Analysis of caretaker histories in abuse: comparing initial histories with subsequent confessions

OBJECTIVE: We hypothesize that perpetrators of abuse include elements of truth in their initial history and that an analysis of perpetrator confessions can teach professionals how to identify these initial truths. METHODS: The information from a consecutive sample of perpetrators' confessions concerning 41 children hospitalized because of injuries caused by child abuse was reviewed. The details about the injuries contained in the confessions were compared with the details provided when these children initially presented for medical care. Information about the perpetrator's gender and relationship to the child, the victim's age and gender, type of injury, family risk factors, the trigger of the abusive event, the circumstances surrounding the event, and the type of trauma were collected. RESULTS: A total of 45 perpetrators abused 41 children; 76% of perpetrators were male; 56% were the child's father; 34% were the child's mother. The perpetrators initially provided no explanation about how 68% of the children received an injury. In 91% of their initial histories, the perpetrators provided some element of truth about the circumstances or triggering event for the abuse. In 67% of confessions, crying was the circumstance that triggered the abuse. Mothers were more likely to describe the situation that triggered the abuse (85% of mothers versus 58% of fathers, p=ns), while fathers were more likely to describe accurately the circumstances surrounding the abuse (79% of fathers versus 62% of mothers, p=ns). CONCLUSIONS: Perpetrators of abuse provide initial truths in their presenting history. Child abuse professionals must take a careful history from all caretakers and "listen" for the "elements of truth." These truths are the child's behavior or circumstance that increased stress and triggered the abuse. Employing this method in a careful analysis of confessions can make a significant contribution to the capacity to identify child abuse. In addition, more information about the role of triggers may help to focus child abuse prevention strategies.     

Understanding forearm fractures in young children: Abuse or not abuse?

This retrospective study describes the characteristics and mechanisms of forearm fractures in children <18 months adding to the evidence-base about forearm fractures. It also examines which features of forearm fractures in young children may help discriminate between abusive and noninflicted injuries. Electronic medical records were reviewed for eligible patients evaluated between September 1, 2007 and January 1, 2012 at two children's hospitals in Chicago, IL. The main outcome measures were the type of fracture and the etiology of the fracture (abuse versus not abuse). The 135 included patients sustained 216 forearm fractures. Most were buckle (57%) or transverse (26%). Child protection teams evaluated 47 (35%) of the patients and diagnosed 11 (23%) as having fractures caused by abuse. Children with abusive versus non-inflicted injuries had significant differences in age (median age 7 versus 12 months), race, and presence of additional injuries. Children with abusive forearm fractures often presented without an explanation or a changing history for the injury. Children with non-inflicted forearm fractures often presented after a fall. No particular type of forearm fracture was specific for child abuse. Any forearm fracture in a young child should be evaluated with special attention to the details of the history and the presence of other injuries. Young age, additional injuries, and an absent or inconsistent explanation should increase concern that the fracture was caused by child 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.     

Social history: A qualitative analysis of child abuse pediatricians’ consultation notes

BackgroundChild abuse pediatricians (CAPs) are often consulted for injuries when child physical abuse is suspected or when the etiology of a serious injury is unclear. CAPs carefully evaluate the reported mechanism of the child’s injury and the medical findings in the context of the child’s family and social setting to identify possible risk and protective factors for child abuse and the need for social services. It is unknown what population risk indicators along with other social cues CAPs record in the social history of the consultation notes when assessing families who are being evaluated for child physical abuse.Participants and settingThirty-two CAPs representing 28 US child abuse programs.MethodsParticipants submitted 730 completed cases of inpatient medical consultation notes for three injury types: traumatic brain injury, long bone fracture, and skull fracture in hospitalized children 4 years of age and younger. We defined a priori 12 social cues using known population risk indicators (e.g., single mother) and identified de novo 13 negative (e.g., legal engagement) and ten positive social cues (e.g., competent parenting). Using content analysis, we systematically coded the social history for the social cues.ResultsWe coded 3,543 cues resulting in a median of 7 coded cues per case. One quarter of the cues were population indicators while half of the cues were negative and one quarter positive.ConclusionsCAPs choose a wide variety of information, not always related to known population risk indicators, to include in their social histories.     

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.     

Children with reported histories of sexual abuse: utilizing multiple perspectives to understand clinical and psychosocial profiles

OBJECTIVE: The current study examines multiple empirically based perspectives (i.e., child, caregiver, and clinician) of behavior and functioning as they contribute to the clinical and psychosocial profile of children (aged 5 to 17.5 years) with reported histories of sexual abuse.METHOD: A large, multi-site data set of children referred into Comprehensive Community Mental Health Services both with and without reported histories of sexual abuse, was examined. Seven hundred and fifty-nine children with a reported history of sexual abuse were compared to 2722 without such a history on caregiver and child reported behavior, clinician rated functioning, diagnosis, demographic variables, and life challenges.RESULTS: The multiple perspectives contributed unique and specific information to regression models: caregiver-reported behavior contributed information about externalizing behavior while child-reported behavior added information about internalizing behavior and clinician ratings about self-harmful behavior. Children with reported histories of sexual abuse were also more likely to be female, Caucasian, and have reported histories of life challenges (e.g., physical abuse, substance use, running away). Child sexual abuse was associated with higher rates of depression and anxiety diagnoses, and lower rates of substance abuse, conduct, and attention deficit disorder diagnoses.CONCLUSIONS: The findings indicate that the profile of children entering into Comprehensive Community Mental Health Services with reported histories of sexual abuse, as compared to those without such histories, is complex and best understood via multiple perspectives. Caregiver, child and clinician rated information, when taken together, provide a comprehensive clinical and psychosocial profile around which to plan and implement individualized service plans.     

Three models of child abuse consultations: A qualitative study of inpatient child abuse consultation notes

Child abuse pediatricians have multiple roles in caring for abused children, including prevention, diagnosis, treatment, and, when needed, expert legal opinion. The child physical abuse consultation differs from the traditional medical consultation in that it has medical, investigative and legal audiences, all of whom have different information needs. How child abuse pediatricians approach their cases and how they document their initial inpatient consultations that will be used by such a diverse audience is currently unexplored. We used content analysis to examine 37 child physical abuse consultation notes from a national sample of child abuse pediatricians in order to understand physicians’ approaches to these consultations. Three commonly used models of child physical abuse consultation were identified in the data that we named the base model, the investigative model, and the family-dynamic model. While model types overlap, each is distinguished by key features including the approach used to gather information, the information recorded, and the language used in documentation. The base model most closely mirrors the traditional medical approach; the investigative model concentrates on triangulation of sources of information; and, the family-dynamic model concentrates on physician perceptions of family relationships. The three models of consultations for child physical abuse mirror the areas of child abuse pediatrics: diagnostic, forensic and therapeutic. These models are considered in relationship to best practice from other medical specialties with forensic components.     

A child abuse research network: Now what?

As foundational work in preparation for a sustainable, multi-center network devoted to child abuse medical research, we recently used a combination of survey and modified Delphi methodologies to determine research priorities for future multi-center studies. Avoiding missed diagnoses, and improving selected/indicated prevention were the topics rated most highly in terms of research priority. Several constructive commentaries in this issue identify the key challenges which must be overcome to ensure a successful network. Indeed, as with the clinical work of child abuse pediatrics, a scientific network will also require constant collaboration within and outside the community of child abuse pediatricians, the wider medical community, and even non-medical professions.     

Children referred for possible sexual abuse: medical findings in 2384 children

OBJECTIVE: The goal of this study was to compare rates of positive medical findings in a 5-year prospective study of 2384 children, referred for evaluation of possible sexual abuse, with two decades of research. The prospective study summarizes demographic information, clinical history, relationship of perpetrators, nature of abuse, and clinical findings. The study reports on the results by patterns of referral and the medical examination. RESULTS: There were 2384 children evaluated in a tertiary referral center between 1985 and 1990 for possible sexual abuse. Children were referred after they disclosed sexual abuse, because of behavioral changes or exposure to an abusive environment, and because of possible medical conditions. A total of 96.3% of all children referred for evaluation had a normal medical examination; 95.6% of children reporting abuse were normal, 99.8% who were referred for behavioral changes or exposure to abuse were also normal. Of the 182 children referred for evaluation of medical conditions, 92% were found to be normal at the time of examination by the Child Advocacy Center. The remaining 15/182 (8%) that were found to be abnormal were diagnosed with sexually transmitted diseases, acute or healed genital injuries, and were 17% (15/88) of the total cases found to have medical findings diagnostic of abuse. Interviews of the children indicated that 68% of the girls and 70% of the boys reported severe abuse, defined as penetration of vagina or anus. Penetration was associated with a higher percentage of abnormal findings in girls (6%) compared to 1% of the boys. The relationship of the abuser impacted on the severity of the abuse. CONCLUSION: Research indicates that medical, social, and legal professionals have relied too heavily on the medical examination in diagnosing child sexual abuse. History from the child remains the single most important diagnostic feature in coming to the conclusion that a child has been sexually abused. Only 4% of all children referred for medical evaluation of sexual abuse have abnormal examinations at the time of evaluation. Even with a history of severe abuse such as vaginal or anal penetration, the rate of abnormal medical findings is only 5.5%. Biological parents are less likely to engage in severe abuse than parental substitutes, extended family members, or strangers.     

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.     

History of physical and/or sexual abuse and current suicidality in college women

OBJECTIVE: The purpose of this study was to examine the relationship between a history of physical and/or sexual abuse and current suicidality in college-age women. It was hypothesized that abuse history would significantly predict level of suicidality. A secondary hypothesis was that abuse status would predict attitudes about life and death. METHOD: Female college students (n = 707) were screened for histories of childhood (before age 15) and adulthood (after age 15) contact sexual abuse and physical abuse sequelae. Ninety-five women reported a history of childhood sexual abuse, 116 adult sexual abuse, 104 child physical abuse, and 55 adult physical abuse. Participants completed measures of attitudes about life and death and current suicidal ideation. RESULTS: Child physical abuse and child sexual abuse accounted for variance in current suicidal ideation. Adult sexual abuse explained variance in positive attitudes about life. Adult physical abuse, adult sexual abuse, and child sexual abuse accounted for variance in negative attitudes about life. Finally, child sexual abuse and adult sexual abuse accounted for variance in fear of death. CONCLUSIONS: Detailed assessment of female college students' abuse histories should facilitate understanding of their level of suicide risk. Patterns of attitudes about life and death may also be informative.     

Childhood sexual abuse history and role reversal in parenting

OBJECTIVE: This study explored the main and interactive effects of sexual abuse history and relationship satisfaction on self-reported parenting, controlling for histories of physical abuse and parental alcoholism. METHOD: The community sample consisted of 90 mothers of 5- to 8-year-old children. The sample was limited to those mothers currently in an intimate relationship, 19 of whom reported a history of childhood sexual abuse. Participants completed the Child Behavior Checklist, the Parenting Stress Inventory, the Family Cohesion Index, and questions assessing parent-child role reversal, history of abuse and parental alcoholism, and current relationship satisfaction. RESULTS: Results of analyses and multivariate analyses of covariance suggested that sexual abuse survivors with an unsatisfactory intimate relationship were more likely than either sexual abuse survivors with a satisfactory relationship or nonabused women to endorse items on a questionnaire of role reversal (defined as emotional overdependence upon one's child). Role reversal was not significantly predicted by histories of physical abuse or parental alcoholism or child's gender. While parenting stress was inversely predicted by the significant main effect of relationship satisfaction, neither parenting stress nor child behavior problems were predicted by the main effect of sexual abuse history or by the interaction between sexual abuse history and relationship satisfaction. CONCLUSIONS: These results suggest the unique relevance of sexual abuse history and relationship satisfaction in the prediction of a specific type of parent-child role reversal--namely, a mother's emotional overdependence upon her child.     

A study of the relationship between child abuse and drug addiction in 178 patients: Preliminary results

Social histories and demographic data were collected on 178 patients—101 in the United States and 77 in Australia—in treatment for drug/alcohol addiction. The purpose of the study was to determine the degree to which a correlation exists between child abuse/neglect and the later onset of drug/alcohol addiction patterns in the abuse victims. The questionnaire explored such issues as family intactness. parental violence/abuse/neglect, parental drug abuse, sibling relationships and personal physical/ sexual abuse histories, including incest and rape. The study determined that 84% of the sample reported a history of child abuse/neglect.     

Child abuse history in teen mothers and parent–child risk processes for offspring externalizing problems

This study examined whether child abuse history in teen mothers impacts offspring externalizing problems indirectly, through its influence on attachment and maternal hostility. In a longitudinal sample of 112 teen mother–child dyads, mothers reported on their own abuse experiences, attachment and maternal hostility were assessed via direct observations, and externalizing problems were measured using maternal reports. Compared with mothers with no abuse history, mothers with a history of sexual and physical abuse were more likely to have an insecurely attached infant, which predicted higher externalizing problems in preschool, which in turn predicted subsequent increases in externalizing problems in Grade 3. Furthermore, relative to the no abuse history group, mothers with a history of sexual and physical abuse showed more hostility toward their child at preschool, which in turn predicted elevated externalizing problems in Grade 3. Mothers’ history of either sexual or physical abuse alone did not have significant indirect effects on externalizing problems. Fostering secure attachment and reducing risk for maternal hostility might be important intervention goals for prevention programs involving at-risk mothers with abuse histories.     

Munchausen syndrome by proxy

Munchausen syndrome by proxy is a form of child abuse in which a disorder of the child is fabricated by a parent. Although often considered rare, it may have been overlooked frequently in the past. The reported cases of children with Munchausen syndrome by proxy range in age from infancy to 8 years. Their "illnesses" consist of fabricated histories, inflicted physical findings, altered laboratory specimens, and induced disorders. The perpetrator usually is the child's mother, who may have Munchausen syndrome. Consequences of the syndrome may include painful tests, frequent hospitalizations, potentially harmful treatment, and death. The diagnosis can be made when medical and social histories are characteristic of the syndrome and clinical findings are absent, suggestive of induced illness, or resolve upon separation of the child and parent. Suspicion of the syndrome should be discussed with the family once the safety of the child is insured, and the case should be reported under the child abuse reporting law of the state. Social, family, and medical histories must be obtained and verified, and court intervention should be considered. Four patients who illustrate typical features of the syndrome are described.     

Child abuse potential in parents with histories of substance use disorder

OBJECTIVE: To examine the relationship between parental history of substances use disorders (SUDs) and abuse potential. METHOD: Milner's (1986) Child Abuse Potential Inventory (CAPI) was administered to fathers and mothers (with and without histories of SUDs) of 10- to 12-year-old boys. RESULTS: Fathers and mothers with lifetime histories of SUDs had higher Abuse Scale scores and were more likely to score in the Elevated range (as determined by clinically significant cutoff scores) than parents without such histories. No differences were found between parents with current diagnoses of SUD and those with past (but not current) histories of SUD. Fathers and mothers with a partner who had a history of SUD were more likely to score in the Elevated range, regardless of their own SUD histories. Separate regression models revealed that, for both fathers and mothers, emotional dysregulation (positive and negative affectivity) predicted Abuse Scale scores. Additional contributors to Abuse Scale scores were SUD status in fathers, and lack of involvement with the child in mothers. CONCLUSIONS: History of SUDs in both fathers and mothers increases abuse potential. Contributors to abuse potential differed in fathers and mothers, underscoring the importance of examining parents separately in child maltreatment research.     

Abusive head trauma in Maine infants: medical,child protective,and law enforcement analysis

OBJECTIVE: To collect and compare the results of medical, child protective, and law enforcement evaluation of a sample of Maine children who were victims of abusive head trauma (AHT) in order to describe the clinical and evaluative characteristics as they relate to victims, families and perpetrators of such trauma and to improve the professional response to AHT in Maine.METHOD: Retrospective chart review of medical, child protective, and law enforcement records of all AHT victims admitted to two tertiary care hospitals in Maine or seen by the state medical examiner from 1991 to 1994.RESULTS: Nineteen children (age range 2 weeks to 17 months) were identified as victims of AHT (out of a total of 94 head trauma admissions) accounting for 20 hospitalizations during the study period. There was a history of prior injury in 30%, history of prior medical evaluations for possibly abuse related problems in 65%, while, on presentation, 75% had evidence or history of prior injury. The hospitals notified child protective services (CPS) in all 20 cases and correctly identified abuse in 18 (90%). Parental risk factors for abuse identified in CPS records included substance abuse (53%), domestic violence (42%), criminal history (32%), unrealistic expectations (42%), and attachment problems (32%). However, risk factors were inadequately assessed in 53% of homes. Law enforcement identified a likely perpetrator in 79% of cases and in the majority the identified suspect was the father. In the 15 cases where a perpetrator was identified by law enforcement, that person was alone with the child at symptom onset in 14 (93%).CONCLUSIONS: The medical response, at least at the inpatient level, was generally well done with regard to suspicion and reporting. Cases are possibly being missed at the outpatient level. Child protective risk assessment was limited overall yet in a third of the homes where AHT occurred, few if any risk factors were present to aid in identification and prevention. Law enforcement results suggest that a primary suspect for AHT is the caretaker alone with the child at the time of symptom onset.     

Do abused young children feel less pain?

The objective of this study was to investigate whether acute pain in abused children was under recognized by doctors and nurses compared to children evaluated for accidental injuries. We hypothesize that an abused child’s reaction to physical pain could be an additional symptom of this challenging diagnosis. For the observational prospective case control study in an emergency department, children were eligible when: younger than six years old, the reported trauma occurred within the previous seven days, the trauma comprised a bone injury or burn, and the child was able to express his or her pain. The case group comprised children for whom the medical team reported their abuse suspicions and supporting information to a court, and whose cases of abuse were subsequently confirmed. The control group consisted of children with a plausible cause for their injury and no obvious signs of abuse. The children were matched according to their age and type of trauma. The pain was assessed by doctors and nurses before analgesic administration using a certified pain scale.Among the 78 included children, pain was significantly less recognized in the abused children vs. the controls (relative risk = 0.63; 95% CI: 0.402–0.986; p = 0.04). We observed a discrepancy between the nurses’ and doctors’ scores for the pain assessments (Kappa coefficient = 0.59, 95% CI: 0.40–0.77). Our results demonstrate that pain expression in abused children is under recognized by medical staff. They also suggest that abused children may have reduced pain expression after a traumatic event. Paying particular attention to the pain of abused children may also optimize the analgesic treatment.     

Childhood histories of women imprisoned for fatal child maltreatment

A history of childhood maltreatment is the most consistently reported characteristic of abusive parents. Retrospective research with nine women imprisoned for fatal child abuse revealed childhood histories of maltreatment. Detailed life histories indicated that the meaning of the abuse to the individual had an important impact on later abusive parenting. The types of childhood abuse varied. Childhood abuse was one in a set of factors contributing to abusive parenting. Retrospective studies underline the need for prospective research on long-term outcomes of childhood abuse.     

Research priorities for a multi-center child abuse pediatrics network − CAPNET

Although child maltreatment medical research has benefited from several multi-center studies, the new specialty of child abuse pediatrics has not had a sustainable network capable of pursuing multiple, prospective, clinically-oriented studies. The Child Abuse Pediatrics Network (CAPNET) is a new multi-center research network dedicated to child maltreatment medical research. In order to establish a relevant, practical research agenda, we conducted a modified Delphi process to determine the topic areas with highest priority for such a network. Research questions were solicited from members of the Ray E. Helfer Society and study authors and were sorted into topic areas. These topic areas were rated for priority using iterative rounds of ratings and in-person meetings. The topics rated with the highest priority were missed diagnosis and selected/indicated prevention. This agenda can be used to target future multi-center child maltreatment medical research.