Occult abusive injuries in children brought for care after intimate partner violence: An exploratory study

Children in homes with intimate partner violence (IPV) are at increased risk for physical abuse. We determined the frequency and injury patterns in children who underwent child abuse consultation after IPV exposure by retrospectively analyzing the "Examination of Siblings To Recognize Abuse" cohort of children referred for physical abuse. Children were selected who presented after IPV exposure. Among 2890 children evaluated by child abuse pediatricians, 61 (2.1%) patients presented after IPV exposure. Of the 61, 11 (18.0%) were exposed to IPV, but had no direct involvement in the IPV event, 36 (59.0%) sustained inadvertent trauma during IPV, and 14 (23.0%) were directly assaulted during IPV. Thirty-six patients (59.0%) had an injury: 31 (51.0%) had cutaneous injuries and 15 (24.6%) had internal injuries including fracture(s), intracranial or intra-abdominal injury. Of the 15 patients with internal injuries, 14 (93.3%) were less than 12 months old. Among the 36 patients with injuries, 16 (44.4%) had no report of direct injury, a report of a mechanism that did not explain the identified injuries, or a report of trauma without a specific mechanism. Five (13.9%) did not have physical examination findings to suggest the extent of their internal injuries. Injuries are present in a significant proportion of children presenting to Emergency Departments after IPV exposure. History and physical examination alone are insufficient to detect internal injuries especially in infants. These preliminary results support the need for future, prospective studies of occult injury in children exposed to IPV.     

Pelvic fractures in infants as a sign of physical abuse

OBJECTIVE: The purpose of this article is to describe pelvic fractures in two abused male infants, and to determine if the literature describes pelvic fractures in infants as suspicious for child physical abuse. RESULTS: Two infants are described with unexplained pelvic fractures. While in one case child abuse was obvious, careful attention to the radiological evaluation and case history led to the correct diagnosis of child abuse in the second case. A search for information regarding pelvic fractures in children resulted in information limited to the radiological and surgical literature. CONCLUSIONS: Medical providers frequently encounter children with fractures suspicious for child abuse. The most common fractures seen in abused children are metaphyseal, rib, skull, and long bone fractures. This report illustrates that pelvic fractures occurring in the absence of serious, well documented accidents should be considered highly suspicious for child physical abuse.     

Pregnancy and delivery for women with a history of child sexual abuse

OBJECTIVE: To study whether women with a history of child sexual abuse are at increased risk of delivering low birth weight infants. Secondary aims were to study smoking habits, obstetric complications, health care use, and health complaints during pregnancy among women with a history of child sexual abuse. METHOD: In a case control study, 82 women with birth of a low birth weight infant (< 2500 g) (cases) and 91 women with birth of a normal birth weight infant (controls) were interviewed about experiences of child sexual abuse. RESULTS: Fourteen percent of the women disclosed a history of child sexual abuse involving at least genital touch. Birth of a low birth weight infant was not associated with a history of child sexual abuse (OR 1.03, 95% CI .44-2.40). More women with a history of child sexual abuse were smokers during pregnancy (56% vs. 31%) compared with nonabused women. Abused women reported lower age at menarche and sexual debut. Nonscheduled contacts with the antenatal care clinic and discomfort during pregnancy were more frequent among abused women when controlled for low birth weight. CONCLUSIONS: Women who delivered low birth weight infants were not more likely to have experienced child sexual abuse than women who delivered nonlow birth weight infants. Abused women were unemployed and daily smokers more often than nonabused women. Some of the abused women reported more health complaints, and more use of health care services during pregnancy, but did not have more obstetric complications during pregnancy and delivery.     

Child abuse: Thoughts on doctors, nurses and prevention

It is obviously better if child abuse can be prevented in the first place. There are many problems in society which doctors and nurses and other health care professionals can hardly be expected to fix up, but there are many weaknesses in what we do which can and should be repaired. As a group we are weak in our appreciation of the demoralizing strain that an awkward or crying baby can bring upon a household, particularly that of the nuclear family. The media paint a mythical picture of parenthood, possibly unreal, and leading to the isolation of the mother who wants to complain that her child is very trying. As a group, doctors and nurses are more concerned about reassurances that a child is not seriously ill or else will outgrow his particular symptom and are not very good at bending their energies towards providing relief of the symptom. The sanity of many families has been preserved by the judicious use of safe analgesics and sedatives. Many people obtain these in spite of the physician and not through him.To turn to an even earlier phase of infancy, where hospital personnel are intensely involved and could well mend their ways often — in Western countries more and more babies are being born in hospital. Frequently, insufficient efforts are made to ensure that the labour and delivery are pleasant emotional experiences for the mother. In the name of safety, sterility and administrative needs, many of the emotional needs of the parents are unmet. It is now being shown that actual physical attachment between mother and baby in the time — hours and days — after the baby is born can be extremely important in developing the mother/child bond which is the child's greatest protection. In many countries including mine there have to be associations of mothers who want to breast feed their own children, and these mothers often find that their greatest difficulties are with hospital personnel.The very necessary scientific measures required to ensure the safety of low birth weight and premature infants can separate mother from baby even more and this is reflected in the well-known increase in later child abuse among babies who have spent their early weeks in intensive care units. If the hospital personnel really try, they can make the mother and father feel at home in these ultrascientific units. The staff must not merely permit but must actively invite the parents into the special nursery, explain the surroundings and equipment, show how to gown and hand wash, how to open the Humidicrib, touch the baby and take part in the nursing management from the earliest possible time — the second or first day. Explanations appropriate to the parental level of understanding must be given and repeated.Anything which will strengthen the bonds within the family must be welcomed as something that will prevent child abuse.     

Is race or ethnicity a predictive factor in Shaken Baby Syndrome?

OBJECTIVE: Previous studies have concluded that shaken baby syndrome occurs more often among Whites than among Blacks. The purpose of this study was to determine whether race is a predictive factor in Shaken Baby Syndrome when population and referral patterns are considered. METHODS: A retrospective medical record review of closed head injuries due to child abuse during the time period January 1992 to July 1997 was conducted at three pediatric tertiary care medical centers in North Carolina. Patients included children, ages 0-4 years, identified from medical record reviews and child abuse databases. Only North Carolina residents were included. The specific rates of shaken baby syndrome in Whites versus non-Whites in the referral area were computed. RESULTS: The difference in the rate of shaken baby syndrome from the referral area was not statistically significant among Whites versus non-Whites (26.7/100,000 versus 38.6/100,000, p = .089) Most of the perpetrators were male (68%), and most victims (76%), lived with their mothers and biologic father or mother's boyfriend. CONCLUSION: Race was not a significant factor in predicting shaken baby syndrome in the referral area studied, and therefore is not a useful factor in targeting groups for intervention.     

Child abuse and neglect in Denmark: Medicolegal aspects

On the basis of material selected at the Institute of Forensic Medicine. Aarhus, from 1959 to 1980. we estimated the frequency of mortality from child abuse in Denmark to be 0.5 child deaths per million inhabitants per year. This figure is equal to that in Sweden and Norway but lower than most other countries. The study population included 53 abused children: 33 living children (18 boys and 15 girls) and 20 fatalities (11 boys and 9 girls). The social background of the children and abusers (32 men and 15 women) is described in connection with the juridical and social outcome of the cases. Cases with repetitive lesions were the most important evidence of child abuse. In cases with non-repetitive injuries, it was more difficult to prove that child abuse had taken place, but subdural hematoma and abdominal lesions with rupture of the duodenum or tearing of the mesenterium were very strong evidence. We think that a better handling of cases of child abuse or neglect could be obtained with extended collaboration between the social authorities, the police, the public prosecutor, the pediatrician and the forensic pathologist.     

Relationships among parental beliefs in corporal punishment, reported stress, and physical child abuse potential.

OBJECTIVE: The present study examined the extent to which parental belief in the value of corporal punishment moderates the association between level of parenting stress and physical child abuse potential. Based on existing theory, it was expected that levels of parenting stress would be positively associated with physical child abuse potential among parents who reported high levels of belief in the value of corporal punishment. METHOD: Forty-one parents (25 general population and 16 at-risk parents) were assessed for belief in the value of corporal punishment, level of parenting stress, and physical child abuse potential using self-report measures. After removal of respondents due to response distortion or missing data, the final sample consisted of 31 parents with valid and complete protocols. Based on their responses on the study measures, respondents were categorized as either high or low on belief in corporal punishment and parenting stress. RESULTS: Level of parenting stress was positively associated with physical child abuse potential. As expected, the interaction of parenting stress and belief in the value of corporal punishment was significant. Level of parenting stress was positively associated with physical child abuse potential among parents who reported high levels of belief in the value of corporal punishment. In contrast, level of parenting stress was not associated with physical child abuse potential among parents who reported low belief in the value of corporal punishment. CONCLUSIONS: The present findings are consistent social information processing and stress and coping models of the etiology of physical child abuse, and underscore the importance of considering both parental cognitions and levels of parenting stress in assessing potential for physical child abuse.     

Fatal child abuse in Georgia: the epidemiology of severe physical child abuse

Decisions about the occurrence of child abuse are increasingly difficult to make because concepts of what qualifies as reportable child abuse may be broadening. We examined this question by comparing 51 fatal child abuse cases occurring in Georgia between July 1975 and December 1979 to non-fatal cases and to the Georgia population. Overall rates of fatal child abuse were higher for male perpetrators compared with female and black perpetrators compared with white. However, the latter finding varied with economic and geographic status. The highest child abuse fatality rates were found in poor, rural, white families (3.3/100,000 children) and in poor, urban, black families (2.4/100,000 children). Risk factors for fatal abuse included early childhood (RR 6:1), parental teenage childbearing (RR 4:1), and low socioeconomic status. These characteristics were similar to those of the severe child abuse cases noted in the early child abuse literature. Non-fatal cases did not clearly share these risk factors. Severe abuse, here represented by fatal cases, is a distinct subset of reported child abuse, but characteristics associated with it are frequently attributed to all reportable child abuse. Medical personnel should be aware that they cannot rely on the presence or absence of these characteristics in screening for risk of reportable child abuse. Child abuse research should use restricted, stated case definitions. When intervention and prevention programs are being organized, they should not generalize research findings to all forms of child abuse.     

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.     

Risk factors for infant maltreatment: a population-based study

CONTEXT: Of the approximately 900,000 children who were determined to be victims of abuse or neglect by US child protective services in 2002, the birth-to-3 age group had the highest rate of victimization (1.6%) and children younger than 1 accounted for the largest percentage of victims (9.6%). OBJECTIVE: To identify perinatal and sociodemographic risk factors associated with maltreatment of infants up to 1 year of age. DESIGN AND SETTING: Observational cohort study. PARTICIPANTS: 189,055 children born in 1996 in Florida. MAIN OUTCOME MEASURE: Infant maltreatment, defined as a verified report of abuse, neglect, or threatened harm that occurred between day 3 of life and 1 year. RESULTS: 1,602 children (.85%) of the 1996 birth cohort had verified instances of maltreatment by age 1. Of 15 perinatal and sociodemographic variables studied, 11 were found to be significantly related to infant maltreatment. Five factors had adjusted relative risks (RR) of two or greater: Mother smoked during pregnancy (RR 2.8); more than two siblings (RR 2.7); Medicaid beneficiary (RR 2.1); unmarried marital status (RR 2.0); low birth weight infant (RR 2.0). Infants who had four of these five risk factors had a maltreatment rate seven times higher than the population average. CONCLUSIONS: Data on nearly all risk factors found to be significantly associated with infant maltreatment are available on the birth certificate. Such information can be incorporated into a population-based risk-assessment tool that could identify subpopulations at highest risk for infant maltreatment. Because resources are limited, these groups should be given priority for enrollment in child abuse prevention programs.     

Urgent medical assessment after child sexual abuse

BACKGROUND: Immediate medical assessment has been recommended for children after sexual abuse to identify physical injuries, secure forensic evidence, and provide for the safety of the child. However, it is unclear whether young children seen urgently within 72 hours of reported sexual contact would have higher frequencies of interview or examination findings as compared to those seen non-urgently or whether forensic findings would be affected by child characteristics, type of reported contact, or later events. DESIGN/SETTING: We evaluated 190 consecutive cases of children under 13 years of age urgently referred during a 5-year period in 1998-2003 to a community child advocacy center and compared them to those non-urgently referred with regard to their physical examination findings, any sexually transmitted infections or forensic evidence, gender, pubertal development, type of contact, reported ejaculation, later bathing or changing clothes, time to examination, and gender, age and relationship of alleged perpetrator. RESULTS: Children seen urgently were younger and had less frequent CPS involvement, more disclosures, and more positive physical examinations, and had more contact with older perpetrators than those seen non-urgently. Overall, most children were female and had normal or non-specific physical examinations. Certain case characteristics were predictive of evidence isolation in the 9% who had positive forensic evidence identified. Semen or sperm was identified from body swabs only from non-bathed, female children older than 10 years of age or on clothing or objects. CONCLUSIONS: Female children over 10 years old who report ejaculation or genital contact without bathing have the highest likelihood of positive examinations or forensic evidence. While there are other potential benefits of early examination, physicians seeking to identify forensic evidence should consider the needs of the child and other factors when determining the timing of medical assessment after sexual abuse.     

Analog assessment of frustration tolerance: Association with self-reported child abuse risk and physiological reactivity

Although frustration has long been implicated in promoting aggression, the potential for poor frustration tolerance to function as a risk factor for physical child abuse risk has received minimal attention. Instead, much of the extant literature has examined the role of anger in physical abuse risk, relying on self-reports of the experience or expression of anger, despite the fact that this methodology is often acknowledged as vulnerable to bias. Therefore, the present investigation examined whether a more implicit, analog assessment of frustration tolerance specifically relevant to parenting would reveal an association with various markers of elevated physical child abuse risk in a series of samples that varied with regard to age, parenting status, and abuse risk. An analog task was designed to evoke parenting-relevant frustration: the task involved completing an unsolvable task while listening to a crying baby or a toddler's temper tantrum; time scores were generated to gauge participants’ persistence in the task when encountering such frustration. Across these studies, low frustration tolerance was associated with increased physical child abuse potential, greater use of parent–child aggression in discipline encounters, dysfunctional disciplinary style, support for physical discipline use and physical discipline escalation, and increased heart rate. Future research directions that could better inform intervention and prevention programs are discussed, including working to clarify the processes underlying frustration intolerance and potential interactive influences that may exacerbate physical child abuse.     

Perceptions of caregivers and adolescents of the use of telemedicine for the child sexual abuse examination

BackgroundChildhood sexual abuse is a common cause of morbidity and mortality. All victims should receive a timely comprehensive medical exam. Currently there is a critical shortage of child abuse pediatricians who can complete the comprehensive child sexual abuse examination. Telemedicine has emerged as an innovative way to provide subspecialty care to this population. Despite the growing popularity of telemedicine, no literature exists describing patient and caregiver perceptions of telemedicine for this sensitive exam.ObjectiveTo explore caregiver and adolescent perspectives of the use of telemedicine for the child sexual abuse examination and discover factors that drive satisfaction with the technology.Participants and SettingCaregivers and adolescents who presented for a child sexual abuse medical evaluation at our county’s child advocacy center.MethodsWe completed semi structured interviews of 17 caregivers and 10 adolescents. Guided by the Technology Acceptance Model interviews assessed perceptions about: general feelings with the exam, prior use of technology, feelings about telemedicine, and role of the medical team. Interviews were audio-recorded, transcribed, coded and analyzed using content analysis with constant comparative coding. Recruitment ended when thematic saturation was reached.ResultsThere was an overwhelming positive response to telemedicine. Participants reported having a good experience with telemedicine regardless of severity of sexual abuse or prior experience with technology. Behaviors that helped patients and caregivers feel comfortable included a clear explanation from the medical team and professionalism demonstrated by those using the telemedicine system.ConclusionTelemedicine was widely accepted by adolescents and caregivers when used for the child sexual abuse examination.     

The incidence of infant physical abuse in Alaska

OBJECTIVES: To determine the incidence of and risk factors associated with infant (< 1 year of age) physical abuse in Alaska. METHODS: A population-based retrospective cohort study for the 1994-2000 resident birth cohort was conducted by linking data from birth certificates, Child Protective Services, a statewide hospital-based trauma registry, hospital discharge data, and the Alaska Infant Mortality Review (including death certificates). The main outcome measures were the incidences of overall physical abuse and abuse resulting in hospitalization or death. A case of child abuse was defined as an instance of substantiated physical abuse to an infant identified in the Child Protective Services database or an infant death with homicide identified on the death certificate as the manner of death. RESULTS: During the 7-year study period, there were 70,842 births and 325 cases of physical abuse including 72 that led to hospitalization (n = 58), death (n = 4), or both (n = 10); respective incidences for all abuse and abuse leading to hospitalization or death were 4.6 and 1.0 per 1000 live births. Following multivariate analyses, the risk factors with the highest population attributable risks were maternal or paternal education < or = 12 years, unmarried mother, and maternal prenatal substance use. To determine if the study methodology was likely to have missed cases of severe abuse, we examined information for all 216 infants hospitalized for trauma during the study period who did not have identification of abuse in one of the study databases; of these, at least 39 had injuries inconsistent with the reported mechanism (a long bone or skull fracture that reportedly resulted from a fall of less than 3 feet or from a caretaker's arms or for which the caretaker denied a history of trauma). Conclusions: Alaska has one of the highest documented infant physical abuse incidences reported in the literature and abuse is associated with potentially modifiable-primarily social-risk factors. Despite this high incidence, substantial under-reporting of hospitalized cases likely occurs.     

Identified spouse abuse as a risk factor for child abuse

CONTEXT: There are limited data on the extent to which spouse abuse in a family is a risk factor for child abuse. OBJECTIVE: To estimate the subsequent relative risk of child abuse in families with a report of spouse abuse compared with other families. DESIGN: Cohort study. SETTING: Analysis of a centralized US Army database PARTICIPANTS: Married couples with children with at least one spouse on active duty in the US Army during 1989-95. MAIN OUTCOME MEASURES: The US Army Family Advocacy Program's Central Database was used to identify child and spouse abuse. The exposure was an episode of identified spouse abuse and the main outcome was a substantiated episode of subsequent child abuse.RESULTS: During the study period of an estimated 2,019,949 person years, 14,270 incident child abuse cases were substantiated. Families with an incident case of spouse abuse identified during the study period were twice as likely to have a substantiated report of child abuse compaired with other military families, rate ratio, 2.0, (95% confidence interval [CI] 1.9-2.1). Young parental age had the highest rate ratio, 4.9 (95% CI 4.5-5.3) in the subgroup analysis controlling for rank. Identified spouse abuse was associated with physical abuse of a child, rate ratio 2.4 (95% CI 2.2-2.5), and with sexual abuse of a child, rate ratio 1.5 (95% CI 1.3-1.7). Identified spouse abuse was not associated with child neglect or maltreatment, rate ratio, 1.0 95% CI 0.9-1.1) CONCLUSION: An identified episode of spouse abuse in a family appears to be associated with an increased risk of subsequent child abuse and serves as an independent risk factor. Therefore. care providers should consider the potential risk to children when dealing with spouse abuse.     

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.     

Adolescents at risk for mistreating their children. Part II: A home- and clinic-based prevention program

OBJECTIVE: To determine if adding an intensive home visitation component to a comprehensive adolescent-oriented maternity program prevents child abuse and neglect. METHODS: We studied 171 participants in a comprehensive, adolescent-oriented maternity program who were deemed to be at high risk for child abuse and neglect. Half were randomly assigned to receive in-home parenting instruction. Major disruptions of primary care-giving by the adolescent mother were classified hierarchically as abuse, neglect, and abandonment. RESULTS: Compliance with home visits varied in relation to the support the teenage mothers received from their families and the fathers of their babies (p < .0001). There were no significant treatment group differences in the pattern of health care utilization, the rate of postpartum school return, repeat pregnancies, or child abuse and neglect. The incidence of maltreatment rose in tandem with the predicted risk status of the mother. Ultimately, 19% of the children were removed from their mother's custody. CONCLUSIONS: Prediction efforts were effective in identifying at-risk infants, but this intensive home- and clinic-based intervention did not alter the incidence of child maltreatment or maternal life course development. A parenting program that was more inclusive of the support network might be more popular with teenagers and therefore more effective. Our findings also emphasize the importance of including counseling specifically designed to prevent teenagers from abandoning their children.     

Conceptualization, reporting and underreporting of child abuse in Hong Kong

OBJECTIVE: To understand the conceptualization of child abuse and attitudes on reporting behaviors of Hong Kong adults. METHODS: Cross-sectional telephone survey of 1,001 randomly selected subjects. MAIN RESULTS: There is a discrepancy between perceived prevalence and the ability to name different child abuse types without prompting: 79.9% named physical abuse, while 41.2% felt it was common: 21.0% named child neglect, while 76.9% felt it was common; 13.4% named psychological abuse, while 47.4% felt it was common; 6.8% named sexual abuse, while 23.5% felt it was common. Most respondents classified severe physical abuse situations as abusive (e.g., "severely injuring a child"). Other scenarios such as "mildly injuring a child" and neglect and psychological abuse scenarios (e.g., "leaving a young child alone at home" and "shouting at a child often") were often not classified as abusive. As regards case-reporting behavior, only about 40% would report abuse cases to authorities. Those who would not report abuse were less likely to classify abuse situations as abusive and more likely to think that seeking help is difficult, troublesome and unhelpful. CONCLUSIONS: The official reported prevalence figures for child abuse in Hong Kong should be interpreted with care, because underreporting is likely to be serious. Hong Kong people's conceptualization and awareness of what comprises child abuse is found to differ from official definitions. They are reluctant to report abuse cases, due to their perceived low efficacy of case reporting. Both the difference in conceptualization and the reluctance to report might partly be attributable to Chinese culture.     

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.