Injury variables in child abuse

The child abuse reporting records of 616 children seen by the child abuse team in a metropolitan children's hospital were analyzed. Boys were referred for abuse more often than girls, and black children were reported disproportionately more often than were white children. Mothers were the most frequent perpetrators of abuse, although males constituted more than half of the abusers. Bruises were the most frequent manifestation of abuse. The types of injury, injury site and types of instruments used varied with the age and race, but not the sex of the child. The wide variety of instruments used to perpetrate child abuse resulted in a broad spectrum of injury types. If professionals are to recognize common and early manifestations of child abuse, they must be aware of the influence of regional socioeconomic and cultural factors on the spectrum of 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.     

Children's views on child abuse and neglect: findings from an exploratory study with Chinese children in Hong Kong

Objectives

This research study explored children's views on issues about child abuse in Hong Kong and examined their implications on child protection work and research in Chinese societies.

Method

Six primary schools were recruited from different districts of Hong Kong. Five vignettes of child maltreatment in the form of flash movies were presented to 87 children in 12 focus groups for discussion. The process was video-taped and the data were transcribed verbatim for data analysis by NUDIST.

Results

(1) Children do not have a homogeneous view on issues about child abuse and neglect, and their awareness and sensitivity to different kinds of child abuse are also different; (2) some of their views on child abuse and neglect are uniquely their own and are markedly different from those of adults; (3) some of the views expressed by children, however, are very much akin to those of adults, such as the factors they would consider in deciding whether a case is child abuse or not; (4) children's disclosure of abuse in Hong Kong is often affected by the Chinese culture in which they live, like filial piety and loyalty to parents.

Conclusion

Children's views on issues of child abuse and neglect, no matter they are the same or different from those of adults, serve to inform and improve child protection work. Children are not only victims in need of protection. They are also valuable partners with whom adult practitioners should closely work.

Practice implications

Children have, and are able to give, views on child abuse. They should be listened to in any child protection work no matter their views are same with or different from those of adults. As this study suggests, the relatively low sensitivity of the children to child neglect and sexual abuse, and their reluctance to disclose abuse and neglect due to their loyalty to parents are areas to focus on in preventive child protection work in a Chinese society like Hong Kong.     

Children hospitalized with child abuse and neglect: a case-control study

A case-control study of 45 hospitalized abused children was conducted to reassess the risk factors for child abuse when confounding by social class was minimized. Cases were matched for age, sex, family structure, and social class with children admitted to hospital for an acute illness. Abused children were more likely to have younger parents, fewer siblings, and to have been separated from their mothers during the first year of life. Their parents were more likely to have been abused as children and to have a poor relationship with the child's other parent. The families of abused children had encountered more stressful life events in the preceding 12 months. Other previously recognized "risk factors" were not shown to have a statistically significant association with child abuse. Because child abuse is more prevalent in lower socioeconomic families, the association with many of these factors has been accepted as implying a causal relationship. Matching procedures which attempted to eliminate confounding by social class and family structure cast doubts on some previously held beliefs about the risk factors for child abuse.     

Child maltreatment and adult socioeconomic well-being

ObjectiveLittle empirical research has examined the impact that child maltreatment may have on victims’ long-term socioeconomic well-being. The current study sought to address this gap by exploring the relationship between childhood experiences of abuse and neglect and several indicators of socioeconomic well-being in adulthood.MethodData from the nationally representative National Comorbidity Survey (NCS) (n = 5004) were analyzed using logistic regression models to examine whether maltreatment in childhood (any maltreatment, physical abuse, sexual abuse, severe neglect, and multiple types of maltreatment) affected employment status, income, and health care coverage in adulthood. Several potential confounds of this relationship were included as covariates in the models, including race, sex, age, and several indicators of childhood socioeconomic status (SES).ResultsThe results show that adults who had experienced maltreatment differed significantly from non-maltreated adults across each of the socioeconomic domains examined. Effects were additionally found to differ depending on the number of types of maltreatment experienced.ConclusionsIncreased rates of unemployment, poverty, and Medicaid usage indicate the significant long-term personal impact of early victimization. They also suggest a substantial societal cost from this problem through lost economic productivity and tax revenue, and increased social spending. Low socioeconomic status among parents has also been identified as a salient risk factor for the perpetration of maltreatment, and, as such, these results indicate a potential mechanism in the intergenerational transmission of violence.Practice implicationsThe findings from this study suggest that victims of child maltreatment are at increased risk for financial and employment-related difficulties in adulthood. Approximately one million children are identified each year by state agencies as victims of maltreatment in the United States. Many maltreated children, furthermore, go undetected by protective service agencies, indicating the high prevalence of this problem, and underscoring its large economic costs to society. By highlighting the long-term socioeconomic costs of maltreatment, this research should encourage policy makers to focus on improving prevention, intervention, and treatment efforts for victims of abuse and neglect.     

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

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

Practitioner and communities’ awareness of CALFB: Child abuse linked to faith or belief

This paper reports the results of an online survey which aimed to explore practitioners’ and faith community groups’ awareness and understanding of child abuse linked to faith or belief (CALFB) and to identify their further training needs in this area. The survey was founded in the work of the National working group for CALFB; a multi-agency response group committed to raising knowledge and awareness of this form of child abuse. Despite the relatively small number of recorded cases, CALFB continues to be a matter of concern to professionals and faith communities in the UK and beyond. One thousand three hundred and sixty two respondents comprising of frontline practitioners, faith and community group members completed the survey. A mixed-method analysis of the survey data illustrates a wide-ranging understanding of the term CALFB and disagreement about whether this is a specific form of child abuse. The results also indicate a relationship between confidence levels in identifying and responding to CALFB and specific training in this area. There is a call for specialised training to be more readily available. Further work is needed to develop a toolkit, which identifies indicators of CALFB and effective response pathways together with research across communities. The current research is timely and important in providing a foundation on which to build more effective identification of cases, policy and intervention.     

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.     

Alternative responses to child protective services: emerging issues and concerns

PROBLEM: Increased calls to "do something" about child protective services (CPS) have resulted in proposals or new "paradigms" for services to at-risk or abusive families. These new paradigms call for the reform or revamping of CPS through the development of a community-based alternative response to some reports of child abuse and/or neglect. METHOD: This article reports on outcomes for 1,263 "low" risk CPS referrals diverted to a community-based alternative response system. Data on child, family, and case characteristics and services provided are presented as well as outcomes associated with re-referral and placement post service provision. RESULTS: The risk level and severity of some of the referrals to alternative response systems seems inappropriately high. The rates of re-referral were similar for families who did or did not engage in assessment services, and were highest for families where domestic violence was present. CONCLUSIONS: Criteria for diversion to community alternatives to CPS must be clearly articulated and applied. Both CPS and alternative response system workers must have the skills required to address a family's recognition of the problem and degree of motivation to engage in problem resolution, and to understand their relationship to continued risk of CA/N.     

Supermarket Speak: Increasing Talk Among Low‐Socioeconomic Status Families

Children from low‐socioeconomic status (SES) families often fall behind their middle‐class peers in early language development. But interventions designed to support their language skills are often costly and labor‐intensive. This study implements an inexpensive and subtle language intervention aimed at sparking parent–child interaction in a place that families naturally visit: the supermarket. We placed signs encouraging adult–child dialogue in supermarkets serving low‐ and mid‐SES neighborhoods. Using an unobtrusive observational methodology, we tested how these signs affected adult–child interactions. When signs were present in supermarkets serving low‐SES neighborhoods, both the amount and the quality of talk between adults and children increased significantly, compared to when the signs were not present; signs had little effect in middle‐SES supermarkets. This study demonstrates that implementing simple, cost‐effective interventions in everyday environments may bolster children's language development and school readiness skills.     

Agreement among professionals about a child's sexual abuse status: interviews with sexually anatomically correct dolls as indicators of abuse.

This study was designed to define clinicians' ratings of the comments, behaviors, and affects of abused children and compare them with the same clinicians' decisions about the child's abuse status. The authors concluded that sexually anatomically correct dolls used alone are inadequate in providing enough information for professionals to accurately assess the abuse status of young children. Also it is unclear what observations of the child by mental health professionals are best correlated with their determinations of a child's abuse status. Of concern was the finding that the mental health professionals were more likely to be in agreement with the interviewer's determination of abuse than with the actual status of the child, suggesting undue influence of the interviewer, or, alternatively, both observer and interviewer were responding to unidentified child factors.     

Emotional abuse and neglect (psychological maltreatment): a conceptual framework

OBJECTIVE: Emotional abuse and neglect is an under-recognized, but actually common, form of child abuse. Professionals in the field continue to find difficulty in recognizing and operationally defining it, and experience uncertainty about proving it legally. There are also questions about intervention and therapy to protect the child in the least detrimental manner. These difficulties have led to delays in recognition and protective intervention. Emotional abuse and neglect are defined as a carer-child relationship that is characterized by patterns of harmful interactions, requiring no physical contact with the child. Motivation to harm the child is not necessary for the definition. Unlike sexual abuse that is a secret activity, these forms of ill treatment are easily observable. The child's development is impaired in all domains of functioning but, not being specific to emotional abuse and neglect, cannot be regarded as diagnostic. METHOD: Research, clinical experience and theoretical considerations have led to a conceptual framework and operational definitions of five categories of harmful interactions between parent and child. This framework is contrasted with the APSAC categories. RESULTS: It is postulated that the different categories of ill treatment respectively require different therapeutic interventions. CONCLUSION: Concerns about the presence of emotional abuse need to trigger an assessment process that includes identifying the nature of the abusive or neglectful interactions and a time-limited trial of specific interventions. The family's response to this process and its outcome will determine the need for statutory involvement, as well as providing a basis for litigation if this is required.     

Emotion recognition in fathers and mothers at high-risk for child physical abuse

Objective

The present study was designed to determine whether parents at high risk for physical child abuse, in comparison with parents at low risk, show deficits in emotion recognition, as well as to examine the moderator effect of gender and stress on the relationship between risk for physical child abuse and emotion recognition.

Methods

Based on their scores on the Abuse Scale of the CAP Inventory (Milner, 1986), 64 parents at high risk (24 fathers and 40 mothers) and 80 parents at low risk (40 fathers and 40 mothers) for physical child abuse were selected. The Subtle Expression Training Tool/Micro Expression Training Tool ( [Ekman, 2004a] and [Ekman, 2004b]) and the Diagnostic Analysis of Nonverbal Accuracy II (Nowicki & Carton, 1993) were used to assess emotion recognition.

Results

As expected, parents at high risk, in contrast to parents at low risk, showed deficits in emotion recognition. However, differences between high- and low-risk participants were observed only for fathers, but not for mothers. Whereas fathers at high risk for physical child abuse made more errors than mothers at high risk, no differences between mothers at low risk and fathers at low risk were found. No interaction between stress, gender, and risk status was observed for errors in emotion recognition.

Conclusions and practice implications

The present findings, if confirmed with physical abusers, could be helpful to further our understanding of deficits in processing information of physically abusive parents and to develop treatment strategies specifically focused on emotion recognition. Moreover, if gender differences can be confirmed, the findings could be helpful to develop specific treatment programs for abusive fathers.     

Neighborhood alcohol outlet density and rates of child abuse and neglect: Moderating effects of access to substance abuse services

This study investigates the relationship between concentrations of on- and off-premises alcohol outlets and rates of child abuse and neglect. Additionally, the study seeks to locate protective features of a neighborhood's built environment by investigating the potentially moderating role that access to substance abuse treatment and prevention services plays in the relationship between alcohol outlet density and child maltreatment. Using a cross-sectional design, this ecological study utilized data from 163 census tracts in Bergen County, New Jersey, on reports of child abuse and neglect, alcohol outlets, substance abuse treatment and prevention facilities, and the United States Census to investigate the linkages between socioeconomic structure, alcohol availability, and access to substance abuse service facilities on rates of child abuse and neglect. Findings indicate areas with a greater concentration of on-premises alcohol outlets (i.e., bars) had higher rates of child neglect, and those with easier access to substance abuse services had lower rates of neglect, controlling for neighborhood demographic and socioeconomic structure. Additionally, the relationship between on-premises alcohol outlet density and rates of child neglect was moderated by the presence of substance abuse service facilities. A greater concentration of off-premises outlets (i.e., liquor stores) was associated with lower rates of physical abuse. Findings suggest that the built environment and socioeconomic structure of neighborhoods have important consequences for child well-being. The implications for future research on the structural features of neighborhoods that are associated with child well-being are discussed.     

Teachers' attitudes toward and knowledge of child maltreatment

OBJECTIVE: The purpose of this study was to determine teachers' self-reported knowledge of the signs and symptoms of child maltreatment, reporting procedures, legal issues surrounding child abuse and their attitudes toward corporal punishment. In addition, a factor analysis was performed on the Educators and Child Abuse Questionnaire (ECAQ) (Kenny, 2001a). METHOD: Two hundred teachers, who work in the southeast region of the US in a large, ethnically diverse school system, were administered the ECAQ which contains questions on knowledge concerning: (1) signs and symptoms of child abuse, (2) laws, and (3) procedures for reporting child abuse as well as number of reports filed. RESULTS: Most teachers reported being unaware of the signs and symptoms of child maltreatment, as well as reporting procedures. They also felt administration would not be supportive and were in disagreement with their legal role as mandated reporters. The ECAQ was found to be a reliable measure with four factors: (1) Awareness of signs and symptoms of child abuse, (2) Knowledge of reporting procedures, (3) Attitudes toward discipline, and (4) Seriousness of child abuse. CONCLUSIONS: In general, teachers reported a lack of awareness of the signs of child abuse and reporting procedures, which may affect their ability to report cases of suspected abuse. There is a need for standardized training in child maltreatment for all teachers as well as clear, concise institutional guidelines for reporting child abuse and support for teachers confronted with suspected victims.     

A survey of pediatricians' attitudes and experiences with court in cases of child maltreatment

OBJECTIVES: To explore pediatricians' attitudes and experiences with the court system in child maltreatment cases. DESIGN: An anonymous, cross-sectional survey of a random sample of pediatricians registered with the North Carolina Medical Board. RESULTS: The response rate of the study was 60% (N=270). Few pediatricians (10%) reported that they had "ever" suspected maltreatment but decided not to report it. Pediatricians were equally likely to recall positive and negative experiences in court for child abuse cases. Pediatricians with negative court experiences were more likely to view reporting as time-consuming and were more than twice as likely not to report suspected cases of maltreatment (OR 2.4, 95% CI 1.04, 6.0). Seventy-five percent of pediatricians felt that court is harmful or distressing for children. CONCLUSIONS: The majority of pediatricians report suspected cases of child maltreatment. Pediatrician's court experiences play a role in the response to child maltreatment cases, influencing attitudes towards the legal system and the process of caring for maltreated children. Future research efforts should address physicians' concerns about the impact of court on children, ways to improve the working relationship between the legal system and physicians, and the training needs of physicians in child maltreatment, including testifying and understanding the court process.     

Pediatric response to a large-scale child protection intervention

Objective

In a rural area of the US state of Texas, in April 2008, the Texas Department of Family and Protective Services (DFPS) responded to evidence of widespread child abuse in an isolated religious compound by removing 463 individuals into state custody. This mass child protection intervention is the largest such action that has ever occurred in the United States. The objective of this paper is to characterize the burdens placed on the area's community resources, healthcare providers, and legal system, the limitations encountered by the forensic and public health professionals, and how these might be minimized in future large-scale child protection interventions.

Methods

Drawing on publicly available information, this article describes the child abuse investigation, legal outcomes, experiences of pediatric healthcare providers directly affected by the mass removal, and the roles of regional child abuse pediatric specialists.

Results

Because the compound's residents refused to cooperate with the investigation and the population of the compound was eight times higher than expected, law enforcement and child protection resources were insufficient to conduct standard child abuse investigations. Local medical and public health resources were also quickly overwhelmed. Consulting child abuse pediatricians were asked to recommend laboratory and radiologic studies that could assist in identifying signs of child abuse, but the lack of cooperation from patients and parents, inadequate medical histories, and limited physical examinations precluded full implementation of the recommendations.

Conclusions

Although most children in danger of abuse were removed from the high-risk environment for several months and some suspected abusers were found guilty in criminal trials, the overall success of the child protection intervention was reduced by the limitations imposed by insufficient resources and lack of cooperation from the compound's residents.

Practice implications

Recommendations for community and child abuse pediatricians who may become involved in future large child-protection interventions are presented.     

Teachers' recognition and reporting of child abuse: a factorial survey

OBJECTIVE: The major aim of this study was to determine the effect of characteristics of the case, the teacher, and the organizational setting on recognition and reporting of child abuse. METHOD: A factorial survey design was employed in which a probability sample of teachers (N = 480) responded to vignettes in which case characteristics were systematically manipulated. RESULTS: Analysis using OLS regression showed that case characteristics alone accounted for 50.30% of the variance in recognition and 51.08% of the variance in reporting: the strongest effects were from type and seriousness of abuse, positive behavior of the victim and positive psychology of the perpetrator. The inclusion of variables describing the teachers and the school explained only a very small additional proportion of the variance in teacher's responses. CONCLUSIONS: Teachers responses to child abuse are relatively unbiased by either the extraneous characteristics of the perpetrator or victim, the responding teacher, or the school setting. The findings do not appear to support the problem of "overreporting." There is evidence for "underreporting," particularly in less serious cases involving physical and emotional abuse. Teachers are undeterred by the many problems and fears that may accompany a report of child abuse to Child Protective Services. Teachers use discretion in reporting abuse they recognize.     

Assessment of factors resulting in abuse evaluations in young children with minor head trauma

OBJECTIVE: The primary objective was to determine which of the examined factors prompted physicians to initiate a further abuse evaluation in young children with minor head injury. The recording of important historical elements in the charts of these patients was also evaluated. METHODS: Charts of 349 children less than 3 years of age with minor head injury were retrospectively reviewed. Age, race, sex, insurance status, findings on head CT, mechanism of injury, witnessing of event and delay in seeking care were analyzed for association with performance of skeletal survey and referral to Child Protective Services (CPS). RESULTS: Increased odds of CPS referral and increased odds of obtaining a skeletal survey were associated with positive findings on head CT, delay in seeking care, and unknown mechanism of injury. Despite a known association of age/ambulatory status with abuse, the age of the child was not associated with increased odds of abuse evaluation, and younger age was not associated with increased odds of documenting whether the injury was witnessed or when the injury occurred. Documentation of timing of injury was lacking in 29.2% of the charts. Witnessing of the event was undocumented in 48.7% of cases. CONCLUSION: Clinicians may not be using readily available, important information when considering the initiation of an abuse evaluation in young children. Clinicians seeing acutely injured children may need further education regarding developmental status and its effect on mechanisms of injury and the importance of detailed documentation in cases where abuse is a possible cause of injury. PRACTICE IMPLICATIONS: Historical factors associated with injuries in young children continue to be poorly documented. Increased pediatric training for emergency medicine physicians, clinical protocols for evaluation and documentation of injured children, and regular continuing medical education on child development and its implications on mechanisms of injury for clinicians practicing in acute care settings are needed changes that may bring about improvements.     

Interpretations of colposcopic photographs: evidence for competence in assessing sexual abuse?

Accurate assessment of physical findings for child sexual abuse is medically and legally important. This study evaluated (1) interobserver reliability of clinicians rating colposcopic photographs, and (2) correlates of reliable interpretations. Seventy physicians and two nurse practitioners, divided by professional levels, assessed colposcopic photographs and completed a questionnaire. Ratings by a professional with extensive experience in this field were used as an accuracy standard. Leaders in the field of child sexual abuse assessment made significantly more "accurate" assessments than pediatricians, pediatric and family practice residents, and intern physicians. Leaders made fewer "inaccurate" interpretations than interns. Predictors of agreement with standard assessments, although weak, were knowledge of female perineal anatomy and professional level. Total number of sexual abuse examinations conducted and knowledge of sexually transmitted diseases as acquired by children were not significant predictors of accurate assessment. The findings are interpreted as to their potential relevance to actual sexual abuse evaluations of children.