Genital examinations for alleged sexual abuse of prepubertal girls: findings by pediatric emergency medicine physicians compared with child abuse trained physicians

OBJECTIVE: This study compares abnormal genital examination findings made by pediatric emergency medicine (PEM) physicians to examinations by physicians with training in child sexual abuse in the evaluation of prepubertal girls for suspected sexual abuse. METHOD: A prospective study was performed following the genital examination by a PEM physician of prepubertal girls suspected of being sexually abused. A physician with training in child sexual abuse re-examined those girls whose examinations were interpreted as abnormal by the PEM physicians. The findings and interpretations of the PEM physician were then compared to those by the physicians with training in child abuse. RESULTS: Between October 1994 and October 1998, 46 patients diagnosed by PEM physicians with nonacute genital findings indicative of sexual abuse were re-examined by a physician with training in child abuse. The follow-up examinations were done 2 days-16 weeks (mean 2.1 weeks) after the emergency department visit. The physicians with training in child abuse concluded that only eight of these children (17%) showed clear evidence of abuse. Normal findings were noted in 32 children (70%), nonspecific changes were noted in 4 children (9%), and 2 children (4%) had findings that are more commonly seen in abused children than nonabused children but are not diagnostic for abuse (concerning for abuse). CONCLUSIONS: There was poor agreement between the pediatric emergency medicine physicians and the physicians with training in child sexual abuse. This study suggests that emergency medicine physicians should consider additional training in this area. In addition, all children with abnormal ED examinations should have follow-up examinations by a child abuse trained physician.     

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.     

Skeletal surveys in young,injured children: A systematic review

Skeletal surveys (SSs) have been identified as a key component of the evaluation for suspected abuse in young children, but variability in SS utilization has been reported. Thus, we aimed to describe the utilization patterns, yield, and risks of obtaining SS in young children through a systematic literature review. We searched PubMed/MEDLINE and CINAHL databases for articles published between 1990 and 2016 on SS. We calculated study-specific percentages of SS utilization and detection of occult fractures and examined the likelihoods that patient characteristics predict SS utilization and detection of occult fractures. Data from 32 articles represents 64,983 children <60 months old. SS utilization was high (85%-100%) in studies of infants evaluated by a child protection team for suspected abuse and/or diagnosed with abuse except in one study of primarily non-pediatric hospitals. Greater variability in SS utilization was observed across studies that included all infants with specific injuries, such as femur fractures (0%–77%), significant head injury (51%–82%), and skull fractures (41%–86%). Minority children and children without private insurance were evaluated with SS more often than white children and children with private insurance despite lack of evidence to support this practice. Among children undergoing SS, occult fractures were frequently detected among infants with significant head injury (23%–34%) and long bone fractures (30%) but were less common in infants with skull fractures (1%–6%). These findings underscore the need for interventions to decrease disparities in SS utilization and standardize SS utilization in infants at high risk of having occult fractures.     

Child care workers' knowledge about reporting suspected child sexual abuse.

As reports of the sexual abuse of preschool-aged children increase and the number of children in day care expands, it is important to recognize child care workers as potentially important resource persons for sexually abused preschoolers. Although they are potential resources for abused children, they may fail to report suspected abuse if they do not know their legal responsibilities and their rights and protections under the law. The purpose of this study was to determine child care workers' knowledge about their reporting rights and responsibilities. Relative to child sexual abuse experts, day care personnel knew significantly less about the procedures for reporting suspected abuse and their protection under the law. Suggestions for improving child care workers' knowledge about reporting suspected sexual abuse cases are provided.     

Hospital-based multidisciplinary teams can prevent unnecessary child abuse reports and out-of-home placements

OBJECTIVE: To determine how often and for what reasons a hospital-based multidisciplinary child abuse team concluded that a report of alleged or suspected child abuse was unnecessary in young children with fractures. METHODS: A retrospective review was completed of all children less than 12 months of age who, because of fractures, were referred to the hospital multidisciplinary child abuse team for consultation regarding the need to consider child abuse. RESULTS: The team received 99 consultations, reported 92 (93%) children as alleged or possible victims of physical abuse, and did not report 7 (7%). Age at presentation of those who were reported was 4.2 months compared to 3.0 months in the non-reported group. The average number of fractures in the reported group was 2.9 (SD 3.53) compared to 3.4 (SD 4.6) in the non-reported group. Factors that led to cases not being reported included: (a) a trauma history consistent with the fracture (n=4), (b) a diagnosis of bone fragility secondary to genetic, nutritional or medical therapy etiologies (n=2), and (c) iatrogenic fracture (n=1). CONCLUSIONS: Seven percent of the children less than 12 months of age and with at least one fracture referred to the multidisciplinary team for evaluation of possible child abuse were not reported as alleged or suspected physical abuse. The involvement of the hospital multidisciplinary child abuse team may have prevented unnecessary investigation by the county social services agency and/or police, and possible out-of-home temporary placement.     

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.     

Sexually abused boys

Male victims of child sexual abuse have received inadequate attention in the literature. This article is a retrospective review of the reports of 189 boys evaluated during 1983-85. This population was younger than those previously reported. Comparison to an age- and race-matched group of girl victims seen during the same period revealed many similarities in patterns of disclosure and perpetrator characteristics. The acts perpetrated against the boys included a wide array of invasive acts at all ages, but sodomy was more frequently reported in the older victims. Abnormal anogenital findings were seen more often in younger children, but the findings were often nonspecific. An examiner experienced with young children and infants is essential.     

Whiplash shaking syndrome: retinal hemorrhages and computerized axial tomography of the brain

Three cases of whiplash shaking injury of infants are presented. All children presented with seizures and had minimal signs of external injury. Examination of the retina revealed extensive retinal hemorrhages. These were missed on initial examination and were only discovered after pupillary dilatation. The presence of these palecentered retinal hemorrhages suggested the diagnosis of child abuse and skeletal surveys and thorough social histories confirmed the diagnosis. Despite extensive retinal hemorrhages, computerized axial tomography (C.T.) scan showed minimal inter-hemispheric bleeding. In contrast to the "Battered Child Syndrome," all the findings in whiplash shaking syndrome of infants are subtle and demand an awareness, an index of suspicion and a thorough examination which may include extensive retinal examination following dilatation of the pupils. This latter examination is frequently not performed by family physicians and residents so that the syndrome may be missed. A fourth case is also discussed where shaking is admitted on initial presentation but said to be done for resuscitation. This poses an immense diagnostic dilemma to the pediatrician since in this case the child presented later with all the signs of physical abuse.     

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.     

虐童行为的刑法思考

基于我国刑法不能评价虐童行为的现状,学者们呼吁"虐童"入刑,用刑法来保护低幼儿童的合法权益。但什么样的行为属于"虐童"行为,"虐童"行为的对象是什么呢?"虐童"行为的主体持怎样的心态呢?本文探讨了这些问题。     

The co-occurrence of adverse childhood experiences among children investigated for child maltreatment: A latent class analysis

Children investigated for maltreatment are particularly vulnerable to experiencing multiple adversities. Few studies have examined the extent to which experiences of adversity and different types of maltreatment co-occur in this most vulnerable population of children. Understanding the complex nature of childhood adversity may inform the enhanced tailoring of practices to better meet the needs of maltreated children. Using cross-sectional data from the National Survey of Child and Adolescent Well-Being II (N = 5870), this study employed latent class analysis to identify subgroups of children who had experienced multiple forms of maltreatment and associated adversities among four developmental stages: birth to 23 months (infants), 2–5 (preschool age), 6–10 (school age), and 11–18 years-old (adolescents). Three latent classes were identified for infants, preschool-aged children, and adolescents, and four latent classes were identified for school-aged children. Among infants, the groups were characterized by experiences of (1) physical neglect/emotional abuse/caregiver treated violently, (2) physical neglect/household dysfunction, and (3) caregiver divorce. For preschool-aged children, the groups included (1) physical neglect/emotional abuse/caregiver treated violently, (2) physical neglect/household dysfunction, and (3) emotional abuse. Children in the school-age group clustered based on experiencing (1) physical neglect/emotional neglect and abuse/caregiver treated violently, (2) physical neglect/household dysfunction, (3) emotional abuse, and (4) emotional abuse/caregiver divorce. Finally, adolescents were grouped based on (1) physical neglect/emotional abuse/household dysfunction, (2) physical abuse/emotional abuse/household dysfunction, and (3) emotional abuse/caregiver divorce. The results indicate distinct classes of adversity experienced among children investigated for child maltreatment, with both stability across developmental periods and unique age-related vulnerabilities. Implications for practice and future research are discussed.     

Dynamics of forensic interviews with suspected abuse victims who do not disclose abuse

OBJECTIVES: The present study was designed to explore structural differences between forensic interviews in which children made allegations and those in which children did not make allegations. METHODOLOGY: Fifty forensic interviews of 4- to 13-year-old suspected victims of abuse who did not disclose abuse during the interview were compared with the same number of forensic interviews of alleged victims who made allegations of sexual or physical abuse. Only cases in which there was substantial reason to believe that abuse had taken place were included in the study. Audiotapes of the interviews were examined with a focus on interviewer utterances and children's responses during the pre-substantive rapport-building, episodic memory training, and 'getting the allegation' phases of the interviews, which all employed the NICHD Investigative Interview Guide. FINDINGS: Forensic interviews which yielded allegations of child abuse were characterized by quite different dynamics than interviews with children who did not make allegations. When interviewing non-disclosers, interviewers made less frequent use of free recall prompts and offered fewer supportive comments than when interviewing children who made allegations of abuse. Children who did not disclose abuse were somewhat uncooperative, offered fewer details, and gave more uninformative responses, even at the very beginning of the interview, before the interviewers focused on substantive issues and before the interviewers themselves began to behave differently. CONCLUSIONS: A premature focus on substantive issues may prevent children who are not responsive in the episodic memory training phase from disclosing abuse. Identifying reluctant disclosers and making more extensive efforts to build rapport before substantive issues are broached, or interviewing such children in more than one session, may help suspected victims disclose their experiences.     

Medical evaluation referral patterns for sexual abuse victims.

It has been recommended that all children suspected of being sexually abused should have medical evaluations. To better understand practices and perceptions of child sexual abuse medical evaluations, a survey was conducted of 579 professionals attending educational programs on child sexual abuse; 85.8% (N = 497) responded. Half (50%) of the respondents reported no previous training in child sexual abuse. Of the 336 nonphysician professionals, 194 (57.7%) were in positions where they make referrals of the victims, and 69% of these did not refer all of the children they saw for medical evaluations. The first referral choice for medical evaluation was most often to the victim's primary physician (57%). For those professionals who did not refer all alleged victims for medical evaluation, neither the victims' age, gender, nor accessibility to care were generally considered relevant in determining the decision to refer. However, the type of abuse and presence of physical and psychological symptoms were considered relevant in making the decision. The majority indicated that the findings of the medical exam were very useful in substantiating or refuting the allegation of abuse. Further training for both medical and nonmedical professionals is needed to increase awareness of the need for and implications of the medical evaluation if children are to receive comprehensive assessments. Physicians may play an active role in this process through education of professionals and provision of care.     

Exploratory assessments of child abuse: Children's responses to interviewer's questions across multiple interview sessions

ObjectiveThe present study extends field research on interviews with young children suspected of having been abused by examining multiple assessment interviews designed to be inquisitory and exploratory, rather than formal evidential or forensic interviews.MethodsSixty-six interviews with 24 children between the ages of 3 and 6 years who were undergoing an assessment for suspected child abuse were examined. Each child was interviewed 2, 3, or 4 times. The interviewer's questions were categorized in terms of openness (open, closed or choice), in terms of the degree of interviewer input (free recall, direct, leading, suggestive), and for topic (whether the question was abuse-specific or nonabuse-related). Children's on-task responses were coded for amount of information (number of clauses) reported in relation to each question type and topic, and off-task responses were categorized as either ignoring the question or a diverted response.ResultsChildren provided a response to most questions, independent of question type or topic and typically responded with one or two simple clauses. Some children disclosed abuse in response to open-ended questions; generally, however, failure to respond to a question was more likely for abuse-specific than for nonabuse-related questions.ConclusionThe findings are discussed in terms of the growing literature on interviewing children about suspected abuse, particularly in interviews conducted over multiple sessions.Practice implicationsAssessment of suspected child abuse may involve more than a single investigative interview. Research examining children's responses to questioning over multiple interviews (or single interviews conducted over multiple sessions) is necessary for the development of best practise guidelines for the assessment of abuse.     

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.     

Forced suffocation of infants with baby wipes: a previously undescribed form of child abuse

BACKGROUND: Foreign body aspiration in children is commonly seen in emergency departments and carries a significant mortality. Abusive foreign body suffocation is not well described. METHODS: We present a case-series of four infants who presented with aspiration of a baby wipe. RESULTS: Each child was found to be a victim of child physical abuse with substantial morbidity and mortality associated with the aspiration of the wipe and associated injuries. CONCLUSIONS: We recommend that infants who present with a baby wipe aspiration should be considered as likely victims of child abuse and physicians should evaluate each infant for associated injuries of the oropharynx, skin, skeleton, and head.     

Impact of a new mandatory reporting law on reporting and identification of child sexual abuse: A seven year time trend analysis

Child sexual abuse is widespread and difficult to detect. To enhance case identification, many societies have enacted mandatory reporting laws requiring designated professionals, most often police, teachers, doctors and nurses, to report suspected cases to government child welfare agencies. Little research has explored the effects of introducing a reporting law on the number of reports made, and the outcomes of those reports. This study explored the impact of a new legislative mandatory reporting duty for child sexual abuse in the State of Western Australia over seven years. We analyzed data about numbers and outcomes of reports by mandated reporters, for periods before the law (2006–2008) and after the law (2009–2012). Results indicate that the number of reports by mandated reporters of suspected child sexual abuse increased by a factor of 3.7, from an annual mean of 662 in the three year pre-law period to 2448 in the four year post-law period. The increase in the first two post-law years was contextually and statistically significant. Report numbers stabilized in 2010–2012, at one report per 210 children. The number of investigated reports increased threefold, from an annual mean of 451 in the pre-law period to 1363 in the post-law period. Significant decline in the proportion of mandated reports that were investigated in the first two post-law years suggested the new level of reporting and investigative need exceeded what was anticipated. However, a subsequent significant increase restored the pre-law proportion, suggesting systemic adaptive capacity. The number of substantiated investigations doubled, from an annual mean of 160 in the pre-law period to 327 in the post-law period, indicating twice as many sexually abused children were being identified.     

Evaluation of parenting,depression and violence profiles in methadone maintained women

Twenty-one patients of the Family Center Program for pregnant drug dependent women were studied employing tools which indicate potential ability to parent or risk of child abuse. The Profile of Mood States and Beck Depression Inventory were administered, and a Violence Questionnaire was self-administered to ascertain the presence of physical or sexual abuse in the mothers' lives. These results were compared to an assessment of parenting ability as well as general demographics and urinalyses which indicate whether the mothers were taking any drugs in addition to their methadone. Results revealed that there were strong relationships between parenting ability and abusive life events, prenatal clinic attendance, use of depressant drugs, number of children, age, and education and/or employment. These variables were also interrelated with depression, abnormal mood states, and general drug abuse. It appears that while polydrug abuse, psychological problems, and stressful life events are strong indicators of poor parenting ability, the successfully methadone maintained woman who does not feel the need to supplement her methadone with other drugs, whose life has stabilized, and who is relatively normal in her affect and mood, has a strong potential for good childrearing ability.     

Vaginal inspection as it relates to child sexual abuse in girls under thirteen

Inclusion of vaginal inspection in all physical examinations resulted in doubling identification of cases of child sexual abuse. Forty-five of 247 girls under 13 years of age were admitted because sexual abuse had been reported. Of the 202 girls not suspected, 45 additional cases of sexual abuse were discovered by suspicious findings on vaginal inspection. The horizontal diameter of the vaginal opening exceeding 4 mm correlated in three of four instances with a confirming history for past sexual abuse. It is recommended that physical examination of young girls routinely include inspection of the vaginal opening. Pediatric caregivers need to teach themselves the parameters of the normal to protect those children who are suffering sexual abuse in their environment.     

Why children tell: a model of children's disclosure of sexual abuse

OBJECTIVE: The present study investigated variables associated with delay of disclosure of child sexual abuse and tested a model of time to disclosure. METHOD: Data were obtained for 218 alleged child sexual abuse victims whose cases had been referred to District Attorneys' Offices. Five variables were posited to influence the delay between an abusive event and children's disclosure of that event to a reporting adult: child's age, gender, type of abuse experienced (intrafamilial or extrafamilial), perceived responsibility for the abuse, and fear of negative consequences of disclosure. These variables were used to create a model of factors influencing children's disclosure of sexual abuse. RESULTS: Results indicated that age, type of abuse, fear of negative consequences, and perceived responsibility all contributed to predicting time to disclosure. There was significant support for the model, suggesting that children who were older, came from incestuous families, felt greater responsibility for the abuse, and feared negative consequences of disclosure took longer to disclose. CONCLUSIONS: Children's cognitive appraisal of others' tolerance of disclosure of child sexual abuse, and their own perceptions of responsibility for the abuse, are crucial to the decision to disclose. When evaluating children for possible sexual abuse, developmental, cognitive, and socio-emotional factors need to be taken into consideration.