Utility of follow-up skeletal surveys in suspected child physical abuse evaluations

OBJECTIVE: To evaluate the utility of a follow-up skeletal survey in suspected child physical abuse evaluations. METHODS: In this prospective study, follow-up skeletal surveys were recommended for 74 children who, after an initial skeletal survey and evaluation by the Child Abuse Team, were suspected victims of physical abuse. The number and location of the fractures were recorded for the initial skeletal survey and for the follow-up skeletal survey in each case. RESULTS: Forty-eight of the 74 (65%) children returned for a follow-up skeletal survey. The follow-up skeletal survey yielded additional information in 22 of 48 patients (46%). In three patients (6%) the additional information changed the outcome of cases; child abuse was ruled out in one of these patients and abuse was confirmed in two cases. In three other patients, the follow-up skeletal survey refuted tentative skeletal findings, but did not change the outcome because of other physical findings. CONCLUSION: A follow-up skeletal survey identified additional fractures or clarified tentative findings in children who were suspected victims of physical child abuse. The follow-up skeletal survey should be completed on all patients who have an initial skeletal survey performed for suspected physical child abuse and for whom child abuse is still a concern.     

Occult drug exposure in young children evaluated for physical abuse: An opportunity for intervention

BackgroundAlthough screening for drug exposure is an important consideration in the evaluation of suspected child maltreatment, limited data are available on the frequency of drug exposure in children with suspected physical abuse.ObjectiveTo examine occult drug and pharmaceutical exposure in young children with suspected physical abuse.Participants and settingChildren ages 2 weeks –59 months evaluated for physical abuse by a tertiary referral center Child Protection Team.MethodsCross-sectional study of young children diagnosed with high, intermediate, or low concern for physical abuse and tested for occult drug exposure from 2013-2017. Chart review was performed to determine adherence to recommended testing and drug test results with comparison between groups.ResultsOccult drug exposures were found in 5.1% (CI 3.6–7.8) of 453 children tested: 6.0% (CI 3.6–10.0) of 232 children with high concern for physical abuse, 5.0% (CI 2.7–9.3) of 179 children with intermediate concern, and 0% of 42 children with low concern. As adherence to protocol-based screening improved during the second half of the study, so did the overall rate of detection of occult drug exposures (7.9%, CI 5.2–11.9) in 252 children with intermediate or high concern for physical abuse. Most exposures were to cocaine, although non-prescribed pharmaceutical exposures were also detected.ConclusionsUp to 7.9% of young children suspected of being physically abused also had an occult drug exposure. Given the adverse health consequences associated with exposure to a drug-endangered environment, screening for occult drug exposure should be considered in the evaluation of young children with intermediate or high concern for physical abuse.     

Implementation of routine electronic health record-based child abuse screening in General Emergency Departments

BackgroundRoutine child abuse screening is an approach to early identification of abuse. Previous studies evaluated paper-based screens; the widespread use of electronic health records suggests that screening is more likely to succeed if integrated into the electronic record.ObjectiveTo implement an electronic health record-based child abuse screen in a diverse hospital system and to evaluate the screening rate, rate of positive screens, and number of reports to Child Protective Services and assess whether hospital and patient characteristics are associated with these rates.Participants and settingChildren <13 years of age evaluated at one of 13 Emergency Departments within University of Pittsburgh Medical Center Health System.MethodsA previously validated child abuse screen was slightly modified and integrated into Cerner. Multivariable logistic regression models were used to estimate the odds of the outcomes of interest, controlling for key covariates.ResultsOf 17,163 eligible children: 68% received the screen of which 1.9% were positive. The rate of reports to Child Protective Services was higher among children who were screened (p < 0.0001). Younger children were more likely to be screened, have a positive screen, and have a report filed. There was no difference in the odds of being screened according to hospital teaching status, size or urban vs rural location.ConclusionsA child abuse screening tool can be integrated into the electronic health record in a large health-care network. The increased number of reports among children who were screened suggests that screening facilitates detection of suspected maltreatment.     

The role of cranial MRI in identifying patients suffering from child abuse and presenting with unexplained neurological findings

OBJECTIVE: The aim of this study was to demonstrate the usefulness of cerebral MRI to detect possible child abuse in children with unexplained neurologic findings. METHOD: Between 1990 and 1997, 208 children were referred for suspected physical child abuse to the Child Protection Clinic of Ste-Justine Hospital, a tertiary care pediatric hospital. Among them, 39 children presented initially with neurological findings. For 27 of them, the CT Scan results prompted the diagnosis of child abuse. However, in 12 children, even if a CT-Scan was performed, the diagnosis and/or the mechanisms of the neurologic distress remained obscure. Investigation was completed with MRI study in those 12 cases. RESULTS: MRI findings were diagnostic for physical abuse in eight cases. A diagnosis of child abuse was made in two more cases by a combination of MRI and skeletal survey findings. In one case, MRI was suggestive but the diagnosis of child abuse could not be confirmed. One case was misinterpreted as normal. CONCLUSIONS: MRI is the test of choice to rule out child abuse when faced with a child presenting unexplained neurologic signs lasting for few days. The fact that MRI can better differentiate collections of different ages makes this imaging test particularly useful in identifying cases of child abuse. These results, however, always have to be integrated in a well conducted multidisciplinary clinical approach.     

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.     

Prevalence of child abuse in Kerala,India: An ICAST-CH based survey

BackgroundChild abuse is a major concern in India with frequent reports of extreme maltreatment and fatalities. A dearth of robust and methodologically sound studies has resulted in ambiguity regarding the extent of child abuse in the general population.ObjectivesTo estimate the one-year and lifelong prevalence of exposure to violence, physical abuse, emotional abuse, sexual abuse, and neglect using a validated instrument—the International Society for the Prevention of Child Abuse and Neglect (ISPCAN) Child Abuse Screening Tool – Child, Home Version (ICAST-CH).Participants and Setting: Adolescents (n = 6957) attending randomly selected schools in one city in Kerala, India.MethodsCross-sectional survey using self-report instrument.ResultsThe one-year prevalence of any abuse was 89.9% (95% CI: 89.1–90.7) suggesting that child maltreatment was widespread. Physical and emotional abuses were also very common. Although sexual abuse was least common, a considerable proportion of adolescents reported it; one-year prevalence of sexual abuse was 16.7% and lifetime prevalence was 19.9%. Boys reported more abuse than girls across all the categories of abuse (including sexual abuse). Abuse was more frequent in the higher age groups and classes at school. Abuse was also more frequent in nuclear families and families that reported alcohol use. Children who reported an abusive experience usually faced more than one category of abuse; abuse in one category was significantly associated with abuse in other categories.ConclusionsAbuse of children is alarmingly common. There is an urgent need for improving the awareness surrounding this issue as it is a major public health challenge faced by the country. The priority should be on setting up easily accessible support services for children.     

Evaluation of the effect of the child protection act on serious child physical abuse in Taiwan

BackgroundFew studies have examined the effects of the Child Protection Act on child maltreatment in Taiwan.ObjectiveThis study estimated the secular trends in the incidence rate of physical abuse of children requiring hospitalization between 1996 and 2013, and the subsequent in-hospital death proportion before and after implementation of the Act in 2003.Participants and settingThe cases were children younger than 12 years old who were hospitalized due to child abuse, shaken-baby syndrome, neglect, or homicide between 1996 and 2013. A comparison group consisted of children requiring hospitalization for other reasons. We used the National Health Insurance database to identify patients.MethodsThe Joinpoint Regression Program was used to estimate temporal trends in the standardized incidence rates.ResultsBetween 1996 and 2013, 2050 children required hospitalization for physical abuse. Before 2005, the annual percent change increased by 9.40 [95% confidence interval (CI), 4.98–14.00] per year, and after 2005 the annual percent change was –4.80 (95% CI, –9.53–0.17) per year. Among the 2050 physically abused children requiring hospitalization, 83 (4%) died in hospital. The in-hospital death proportion was 2.62% before 2003 and 4.90% after 2003, and the ratio of these two proportions was 1.43 (95% CI, 0.80–2.58).ConclusionsThe trend in the incidence of hospitalization of children due to physical-abuse-related injuries started to decline 2 years after implementation of the Child Protection Act. However, the proportion of children who died in hospital as a result of physical abuse requiring hospitalization did not change.     

The impact of a management protocol on the outcomes of child abuse in hospitalized children in Hong Kong

OBJECTIVE: To study the outcomes of children hospitalized for suspected child abuse before and after the implementation of a management protocol in a hospital in Hong Kong. STUDY PERIOD: Two 2-year periods before (1994-1995) and after (2002-2003) the implementation of the protocol in 1998. METHODS: This is a retrospective hospital chart review in which the patients' characteristics, the use of laboratory and radiological examination, abuse substantiation and official registrations are compared between the two study periods. RESULTS: There were 109 and 320 patients admitted for evaluation of child abuse for the periods 1994-1995 and 2002-2003, respectively. Children in both periods were similar in sex ratio, proportion of severe forms of child abuse, rates of abuse substantiation and inclusion in the Child Protection Registry. After the implementation of a management protocol, there has been a significant drop in the proportion of children subjected to investigations such as blood counts (86% vs. 16%, p<.001), clotting study (75% vs. 9%, p<.001), and skeletal survey (78% vs. 6%, p<.001). The average length of hospital stay also dropped from 15.3 days to 6.1 days (p<.001). CONCLUSIONS: There has been an almost threefold rise in the number of child abuse cases handled at the hospital during the 10-year interval. With the implementation of a management protocol, only a small proportion of children need laboratory investigations or skeletal survey without any drop in abuse substantiation and official registration. The length of hospital stay has also been significantly reduced.     

Interdisciplinary collaboration needed in obtaining high-quality medical information in child abuse investigations

BackgroundDespite reporting legislation, healthcare providers (HCPs) do not always report and collaborate in cases of suspected child abuse. Recognizing this leaves children at risk, the Wisconsin Child Abuse Network (WI CAN) sought to understand barriers to mandated reporting and collaboration with child abuse investigators.ObjectiveThe purpose of the study was to investigate barriers for professionals in providing and obtaining high-quality medical information in child abuse investigations.Participants and settingParticipants included five discipline-specific focus groups: HCPs, child protective services (CPS), law enforcement, lawyers, and judges. All professionals had been directly involved in Wisconsin child abuse cases.MethodsThis qualitative study consisted of discipline-specific focus groups, directed by open-ended interview questions. Data analysis was completed through the narrative inquiry methodology.ResultsBarriers to providing and obtaining high-quality medical information in child abuse investigations were both discipline-specific and universal amongst all groups. Discipline-specific barriers included: HCPs’ discomfort with uncertainty; CPS’ perception of disrespect and mistrust by HCPs; law enforcement’s concerns with HCPs’ overstepping professional boundaries; lawyers’ concern of HCPs’ discomfort with court proceedings; and judges’ perception of a lack of understanding between all disciplines. Universal barriers included: value of high-quality medical information in child abuse investigations, burden of time and money; unequal resources between counties; a need for protocols, and a need for interdisciplinary collaboration.ConclusionFindings from this study suggest several ways to address identified barriers. Possible interventions include equalizing resources between urban and rural counties (specifically financial resources and access to child abuse experts); protocolizing reporting and investigations; and, increasing interprofessional education.     

Accuracy of a screening instrument to identify potential child abuse in emergency departments

Although screening for child abuse at emergency departments (EDs) increases the detection rate of potential child abuse, an accurate instrument is lacking. This study was designed to measure the accuracy of a screening instrument for detection of potential child abuse used in EDs. In a prospective cohort study at three Dutch EDs, a 6-item screening instrument for child abuse, Escape, was completed for each child visiting the ED. The data from the completed Escape instrument was used to calculate sensitivity, specificity, and the positive/negative predictive value per item. The clinical notes and conclusions of the screen instruments of all potentially abused children reported to the hospitals’ Child Abuse Teams were collected and reviewed by an expert panel. A logistic regression model was used to evaluate the predictors of potential abuse. Completed Escape instruments were available for 18,275 ED visits. Forty-four of the 420 children with a positive screening result, and 11 of the 17,855 children with a negative result were identified as potentially abused. Sensitivity of the Escape instrument was 0.80 and specificity was 0.98. Univariate logistic regression showed that potentially abused children were significantly more likely to have had an aberrant answer to at least one of the items, OR = 189.8, 95% CI [97.3, 370.4]. Most of the children at high risk for child abuse were detected through screening. The Escape instrument is a useful tool for ED staff to support the identification of those at high risk for child abuse.     

Intergenerational transmission of child maltreatment: Predictors of child emotional maltreatment among 11 to 17 years old children residing in communities of Karachi,Pakistan

ObjectiveFamilies where parents had childhood history of victimization may likely to abuse their children; hence contributing as an important predictor of child emotional maltreatment (CEM). This study aimed to determine the relationship of intergenerational abuse with CEM among 11–17 years old children residing in peri-urban and urban communities of Karachi, Pakistan.MethodStructured interviews were conducted with 800 children and parents-pair using validated questionnaire “International Child Abuse Screening Tool for Child (ICAST-C)” comprised of 4 domains. Domain of child emotional maltreatment was considered as outcome (CEM-score). The relationship between Parental history of childhood victimization and CEM-Score was measured using linear regression.ResultsThe average CEM-score was came to be 19+5.2 among children whom parental history of childhood victimization was present (P < 0.001). The estimated mean CEM-score increased by 5.59 units (95% CI= {2.61, 8.51}) among children whom parents had a history of childhood victimization (Intergenerational abuse) with severe physical familial abuse.ConclusionThe current study provided evidence on intergenerational transmission of maltreatment suggesting early prevention to break the cycle of child maltreatment through generations. Preventive measures can be taken, once a parental history of childhood victimization has been identified, by providing appropriate services to those families who belong to lower socioeconomic status, where mothers are young, presence of siblings’ rivalry/ bullying and/or violence among family members. However, these factors do not explain a complete causality of the intergenerational transmission therefore additional factors, for instance parenting styles must be taken into consideration.     

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.     

Medical neglect at a tertiary paediatric hospital

Medical neglect is under-researched and the extent of the problem in Australia is unknown. We conducted a review of the referrals for medical neglect to the Child Protection Unit (CPU) at a tertiary children’s hospital in Sydney over a 5 years period, from 2011 to 2016, to determine what medical conditions are being referred, the reason for the medical neglect concern and whether cases are managed in line with American Academy of Pediatrics (AAP) guideline on medical neglect.61 cases of medical neglect were identified, constituting 4.1% of all referrals to the Child Protection Unit for physical abuse and neglect. There was a wide variety of medical conditions. Most were chronic medical conditions (87%). The top two medical conditions were chronic and complex multi-system disorders (37.7%) and endocrine disorders (18%). The majority of medical neglect were related to concerns that the caregivers were unwilling to follow medical advice (45.9%) or unable to provide necessary medical care (26.2%). In line with the AAP guideline on medical neglect, all cases were managed by addressing communication difficulties (100%) and resource issues were addressed in 80% of cases. A report to statutory child protection agencies was made in 50% of cases. Directly observed therapy and medical contracts were used in 30% and 26% of cases. We conclude that children with chronic medical conditions may be at risk of medical neglect. Communication difficulties were a factor in all cases. Statutory agency intervention is often required.     

The international epidemiology of child sexual abuse: A continuation of Finkelhor (1994)

ObjectiveThe purpose of this paper was to compare the prevalence rates of child sexual abuse reported by [Finkelhor, D. (1994). The international epidemiology of child sexual abuse. Child Abuse & Neglect, 18 (5), 409–417] with those found in recent publications in order to confirm the widespread prevalence of child sexual abuse.MethodsRelevant articles about prevalence of child sexual abuse were identified through searches of computerized databases and a handsearch of Child Abuse & Neglect and the Journal of Child Sexual Abuse.ResultsThirty-eight independent articles were identified, corresponding to 39 prevalence studies; these articles report the prevalence of childhood sexual abuse in 21 different countries, ranging from 0 to 53% for women and 0 to 60% for men.ConclusionsComparison of the present study with that of [Finkelhor, D. (1994). The international epidemiology of child sexual abuse. Child Abuse & Neglect, 18 (5), 409–417] shows a similarity between prevalence distributions; there appears to be a general pattern that remains more or less constant over the years, especially in women.Practice implicationsTwelve years after the first revision study about the international prevalence of child sexual abuse, there is still a need for new data about this topic. The present study shows child sexual abuse is still a widespread problem in the society. In this research, carried out on 38 independent studies, there is new data for 21 countries over the world, being especially relevant the results obtained from other countries different from those pertaining to North America or Europe. It is important to point out the high prevalence found in most of the countries, so this information could be a new warning to make society and governments aware of this problem and undertake actions to prevent sexual abuse in childhood.     

Profile of abused and neglected American Indian children in the Southwest

From both knowledge gained working in Indian communities and a major data collection program, this article examines child abuse and neglect among the Indian tribes in a southwestern state. The period of study covers 1982 through 1985. The study sample consists of 53 children targeted by the local Indian Health Service Hospital Child Protection Team as being abused and/or neglected. In addition, information on the parents, grandparents and, in a number of cases, great-grandparents are examined. The study is a secondary data analysis of clinic and hospital records and interviews with local community health care providers and tribal officials. The results indicate that alcohol abuse was present in 85% of the neglect cases and in 63% of the abuse cases. In addition, child abuse and neglect occurred simultaneously in 65% of the sample. Child abuse and neglect are found to be part of a larger phenomenon of multiproblem families which raises the issue of intergenerational perpetuation of these problems. The results underscore the importance of interagency cooperation in surveillance, treatment, and prevention, as well as more careful and thorough documentation of record maintenance.     

Primary care pediatricians’ experience,comfort and competence in the evaluation and management of child maltreatment: Do we need child abuse experts?

ObjectiveWe assessed the self-reported experience, comfort and competence of primary care pediatricians in evaluating and managing child maltreatment (CM), in rendering opinions regarding the likelihood of CM, and in providing court testimony. We examined pediatricians’ need for expert consultation when evaluating possible maltreatment.MethodsA questionnaire was mailed to 520 randomly selected AAP members. Pediatricians were asked how frequently they evaluated and reported children for suspected maltreatment, and whether child abuse pediatricians were available to and used by them. Pediatricians were asked to rate their knowledge, comfort and competence in the management of CM. Demographic information was also gathered. Pediatricians’ experience with CM, their comfort, self-reported competence, and need for expert assistance is described. Logistic regression was used to assess factors that predicted pediatricians’ sense of competence while controlling for covariates found to be significant in bivariate analyses.ResultsOne hundred forty-seven questionnaires were eligible for analysis. The majority of respondents had little experience evaluating and reporting suspected CM, and was interested in having expert consultation. While pediatricians often felt competent in conducting medical exams for suspected maltreatment, they felt less competent in rendering a definitive opinion, and did not generally feel competent to testify in court. Sense of competence was particularly low for sexual abuse. Increased practice experience and more courses in CM led to increased sense of competence in some areas.ConclusionsPediatricians acknowledged many limitations to providing care to maltreated children, and expressed interest in subspecialist input.Practice implicationsThese findings add additional support to the American Board of Pediatrics’ decision to create a Child Abuse Pediatrics subspecialty. The findings also indicate a need to ensure funding for fellowship training programs in this field.     

An examination of trends in child sexual abuse investigations in Ontario over time

BackgroundChild sexual abuse (CSA) rates have been declining since the 1990s (Dunne et al., 2003; Finkelhor & Jones, 2004, 2012; Jones et al., 2001). Discrepancies in contexts and measures complicate comparing CSA rates across jurisdictions and studies, and there is limited literature about trends in CSA in Canada.ObjectiveUsing data from the Ontario Incidence Study of Reported Child Abuse and Neglect (OIS), the only source of provincially aggregated data in Ontario, Canada, that describes child welfare investigations, this paper provides information on reported and investigated CSA over the past 20 years.Participants and settingThe OIS uses a file review methodology; information is collected directly from investigating child welfare workers.MethodsA sample of child welfare agencies is selected for the study, and data are collected over a three-month period. Weights are applied to produce annual provincial estimates.ResultsThe rates of investigated CSA in Ontario decreased between 1993 and 2013, from 5.20 (95% CI [3.94, 6.47]) to 1.81 (95% CI [0.97, 2.66]) children per 1000. During this time, the rate of all child maltreatment-related investigations doubled, from 21.41 (95% CI [18.38, 24.42]) to 53.32 ([29.61, 77.03]) children per 1000.ConclusionsUnlike other forms of child maltreatment, the incidence of investigated CSA in Ontario declined since 1993. Substantiation rates for CSA investigations decreased more dramatically than the rate of all CSA investigations, which could indicate a true decline in rate or an inability to accurately identify cases of CSA.     

Interdisciplinary Training Program (ITP) in child abuse and neglect: Long term effects

BackgroundUniversity of Oklahoma Health Sciences Center has offered Interdisciplinary Training Program (ITP) for Child Abuse and Neglect since 1987. However, there are limited evaluations on multidisciplinary/interprofessional training for early professionals in the field of child abuse and neglect.ObjectiveThis study aimed to examine the effects of the ITP on young professionals in developing their careers and taking leadership roles in the field of child abuse and neglect.MethodsThe anonymous online survey was conducted for students who completed in the ITP from 1989 to 2016 (n = 405, with contact information out of total 508 graduates). One hundred seventy nine alumni (44.2%) responded to the survey.ResultsSatisfaction for the ITP was high (m = 9.3, sd = 0.97 on a 10 point scale with higher numbers being positive). Their current contributions to the field of child abuse and neglect were widely seen in child advocacy (43.0%), clinical treatment (39.1%), primary prevention (29.6%), or research (27.9%). Graduates reported they made 133 presentations to civic or professional groups and published 69 articles since they finished the ITP.ConclusionThe ITP trainees have made significant contributions to the field in clinical treatment, research, and child advocacy. Alumni were highly satisfied with their experience and continue to see the importance of the ITP to their jobs and career.     

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.