Inflicted skeletal trauma: the relationship of perpetrators to their victims

OBJECTIVE: Although inflicted skeletal trauma is a very common presentation of child abuse, little is known about the perpetrators of inflicted skeletal injuries. Studies exist describing perpetrators of inflicted traumatic brain injury, but no study has examined characteristics of perpetrators of inflicted skeletal trauma. METHODS: All cases of suspected child physical abuse evaluated by the child abuse evaluation teams at Vanderbilt University Medical Center (January 1996 to August 2000) and at the Children's Hospital at Denver (January 1996 to December 1999) were reviewed for the presence of fractures. All children with inflicted fractures were entered into the study, and demographic data, investigative data, and identity of perpetrators were collected. RESULTS: There were a total of 630 fractures for 194 patients. The median number of fractures per patient was 2, and the maximum was 31. Sixty-three percent of children presented with at least one additional abusive injury other than the fracture(s). Perpetrators were identified in 79% of the cases. Nearly 68% of the perpetrators were male; 45% were the biological fathers. The median age of the children abused by males (4.5 months) significantly differed from the median age of those abused by females (10 months) (p=.003). CONCLUSION: In the cases where a perpetrator of inflicted fractures could be identified, the majority were men, most commonly the biological fathers. Children injured by men were younger than those injured by women.     

Use of epidemiological data in the diagnosis of physical child abuse: variations in response to hypothetical cases.

This study was undertaken to determine whether epidemiological data describing the injuries associated with unintentional trauma could help physicians differentiate intentional from unintentional injury. The authors also wished to determine if case and physician-specific factors altered how epidemiological data were used. Study subjects were 280 physicians who had registered for an advanced course in pediatric life support. Responses were received from 166 (59%); 48% were pediatricians and 37% had trained in emergency medicine. Case vignettes were written describing a child's fall from a highchair. The vignettes systematically varied the type of injury sustained, the presence of a social risk factor, and whether the child was followed by a primary care provider. Vignettes were administered with and without provision of epidemiological data describing injuries associated with highchair falls. Each study participant received one vignette, and was asked to mark, on a 0-100 scale, their confidence in the injury history given. In vignettes where the presenting injury (femur fracture) would not be expected based on the epidemiological data, the availability of data appropriately decreased confidence that the injury was unintentional (average decrease = 14.3, 95% confidence limits = 3.8 to 25.9). When the presenting injury (skull fracture) matched the epidemiological data, its availability did not alter confidence (average change = 0.5, 95% to -13.1 to + 12.1). The impact of a contrast between presenting injury and data varied with specialty: It caused a marked drop in confidence among pediatricians but caused no change among emergency room/intensive care unit (ER/ICU) physicians. Data did, however, lead ER/ICU physicians to respond more strongly to a social risk cue (mean confidence 14.9 vs. 42.4, p less than .05) than they had in the absence of data. We concluded that epidemiological data has the potential for influencing physician decision-making in cases of suspected maltreatment, but that its impact may vary among physicians with differing training.     

Cerebral infarct in head injury: relationship to child abuse

BACKGROUND: To determine whether CT-detected cerebral infarct in young children is associated more often with abuse or unintentional head injury. METHODS: Retrospective case-control study of injured children under age 6 who had abnormal initial head CT scans and who were admitted to the only Level I pediatric trauma center in Washington State for closed head injury (CHI) from January 1, 1992 to December 31, 1998. RESULTS: Fifteen children developed cerebral infarct after CHI during the 7 year period. These cases were compared to 53 controls (those who did not develop infarct). After adjusting for the presence of SDH and for severity of injury, patients with infarcts were six times more likely to have been abused than patients without infarcts (OR 6.1; 95% CI, 1.02-36.0). CONCLUSIONS: Cerebral infarct after CHI appears to result more frequently from abuse than unintentional injury in young children.     

Are abusive fractures in young children becoming less common? Changes over 24 years

OBJECTIVE: To determine whether the proportion of fractures rated as abusive in children <36 months of age evaluated at a regional pediatric hospital increased over a 24-year period from 1979 to 2002. Fractures were chosen as an example of serious injuries in young children. METHODS: Medical records were abstracted for all children <36 months of age who were seen at a single pediatric hospital with a fracture during three time periods: 1979-1983, 1991-1994, and 1999-2002. After reviewing the abstracted and radiographic information, two clinicians (one an expert on child abuse) and two pediatric radiologists each rated the likelihood of abuse using explicit criteria and a seven-point scale from definite abuse to definite unintentional injury. Ratings were done independently; when disagreements occurred, the case was discussed, and a joint rating was agreed upon, if possible. The proportions of cases rated as abuse were compared over the three time periods, and logistic regression was used to calculate adjusted odds ratios (OR). RESULTS: In the early, middle, and late samples, there were 200, 240, and 232 children, respectively, with fractures. The proportion of cases rated as abuse decreased from 22.5% in the early period to 10.0% in the middle period and was 10.8% in the late period (p<.001). When comparing the odds of abuse in the middle and late groups to the odds of abuse in the early group (controlling for age, gender, ethnicity, type of medical insurance, and site of pediatric care), the adjusted ORs were .31 (95% CI=.15, .62) for the middle group and .45 (95% CI=.23, .86) for the late group. Thus, the odds of a given case being rated as abuse decreased by over 50% from the early period to the middle and late time periods. No statistically significant difference was found when comparing the odds of abuse for the middle group to those of the late group, OR: 1.46 (95% CI=.69, 3.08). CONCLUSIONS: The proportion of abusive fractures in young children decreased substantially from 1979-1983 to 1991-1994 and 1999-2002 at a major pediatric hospital. We speculate that this decrease may reflect early recognition of less serious forms of maltreatment and the availability of services to high-risk families.     

Gray cases of child abuse: Investigating factors associated with uncertainty

Research in child abuse pediatrics has advanced clinicians’ abilities to discriminate abusive from accidental injuries. Less attention, however, has been paid to cases with uncertain diagnoses. These uncertain cases – the “gray” cases between decisions of abuse and not abuse – represent a meaningful challenge in the practice of child abuse pediatricians. In this study, we describe a series of gray cases, representing 17% of 134 consecutive children who were hospitalized at a single pediatric hospital and referred to a child abuse pediatrician for concerns of possible abuse. Gray cases were defined by scores of 3, 4, or 5 on a 7-point clinical judgment scale of the likelihood of abuse. We evaluated details of the case presentation, including incident history, patient medical and developmental histories, family social histories, medical studies, and injuries from the medical record and sought to identify unique and shared characteristics compared with abuse and accidental cases. Overall, the gray cases had incident histories that were ambiguous, medical and social histories that were more similar to abuse cases, and injuries that were similar to accidental injuries. Thus, the lack of clarity in these cases was not attributable to any single element of the incident, history, or injury. Gray cases represent a clinical challenge in child abuse pediatrics and deserve continued attention in research.     

Decision making in determining eligibility of culturally and linguistically diverse learners: Reasons given by assessment personnel

Assessment personnel from the southern borderlands area of Texas participated in analyzing one of four different hypothetical cases. Respondents were expected to defer making eligibility decisions due to language proficiency, environment, culture, or lack of data. When data were lacking, the investigators proposed that respondents would recognize the need for additional information and defer making a decision. Differences in eligibility decisions were found when the respondents analyzed cases in which a significant discrepancy existed and in cases in which language proficiency information was provided. Experience in assessment was significant in the determination that additional information was needed to reach a decision, F(2, 87) = 3.99, p < .05. A majority of the respondents (83%) made an eligibility decision using insufficient data.     

Misconceptions about traumatic brain injury among students preparing to be special education professionals

The researchers performed a survey study to determine the effectiveness of collegiate programmes in dispelling common misconceptions about traumatic brain injury (TBI) while preparing undergraduate and graduate students for special education (SpEd) careers. Respondents included 136 undergraduate and 147 graduate SpEd students in their final semesters before obtaining degrees. Each completed an 18‐item true/false survey about TBI and the associated recovery process. Results were compared with survey responses from 318 lay public respondents who participated in a previous study. Two major findings emerged: (a) no significant differences existed in misconception endorsement between SpEd students completing Bachelor's versus Master's degrees; and (b) graduating students in SpEd teacher preparation programmes endorsed similar misconceptions as lay public respondents; hence, these programmes do not appear effective in dispelling common TBI misconceptions. Improving academic preparation for special educators regarding TBI is imperative for effectively identifying, assessing and serving student survivors.     

Assessment of factors resulting in abuse evaluations in young children with minor head trauma

OBJECTIVE: The primary objective was to determine which of the examined factors prompted physicians to initiate a further abuse evaluation in young children with minor head injury. The recording of important historical elements in the charts of these patients was also evaluated. METHODS: Charts of 349 children less than 3 years of age with minor head injury were retrospectively reviewed. Age, race, sex, insurance status, findings on head CT, mechanism of injury, witnessing of event and delay in seeking care were analyzed for association with performance of skeletal survey and referral to Child Protective Services (CPS). RESULTS: Increased odds of CPS referral and increased odds of obtaining a skeletal survey were associated with positive findings on head CT, delay in seeking care, and unknown mechanism of injury. Despite a known association of age/ambulatory status with abuse, the age of the child was not associated with increased odds of abuse evaluation, and younger age was not associated with increased odds of documenting whether the injury was witnessed or when the injury occurred. Documentation of timing of injury was lacking in 29.2% of the charts. Witnessing of the event was undocumented in 48.7% of cases. CONCLUSION: Clinicians may not be using readily available, important information when considering the initiation of an abuse evaluation in young children. Clinicians seeing acutely injured children may need further education regarding developmental status and its effect on mechanisms of injury and the importance of detailed documentation in cases where abuse is a possible cause of injury. PRACTICE IMPLICATIONS: Historical factors associated with injuries in young children continue to be poorly documented. Increased pediatric training for emergency medicine physicians, clinical protocols for evaluation and documentation of injured children, and regular continuing medical education on child development and its implications on mechanisms of injury for clinicians practicing in acute care settings are needed changes that may bring about improvements.     

Child maltreatment in U.S. emergency departments: Imaging and admissions

ObjectiveWe report imaging and admission ratios for children with definitive and suggestive maltreatment in a national sample of emergency departments (EDs).MethodsUsing the 2012 Nationwide Emergency Department Sample (NEDS), we generated national estimates of ED visits for children <10 years with both definitive and suggestive maltreatment. Outcomes were admission/transfer ratios for children <10 years and screening ratios by skeletal surveys and head computed tomography (CT) for children <2 years with suspected physical abuse. We compared hospitals with low, medium, and high pediatric ED volumes using multivariable logistic regression.ResultsThe 2012 national estimate of U.S. ED visits (children <10 years) with definitive maltreatment is 14,457 (95% CI: 11,987–16,928). Suggestive child maltreatment was seen in an additional 103,392 (95% CI: 90,803–115,981) pediatric ED visits. After controlling for patient case mix, high volume hospitals had a significantly higher adjusted odds ratio (AOR) of admission/transfer among definitive cases (AOR = 1.74, 95% CI: 1.08–2.81), and medium volume hospitals had a higher odds of admission/transfer among suggestive cases (AOR = 1.24, 95% CI: 1.02–1.50) when compared with low volume hospitals. In hospitals with reliable reporting of imaging procedures, high volume hospitals reported skeletal surveys (age <2 years) significantly more often than low volume hospitals, AOR = 3.32 (95% CI: 1.25–8.84); the AORs for head CT did not differ by hospital volume.ConclusionsLow volume hospitals were less likely to screen by skeletal survey, but head CT ratios were not affected by ED volume. Low volume hospitals were also less likely to admit or transfer.     

Which sexual abuse victims receive a forensic medical examination? The impact of Children's Advocacy Centers

OBJECTIVE: This study examines the impact of Children's Advocacy Centers (CAC) and other factors, such as the child's age, alleged penetration, and injury on the use of forensic medical examinations as part of the response to reported child sexual abuse. METHODS: This analysis is part of a quasi-experimental study, the Multi-Site Evaluation of Children's Advocacy Centers, which evaluated four CACs relative to within-state non-CAC comparison communities. Case abstractors collected data on forensic medical exams in 1,220 child sexual abuse cases through review of case records. RESULTS: Suspected sexual abuse victims at CACs were two times more likely to have forensic medical examinations than those seen at comparison communities, controlling for other variables. Girls, children with reported penetration, victims who were physically injured while being abused, White victims, and younger children were more likely to have exams, controlling for other variables. Non-penetration cases at CACs were four times more likely to receive exams as compared to those in comparison communities. About half of exams were conducted the same day as the reported abuse in both CAC and comparison communities. The majority of caregivers were very satisfied with the medical professional. Receipt of a medical exam was not associated with offenders being charged. CONCLUSIONS: Results of this study suggest that CACs are an effective tool for furthering access to forensic medical examinations for child sexual abuse victims.     

A profile of the oro-facial injuries in child physical abuse at a children's hospital

OBJECTIVE: The aim of the present study was to determine the head, face and neck injuries associated with child abuse cases in the Cape Peninsula, Cape Town. South Africa. METHOD: A retrospective, record-based analysis (n = 300) of non-accidental injuries at a Children's Hospital over a 5-year period (1992-1996) was carried out. RESULTS: The mean age of the sample was 4.75 years--54.3% were boys and 45.7% were girls. Most of the crimes were committed in the child's own home (88.7%). Crimes were reported by mothers (48.7%), grandmothers (11.7%) and day hospitals (13%). Ninety percent of the perpetrators were known to the victim. The majority of the perpetrators were male (79%)--20% the perpetrators were the mother's boyfriend; 36% the father or step father, and in 12% the mother was responsible. Thirty-five percent of perpetrators were under the influence of alcohol or drugs when they committed the offence: 64.7% of cases suffered serious injuries, 48.7% had to be hospitalized, four children were critically injured and died. The head, face, neck, and mouth were the sites of physical injury in 67% of the 300 cases reviewed. The face was the most frequently injured (41%) part of the body, with the cheek being the most common site for the injury. The range and diversity of the oro-facial injuries included skull fractures, subdural hematomas, retinal hemorrhages, bruises, burns, and lacerations. Injuries to the mouth included fractured teeth, avulsed teeth, lacerations to the lips, frenum, tongue, and jaw fractures. CONCLUSIONS: The main conclusions of this study were (i) under 2-year-old children were most at risk from abuse (36%); (ii) the number of the reported injuries to the oral cavity was extremely low (11%); and (iii) no dentists participated in the examination of any of the patients. Intra-oral injuries may be overlooked because of the medical examiner's unfamiliarity with the oral cavity. Oral health professionals should be consulted for diagnosis, advice and treatment.     

The effects of personal and situational factors on university administrators' responses to sexual harassment

The present study was designed to assess how managerial personnel respond to various sexual harassment scenarios. Much of the sexual harassment research has utilized samples other than managerial personnel. Therefore, this study attempts to determine whether the findings in the literature generalize to a managerial sample. University administrators' responses to sexual harassment scenarios were assessed, with type of harassment (economic injury, hostile environment, or no harassment) and offender's status (supervisor or co-worker) being varied. Analyses revealed a lack of predicted sex differences in perceptions and definitions of sexual harassment and unanticipated sex differences in complaint handling and belief in sexual harassment myths. There were no offender status effects. The significant type of harassment effects was present for complaint handling, familiarity, and situation perceptions. In all cases, the respondents who received the “no harassment” scenario differed in their responses from the participants who had received one of the two harassment scenarios.     

Biochemical markers of brain injury: could they be used as diagnostic adjuncts in cases of inflicted traumatic brain injury?

Child abuse is the leading cause of serious traumatic brain injury (TBI) in infants and young children (Billmire & Myers, 1985; Bruce & Zimmerman, 1989). The incidence of serious or fatal inflicted traumatic brain injury (iTBI) in children < 1 year of age is approximately 1 in 3,300 ( Keenan et al., 2003); since many cases of iTBI are of mild or moderate severity, the incidence is probably significantly higher. Even at an incidence of 1 in 3,300, iTBI is as common as the incidence of cystic fibrosis (CF), the most common genetic recessive disease in the Caucasian population. Proper diagnosis of iTBI is difficult even for experienced and astute physicians because its presentation can be subtle and important historical data are often lacking. As a result, misdiagnosis is common and can have catastrophic medical consequences for patients and significant financial consequences for society ( Ewing-Cobbs et al., 1998; Jenny, Hymel, Pitzen, Reinert, & Hay, 1999). Unlike CF for which there are several well established screening tests, there are currently no diagnostic adjuncts to help physicians screen for possible iTBI.     

Longitudinal and Concurrent Relations among Temperament, Ability Estimation, and Injury Proneness

This study examined longitudinal and concurrent relations between temperament, ability estimation, and injury proneness. Longitudinal assessments of Inhibitory Control were collected through a behavioral battery at toddler (33 months) and preschool ages (46 months). Parent-reported measures of Inhibitory Control and Extraversion also were obtained at those ages. At school age (76 months), children participated in a set of tasks to assess overestimation and underestimation of physical abilities. Parents provided reports of children's temperament and injury history at school age. Results showed that children who were high on Extraversion and low on Inhibitory Control as toddlers and preschoolers tended to overestimate their physical abilities and to have more unintentional injuries at age 6. Children low on Extraversion and high on Inhibitory Control tended to underestimate their physical abilities. Implications for injury prevention are discussed.     

Trends in US physician diagnosis of child physical abuse and neglect injuries, 2006–2014

ObjectiveTo determine if US child physical abuse and neglect injury rates changed from 2006 to 2014, whether definitive diagnoses of physical abuse and neglect were used more often over time, and what patient factors influenced definitive physical maltreatment diagnoses.MethodsNationally estimated rates of definitive and suggestive physical abuse and neglect injuries for children <10 years were generated using the Nationwide Emergency Department Sample, the National Inpatient Sample, and census estimates. Trends over time were evaluated, including the trend in the proportion of definitive diagnoses to all diagnoses (definitive plus suggestive). Logistic regression was used to evaluate whether patient characteristics and hospital patient volumes were associated with definitive versus suggestive diagnoses.ResultsThe population rates of child physical maltreatment medically treated injuries were unchanged from 2006 to 2014; the trends were not statistically significant for ED or hospitalized patients. Over time, physician definitive diagnoses as a proportion of all physical maltreatment diagnoses (definitive plus suggestive) increased in admitted children from 17.6% in 2006 to 22.0% in 2014 (p = 0.02). Older age, white race, lower income by zip code, and public insurance as well as larger patient volumes increased the odds of definitive rather than suggestive diagnoses of physical abuse and neglect injuries.ConclusionsDefinitive diagnoses of physical abuse and neglect increased over the study period and were associated with hospital volume and patient characteristics which may reflect provider experience and possible bias. The use of electronic medical records may have influenced the coding of definitive diagnoses.     

Child abuse in Malmö 1967–1974

All cases of suspected or verified child abuse (the battered child syndrome) registered at the Department of Paediatrics in Malmö from 1967 through 1974 were surveyed. During this period 52 patients (54 incidents) were observed, the majority in the years 1970 to 1974. In 5 suspected cases the examination, social history and other circumstances excluded physical abuse. The incidence of child abuse in the city of Malmö for the years 1970 to 1974 was estimated at 35 cases per million inhabitants and year. When compared to the incidence reported in an earlier Swedish investigation (Barnmisshandel 1969) the figures suggest a real increase in the rate of child abuse. In comparison with the estimated incidence in USA and Great Britain the Malmö figures appear low, however. The age of the battered children, the family situation and the social characteristics were essentially in agreement with previous reports. Of the inflicted injuries 37 per cent were regarded as serious or very serious. One child died and in another the injuries resulted in permanent damage. Sixteen children had been repeatedly battered. Up to the end of 1974 10 per cent of the children had been rebattered in spite of what had been thought to be adequate measures to prevent further abuse. Forty-three families (6 were excluded for different reasons) were retrospectively analyzed with regard to the domestic and social situation. It was concluded that in 16 of these families it had not been possible to discern that the child was at risk. The investigation emphasizes the need for psychological assessment of battering parents, and suggests that cases of child abuse should be handled by a team of medical and social experts.     

TEACHERS’ MINDSETS FOR STUDENTS WITH AND WITHOUT DISABILITIES

Research suggests beliefs about the stability of ability can be dichotomized into two mindsets: fixed and growth (Dweck, 1999 ). Teachers’ (n = 238) beliefs regarding the stability of ability (mindset) and the stability of ability for 4 hypothetical students scenarios (mindset for scenarios) were measured. Mindset scores were related to mindset for scenario scores. Moreover teachers demonstrated increased neutral mindset scores and decreased fixed mindset scores for hypothetical student scenarios with no discernible differences for student gender or disability status.     

Children with burns referred for child abuse evaluation: Burn characteristics and co-existent injuries

Intentional burns represent a serious form of physical abuse that must be identified to protect children from further harm. This study is a retrospectively planned secondary analysis of the Examining Siblings To Recognize Abuse (ExSTRA) network data. Our objective was to describe the characteristics of burns injuries in children referred to Child Abuse Pediatricians (CAPs) in relation to the perceived likelihood of abuse. We furthermore compare the extent of diagnostic investigations undertaken in children referred to CAPs for burn injuries with those referred for other reasons. Within this dataset, 7% (215/2890) of children had burns. Children with burns were older than children with other injuries (median age 20 months vs. 10 months). Physical abuse was perceived as likely in 40.9% (88) and unlikely in 59.1% (127). Scalds accounted for 52.6% (113) and contact burns for 27.6% (60). Several characteristics of the history and burn injury were associated with a significantly higher perceived likelihood of abuse, including children with reported inflicted injury, absent or inadequate explanation, hot water as agent, immersion scald, a bilateral/symmetric burn pattern, total body surface area ≥10%, full thickness burns, and co-existent injuries. The rates of diagnostic testing were significantly lower in children with burns than other injuries, yet the yield of skeletal survey and hepatic transaminases testing were comparable between the two groups. This would imply that children referred to CAPs for burns warrant the same level of comprehensive investigations as those referred for other reasons.