Prior opportunities to identify abuse in children with abusive head trauma

Infants with minor abusive injuries are at risk for more serious abusive injury, including abusive head trauma (AHT). Our study objective was to determine if children with AHT had prior opportunities to detect abuse and to describe the opportunities. All AHT cases from 7/1/2009 to 12/31/2011 at four tertiary care children's hospitals were included. A prior opportunity was defined as prior evaluation by either a medical or child protective services (CPS) professional when the symptoms and/or referral could be consistent with abuse but the diagnosis was not made and/or an alternate explanation was given and accepted. Two-hundred-thirty-two children with AHT were identified; median age (IQR) was 5.40 (3.30, 14.60) months. Ten percent (22/232) died. Of the 232 patients diagnosed with AHT, 31% (n = 73) had a total of 120 prior opportunities. Fifty-nine children (25%) had at least one prior opportunity to identify abuse in a medical setting, representing 98 prior opportunities. An additional 14 (6%) children had 22 prior opportunities through previous CPS involvement. There were no differences between those with and without a prior opportunity based on age, gender, race, insurance, mortality, or institution. Children with prior opportunities in a medical setting were more likely to have chronic subdural hemorrhage (48 vs. 17%, p < 0.01) and healing fractures (31 vs. 19%, p = 0.05). The most common prior opportunities included vomiting 31.6% (38/120), prior CPS contact 20% (24/120), and bruising 11.7% (14/120). Improvements in earlier recognition of AHT and subsequent intervention might prevent additional injuries and reduce mortality.     

Epidemiology of abusive head trauma in West Virginia children <24 months: 2000–2010

BackgroundFew states have published statewide epidemiology of abusive head trauma (AHT).ObjectiveTo examine the statewide epidemiology of AHT in West Virginia (WV), with the primary objective of establishing AHT incidence for comparison to national data, and to use as a baseline for comparison to incidence post-implementation of a statewide AHT prevention program.Participants and settingAHT cases in children less than 2 years old were identified from the 3 tertiary pediatric centers in WV.MethodsCases were identified by using ICD-9 codes for initially identifying those with injuries which might be consistent with AHT, followed by medical record review to determine which of these met the criteria for inclusion as a case. Medical examiner data was used to find additional cases of AHT. Using the number of cases identified along with relevant census data, incidence of AHT was calculated.ResultsThere were 120 cases of AHT treated in WV hospitals from 2000 to 2010, 100 of which were WV residents. The incidence was 36.1/100,000 children <1 year of age and was 21.9 cases per 100,000 children <2 years of age. Incidence in infants increased during the latter years (2006–2010) of the study to 51.8/100,000 compared to the incidence during 2000–2005, which was 24.0/100,000 (p < .01).ConclusionsCompared to US national, state and regional figures, the WV incidence of AHT was among the highest. In addition, the incidence of AHT increased significantly over the study period. Possible factors contributing to the rise in incidence are discussed.     

Parents’ behavior in response to infant crying: Abusive head trauma education

Abusive head trauma (AHT) is still too common, and probably underestimated. It is the leading cause of death from child abuse. Crying is thought to contribute to the act of shaking. Objectives of this study were to (a) assess parents’ knowledge about infant crying, their ability to manage crying, and their knowledge about AHT; and (b) assess the feasibility and the impact of a simple educational intervention about crying and AHT with parents shortly after their child's birth. A short questionnaire was completed orally by the parents of 190 consecutive newborns in a maternity hospital at day 2 of life. Then, during the routine examination of the child, the pediatrician gave parents a short talk about infant crying and AHT, and a pamphlet. Finally, parents were contacted by phone at 6 weeks for the post-intervention questionnaire assessing their knowledge about crying and AHT. Among 202 consecutive births, parents of 190 children were included (266 parents; 70% mothers) over a 1-month period and answered the pre-intervention questionnaire. The intervention was feasible and easy to provide. Twenty-seven percent of mothers and 36% of fathers had never heard of AHT. At 6 weeks, 183 parents (68% of the sample; 80% mothers) answered the post-intervention questionnaire. Parents’ knowledge improved significantly post-intervention. Parents found the intervention acceptable and useful. Health care professionals such as pediatricians or nurses could easily provide this brief talk to all parents during systematic newborn examination.     

Association of perpetrator relationship to abusive head trauma clinical outcomes

The diagnosis of abusive head trauma (AHT) remains a significant public health problem with limited prevention success. Providing protection from further harm is often challenged by the difficulty in identifying the alleged perpetrator (AP) responsible for this pediatric trauma. The objective of this study was to evaluate demographic and clinical characteristics of children with AHT and the relationship between APs and their victims in a large, multi-site sample. Understanding the AHT risks from various caregivers may help to inform current prevention strategies. A retrospective review of all cases of AHT diagnosed by child protection teams (CPT) from 1/1/04 to 6/30/09 at four children's hospitals was conducted. Clinical characteristics of children with AHT injured by non-parental perpetrators (NPP) were compared to parental perpetrators (PP). There were 459 children with AHT; 313 (68%) had an identified AP. The majority of the 313 children were <1 year of age (76%), Caucasian (63%), male (58%), receiving public assistance (80%), and presented without a history of trauma (62%); mortality was 19%. Overall, APs were: father (53%), parent partner (22%), mother (8%), babysitter (8%), other adult caregiver (5%); NPP accounted for 39% of APs. NPPs were more likely to cause AHT in children ≥1 year (77% vs. 23%, p < 0.001) compared to PP. Independent associations to NPP included: older child, absence of a history of trauma, retinal hemorrhages, and male perpetrator gender. While fathers were the most common AP in AHT victims, there is a significant association for increased risk of AHT by NPPs in the older child, who presents with retinal hemorrhages, in the hands of a male AP. Further enhancement of current prevention strategies to address AHT risks of non-parental adults who provide care to children, especially in the post-infancy age seems warranted.     

Promoting young children’s interpersonal safety knowledge,intentions, confidence,and protective behavior skills: Outcomes of a randomized controlled trial

Promoting young children’s interpersonal safety knowledge, intentions confidence and skills is the goal of many child maltreatment prevention programs; however, evaluation of their effectiveness has been limited. In this study, a randomized controlled trial was conducted examining the effectiveness of the Australian protective behaviors program, Learn to be safe with Emmy and friends™ compared to a waitlist condition. In total, 611 Australian children in Grade 1 (5–7 years; 50% male) participated, with assessments at Pre-intervention, Post-intervention and a 6-month follow-up. This study also included a novel assessment of interpersonal safety skills through the Observed Protective Behaviors Test (OPBT). Analyses showed participating in Learn to be safe with Emmy and friends™ was effective post-program in improving interpersonal safety knowledge (child and parent-rated) and parent-rated interpersonal safety skills. These benefits were retained at the 6-month follow-up, with participating children also reporting increased disclosure confidence. However, Learn to be safe with Emmy and friends™ participation did not significantly impact children’s disclosure intentions, safety identification skills, or interpersonal safety skills as measured by the OPBT. Future research may seek to evaluate the effect of further parent and teacher integration into training methods and increased use of behavioral rehearsal and modelling to more effectively target specific disclosure intentions and skills.     

A police-led community response to Child abuse and Youth Sexual Violence and Abuse in Indigenous communities in Far North Queensland: “Speak Up. Be strong. Be Heard.”

BackgroundChild abuse and Youth Sexual Violence and Abuse (YSVA) are persistent social issues across the globe. The development and implementation of effective prevention strategies are a common focus for those working at the coalface. The Cairns Child Protection Investigation Unit of the Queensland Police Service (QPS) developed and implemented the “Speak Up. Be Strong. Be Heard.” (SUBSBH) initiative. This police-led multi-component child abuse prevention initiative has been implemented in 26 Aboriginal and Torres Strait Islander communities across the Far North Queensland Police District since June 2016.ObjectiveThe aim of this research was to evaluate the success of the SUBSBH initiative.Participants and settingExisting data held by QPS were examined. These data include statistics on reporting of YSVA offences, internal program documents and reports, and evaluation feedback forms completed prior to this evaluation study. Information collected via these sources pertained to 26 Indigenous communities within the Far North Queensland Police District. The above-mentioned feedback forms were completed by 307 participants, of whom approximately 90% are Indigenous.MethodsThis study adopted desktop analysis and triangulation through a range of qualitative and quantitative data to ensure robust and rigorous evaluation of the SUBSBH initiative.ResultsThe study found that the initiative was successful in meeting basic accepted practice for child abuse and YSVA prevention programs, receiving positive participant feedback on the educational program, achieving the initiative’s objective to increase reporting of YSVA, and achieving cost-efficiency in meeting outcomes. Importantly, the increase in reporting of YSVA was statistically significant.ConclusionThis study contributes to current understanding regarding the implementation of multi-component child abuse prevention initiatives and provides an example of a cost-efficient police-led community response to child abuse and YSVA in Indigenous communities. The findings may guide responses in other communities which grapple with this critical social issue.     

What predicts injury from physical punishment? A test of the typologies of violence hypothesis

OBJECTIVE: This study examined the power of child, perpetrator, and socio-economic characteristics to predict injury in cases of reported child physical abuse. The study was designed to assess the validity of the assumption that physically injurious incidents of child physical abuse are qualitatively different from those that do not result in injury, that their generative factors are distinctive, and that the quality of caregiving in these two types of incidents is different. METHOD: A weighted, nationally representative sample of 8,164 substantiated punishment abuse cases in Canada was used. Various models were constructed and evaluated through logistic regression. RESULTS: Of six potential predictors - child age, perpetrator sex, child functioning, parent functioning, economic stress, and social stress - none predicted injury to the child. CONCLUSIONS: The findings suggest that injurious and non-injurious physical abuse cannot be distinguished on the basis of the personal characteristics or circumstances of the child or perpetrator. PRACTICE IMPLICATIONS: A common criterion for child welfare intervention into cases of suspected physical abuse is injury or risk of injury. This criterion assumes that injurious and non-injurious assaults are qualitatively different phenomena, predicted by different risk factors. In the present study an attempt was made to differentiate between injurious and non-injurious cases of punitive physical abuse on the basis of characteristics of the child, perpetrator, family, and social context. None of these factors explained the likelihood of injury, suggesting that the prediction of injury as an intervention criterion may be questionable.     

The impact of Australia’s Royal Commission on child- and youth-serving organizations

This commentary considers the impact to date of Australia’s Royal Commission into Institutional Responses to Child Sexual Abuse on child- and youth-serving organizations, particularly its influence on organizations’ efforts to create and maintain ‘child safe, child friendly’ cultures, policies and practices. Opportunities and challenges for organizational leaders are outlined. The commentary calls for more involvement by researchers in empirical research that is relevant to the causes and prevention of abuse in organizations, and for findings to be disseminated in ways that are useful to organizations.     

Helping children to the other side of silence: a study of the impact of the stay safe programme on Irish children's disclosures of sexual victimization

OBJECTIVE: This study aimed to evaluate the effectiveness of a school based safety skills program--The Stay Safe Programme--in facilitating the disclosure of sexual abuse among sexually victimized children and adolescents in Dublin. METHOD: A Cohort of 145 children who had participated in the Stay Safe Programme prior to their referral to a sexual abuse assessment unit were compared with a cohort of 443 children who had not participated in the prevention program on a range of disclosure related variables abstracted from case notes. RESULTS: More Stay Safe participants, particularly female adolescents, made disclosures of suspected sexual abuse than non-participants. A higher rate of initial disclosure to teachers was made by Stay Safe participants and more teachers in schools participating in the Stay Safe Programme initiated referrals for evaluation of suspected child sexual abuse. Following assessment a higher rate of confirmed abuse occurred among Stay Safe participants and for these confirmed cases more Stay Safe participants made purposeful disclosures and in significantly more cases referral was due to the child telling someone about the abuse. These differences in disclosure between program participants and non-participants were unrelated to demographic factors or characteristics of the abuse. CONCLUSIONS: The Stay Safe Programme was an effective secondary prevention intervention deserving widespread implementation.