abuse are relatively unbiased by either the extraneous characteristics of the perpetrator or victim, the responding teacher, or the school setting. The findings do not appear to support the problem of "overreporting." There is evidence for "underreporting," particularly in less serious cases involving physical and emotional abuse. Teachers are undeterred by the many problems and fears that may accompany a report of child abuse to Child Protective Services. Teachers use discretion in reporting abuse they recognize.     

A review of the short-term effects of child sexual abuse

This is the first of a two-part report that critically evaluates empirical studies on the short- and long-term effects of child sexual abuse. With the exception of sexualized behavior, the majority of short-term effects noted in the literature are symptoms that characterize child clinical samples in general. Among adolescents, commonly reported sequelae include sexual dissatisfaction, promiscuity, homosexuality, and an increased risk for revictimization. Depression and suicidal ideation or behavior also appear to be more common among victims of sexual abuse compared to normal and psychiatric nonabused controls. Frequency and duration of abuse, abuse involving penetration, force, or violence, and a close relationship to the perpetrator appear to be the most harmful in terms of long-lasting effects on the child. The high prevalence of marital breakdown and psychopathology among parents of children who are sexually abused makes it difficult to determine the specific impact of sexual abuse over and above the effects of a disturbed home environment. Given the broad range of outcome among sexual abuse victims, as well as the methodological weaknesses present in many of the studies reviewed, it is not possible at this time to postulate the existence of a "post-sexual-abuse-syndrome" with a specific course or outcome.     

Characteristics of child abuse homicides in the state of Kansas from 1994 to 2007

Objective

This study described the epidemiology of child abuse homicides in the state of Kansas from 1994 to 2007. It focused on obtaining significant details on all recorded child abuse homicides in Kansas during this time frame to provide critical information that can be used for future preventive measures.

Methods

A retrospective case review was conducted on data gathered by the Kansas State Child Death Review Board for all cases of “child abuse homicides” that occurred from 1994 to 2007.

Results

A total of 170 child abuse homicide cases in Kansas between 1994 and 2007 were identified. The majority of these cases (63.5%) were considered fatal child physical abuse. There was a predominance of female victims (55.9%). The vast majority of victims were White (78.8%), followed by Black (17.1%). One to 2-year-olds accounted for the largest age group of children who were victimized (33.5%). For cases with known prenatal care status, 74% of mothers received adequate prenatal care. The largest percentage of victims was children of single mothers (40.6%), with no prior history of child abuse (60%). The majority of deaths occurred in the victim's residence (81.8%). The greatest number of deaths occurred secondary to abusive head trauma (42.9%), followed by asphyxia (21.8%). When a trigger was known, 44.2% involved inconsolable crying. The most common perpetrator was the victim's biological father (26.6%), followed by the victim's biological mother (24.9%), then the victim's mother's male paramour (19.8%).

Conclusions

Familiarity with characteristics involved in child abuse homicide allows for opportunities to enlist important preventive measures. Most child abuse homicides occurred at the hands of the victim's biological parents and in the victim's own residence. Prevention should be focused on parent education and coping mechanisms for the frustrating features of crying in normal infants that lead to shaking or abuse.     

Emotion recognition in fathers and mothers at high-risk for child physical abuse

Objective

The present study was designed to determine whether parents at high risk for physical child abuse, in comparison with parents at low risk, show deficits in emotion recognition, as well as to examine the moderator effect of gender and stress on the relationship between risk for physical child abuse and emotion recognition.

Methods

Based on their scores on the Abuse Scale of the CAP Inventory (Milner, 1986), 64 parents at high risk (24 fathers and 40 mothers) and 80 parents at low risk (40 fathers and 40 mothers) for physical child abuse were selected. The Subtle Expression Training Tool/Micro Expression Training Tool ( [Ekman, 2004a] and [Ekman, 2004b]) and the Diagnostic Analysis of Nonverbal Accuracy II (Nowicki & Carton, 1993) were used to assess emotion recognition.

Results

As expected, parents at high risk, in contrast to parents at low risk, showed deficits in emotion recognition. However, differences between high- and low-risk participants were observed only for fathers, but not for mothers. Whereas fathers at high risk for physical child abuse made more errors than mothers at high risk, no differences between mothers at low risk and fathers at low risk were found. No interaction between stress, gender, and risk status was observed for errors in emotion recognition.

Conclusions and practice implications

The present findings, if confirmed with physical abusers, could be helpful to further our understanding of deficits in processing information of physically abusive parents and to develop treatment strategies specifically focused on emotion recognition. Moreover, if gender differences can be confirmed, the findings could be helpful to develop specific treatment programs for abusive fathers.