pediatric child abuse case study

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A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy

• Magdalena Romanowicz   ORCID: orcid.org/0000-0002-4916-0625 1 ,
• Alastair J. McKean 1 &
• Jennifer Vande Voort 1  

BMC Psychiatry volume  17 , Article number:  330 ( 2017 ) Cite this article

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Long-term effects of neglect in early life are still widely unknown. Diversity of outcomes can be explained by differences in genetic risk, epigenetics, prenatal factors, exposure to stress and/or substances, and parent-child interactions. Very common sub-threshold presentations of children with history of early trauma are challenging not only to diagnose but also in treatment.

Case presentation

A Caucasian 4-year-old, adopted at 8 months, male patient with early history of neglect presented to pediatrician with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. He was subsequently seen by two different child psychiatrists. Pharmacotherapy treatment attempted included guanfacine, fluoxetine and amphetamine salts as well as quetiapine, aripiprazole and thioridazine without much improvement. Risperidone initiated by primary care seemed to help with his symptoms of dyscontrol initially but later the dose had to be escalated to 6 mg total for the same result. After an episode of significant aggression, the patient was admitted to inpatient child psychiatric unit for stabilization and taper of the medicine.

Conclusions

The case illustrates difficulties in management of children with early history of neglect. A particular danger in this patient population is polypharmacy, which is often used to manage transdiagnostic symptoms that significantly impacts functioning with long term consequences.

Peer Review reports

There is a paucity of studies that address long-term effects of deprivation, trauma and neglect in early life, with what little data is available coming from institutionalized children [ 1 ]. Rutter [ 2 ], who studied formerly-institutionalized Romanian children adopted into UK families, found that this group exhibited prominent attachment disturbances, attention-deficit/hyperactivity disorder (ADHD), quasi-autistic features and cognitive delays. Interestingly, no other increases in psychopathology were noted [ 2 ].

Even more challenging to properly diagnose and treat are so called sub-threshold presentations of children with histories of early trauma [ 3 ]. Pincus, McQueen, & Elinson [ 4 ] described a group of children who presented with a combination of co-morbid symptoms of various diagnoses such as conduct disorder, ADHD, post-traumatic stress disorder (PTSD), depression and anxiety. As per Shankman et al. [ 5 ], these patients may escalate to fulfill the criteria for these disorders. The lack of proper diagnosis imposes significant challenges in terms of management [ 3 ].

J is a 4-year-old adopted Caucasian male who at the age of 2 years and 4 months was brought by his adoptive mother to primary care with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. J was given diagnoses of reactive attachment disorder (RAD) and ADHD. No medications were recommended at that time and a referral was made for behavioral therapy.

She subsequently took him to two different child psychiatrists who diagnosed disruptive mood dysregulation disorder (DMDD), PTSD, anxiety and a mood disorder. To help with mood and inattention symptoms, guanfacine, fluoxetine, methylphenidate and amphetamine salts were all prescribed without significant improvement. Later quetiapine, aripiprazole and thioridazine were tried consecutively without behavioral improvement (please see Table  1 for details).

No significant drug/substance interactions were noted (Table 1 ). There were no concerns regarding adherence and serum drug concentrations were not ordered. On review of patient’s history of medication trials guanfacine and methylphenidate seemed to have no effect on J’s hyperactive and impulsive behavior as well as his lack of focus. Amphetamine salts that were initiated during hospitalization were stopped by the patient’s mother due to significant increase in aggressive behaviors and irritability. Aripiprazole was tried for a brief period of time and seemed to have no effect. Quetiapine was initially helpful at 150 mg (50 mg three times a day), unfortunately its effects wore off quickly and increase in dose to 300 mg (100 mg three times a day) did not seem to make a difference. Fluoxetine that was tried for anxiety did not seem to improve the behaviors and was stopped after less than a month on mother’s request.

J’s condition continued to deteriorate and his primary care provider started risperidone. While initially helpful, escalating doses were required until he was on 6 mg daily. In spite of this treatment, J attempted to stab a girl at preschool with scissors necessitating emergent evaluation, whereupon he was admitted to inpatient care for safety and observation. Risperidone was discontinued and J was referred to outpatient psychiatry for continuing medical monitoring and therapy.

Little is known about J’s early history. There is suspicion that his mother was neglectful with feeding and frequently left him crying, unattended or with strangers. He was taken away from his mother’s care at 7 months due to neglect and placed with his aunt. After 1 month, his aunt declined to collect him from daycare, deciding she was unable to manage him. The owner of the daycare called Child Services and offered to care for J, eventually becoming his present adoptive parent.

J was a very needy baby who would wake screaming and was hard to console. More recently he wakes in the mornings anxious and agitated. He is often indiscriminate and inappropriate interpersonally, unable to play with other children. When in significant distress he regresses, and behaves as a cat, meowing and scratching the floor. Though J bonded with his adoptive mother well and was able to express affection towards her, his affection is frequently indiscriminate and he rarely shows any signs of separation anxiety.

At the age of 2 years and 8 months there was a suspicion for speech delay and J was evaluated by a speech pathologist who concluded that J was exhibiting speech and language skills that were solidly in the average range for age, with developmental speech errors that should be monitored over time. They did not think that issues with communication contributed significantly to his behavioral difficulties. Assessment of intellectual functioning was performed at the age of 2 years and 5 months by a special education teacher. Based on Bailey Infant and Toddler Development Scale, fine and gross motor, cognitive and social communication were all within normal range.

J’s adoptive mother and in-home therapist expressed significant concerns in regards to his appetite. She reports that J’s biological father would come and visit him infrequently, but always with food and sweets. J often eats to the point of throwing up and there have been occasions where he has eaten his own vomit and dog feces. Mother noticed there is an association between his mood and eating behaviors. J’s episodes of insatiable and indiscriminate hunger frequently co-occur with increased energy, diminished need for sleep, and increased speech. This typically lasts a few days to a week and is followed by a period of reduced appetite, low energy, hypersomnia, tearfulness, sadness, rocking behavior and slurred speech. Those episodes last for one to 3 days. Additionally, there are times when his symptomatology seems to be more manageable with fewer outbursts and less difficulty regarding food behaviors.

J’s family history is poorly understood, with his biological mother having a personality disorder and ADHD, and a biological father with substance abuse. Both maternally and paternally there is concern for bipolar disorder.

J has a clear history of disrupted attachment. He is somewhat indiscriminate in his relationship to strangers and struggles with impulsivity, aggression, sleep and feeding issues. In addition to early life neglect and possible trauma, J has a strong family history of psychiatric illness. His mood, anxiety and sleep issues might suggest underlying PTSD. His prominent hyperactivity could be due to trauma or related to ADHD. With his history of neglect, indiscrimination towards strangers, mood liability, attention difficulties, and heightened emotional state, the possibility of Disinhibited Social Engagement Disorder (DSED) is likely. J’s prominent mood lability, irritability and family history of bipolar disorder, are concerning for what future mood diagnosis this portends.

As evidenced above, J presents as a diagnostic conundrum suffering from a combination of transdiagnostic symptoms that broadly impact his functioning. Unfortunately, although various diagnoses such as ADHD, PTSD, Depression, DMDD or DSED may be entertained, the patient does not fall neatly into any of the categories.

This is a case report that describes a diagnostic conundrum in a young boy with prominent early life deprivation who presented with multidimensional symptoms managed with polypharmacy.

A sub-threshold presentation in this patient partially explains difficulties with diagnosis. There is no doubt that negative effects of early childhood deprivation had significant impact on developmental outcomes in this patient, but the mechanisms that could explain the associations are still widely unknown. Significant family history of mental illness also predisposes him to early challenges. The clinical picture is further complicated by the potential dynamic factors that could explain some of the patient’s behaviors. Careful examination of J’s early life history would suggest such a pattern of being able to engage with his biological caregivers, being given food, being tended to; followed by periods of neglect where he would withdraw, regress and engage in rocking as a self-soothing behavior. His adoptive mother observed that visitations with his biological father were accompanied by being given a lot of food. It is also possible that when he was under the care of his biological mother, he was either attended to with access to food or neglected, left hungry and screaming for hours.

The current healthcare model, being centered on obtaining accurate diagnosis, poses difficulties for treatment in these patients. Given the complicated transdiagnostic symptomatology, clear guidelines surrounding treatment are unavailable. To date, there have been no psychopharmacological intervention trials for attachment issues. In patients with disordered attachment, pharmacologic treatment is typically focused on co-morbid disorders, even with sub-threshold presentations, with the goal of symptom reduction [ 6 ]. A study by dosReis [ 7 ] found that psychotropic usage in community foster care patients ranged from 14% to 30%, going to 67% in therapeutic foster care and as high as 77% in group homes. Another study by Breland-Noble [ 8 ] showed that many children receive more than one psychotropic medication, with 22% using two medications from the same class.

It is important to note that our patient received four different neuroleptic medications (quetiapine, aripiprazole, risperidone and thioridazine) for disruptive behaviors and impulsivity at a very young age. Olfson et al. [ 9 ] noted that between 1999 and 2007 there has been a significant increase in the use of neuroleptics for very young children who present with difficult behaviors. A preliminary study by Ercan et al. [ 10 ] showed promising results with the use of risperidone in preschool children with behavioral dyscontrol. Review by Memarzia et al. [ 11 ] suggested that risperidone decreased behavioral problems and improved cognitive-motor functions in preschoolers. The study also raised concerns in regards to side effects from neuroleptic medications in such a vulnerable patient population. Younger children seemed to be much more susceptible to side effects in comparison to older children and adults with weight gain being the most common. Weight gain associated with risperidone was most pronounced in pre-adolescents (Safer) [ 12 ]. Quetiapine and aripiprazole were also associated with higher rates of weight gain (Correll et al.) [ 13 ].

Pharmacokinetics of medications is difficult to assess in very young children with ongoing development of the liver and the kidneys. It has been observed that psychotropic medications in children have shorter half-lives (Kearns et al.) [ 14 ], which would require use of higher doses for body weight in comparison to adults for same plasma level. Unfortunately, that in turn significantly increases the likelihood and severity of potential side effects.

There is also a question on effects of early exposure to antipsychotics on neurodevelopment. In particular in the first 3 years of life there are many changes in developing brains, such as increase in synaptic density, pruning and increase in neuronal myelination to list just a few [ 11 ]. Unfortunately at this point in time there is a significant paucity of data that would allow drawing any conclusions.

Our case report presents a preschool patient with history of adoption, early life abuse and neglect who exhibited significant behavioral challenges and was treated with various psychotropic medications with limited results. It is important to emphasize that subthreshold presentation and poor diagnostic clarity leads to dangerous and excessive medication regimens that, as evidenced above is fairly common in this patient population.

Neglect and/or abuse experienced early in life is a risk factor for mental health problems even after adoption. Differences in genetic risk, epigenetics, prenatal factors (e.g., malnutrition or poor nutrition), exposure to stress and/or substances, and parent-child interactions may explain the diversity of outcomes among these individuals, both in terms of mood and behavioral patterns [ 15 , 16 , 17 ]. Considering that these children often present with significant functional impairment and a wide variety of symptoms, further studies are needed regarding diagnosis and treatment.

Abbreviations

Attention-Deficit/Hyperactivity Disorder

Disruptive Mood Dysregulation Disorder

Disinhibited Social Engagement Disorder

Post-Traumatic Stress Disorder

Reactive Attachment disorder

Norman RE, Byambaa M, De R, Butchart A, Scott J, Vos T. The long-term health consequences of child physical abuse, emotional abuse, and neglect: a systematic review and meta-analysis. PLoS Med. 2012;9(11):e1001349. https://doi.org/10.1371/journal.pmed.1001349 . Epub 2012 Nov 27

Article   PubMed   PubMed Central   Google Scholar  

Kreppner JM, O'Connor TG, Rutter M, English and Romanian Adoptees Study Team. Can inattention/overactivity be an institutional deprivation syndrome? J Abnorm Child Psychol. 2001;29(6):513–28. PMID: 11761285

Article   CAS   PubMed   Google Scholar  

Dejong M. Some reflections on the use of psychiatric diagnosis in the looked after or “in care” child population. Clin Child Psychol Psychiatry. 2010;15(4):589–99. https://doi.org/10.1177/1359104510377705 .

Article   PubMed   Google Scholar  

Pincus HA, McQueen LE, Elinson L. Subthreshold mental disorders: Nosological and research recommendations. In: Phillips KA, First MB, Pincus HA, editors. Advancing DSM: dilemmas in psychiatric diagnosis. Washington, DC: American Psychiatric Association; 2003. p. 129–44.

Google Scholar  

Shankman SA, Lewinsohn PM, Klein DN, Small JW, Seeley JR, Altman SE. Subthreshold conditions as precursors for full syndrome disorders: a 15-year longitudinal study of multiple diagnostic classes. J Child Psychol Psychiatry. 2009;50:1485–94.

AACAP. Practice parameter for the assessment and treatment of children and adolescents with reactive attachment disorder of infancy and early childhood. J Am Acad Child Adolesc Psychiatry. 2005;44:1206–18.

Article   Google Scholar  

dosReis S, Zito JM, Safer DJ, Soeken KL. Mental health services for youths in foster care and disabled youths. Am J Public Health. 2001;91(7):1094–9.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Breland-Noble AM, Elbogen EB, Farmer EMZ, Wagner HR, Burns BJ. Use of psychotropic medications by youths in therapeutic foster care and group homes. Psychiatr Serv. 2004;55(6):706–8.

Olfson M, Crystal S, Huang C. Trends in antipsychotic drug use by very young, privately insured children. J Am Acad Child Adolesc Psychiatry. 2010;49:13–23.

PubMed   Google Scholar  

Ercan ES, Basay BK, Basay O. Risperidone in the treatment of conduct disorder in preschool children without intellectual disability. Child Adolesc Psychiatry Ment Health. 2011;5:10.

Memarzia J, Tracy D, Giaroli G. The use of antipsychotics in preschoolers: a veto or a sensible last option? J Psychopharmacol. 2014;28(4):303–19.

Safer DJ. A comparison of risperidone-induced weight gain across the age span. J Clin Psychopharmacol. 2004;24:429–36.

Correll CU, Manu P, Olshanskiy V. Cardiometabolic risk of second-generation antipsychotic medications during first-time use in children and adolescents. JAMA. 2009;302:1765–73.

Kearns GL, Abdel-Rahman SM, Alander SW. Developmental pharmacology – drug disposition, action, and therapy in infants and children. N Engl J Med. 2003;349:1157–67.

Monk C, Spicer J, Champagne FA. Linking prenatal maternal adversity to developmental outcomes in infants: the role of epigenetic pathways. Dev Psychopathol. 2012;24(4):1361–76. https://doi.org/10.1017/S0954579412000764 . Review. PMID: 23062303

Cecil CA, Viding E, Fearon P, Glaser D, McCrory EJ. Disentangling the mental health impact of childhood abuse and neglect. Child Abuse Negl. 2016;63:106–19. https://doi.org/10.1016/j.chiabu.2016.11.024 . [Epub ahead of print] PMID: 27914236

Nemeroff CB. Paradise lost: the neurobiological and clinical consequences of child abuse and neglect. Neuron. 2016;89(5):892–909. https://doi.org/10.1016/j.neuron.2016.01.019 . Review. PMID: 26938439

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Romanowicz, M., McKean, A.J. & Vande Voort, J. A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy. BMC Psychiatry 17 , 330 (2017). https://doi.org/10.1186/s12888-017-1492-y

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• Review Article
• Published: 24 November 2021

Orthopedic manifestations of child abuse

• John D. Milner 1 ,
• Davis A. Hartnett 1 ,
• Steven F. DeFroda 1 ,
• Brett A. Slingsby 2 ,
• Zachary S. Silber 1 ,
• Amy Z. Blackburn 1 ,
• Alan H. Daniels 1 &
• Aristides I. Cruz Jr 1  

Pediatric Research volume  92 ,  pages 647–652 ( 2022 ) Cite this article

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Child abuse is common in the United States but is often undetected. The incidence of this form of abuse is difficult to quantify, but children with a history of abuse are at risk of chronic health conditions. Medical providers are in the unique position of triaging trauma patients and differentiating unintentional from abusive trauma, as well as having the important position of being a mandated reporter of abuse in all states. Obtaining a detailed history and screening for risk factors can help identify children at risk of abuse. Certain orthopedic injuries may be related to abuse, which may trigger clinical suspicion and lead to further workup or intervention. By increasing awareness, through medical provider education and increased screening, earlier detection of abuse may prevent more serious injuries and consequences. This review evaluates current literature regarding the orthopedic manifestations of child abuse in hopes of increasing medical provider awareness.

Child abuse is common in the United States but often remains undetected.

Medical professionals are in the unique position of evaluating trauma patients and identifying concerns for abusive injuries.

Certain orthopedic injuries may raise concern for abuse triggering clinical suspicion and further workup or intervention.

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Introduction

Child abuse is common in the United States but is often undetected. 1 The definition of child abuse in the United States varies per state but is universally defined in the Federal Child Abuse Prevention and Treatment Act as “any recent act or failure to act on the part of a parent or caretaker which results in death, serious physical or emotional harm, sexual abuse or exploitation” or “an act or failure to act which presents an imminent risk of serious harm.” 2 The incidence of child abuse has been estimated to be approximately 10.3 per 1000 children. 1 Child abuse is a public health issue with lifelong implications. 2 Adolescents who suffered from abuse during childhood have high rates of depression, conduct disorder, drug abuse, and cigarette smoking. 3 , 4 Adults with a history of physical abuse when they were children are more likely to report chronic physical and mental health conditions. 5

Medical professionals are in the unique position of triaging trauma patients and differentiating accidental and abusive trauma. This is an invaluable skill developed through clinical reasoning and recognition of presenting patterns that can have long-lasting effects on a patient’s well-being. This process begins by taking a comprehensive medical history and can be initiated by emergency providers, medical physicians, and surgeons alike, making recognition of signs of child abuse an important skill for all providers to possess. Certain orthopedic injuries, in particular, may be related to abuse, which may trigger clinical suspicion and lead to further workup or intervention. This review evaluates current literature regarding the orthopedic presentations of child abuse in hopes of increasing provider awareness.

Articles were identified through biomedical search engines including PubMed and Google Scholar, identified for relevance and applicability to the topic of orthopedic manifestations of abuse. Emphasis was placed on more recent studies and meta-analyses that have influenced or have the potential to influence provider practice.

Presentation

Children younger than 4 years old are at the greatest risk of serious abuse and are the least able to explain or convey what caused their injuries, 6 and children under 1 year of age are at particularly elevated risk, especially when presenting with orthopedic injuries. 7 History taking is therefore often done with a caregiver who may or may not be knowledgeable of possible abuse. In any case, involving suspected child abuse, it is recommended that parents be allowed to provide full histories without interruption to minimize provider influence on the conversation, with multiple caregivers interviewed separately when possible. 2 Documentation is key during history taking, including all possible means of trauma. Although there is immense value in interviewing an adolescent patient alone, victims may be unwilling to disclose abuse due to fear or out of loyalty to an abuser, and denial is not enough to exclude potential abuse. 1 Patients may also change their history or have one that differs from that of the parent or guardian. Younger children may also be unable to communicate the abuse that took place and may only communicate their abuse with nonverbal cues. 8 Medical history with an emphasis on prior traumatic injuries is imperative, as recurrent admissions are frequently the catalyst for clinical suspicion. 1 Evidence exists suggesting that systematic screening of all pediatric emergency department admissions can increase detection of child abuse. 9 Chan et al. developed a tool to evaluate caregiver abuse risk when they questioned parents of children in the community. Pandya et al. and Baldwin et al. developed diagnostic algorithms to calculate the abuse likelihood of a child presenting with a fracture in the emergency room, based on various factors including age, hospitalization history, and significant historical elements. 10 , 11 Imperative to these risk factor assessments and in general when evaluating a patient’s history, history provided by the family can provide additional information to help make an assessment.

Caregivers’ explanations for an injury in the setting of child abuse can vary greatly, with a fall often stated as the means for a traumatic fracture. 12 Nevertheless, certain details of a patient presentation can warrant further investigation and can be particularly telling in the setting of provider suspicion. Explicit denial of trauma in conflict with clinical symptoms, particularly when given by the patient, can be a particularly sensitive sign. Explanations that are inconsistent with the observed trauma should also raise suspicions and explanations inconsistent with the developmental abilities of the patient can be similarly concerning for abuse; for instance, a purported fall in a nonambulatory infant or child presenting with a high-energy fracture. 13 , 14 Any changes or inconsistencies in caregiver histories should raise concern, especially when discussing major aspects of the injury, although speculation about patient or caregivers’ demeanor while being interviewed should be avoided due to the significant potential for implicit bias and subjective nature of such interviewing. Lastly, any inexplicable delay in seeking care should amplify clinical suspicions of abuse. 2 , 15

Although beyond the scope of this review, it is imperative to recognize that provider bias has been identified in the literature as impacting the reporting and workup of suspected pediatric abuse. 16 , 17 , 18 Child abuse clinical pathways have been identified to improve odds of identifying cases concerning child maltreatment and ensuring that those children receive an appropriate workup and consultation with a child abuse pediatrician while also mitigating the effects of healthcare bias, 19 suggesting that standardization of practice is a valuable means of improving equitable management of suspected abuse. This remains an area of ongoing study.

Fracture properties

After soft tissue injuries, such as bruising, fractures are the second most common medical presentation of child abuse and can be present in 30–50% of abuse cases. 20 Although fractures are common injuries in pediatric patients, some fracture patterns and locations are more suggestive of abuse compared to others. 12 Multiple fractures in varying stages of healing are considered one of the signs of potential abusive trauma (Fig.  1 ). 21 Spiral fractures of any bone with even minor clinical suspicion were once considered pathognomonic for nonaccidental trauma, as the twisting force required for fracture is classically observed when limbs are forcibly rotated by another person. 21 However, evidence in the literature now suggests that spiral fractures can occur frequently in cases of observed accidental trauma and the finding is neither sensitive nor specific for abuse; 20 , 22 the actual evaluation of fractures in suspected trauma is far more complicated than distillation into pathognomonic fracture types. In a review of pediatric long bone fractures, Pierce et al. discuss the importance of connecting patient history with fracture biomechanics. For example, transverse fractures, in which the fracture line is perpendicular to the shaft, require high-energy bending loads that could be in conflict with a caregiver history of a low-energy fall. 23 A spiral lower extremity long bone fracture in a nonambulatory patient would be an injury inconsistent with a patient’s stage of motor development. 24 Fracture morphology should be considered in association with the patient’s time until presentation, as a non-displaced buckle fracture would have minimal symptoms compared to a spiral femur fracture, with time to presentation understandably different regardless of injury etiology. 23 , 25 The fracture type is not itself diagnostic of the origin of injury but can be crucially reflective of the nature of the injury, and discrepancies between this nature and other components of a patient’s history and the presentation should elevate suspicion of potential abuse.

A 3-month-old boy presented with left leg pain. The reported mechanism of injury was a fall from a couch at home. The patient was found to have multiple fractures (left femoral shaft, right tibia, right distal radius, left humeral shaft) in various stages of healing

The location of the fracture can also identify patients for whom abuse is a concern. Rib fractures, specifically posterior rib fractures (Fig.  2 ), are conventionally considered suspicious for abuse, as this is an atypical accidental injury that suggests a squeezing compressive force around the trunk. 15 , 20 , 26 , 27 In one study, posterior rib fractures were found to be due to abuse in 70% of cases. 28 Humerus fractures were found to have a 50% probability of being due to abuse in children under 3 years old when otherwise obvious trauma was excluded; however, with a very wide confidence interval of 6–94%, 28 suggesting that fracture type alone is not specific for abuse. 21 , 29 Atypical injuries without obvious cause are rarely reported, but should immediately raise concern for abusive trauma, such as metaphyseal corner fractures, 20 cervical vertebral fractures, 30 and femoral neck fractures. 31 In these cases, a central tenet is that infants simply cannot generate the force required to sustain such fractures. Swischuk et al. note that it is very unlikely for normal infants to sustain metaphyseal corner fractures (Fig. 3 ) with normal daily activity or mild falls unless the bone appears abnormal due to demineralization and osteoporosis, signifying an underlying bone disorder. 32 Loder et al. found in their review that 15% of femur fractures in children under the age of two were due to abuse, with falls accounting for the majority of femoral fractures. 33

A 3-month-old boy with posterior rib fractures after a reported fall from a couch.

Metaphyseal corner fractures in a 1-year-old boy. The reported mechanism of injury was a fall while running.

Physical exam

In the setting of traumatic fractures, other physical examination findings may be highly significant and assist in identifying cases of physical abuse. Bruising in children of all ages is the most common injury from physical abuse and can be crucial in differentiating accidental and nonaccidental trauma. 34 , 35 , 36 , 37 , 38 In a 2021 study, Pierce et al. validated a refined bruising clinical decision rule, the TEN-4-FACESp, for use in children under 4 years of age. The rule would raise concerns for abuse in young children with bruising to the torso, ear, neck, frenulum, angle of the jaw, fleshy facial cheeks, eyelids, and subconjunctival hemorrhages. The study also identifies concern for abuse when there is patterned bruising to a child or when there is any bruise on a patient <4.99 months old (TEN-4). 37 This rule was performed with high sensitivity (96%) as well as high specificity when screening bruised patients for abuse, with any bruise of the TEN regions alone correctly identifying abuse in 81% of the identified patients. The upcoming implementation of this standardized rule, which effectively utilizes and encompasses up-to-date knowledge on bruising patterns, will be a crucial tool in identifying nonaccidental trauma while helping to minimize stress in accidental trauma cases.

Nearly one-third of young children found to have abusive fractures had signs and symptoms suggestive of trauma previously missed during healthcare interactions. 39 These signs primarily involved swelling or bruising, particularly in unusual areas such as the ears or neck, but also included symptoms such as unexplainable irritability, fever, and vomiting. 14 Exam findings concerning traumatic injury may include bruises, burns, edema, other bony abnormalities, or signs of head or abdominal trauma. Any signs of injury in a preambulatory child should also raise immediate concern for physical abuse and trigger a more thorough evaluation. 2

When a child presents with a nonspecific fracture, a thorough skin examination may reveal concerning bruises or other injuries which should raise concerns of physical abuse and trigger a further workup.

The use of imaging modalities in conjunction with the physical exam is crucial in evaluating suspicions of abuse. Given the minor but inherent risk of imaging in young patients, the American College of Radiology (ACR) has guidelines for imaging suspected physical abuse. 40 Per ACR recommendation, X-ray skeletal surveys are the primary tool for evaluation of skeletal trauma in young children and should consist of frontal and lateral views of the skull, lateral views of the cervical spine and thoracolumbosacral spine, and single frontal views of the long bones, hands, feet, chest, and abdomen. 24 Repeat skeletal surveys can exclude pelvis, spine, and skull radiographs if no injury was seen on primary evaluation, to limit unnecessary radiation exposure. These radiographs should be repeated when there are concerns for abuse and a fracture was identified on the initial skeletal survey, as well as in the case of an ambiguous or negative primary survey with high clinical suspicion for abuse. 40 Since 80% of abused children with fractures are <18 months of age, the ACR recommends a primary skeletal survey in all children <2 years old when abuse is suspected. 25 ACR recommendation of skeletal survey decreases if the child is >24 months since children older than 24 months can often verbalize, so initial imaging may be targeted to a specific area of their body. 25 Noncontrast computed tomography scans should be used for patients with suspected abusive head trauma, which includes any suspected abuse patients with clear head trauma, such as neurologic changes, facial injuries, or hemorrhagic retinopathy, as well as any child under the age of 6 months in which there are concerns for abuse. 24 , 41 Occult head injury was found by Boehnke et al. in 19.7% of children under 2 years of age being evaluated for suspected abuse without signs of head injury, 42 and Henry et al. identified occult head injury in 6.5% of evaluated children under 12 months old, 43 both suggestive of a low threshold for neuroimaging utilization in the setting of suspected abuse. Magnetic resonance imaging of the head can be useful for children with suspected abusive head trauma, but it is not usually utilized in the emergent setting because it often requires sedation.

Imaging is inherently warranted in cases of pediatric fracture but is also valuable in cases of suspected abuse without obvious skeletal injury. Rib fractures and metaphyseal corner injuries of long bones are often not clinically obvious, particularly in infants, with observable indications like bruising not commonly present. 2 , 20 A 2011 study by Duffy et al. found occult orthopedic trauma through a skeletal survey in 11% of patients, which proved to be a crucial component in confirming abuse in over half of those cases. 44 Repeated skeletal surveys per ACR guidelines have been found to increase the number of diagnosed fractures by more than 25% in abused patients. 45 There is evidence suggesting a benefit to performing skeletal surveys on siblings of abused children, with a study by Lindberg et al. finding evidence of fractures on over 11% of surveyed siblings. 46

Treatment/management

If a physician suspects child abuse, most states require them to report their suspicion to the police or appropriate authority. Forty-seven states designate physicians as “mandated reporters,” while Indiana, New Jersey, and Wyoming do not specify specific professional groups as mandated reporters, but nevertheless require all individuals who suspect abuse to report it. 47 In addition, 18 states require reporting of suspected child abuse by any person who suspects it, not just healthcare professionals. 47 While states may mandate that certain people report abuse, anyone can voluntarily report suspected abuse; these people are referred to as “permissive reporters.” 47 Reports are required when the reporter suspects or has reason to believe that abuse is occurring; however, they do not need to have proof that mistreatment has occurred. 47 Mandatory and voluntary reporters are protected in all states from liability when reporting suspected child abuse under “good faith” laws. 48 Many states also provide additional immunity for specific actions medical practitioners take to evaluate suspected child abuse, such as imaging studies or lab tests, performing a medical exam, or disclosing medical records in the court of law. 48

Medical professionals can provide treatment for an injury resulting from abuse as is appropriate for the specific injury or injuries (e.g., splint or casting of fracture) and should fulfill their reporting requirements as soon as possible without delaying treatment. Depending on the severity of injuries, patients may be hospitalized or discharged and scheduled for follow-up care. 2 In cases of child abuse, medical or mental health treatment for family members may also be necessary since domestic violence, drug abuse, and other stressors can co-occur with child abuse. 2

When evaluating pediatric fractures, especially when the fracture type appears to require a higher force mechanism than described by caregivers, an evaluation for genetic and metabolic causes of bone fragility may be necessary for the differential diagnosis of fractures. 49 The possibility of a metabolic cause of fractures may be raised in legal proceedings and therefore should be considered and excluded if appropriate.

The most common metabolic bone disease resulting in fractures is osteogenesis imperfect (OI). 50 Leventhal et al. estimated that each year OI is responsible for roughly 0.85% of 15,000 fractures in children under the age of 36 months. 51 Rickets, which results from vitamin D and calcium deficiency, is the most common metabolic bone disease in the pediatric population. 52 Rickets is a rare but possible etiology of fractures in children, with poor skeletal mineralization putting these patients at increased risk of atypical or major fractures from low-energy trauma. 53 , 54 In clinical practice, it is important to differentiate rickets from low vitamin D status, which is common in children and does not result in increased fracture risk. 55 , 56 , 57 Some reports have also suggested that children with Ehlers–Danlos syndrome (EDS) may have an increased risk of fractures. 58 , 59 , 60 However, controversy exists surrounding this topic and the previous studies which suggest that EDS is associated with an increased risk of fractures in infants. More recently, a population-based case–control study by Rolfes et al. found that individuals with EDS were more likely to have one or more fractures during childhood; however, none had fractures during the first year of life. 61

In addition to genetic causes of pathological fractures, it is also important to consider other effects on bone health such as inflammatory diseases, oncological diseases, chronic total parenteral nutrition, older children who are not weight bearing, extreme prematurity, etc. 62

When there is a concern for fractures resulting from abuse, it is important to complete a comprehensive medical evaluation to rule out other possible causes such as underlying bone disease. However, it is also important to note that while having an underlying bone disease may predispose a child to fractures, it does not rule out simultaneous abuse as a cause of fractures. Consultation with child abuse pediatricians can therefore aid in evaluating patients with complex presentations and underlying diseases.

Future directions

Prevention of future incidents of abuse is important although challenging. By increasing medical provider awareness of child abuse through education and increased screening, abuse may be identified earlier, preventing continued or worsening abuse. Pediatricians or other providers of pediatric care can play an important role in preventing child abuse by recognizing risk factors, providing support for families, and advocating for prevention programs in their communities. 2 By increasing availability and access to resources regarding child abuse, more people may recognize and report suspected abuse. Therefore, it is important to continue to compile and disseminate materials with clear and concise language regarding abuse that both medical and non-medical professionals can understand. 63

Child abuse often remains undetected in the United States despite the frequency at which it occurs. The literature on the presentation and screening of child abuse is constantly evolving, with an emphasis on recognizing and managing such injuries. Child victims of physical abuse may present to a number of physicians and allied healthcare professionals including family practice and emergency medicine physicians, pediatricians, and orthopedists, underscoring the need for a multidisciplinary approach to the management of this problem. Awareness and vigilance practiced by all medical professionals who evaluate pediatric patients can help improve the detection of child abuse. By doing so, we can continually improve care for this vulnerable population.

ACF. Child maltreatment. ACF Archive https://www.acf.hhs.gov/cb/resource/child-maltreatment-2018 (2018).

Christian, C. W. Committee on Child Abuse and Neglect, American Academy of Pediatrics. evaluation suspected child Phys. Abus. Pediatrics 135 , e1337–e1354 (2015).

Google Scholar  

Kaplan, S. J. et al. Adolescent physical abuse: risk for adolescent psychiatric disorders. Am. J. Psychiatry 155 , 954–959 (1998).

Article   CAS   PubMed   Google Scholar  

Hussey, J. M., Chang, J. J. & Kotch, J. B. Child maltreatment in the United States: prevalence, risk factors, and adolescent health consequences. Pediatrics 118 , 933–942 (2006).

Article   PubMed   Google Scholar  

Shaw, B. A. & Krause, N. Exposure to physical violence during childhood, aging, and health. J. Aging Health 14 , 467–494 (2002).

Gross, R. H. & Stranger, M. Causative factors responsible for femoral fractures in infants and young children. J. Pediatr. Orthop. 3 , 341–343 (1983).

Rivara, F. P., Kamitsuka, M. D. & Quan, L. Injuries to children younger than 1 year of age. Pediatrics . 81 , 93–97 (1988).

Katz, C. et al. Non-verbal behavior of children who disclose or do not disclose child abuse in investigative interviews. Child Abuse Negl. 36 , 12–20 (2012).

Louwers, E. et al. Effects of systematic screening and detection of child abuse in emergency departments. Pediatrics 130 , 457–464 (2012).

Pandya, N. K., Baldwin, K. D., Wolfgruber, H., Drummond, D. S. & Hosalkar, H. S. Humerus fractures in the pediatric population: an algorithm to identify abuse. J. Pediatr. Orthop. B 19 , 535–541 (2010).

Baldwin, K. D. et al. Femur fractures in the pediatric population: abuse or accidental trauma? Clin. Orthop. Relat. Res. 469 , 798–804 (2011).

Leventhal, J. M., Thomas, S. A., Rosenfield, N. S. & Markowitz, R. I. Fractures in young children: distinguishing child abuse from unintentional injuries. Am. J. Dis. Child. 147 , 87–92 (1993).

Preer, G., Sorrentino, D. & Newton, A. W. Child abuse pediatrics: prevention, evaluation, and treatment. Curr. Opin. Pediatr. 24 , 266–273 (2012).

Sink, E. L. et al. Child abuse. The role of the orthopaedic surgeon in nonaccidental trauma. Clin. Orthop. Relat. Res. 469 , 790–797 (2011).

Kleinman, P. K., Marks, S. C., Nimkin, K., Rayder, S. M. & Kessler, S. C. Rib fractures in 31 abused infants: postmortem radiologic- histopathologic study. Radiology 200 , 807–810 (1996).

Wood, J. N. et al. Disparities in the evaluation and diagnosis of abuse among infants with traumatic brain injury. Pediatrics 126 , 408–414 (2010).

Lane, W. G., Rubin, D. M., Monteith, R. & Christian, C. W. Racial differences in the evaluation of pediatric fractures for physical abuse. J. Am. Med. Assoc. 288 , 1603–1609 (2002).

Article   Google Scholar  

Rangel, E. L., Burd, R. S. & Falcone, R. A. Socioeconomic disparities in infant mortality after nonaccidental trauma: a multicenter study. J. Trauma 69 , 20–25 (2010).

PubMed   Google Scholar  

Stavas, N., Paine, C., Song, L., Shults, J. & Wood, J. Impact of child abuse clinical pathways on skeletal survey performance in high-risk infants. Acad. Pediatr. 20 , 39–45 (2020).

Scherl, S. A. Orthopaedic aspects of child abuse. Curr. Orthop. Pract. 24 , 625–630 (2013).

Sullivan, C. M. Child abuse and the legal system: the orthopaedic surgeon’s role in diagnosis. Clin. Orthop. Relat. Res. 469 , 768–775 (2011).

Scherl, S. A. et al. Accidental and nonaccidental femur fractures in children. Clin. Orthop. Relat. Res. https://doi.org/10.1097/00003086-200007000-00014 , 96–105 (2000).

Pierce, M. C., Bertocci, G. E., Vogeley, E. & Moreland, M. S. Evaluating long bone fractures in children: a biomechanical approach with illustrative cases. Child Abuse Negl. 28 , 505–524 (2004).

Strait, R. T., Siegel, R. M. & Shapiro, R. A. Humeral fractures without obvious etiologies in children less than 3 years of age: When is it abuse? Pediatrics 96 , 667–671 (1995).

Rex, C. & Kay, P. R. Features of femoral fractures in nonaccidental injury. J. Pediatr. Orthop. 20 , 411–413 (2000).

Barsness, K. A. et al. The positive predictive value of rib fractures as an indicator of nonaccidental trauma in children. J. Trauma 54 , 1107–1110 (2003).

Flaherty, E. G. et al. Evaluating children with fractures for child physical abuse. Pediatrics 133 , e477–e489 (2014).

Kemp, A. M. et al. Patterns of skeletal fractures in child abuse: systematic review. BMJ 337 , 859–862 (2008).

Taitz, J., Moran, K. & O’Meara, M. Long bone fractures in children under 3 years of age: Is abuse being missed in Emergency Department presentations? J. Paediatr. Child Health 40 , 170–174 (2004).

Feldman, K. W., Avellino, A. M., Sugar, N. F. & Ellenbogen, R. G. Cervical spinal cord injury in abused children. Pediatr. Emerg. Care 24 , 222–227 (2008).

Pastor, A. J., Gupta, A., Press, C. M. & Gourineni, P. Femoral neck fracture as the sentinel sign of child abuse in an infant: a case report. J. Pediatr. Orthop. B 21 , 587–591 (2012).

Swischuk, L. E. Metaphyseal corner fractures in infants: a review. Emerg. Radiol. 5 , 103–107 (1998).

Loder, R. T., O’Donnell, P. W. & Feinberg, J. R. Epidemiology and mechanisms of femur fractures in children. J. Pediatr. Orthop. 26 , 561–566 (2006).

Ellerstein, N. S. The cutaneous manifestations of child abuse and neglect. Am. J. Dis. Child 133 , 906–909 (1979).

CAS   PubMed   Google Scholar  

Maguire, S. & Mann, M. Systematic reviews of bruising in relation to child abuse-what have we learnt: an overview of review updates. Evid. Based Child Health 8 , 255–263 (2013).

Pierce, M. C., Kaczor, K., Aldridge, S., O’Flynn, J. & Lorenz, D. J. Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics 125 , 67–74 (2010).

Pierce, M. C. et al. Validation of a clinical decision rule to predict abuse in young children based on bruising characteristics. JAMA Netw. Open 4 , https://doi.org/10.1001/jamanetworkopen.2021.5832 (2021).

Sugar, N. F., Taylor, J. A. & Feldman, K. W. Bruises in infants and toddlers: those who don’t cruise rarely bruise. Arch. Pediatr. Adolesc. Med. 153 , 399–403 (1999).

Thorpe, E. L., Zuckerbraun, N. S., Wolford, J. E. & Berger, R. P. Missed opportunities to diagnose child physical abuse. Pediatr. Emerg. Care 30 , 771–776 (2014).

Expert Panel on Pediatric Imaging: Wootton-Gorges, S. L. et al. ACR Appropriateness Criteria® suspected physical abuse-child. J. Am. Coll. Radiol. 14 , S338–S349 (2017).

Bajaj, M. & Offiah, A. C. Imaging in suspected child abuse: necessity or radiation hazard? Arch. Dis. Child 100 , 1163–1168 (2015).

Boehnke, M., Mirsky, D., Stence, N., Stanley, R. M. & Lindberg, D. M. Occult head injury is common in children with concern for physical abuse. Pediatr. Radiol. 48 , 1123–1129 (2018).

Henry, M. K. et al. Occult head injuries in infants evaluated for physical abuse. Child Abuse Negl. 103 , https://doi.org/10.1016/j.chiabu.2020.104431 (2020).

Duffy, S. O., Squires, J., Fromkin, J. B. & Berger, R. P. Use of skeletal surveys to evaluate for physical abuse: analysis of 703 consecutive skeletal surveys. Pediatrics 127 , e47–e52 (2011).

Article   PubMed   PubMed Central   Google Scholar  

Kleinman, P. K. et al. Follow-up skeletal surveys in suspected child abuse. Am. J. Roentgenol. 167 , 893–896 (1996).

Article   CAS   Google Scholar  

Lindberg, D. M. et al. Prevalence of abusive injuries in siblings and household contacts of physically abused children. Pediatrics 130 , 193–201 (2012).

Child Welfare Information Gateway. Mandatory reporters of child abuse and neglect. https://www.childwelfare.gov/topics/systemwide/laws-policies/statutes/manda/ (2019).

Child Welfare Information Gateway. Immunity for reporters of child abuse and neglect. https://www.childwelfare.gov/pubPDFs/immunity.pdf (2018).

Miller, M. & Mirkin, L. D. Classical metaphyseal lesions thought to be pathognomonic of child abuse are often artifacts or indicative of metabolic bone disease. Med. Hypotheses 115 , 65–71 (2018).

Pepin, M. G. & Byers, P. H. What every clinical geneticist should know about testing for osteogenesis imperfecta in suspected child abuse cases. Am. J. Med. Genet. C 169 , 307–313 (2015).

Leventhal, J. M., Martin, K. D. & Asnes, A. G. Fractures and traumatic brain injuries: abuse versus accidents in a US database of hospitalized children. Pediatrics 126 , https://doi.org/10.1542/PEDS.2009-1076 (2010).

Thacher, T. D. et al. Increasing incidence of nutritional rickets: a population-based study in Olmsted County, Minnesota. Mayo Clin. Proc. 88 , 176–183 (2013).

Chapman, T. et al. Fractures in infants and toddlers with rickets. Pediatr. Radiol. 40 , 1184–1189 (2010).

Servaes, S. et al. The etiology and significance of fractures in infants and young children: a critical multidisciplinary review. Pediatr. Radiol. 46 , 591–600 (2016).

Schilling, S., Wood, J. N., Levine, M. A., Langdon, D. & Christian, C. W. Vitamin D status in abused and nonabused children younger than 2 years old with fractures. Pediatrics 127 , 835–841 (2011).

Contreras, J. J., Hiestand, B., O’Neill, J. C., Schwartz, R. & Nadkarni, M. Vitamin D deficiency in children with fractures. Pediatr. Emerg. Care 30 , 777–781 (2014).

Keller, K. A. & Barnes, P. D. Rickets vs. abuse: a national and international epidemic. Pediatr. Radiol. 38 , 1210–1216 (2008).

Owen, S. M. & Durst, R. D. Ehlers-Danlos syndrome simulating child abuse. Arch. Dermatol. 120 , 97–101 (1984).

Holick, M. F., Shirvani, A. & Charoenngam, N. Fetal fractures in an infant with maternal Ehlers-Danlos syndrome, CCDC134 pathogenic mutation and a negative genetic test for osteogenesis imperfecta. Child 8 , 512 (2021).

Holick, M. F., Hossein-Nezhad, A. & Tabatabaei, F. Multiple fractures in infants who have Ehlers-Danlos/hypermobility syndrome and or vitamin D deficiency: a case series of 72 infants whose parents were accused of child abuse and neglect. Dermatoendocrinology 9 , https://doi.org/10.1080/19381980.2017.1279768 (2017).

Rolfes, M. C. et al. Fracture incidence in Ehlers-Danlos syndrome—a population-based case-control study. Child Abuse Negl. 91 , 95–101 (2019).

Boyce, A. M. & Gafni, R. I. Approach to the child with fractures. J. Clin. Endocrinol. Metab. 96 , 1943–1952 (2011).

Article   CAS   PubMed   PubMed Central   Google Scholar  

Child Welfare Information Gateway. Prevention Resource Guide Chapter 5: tip sheets for parents and caregivers. https://www.childwelfare.gov/topics/preventing/preventionmonth/resources/resource-guide (2019).

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The radiology report in child abuse

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• Jeannette M. Peréz-Rosselló 2 &
• Joëlle A. Moreno 3  

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The radiology report in a case of suspected child abuse is both a medical and a legal document. Such reports should be thorough, specific, well-constructed and without error. Structured templates and standardized reporting contribute to completeness, consistency and communication. Here, the authors discuss common reporting errors. Radiologists should be prepared that the radiology report in a case of suspected child abuse is likely to be used in court.

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Pitfalls in pediatric radiology.

Dawn R. Engelkemier & George A. Taylor

Errors and Pitfalls in Emergency Pediatric Imaging

Preparing for court testimony

Peter J. Strouse, Joëlle A. Moreno, … Sandeep K. Narang

American College of Radiology (2014) ACR practice parameter for communication of diagnostic imaging findings. ACR online report. https://www.acr.org/-/media/ACR/Files/Practice-Parameters/CommunicationDiag.pdf . Accessed 19 June 2020

American College of Radiology and Society for Pediatric Radiology (2016) ACR–SPR practice parameter for the performance and interpretation of skeletal surveys in children. ACR–SPR online report. https://www.acr.org/-/media/ACR/Files/Practice-Parameters/Skeletal-Survey.pdf . Accessed 19 June 2020

Adamsbaum C, Méjean N, Merzoug V, Rey-Salmon C (2010) How to explore and report children with suspected non-accidental trauma. Pediatr Radiol 40:932–938

Article   Google Scholar  

Kleinman PK (2015) The radiologist’s response to child abuse. In: Kleinman PK (ed) Diagnostic imaging of child abuse, 3rd edn. Cambridge University Press, Cambridge, pp 658–664

Chapter   Google Scholar  

Hawkins CM, Hall S, Zhang B, Towbin AJ (2014) Creation and implementation of department-wide structured reports: an analysis of the impact on error rate in radiology reports. J Digit Imaging 27:581–587

Barber I, Bixby SD, Morris NB et al (2014) An electronic tool for systematic reporting of fractures on skeletal surveys in suspected child abuse: prototype development and physician feedback. Pediatr Radiol 44:1564–1572

Larson DB, Towbin AJ, Pryor RM, Donnelly LF (2013) Improving consistency in radiology reporting through the use of department-wide standardized structured reporting. Radiology 267:240–250

Shea LAG, Towbin AJ (2019) The state of structured reporting: the nuance of standardized language. Pediatr Radiol 49:500–508

Karmazyn B, Wanner MF, Marine MB et al (2019) The added value of a second read by pediatric radiologist for outside skeletal surveys. Pediatr Radiol 49:203–209

Royal College of Radiologists & Society of College of Radiographers (2018) The radiological investigation of suspected physical abuse in children. RCR–SCoR online report. https://www.rcr.ac.uk/system/files/publication/field_publication_files/bfcr174_suspected_physical_abuse.pdf . Accessed 11 Nov 2020

Strouse PJ (2018) A comprehensive toolkit for imaging children who may have been abused: new guidance from the Royal College of Radiologists and the Society and College of Radiographers. Clin Radiol 73:446–448

Article   CAS   Google Scholar  

Karmazyn B, Miller EM, Lay SE et al (2017) Double-read of skeletal surveys in suspected non-accidental trauma: what we learned. Pediatr Radiol 47:584–589

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Strouse, P.J., Peréz-Rosselló, J.M. & Moreno, J.A. The radiology report in child abuse. Pediatr Radiol 51 , 1065–1069 (2021). https://doi.org/10.1007/s00247-020-04920-w

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Is It an Accident or Abuse? Researchers Develop Predictive Models for Pediatric Head Injuries

Every year almost 3 million children are brought into emergency rooms with fall-related injuries, and in each case a physician must examine the child to determine if the injury was an accident or a case of abuse. The problem is daunting because accidental falls are common in children, but it’s also common for individuals to conceal child abuse by claiming accidental injury.

More than 600,000 children were determined to be victims of maltreatment in 2021, according to the Department of Health and Human Services Administration for Children and Families. Of that number, 1,820 children died due to maltreatment, and most of them were younger than 3 years of age. 

For more than a decade the National Institute of Justice (NIJ) has supported research to help physicians and law enforcement sort accident from abuse cases when presented with an injured child. The research has often focused on bringing the science of biomechanics to the world of pediatric medical assessment. Although progress is being made, the challenges of getting definitive answers remains.

 Two recently completed NIJ-funded studies continue that progress. 

Computer Modeling Predicts Skull Fracture Patterns

The first study, by University of Utah bioengineer Brittany Coats, is designed to quantify the mechanical properties of infant and toddler skulls to develop a high-fidelity computational model for predicting the widening, lengthening, or increase in the number of cracks and fracture patterns in infant skull (cranial) bone. 

The researchers tested human cranial bone specimens from decedents younger than 3 years old under several different impact and stress levels to determine force and fracture patterns. Each specific impact results in a distinct fracture pattern, allowing the researchers to develop a database correlating impacts to injuries. 

The researchers concluded that computational toolsets, such as the one being developed by Coats’s team, could “evaluate specific cases of skull fracture, can alleviate confusion and uncertainty, and increase overall judicial accuracy.”

Statistical Models Help With Abuse Identification

The second study was conducted by bioengineer Gina Bertocci, University of Louisville, and physician Mary Clyde Pierce, a pediatric emergency medicine specialist at Lurie Children’s Hospital of Chicago.

The goal of their research was to “develop an evidenced-based statistical model capable of predicting the probability of head injury in young children involved in falls.” The model would improve physicians’ ability to determine if an accident was the cause of an injury. The model they developed is based on fall data collected through an earlier NIJ grant that used video to monitor children in a childcare center who wore head accelerometers, which measure the speed of the head in a fall.

The most recent study looked specifically at short-distance falls involving young children. The researchers reconstructed 80 falls for children brought to emergency rooms. Using that injury data combined with fall data from the childcare center project, the researchers developed a comprehensive database that helped create LCAST , a tool used at the Lurie Children’s Hospital that helps physicians identify abuse in children.

The injury modeling data developed by Bertocci and Pierce has already helped physicians and investigators identify pediatric abuse, but the researchers acknowledge there are limitations on what can be concluded from the modeling. The LCAST website describes the data system as “strictly a screening tool to help improve recognition of abuse and cannot be used to diagnose abuse.”

About This Article

The research described in this article was funded by two NIJ grants. NIJ award 2016-DN-BX-0160 , awarded to the University of Utah, and award number 2019-DU-BX-0029 , awarded to the University of Louisville. This article is based on the grant reports “ Skull Fracture Patterns from Head Impact in Infants ,” by Brittany Coats, University of Utah, and “ Development of a Probability Model to Predict Head Injury Risk in Pediatric Falls ,” by Gina Bertocci, University of Louisville, and Mary Clyde Pierce, Ann & Robert H. Lurie Children’s Hospital of Chicago.

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• Skull Fracture Patterns from Head Impact in Infants
• Development of a Probability Model to Predict Head Injury Risk in Pediatric Falls

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Child abuse reports by medical staff linked to children’s race, Stanford Medicine study finds

Over-reporting of Black children and under-reporting of white children as suspected abuse victims suggests systemic bias from medical providers, Stanford Medicine research shows.

February 6, 2023 - By Erin Digitale

Stanford researchers have found that medical professionals are less likely to report suspected abuse when an injured child is white. wavebreakmedia/Shutterstock

Black children are over-reported as suspected victims of child abuse when they have traumatic injuries, even after accounting for poverty, according to new research from the Stanford School of Medicine .

The study , which drew on a national database of nearly 800,000 traumatic injuries in children, appears in the February issue of the Journal of Pediatric Surgery . It also found evidence that injuries in white children are under-reported as suspected abuse.

The study highlights the potential for bias in doctors’ and nurses’ decisions about which injuries should be reported to Child Protective Services, according to the researchers. Medical caregivers are mandated reporters, obligated to report to CPS any situations in which they think children may be victims of abuse. Because caregivers rarely admit to injuring their children, such reports rely in part on providers’ gut feelings, making them susceptible to unconscious, systemic bias.

Bias can harm both Black and white children, said senior study author Stephanie Chao , MD, assistant professor of surgery at Stanford Medicine. The study’s lead author is Modupeola Diyaolu, MD, a resident in general surgery at Stanford Medicine.

“If you over-identify cases of suspected child abuse, you’re separating children unnecessarily from their families and creating stress that lasts a lifetime,” Chao said. “But child abuse is extremely deadly, and if you miss one event — maybe a well-to-do Caucasian child where you think ‘No way’ — you may send that child back unprotected to a very dangerous environment. The consequences are really sad and devastating on both sides.”

Distinguishing race and poverty

Racial disparities in reporting child abuse have been documented before, but prior studies have not controlled well for poverty, which is a risk factor for abuse. Some experts argue that disproportionate reporting of injured Black children as possible abuse victims reflects only that their families tend to have lower incomes, not that medical professionals are subject to bias. Chao’s team wanted to clarify the debate.

The new study drew on data from the National Trauma Data Bank, which is maintained by the American College of Surgeons. The researchers studied records of nearly 800,000 traumatic injuries that occurred in children ages 1 to 17 from 2010 to 2014 and from 2016 to 2017. Of these injuries, 1% were suspected to be caused by abuse, based on medical codes used to report different types of abuse. The researchers controlled their findings for whether children had public or private insurance as a marker for family income.

Suspected victims of child abuse were younger (a median age of 2 versus 10 years), more likely to have public insurance (77% versus 43%) and more likely to be admitted to the intensive care unit (68% versus 48%) than the general population of children with traumatic injuries. Suspected child abuse victims also were 10 times as likely as the general population of children with traumatic injuries to die of their injuries in the hospital, with 8.2% of suspected abuse victims versus 0.84% of all children with traumatic injuries dying during hospitalization.

Stephanie Chao

Similar proportions of children in the suspected child abuse group and in the general population of injured children were of Asian, Native Hawaiian/Pacific Islander, American Indian and “other” races, and similar proportions of both groups were of Hispanic or Latino ethnicity.

However, Black patients were over-represented among suspected child abuse victims, comprising 33% of suspected child abuse victims and 18% of the general population of injured children. White children comprised 51% of suspected child abuse victims and 66% of the general population of injured children.

“Even when we control for income — in this case, via insurance type — African American children are still significantly over-represented as suspected victims of child abuse,” said Chao. “In addition, they were reported with lower injury severity scores, meaning there was more suspicion for children with less-severe injuries in one particular racial group.”

In general, the researchers found medical professionals had a higher threshold for suspecting white families of abuse and a lower threshold for suspecting Black families. For example, white children in the suspected abuse group were more likely than Black children to have worse injuries, and they were more likely to have been admitted to the intensive care unit.

Implementing universal screening

Chao and her colleagues are designing more equitable ways to screen injured children for possible abuse. An important element, she said, is to make the screening universal so evaluation for possible abuse is not initiated primarily by medical providers’ gut feelings.

Chao created a universal screening system, in use at Stanford Medicine Children’s Health since 2019, in which every time a child younger than 6 years old is evaluated for an injury sustained in a private home, the electronic medical record automatically sends an alert to the organization’s child abuse team. Composed of pediatricians and social workers with specialized training in abuse detection, the team checks the medical record for other indications of abuse. In most cases, no such signals are found, and the entire process occurs behind the scenes. However, if the medical record shows any red flags, the medical staff who admitted the patient to the emergency department or hospital can be alerted for further consideration of whether further work-up or a CPS report is warranted.

Chao is also now working with Epic, the nation’s largest electronic medical record company, to include an automated child abuse screening tool in its system. The screening tool will be tested at several medical institutions later this year.

Chao hopes the work will improve the accuracy of CPS reports, especially when it comes to reducing the impact of medical providers’ unconscious bias.

“Everyone means well here, but the consequences of getting these reports wrong are pretty dire in either direction,” she said. “If we don’t recognize bias and always chalk it up to something else, we can’t fix the problem in a thoughtful way. Now, I hope we can recognize it and work toward a solution.”

The study was funded by the National Center for Advancing Translational Sciences (grant KL2TR003143).

About Stanford Medicine

Stanford Medicine is an integrated academic health system comprising the Stanford School of Medicine and adult and pediatric health care delivery systems. Together, they harness the full potential of biomedicine through collaborative research, education and clinical care for patients. For more information, please visit med.stanford.edu .

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CHARACTERISTICS OF VICTIMS AND RISK FACTORS

Role of the pediatrician, definitions, clinical presentations and settings, medical history, physical examination, general assessment, skin injuries, cranial injuries, thoracoabdominal injuries, skeletal injuries, diagnostic testing and consultations, documentation and diagnostic considerations, legal issues, conclusions, committee on child abuse and neglect, 2006–2007, evaluation of suspected child physical abuse.

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Nancy D. Kellogg , and the Committee on Child Abuse and Neglect; Evaluation of Suspected Child Physical Abuse. Pediatrics June 2007; 119 (6): 1232–1241. 10.1542/peds.2007-0883

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This report provides guidance in the clinical approach to the evaluation of suspected physical abuse in children. The medical assessment is outlined with respect to obtaining a history, physical examination, and appropriate ancillary testing. The role of the physician may encompass reporting suspected abuse; assessing the consistency of the explanation, the child's developmental capabilities, and the characteristics of the injury or injuries; and coordination with other professionals to provide immediate and long-term treatment and follow-up for victims. Accurate and timely diagnosis of children who are suspected victims of abuse can ensure appropriate evaluation, investigation, and outcomes for these children and their families.

In 2004, 152250 children and adolescents were confirmed victims of physical abuse in the United States. 1   Of the 4 types of child maltreatment (neglect, physical abuse, sexual abuse, and emotional abuse), physical abuse is second to neglect, constituting approximately 18% of the total. 1  

Despite these statistics, the estimated number of victims is much higher; in 1 retrospective cohort study of 8613 adults, 26.4% reported they were pushed, grabbed, or slapped; had something thrown at them; or were hit so hard they got marks or bruises at some time during their childhood. 2   It has been estimated that 1.3% to 15% of childhood injuries that result in emergency department visits are caused by abuse. 3   Physical abuse remains an underreported (and often undetected) problem for several reasons including individual and community variations in what is considered “abuse,” inadequate knowledge and training among professionals in the recognition of abusive injuries, unwillingness to report suspected abuse, and professional bias. For example, in 1 study, 4   31% of children and infants with abusive head trauma were initially misdiagnosed. Misdiagnosed victims were more likely to be younger, white, have less severe symptoms, and live with both parents when compared with abused children who were not initially misdiagnosed. Such studies suggest a need for practitioners to be vigilant to the possibility of abuse when evaluating children who have atypical accidental injuries or obscure symptoms that are suggestive of traumatic etiologies but who do not have a history of trauma.

Child abuse has significant long-term medical and mental health morbidity. 5   Children with abusive head or abdominal injuries are more likely to die or become more severely incapacitated than are children with head or abdominal injuries caused by accidents. 6 – 8   Victims of physical abuse in childhood are more likely to develop a variety of behavioral and functional problems including conduct disorders, physically aggressive behaviors, poor academic performance, and decreased cognitive functioning. 9 , 10   Additional problems include anxiety and depression, as well as social and relationship deficits.

Child physical abuse affects children of all ages, genders, ethnicities, and socioeconomic groups. Male and female children experience similar rates of physical abuse. In 1 survey study of more than 2000 children and adolescents, 11   15% of adolescents received injuries from a physical assault and were more likely than children in younger age groups to receive injuries from abuse. Although the risk of physical abuse increases with age, fatal abuse and serious abusive injuries are more common among children and infants younger than 2 years. 1   Children in homes with annual incomes of less than $15000 per year have 3 times the number of fatalities, 7 times the number of serious inflicted injuries, and 5 times the number of moderate inflicted injuries when compared with children living in homes with annual incomes of greater than $15000 per year. 12   Risk factors for infant maltreatment include maternal smoking, the presence of more than 2 siblings, low infant birth weight, and an unmarried mother. 13   One study found that children living in households with unrelated adults were approximately 50 times more likely to die of inflicted injuries than were children residing with 2 biological parents. 14   The US Department of Health and Human Services has indicated that the rate of physical abuse is 2.1 times higher among children with disabilities than children without disabilities. 15   The presence of risk factors should not be used as indicators of child abuse but rather to provide guidance in prevention strategies as well as management and treatment plans.

The role of the pediatrician encompasses prevention of abuse and detection and medical management of victims of abuse. Accurate identification of children who are suspected victims of abuse can facilitate appropriate evaluation, referral, investigation, and outcomes for these children and their families. 16   Children usually sustain abuse at the hands of a caregiver who misinterprets and responds inappropriately to the child's behavior. For example, caregivers who had smothered, shook, or slapped their infant within the first 6 months of life were more likely to be worried about crying and to believe that their infants cried excessively. 17   There is a close correlation between the age-specific incidence curve of infants hospitalized with abusive head trauma and the age-specific normal crying behavior of infants up to 36 weeks of age. 18  

In an anonymous telephone survey of 1435 mothers, 2.6% of children younger than 2 years were shaken by their mothers as a means of discipline. 19   Caregivers may respond inappropriately to their child's behavior when they are unduly stressed. Poverty, significant life events, and caregiver role conflicts are stressors that are often associated with abuse. 14   Pediatricians can effectively educate parents regarding the range of normal behaviors in infants and children, provide anticipatory guidance, and be a resource when the behavior becomes unmanageable for parents. In addition, pediatricians can screen for adult-partner violence; in 1 study, child abuse was 4.9 times more likely in families with identified spouse abuse than in families without identified spouse abuse. 20   Other conditions that place children at risk of being abused, such as maternal depression or drug abuse, may also be identified.

Careful medical assessment, detection of suspicious injuries, and reporting of abuse may prevent further abusive trauma in infants and adults. 4   In 1 study of abuse victims younger than 24 months, 75% had evidence of previous trauma or history of a previous injury. 21   Child abuse may recur 35% of the time without appropriate detection and intervention. 22  

As with other types of child maltreatment, there have been recent advances in medical knowledge regarding physical abuse. Most recent developments have addressed more accurate differentiation between inflicted and accidental injuries as well as detecting conditions that may mimic abusive injuries. Although consideration of nonabusive causes of injuries may merit additional evaluation and testing, the physician is mandated by law to report suspicions of abuse and should not delay reporting pending confirmatory testing or information. In all states, the law also provides some type of immunity for good-faith reporting. Once a suspected victim is identified and further assessment and management is required, using a pediatric child abuse consultant, if available, early in this process may obviate the need for invasive or expensive testing and can help direct the pediatrician toward appropriate evaluation. The detection and diagnosis of child physical abuse depends on the clinician's ability to recognize suspicious injuries, conduct a careful and complete physical examination with judicious use of auxiliary tests, and consider whether the caregivers' explanation is supported by the characteristics of the injury or injuries and the child's developmental capabilities. The physician should also ensure that the child's immediate medical and safety needs are met. Child abuse injuries, particularly traumatic brain injuries, may result in significant long-term disabilities including learning deficits, attention-deficit/hyperactivity disorder, behavioral problems, seizures, spasticity, blindness, paralysis, and mental retardation. 23 , 24   Continuity of care for such children is essential, especially if they are transferred to other caregivers or foster homes.

Many hospitals and communities have developed child abuse–assessment teams of pediatricians and other professionals who specialize in the assessment of suspected victims of child abuse. 25   Such teams usually have access to additional information from law enforcement and child protective services, such as scene investigation, that may facilitate more thorough injury assessment and diagnosis. Involving such teams early in the process can ensure accurate and comprehensive assessments and information sharing among the medical and nonmedical disciplines involved and can provide for intermediate and long-term management of the child and family. Pediatricians with expertise in evaluating suspected abuse should provide training and assistance to emergency physicians and other first responders to enhance detection and appropriate referral of these patients.

Many regions do not have specialized child abuse teams but do have physicians with expertise in child abuse. Pediatricians should know which hospitals in their region have the most available expertise in the emergency evaluation of suspected child abuse. In turn, pediatricians with expertise in child abuse often act as consultants for emergency departments and child protective services. Close collaboration is necessary, particularly for establishing how the child should be transported between facilities, who should notify child protective services, who should notify the caregiver(s) of suspected abuse and when, and whether law enforcement should be notified. For those who do not require emergent transportation by ambulance, child protective services may facilitate transportation of a suspected child victim from one facility to another, assist in notifying the caregivers and law enforcement of suspected abuse, and provide an emergent safety plan on hospital discharge or clinic dismissal.

The recognition and reporting of physical abuse is hindered by the lack of uniform or clear definitions. Many state statutes use words such as “risk of harm,” “substantial harm,” “substantial risk,” or “reasonable discipline” without further clarification of these terms. Many states still permit the use of corporal punishment with an instrument in schools; on the other hand, the American Academy of Pediatrics has proposed that “striking a child with an object” is a type of physical punishment that “should never be used” 26   and has recommended that corporal punishment be abolished in schools. 27   The variability and disparities in definitions may hinder consistent reporting practices.

Most physical abuse injuries are likely to not be detected or reported. Minor injuries may not require medical attention and may be obscure or hidden. Infants and children are reported as suspected victims of physical abuse when 1 or more of the following occurs: an individual (including a professional) sees and reports a suspicious injury; an individual witnesses an abusive event; a caregiver observes symptoms and brings the child in for medical care but is unaware that the child has sustained an injury; an individual asks a child if he or she has been hurt in an abusive way; the abuser thinks the inflicted injury is severe enough to require medical attention; or the child victim discloses abuse. The American Academy of Pediatrics has indicated that “hospitalization of children requiring evaluation and treatment for abuse or neglect should be viewed by third-party payors as medically necessary.” 28  

The clinical approach to an infant or child with possible abusive injuries is not significantly different from standard pediatric care. As with all patients, a severely injured child must be stabilized before further evaluation is undertaken. This initial evaluation may encompass a trauma response team and pediatric specialists in surgery, emergency medicine, and critical care. Careful documentation may not be possible initially and must always be secondary to resuscitation and stabilization of the patient. Once the child is stabilized, a careful and well-documented history, as always, is the most critical element of the medical evaluation. Using quotes whenever possible, the pediatrician should document descriptions of the mechanisms of injury or injuries, onset and progression of symptoms, and the child's developmental capabilities. The physical examination should include detailed documentation, either by body diagrams and/or photographs, of any concerning cutaneous findings and should include a thorough search for other signs that may suggest a nontraumatic cause. If the child is verbal, it may be helpful to gather parental and patient histories separately. If abuse is a concern after this preliminary evaluation, consultation with a child abuse pediatrician, pediatric specialist, or pediatrician experienced in this area, if available, may be helpful in determining the best way to proceed with assessment.

Physical discipline is commonly inflicted on areas of the body that are concealed by clothing (eg, back/buttocks). When inflicted injuries are visible or incidentally discovered, child victims and their abusers typically explain the injuries as accidental; if clinicians or professionals are not critical or skeptical of this information, the injuries may be incorrectly attributed to accidental causes. Other victims present with severe inflicted injuries that require medical care. The initial history is typically vague and/or benign and may become inconsistent as the investigation progresses.

The interview of parents or caregivers of infants or children who present with serious injuries may be conducted in an outpatient or inpatient setting. If the child presents to a clinic with a serious injury that requires further medical care in a specialty (eg, orthopedics) or hospital setting, the clinician may opt to gather the minimum information to establish a need for reporting to child protective services. Any statements made by the caregiver regarding the injury should be documented accurately and completely. Once the clinician has assessed all the injuries, including approximate ages of injuries (when possible), a careful, complete, and detailed history should be obtained from the caregivers.

Explanations that are concerning for intentional trauma include:

no explanation or vague explanation for a significant injury;

an important detail of the explanation changes dramatically;

an explanation that is inconsistent with the pattern, age, or severity of the injury or injuries;

an explanation that is inconsistent with the child's physical and/or developmental capabilities; and

different witnesses provide markedly different explanations for the injury or injuries.

Information regarding the child's behavior before, during, and after the injury occurred, including feeding times and levels of responsiveness, should be gathered. Victims of significant trauma usually have observable changes in behavior. Access to caregivers and caregiver activities before, during, and after the injury occurred are also important to document. Frequently, infants and children present to medical settings with a history of a fall. Recent studies have indicated that short falls may result in bruising; however, more significant types of head trauma, including skull fractures, are exceedingly uncommon but possible. 29 , 30  

Information should be gathered in a nonaccusatory but detailed manner. Other information that may be useful in the medical assessment of suspected physical abuse includes:

past medical history (trauma, hospitalizations, congenital conditions, chronic illnesses);

family history (especially of bleeding, bone disorders, and metabolic or genetic disorders);

pregnancy history (wanted/unwanted, planned/unplanned, prenatal care, postnatal complications, postpartum depression, delivery in nonhospital settings);

familial patterns of discipline;

child temperament (easy to care for or fussy child);

history of past abuse to child, siblings, or parents;

developmental history of child (language, gross motor, fine motor, psychosocial milestones);

substance abuse by any caregivers or people living in the home;

social and financial stressors and resources; and

violent interactions among other family members.

Most injuries of childhood are not the result of abuse or neglect. Minor injuries in children are exceedingly common. Physicians must also consider that unusual events, including accidents, do happen to children 31   and may produce injuries that are not characteristically seen from accidental causes. An injury pattern is rarely pathognomonic for abuse or accident without careful consideration of the explanation provided. In addition, both inflicted and accidental injuries may be seen simultaneously in a child.

The child's alertness and demeanor may reflect neurologic status and degree of discomfort and pain. A thorough and complete neurologic examination must be performed. For example, if alertness appears compromised, eye-opening, verbal, and motor responses should be assessed systematically. Spontaneous and symmetrical movement of all extremities should be noted, as well as any of the child's responses that indicate pain when extremities are examined and moved. Because abusive caregivers are rarely informative regarding the injuries that have been inflicted, special care should be taken during the examination of the child's extremities and neck, which may be fractured and require immobilization until diagnostic radiographs can be performed. Evidence of spinal cord injury, such as abnormal reflexes, muscle tone, or responsiveness to tactile stimuli, should be carefully pursued.

When the child is stable, height, weight, and fronto-occipital circumference should be carefully measured and then plotted on a growth chart. Previous measurements obtained from past medical visits should also be obtained to gauge whether growth velocity has been appropriate. Plotting parameters is essential, because clinicians may miss significant growth failure in infants and children if the clinician relies only on their clinical impressions. Physical abuse and failure to thrive are sometimes concurrent 32 , 33   ; in addition, some children are starved intentionally. 34  

Evidence of neglect may be seen during the general examination of the infant or child; extensive dental caries, severe diaper dermatitis, or neglected wound care may be noted in addition to injuries that raise suspicion of abuse. Bald areas on the scalp may sometimes be seen with severe nutritional deficits or with traumatic alopecia. These findings should be differentiated from nonabusive or benign causes such as tinea capitis, alopecia areata, and occipital bald spots caused by supine positioning of young infants.

If the child can be interviewed, his or her demeanor should be noted during questioning. Some children display strong nonverbal cues of anxiety and reluctance when answering questions regarding potential abuse, because they are protective of their abuser or they fear retribution for “telling.” Others may appear openly fearful of their abuser. Such responses may be important to consider when a safety plan for the child is made.

Location, size, and shape of any bruises, lacerations, burns, bites, or other skin injuries should be documented in a medical chart as well as with high-quality 35-mm or digital photographs. Inspection for injuries should be thorough and involve all aspects of the neck and head; mouth; extremities, including feet and hands; genitals; anus; buttocks; torso; and back. Obscure sites for inflicted injuries include the ears, especially the posterior aspects, the neck and angle of the jaw, scalp, and the frenula of the lip and tongue. In contrast to accidental injuries, inflicted injuries tend to occur on surfaces away from bony prominences, such as the neck, head, buttocks, trunk, hands, and upper arms. 35 , 36   In 1 patient series, approximately 60% of abused children had injuries on the head, face, or neck. 37   Hematomas of the scalp may be detected through palpation or may be visualized on radiographs. Some deeper bruises may not be readily visible for several hours; areas that are painful to palpate may require further examination in 1 to 2 days, when bruises may become apparent. Measurement of skin injuries may assist in determining the mechanism of injury and/or object used to inflict the injury. For example, a child that is kicked may have a discernable shoe imprint, or a knuckle imprint may be apparent if the child was punched.

Bite marks can yield important forensic information; referral to professionals that can gather such information and maintain a chain of custody is advisable. 38   Bite marks, recent or healed, should be carefully measured and photodocumented when possible; an intercanine distance of more than 2 cm suggests a human adult-sized bite. 39   In some facilities, forensic odontologists are available and may use special examination and photographic techniques to analyze bite marks. Fresh bites should be swabbed with sterile, premoistened cotton-tipped applicators for forensic analysis of potential genetic markers found in saliva.

The age of a bruise cannot be determined accurately. 40   Soft tissue swelling is seen more commonly with recent trauma but can persist for several days. The age and developmental capabilities of the infant or child also determine the frequency of bruising. For example, 1 study of infants and toddlers presenting for health maintenance examinations found that 17.8% of infants starting to “cruise” and 51.9% of ambulatory toddlers had bruises; bruises were observed only 2.2% of the time in infants who were not yet cruising. 36   In addition to accidents, bruising may occur secondary to coagulopathies and vasculitides such as idiopathic thrombocytopenic purpura, vitamin K deficiency, Henoch-Schönlein purpura, hemophilia, or von Willebrand disease.

Burn injuries may be chemical, thermal (including exposure to scalding liquids or hot objects), or electrical. The child's clothing worn during the burn should be collected and may provide information regarding the cause of the burn. Burns inflicted with hot objects can be difficult to differentiate from accidental mechanisms, because both burns may be patterned. The history, number of burns, and continuity of the burn pattern over curved body surfaces may indicate a greater probability of inflicted trauma. Accidental scalds most commonly involve hot liquids pulled or splashed onto the child's upper extremities, torso, and or neck and head. 41   Inflicted scalds or forced-immersion burns may be well demarcated in pattern, with few or no splash marks. When evaluating an apparent burn injury, other noninflicted causes to consider include chemical burns of the buttocks with senna-containing laxatives, 42   bullous impetigo, and accidents.

Head trauma is the leading cause of child abuse fatalities. 43   When compared with child victims of severe accidents, children with abusive head trauma are more likely to have subdural and subarachnoid hematomas, multiple subdural hematomas of differing ages, more extensive retinal hemorrhages, and associated cutaneous, skeletal, and visceral injuries. 6   The inflicted injuries tend to occur in younger patients. Abusive head trauma tends to result in higher mortality and longer hospital stays than does accidental head trauma. 6 , 7   Infants with intracranial injuries frequently have no or nonspecific symptoms, 44 , 45   so the absence of neurologic symptoms should not exclude the need for imaging. Careful consideration of symptoms, signs, history, and judicious use of other ancillary tests should guide the clinician in determining the need for imaging.

Skull fractures can occur from accidents or inflicted injury. Studies have indicated that simple linear skull fractures can result from short falls of less than 3 ft and that such fractures are usually associated with scalp bruising or swelling. 46   However, it is unknown how many infants and children sustain skull fractures from simple falls, are asymptomatic, and, therefore, never present for a medical evaluation; hence, the incidence of skull fractures among infants who sustain such falls is likely unknown. Abuse should be suspected when there is a history of minor head trauma such as a short fall in children with multiple, complex, diastatic, or occipital skull fractures. 47   Whenever an infant or child presents with a skull fracture, care should be taken to ensure that there are no other injuries.

Conditions that may be confused with abusive head trauma include glutaric aciduria type 1 (macrocranium, subdural hematoma, sparse intraretinal and preretinal hemorrhages, frontotemporal atrophy) and hemorrhagic disease of the newborn (including risk factors such as home birth, no vitamin K prophylaxis, or breastfeeding).

A fundoscopic examination for retinal hemorrhages should be considered for any infant or young child who is a suspected victim of physical abuse. Under optimal conditions, an ophthalmologist with pediatric experience should conduct an examination of dilated pupils by using indirect ophthalmoscopy. The ophthalmologist should provide documentation of the retinal hemorrhages by photography or detailed annotated drawings. Location, depth, and extent of retinal hemorrhages may distinguish between abusive and nonabusive causes of head trauma. 48   Retinal hemorrhages occur in approximately 85% of infants and children who are subjected to abusive, repetitive, acceleration-deceleration (shaking) forces with or without impact. 48   Although newborn infants may have retinal hemorrhages in the superficial nerve fiber layers, most resolve by 2 weeks of age, and most intraretinal hemorrhages resolve by 4 to 6 weeks of age. 49  

Inflicted injuries that involve the heart are rare and severe. Rib fractures in infants are usually caused by forceful squeezing of the chest 50   ; posterior or lateral rib fractures or multiple rib fractures are especially predictive of abusive trauma. 51   Cardiopulmonary resuscitation, whether performed by experienced or inexperienced individuals, is an unlikely cause of rib fractures 52   or retinal hemorrhages. Acute rib fractures may be associated with shallow breathing attributable to pain and splinting; in severe cases, a fractured rib may puncture the lung. Alterations in respiratory patterns may also signal central nervous system damage or response to pain. Other rare injuries associated with abusive blows or compressive forces to the chest include hemopericardium, cardiac contusions occurring as a result of abusive blows to the chest, and shearing of the thoracic duct resulting in chylothorax. 53 , 54  

Auscultation, performed before palpation, may reveal decreased or no bowel sounds if the child has sustained intraabdominal injury. If the intestines, liver, or spleen have been ruptured, guarding or abdominal muscle rigidity may be noted on palpation. Abdominal bruising is often not seen, even with severe blows to the abdomen. 55   In 1 study, 56   solid organ injuries were most common in children with accidental and inflicted abdominal trauma, but abused children were more likely to have a hollow viscus injury or both hollow viscus and solid organ injuries than were children with accidental abdominal injuries. In comparison with children who sustain accidental trauma to the abdomen, victims of inflicted intraabdominal injury tend to be younger, are more likely to have delayed presentations to a clinical setting, have a higher mortality rate, and are more likely to have an injury to hollow viscera. 8   Liver and pancreatic enzyme tests are helpful in screening children for abdominal trauma, especially when the child presents with acute symptoms or shortly after the incident has occurred. A urinalysis may also lead to the discovery of unexpected trauma to the urinary tract and kidneys. Radiographic studies, including computed tomography, are helpful in determining the types and severity of intraabdominal trauma and are warranted in most cases when the physical examination is unreliable because of patient age, presence of other injuries that may obfuscate the abdominal examination, or the presence of head injury.

Careful palpation of the legs, arms, feet, hands, ribs, and head may reveal acute or healing (callus formation) fractures. If a fracture is suspected, surfaces should be carefully examined for “grab marks” that may indicate restraint or areas that were pulled or twisted to create the fracture; however, absence of such bruising does not exclude abusive mechanisms of injury. Soft tissue swelling, with or without bruising, may indicate more recent trauma. Many fractures, including rib and metaphyseal fractures, may not be clinically detectable, so a negative clinical examination should not preclude the need for a skeletal radiologic survey when inflicted trauma is suspected, particularly in children younger than 2 years.

Long-bone fractures that should be evaluated carefully for nonaccidental causes include metaphyseal fractures and spiral/oblique fractures, especially in nonambulatory infants; both types of fractures have been associated with accidental mechanisms of injury as well. Accidental causes of lower-extremity spiral or oblique fractures have been described among infants in “exersaucers” 57   and in the tibia of newly ambulatory toddlers. 58   Osteogenesis imperfecta is a rare congenital disorder that typically presents with bone fragility. Other associated findings are common and include deep-blue sclera, ligamentous laxity, osteopenia, wormian skull bones, dentinogenesis imperfecta, positive family history, and hearing loss. Less common types of this disease may present with fewer and less-severe clinical symptoms. 59   Patients with osteogenesis imperfecta are often suspected as victims of abuse before diagnosis, because the history of the injury insufficiently explains the severity of the fracture, and osteopenia may be lacking in occult cases of this disease. 60  

A complete neurologic assessment, including reflexes, cranial nerves, sensorium, gross motor, and fine motor abilities, should be conducted. Abnormalities may reflect current or past injuries to the central nervous system. Abused children may also have developmental disabilities because of deprivation in the home environment or other causes.

When abuse is suspected as the cause of an injury, the clinician may conduct tests to screen for other injuries or underlying medical causes for the injury. The extent of diagnostic testing depends on several factors including the severity of the injury, the type of injury, the age of the child, and examination findings. In general, the more severe the injury and younger the child, the more extensive is the need for diagnostic testing for other injuries. Table 1 is a summary of tests, some of which may be used during a medical assessment for suspected abuse.

When 1 child is identified as a suspected victim of abuse, siblings and other child contacts of the suspected abuser should also be assessed for injuries. The extent of the assessment depends on the child's age, symptoms, and signs; infants and toddlers may require more extensive testing, because symptoms and signs may be less useful in determining the presence of occult inflicted injuries.

Complete documentation of visible injuries on body diagrams and with photographs is strongly urged and facilitates peer review as well as court testimony, when required. In some regions, investigators from law enforcement or child protective services are specially trained to take forensic photographs. Diagnostic impressions should address whether the explanation adequately correlates with the severity, age, pattern, and distribution of the injury or injuries and the likelihood of nonaccidental causes for the injury. If a child has sustained a serious injury because he or she was left unsupervised in a dangerous environment, the physician should report suspected neglect or inappropriate adult supervision, including injuries sustained while under the care of an intoxicated adult, to child protective services. 69   When the child is evaluated or tested for other nonabusive causes, documentation should reflect the results of this assessment as well. In general, concern for abuse is greatest for infants younger than 12 months regardless of the severity of the injury.

Once medical assessment and stabilization are achieved and a referral has been made to investigative agencies, the physician should ensure that the child receives the necessary follow-up services. The child's primary care physician should be notified, and child protective services should ensure that the family complies with the plan of care. These services should not only include referral to appropriate medical providers but also address the psychological effects of abuse or neglect on the young child, the siblings, and the nonoffending caregiver. Because adult-partner violence commonly co-occurs with child abuse, several family members may require medical and mental health assistance. Medical passports, which are abbreviated medical chart forms usually kept by foster parents and presented at each medical visit, are recommended to optimize treatment regimens in children who are shifted among agencies and individuals during the course of the child abuse investigation. 70  

All 50 states have statutes that mandate reporting of suspected child abuse and neglect; the physician is not required to prove abuse before reporting. Familiarity with state laws will ensure that physicians report to the appropriate agency within the required time frame; some states have provided the option of making such a report through the Internet. Information on specific state laws are provided by the Children's Bureau (Administration for Children and Families, US Department of Health and Human Services; see www.childwelfare.gov/systemwide/laws_policies/search/index.cfm ). Many states have laws that permit physicians to evaluate children who are suspected victims of abuse, to conduct tests, and to take photographs without parental consent.

The physician may be required to write a sworn statement of his or her findings and to testify in civil or criminal trial proceedings. Civil hearings include testimony about the safety of the child and the need for appropriate placement with caregivers or state agencies. Judgments are based on a “preponderance of the evidence” with respect to the likelihood of abuse. Criminal hearings involve testimony about the guilt or innocence of an individual with respect to causing the injuries in a child. The burden of proof is greater than that of civil hearings; cases must be proven “beyond a reasonable doubt.” Physicians are expected to testify to the facts on the basis of their knowledge and experience in pediatrics and, when appropriate, in child abuse. As such, they may be asked to render opinions regarding the normal developmental capabilities of children at certain ages as well as the mechanisms of injury, severity of the injury, and prognosis. Pediatricians should not testify to anything that is beyond their level of knowledge or expertise. Physicians act primarily as scientists and educators in legal settings rather than as child advocates.

Child physical abuse is a common problem of childhood. The physician must be able to recognize suspicious injuries, conduct a comprehensive and careful examination with appropriate auxiliary tests, critically assess the explanation provided for the injury or injuries, and establish the probability that the explanation does or does not correlate with the pattern, severity, and/or age of the injury or injuries. The physician is responsible for reporting suspected abuse, documenting his or her opinions clearly, and providing the necessary information and expertise to investigative and legal personnel and parents, when appropriate. In addition, pediatricians are uniquely qualified to work with parents and caregivers to prevent abuse by providing anticipatory guidance on normal child behavior and its management. Finally, physicians must advocate that children in foster care who have medical or mental health problems receive the appropriate services and medications and continuity of care through a medical home, and that a medical passport is maintained for these children.

Carole Jenny, MD, MBA, Chairperson

Cindy W. Christina, MD

Roberta A. Hibbard, MD

Nancy D. Kellogg, MD

Betty S. Spivack, MD

John Stirling, Jr, MD

David L. Corwin, MD

American Academy of Child and Adolescent Psychiatry

James A. Mercy, PhD

Centers for Disease Control and Prevention

Tammy Hurley

Diagnostic Tests That May Be Used in the Medical Assessment of Suspected Physical Abuse and Differential Diagnoses

Tests should be ordered judiciously and in consultation with the appropriate genetics, hematology, radiology, and child abuse specialists. Careful consideration of the patient's history, age, and clinical findings should guide selection of the appropriate tests. CBC indicates complete blood cell; INR, international normalized ratio; DIC, disseminated intravascular coagulation; CT, computed tomography; IV, intravenous; PO, oral; CK-MB, creatine kinase MB band.

CT scanning may provide clinically relevant information more expeditiously than MRI in some facilities.

All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate

Eye findings and Allegations of Shaking and Non-Accidental Injury

Letter to the Editor

RE: Evaluation of Suspected Child Physical Abuse

I read with interest the recent Clinical Report from Dr. Nancy D. Kellogg and the AAP Committee on Child Abuse and Neglect (1). However, I was very concerned by the authors’ handling of the issue of eye findings and the implication that they are speaking for the Academy in this Clinical Report. Given the role that eye findings presently play in the evaluation of physical abuse of infants, I feel that the authors owe us a clearer justification for their assertions in this article.

First, Kellogg (2007) relied exclusively on the Morad (2002) article for valid information in this area (1). The Morad article relied on data collected between 1993 and 1999 at one hospital and by one examiner (2). In that article, the presence of any abnormal findings on neuroimaging plus any findings of ocular injury was all that was required for the diagnosis of “apparent nonaccidental head injury consistent with SBS” (2). At that time, the potential for short distance falls and accidental injuries to result in retinal hemorrhages, schisis, and perimacular retinal folds had not been published and caregivers giving such histories were assumed to be lying and hiding the fact that they had shaken their wards. At that time, the documentation of the appearance and progression of retinal findings in the presence of markedly increased intracranial pressure (ICP) had not been reported. In my case load alone, I have two cases where the in-hospital documented appearance of schisis and perimacular folds clearly occurred >24 hours post ALTE presentation. It should also be pointed out that in the Morad data, 100% of the infants included had abnormal neuroimaging and 85% had retinal findings, and when retinal hemorrhages were present, greater than 83% were extensive in at least one eye (2). Morad gave no indication of timing between eye exam, neuroimaging, and state of the anterior fontanelle, or data on the measured ICPs when obtained; further, it gave no data on autopsy retinal findings as compared to findings at clinical exam in life, that might have documented the appearance and progression of eye findings under post-event conditions of markedly increased ICP, compromised cerebral profusion pressure induced hypoxia/ischemia, and disseminated intravascular coagulation/coagulopathy. The evaluation of data from a series of patients, attempting to determine the potential cause of a finding has to be suspect, when the finding under scrutiny is essentially universally present in the patient pool and not correlated with secondary issues. Given the experimental and clinical data published since 2001, the Morad article would now appear to be obsolete and certainly not appropriate for exclusive citing in the American Academy of Pediatric’s current position in this area. Even in the final two paragraphs of the Morad article itself, where the vitreous traction hypothesis is discussed, it is not asserted as fact, but only as theory that needs further laboratory and clinical studies (2).

Second, the acceleration-deceleration traction hypothesis, to my knowledge, is the only proposed mechanism of eye injury that would be specific for abuse. If eye findings are to be used as indicators of abuse, this mechanism must be shown to be both valid and uniquely able to cause primary eye findings that cannot be explained by secondary factors common to brain injury from a variety of causes. Kellogg et al. should be required to prove both before making their statement, “Location, depth, and extent of retinal hemorrhages may distinguish between abusive and nonabusive causes of head trauma. Retinal hemorrhages occur in approximately 85% of infant and children who are subjected to abusive, repetitive acceleration-deceleration (shaking) forces with or without impact,” (1) while citing only Morad (2002) as their proof.

Data from Plunkett (2001) indicated that retinal hemorrhages were present in 2/3 of the fatal accidental head injuries when eye exams were recorded (3). Gilles (2003) reported the appearance and progression of eye findings in the presence of a markedly increased intracranial pressure after head injury (4). Lantz (2004), reported on that finding of perimacular folds in a case of crush injury to an infant’s head (5). Goldsmith (2004) reported on a videotaped fatal short distance fall with “extensive” bilateral retinal hemorrhages (6). In the February 2007 issue of the Journal of the American Association of Pediatric Ophthalmology and Strabismus, three abstracts relevant to this issue were published and were subsequently presented at the national meeting of the American Association of Pediatric Ophthalmology and Strabismus in Seattle in April. Obi (2007) reported on two cases where similar retinal hemorrhages, schisis, and folds were found in two patients—one injured accidentally in a witnessed short distance fall and one presumed to have been abused (7). Brown/Levin (2007) reported on the experimental observation of two kittens and a rabbit, which were killed by observed vigorous shaking by a large dog. These animals were found to have no eye findings on autopsy (8). The most provocative is the laboratory experiments by Binenbaum (2007) utilizing an appropriate animal model (3-5 day-old piglets) (9) and the well-published technique of Raghupathi (2002, 2004) (10,11). When subjected to impulse loaded acceleration-deceleration through 110 degrees of rotation over 15 msec., achieving measured accelerations > 55,000 rad/sec2, these researchers could produce no eye findings of retinal hemorrhages, schisis, folds, or intradural optic nerve sheath hemorrhages in the piglets (9). This represents >20 times the rotational acceleration-deceleration that Prange (2003) predicted could even be achievable with a horizontal abusive shaking of a 10 pound infant (12); and still, Binenbaum (2007) could produce no primary eye findings (9). In view of this recent literature, the assertion of any unique ability of repetitive acceleration- deceleration to cause “highly characteristic” eye findings cannot be sustained. Furthermore, these recent publications create a real question as to the validity of the acceleration-deceleration mechanism for the formation of any primary eye findings in the cases of alleged abuse that we presently encounter.

In view of the current published experimental and clinical information available since the Morad article, the AAP Committee on Child Abuse and Neglect has a duty to the Academy, to children and their parents, and to the legal system: 1) to address and deal with current challenges to the acceleration-deceleration vitreous traction hypothesis (shaking); 2) to come forth with real experimental data proving its validity before even implying that it has a role in the genesis of eye findings in head injury; and 3) to justify their implying a role for eye findings to even enter the picture in efforts to distinguish accidental from non-accidental injury in infants.

It should also be noted that since the publication of recent articles in the JAAPOS in February 2007, the American Academy of Ophthalmology has taken down its website on Shaken Baby Syndrome and shaking injury. Pediatricans who continue to assert a role for eye findings in the evaluation of NAI can no longer rely on the American Academy of Ophthalmology for support.

1. Kellogg ND, and Committee on Child Abuse and Neglect. Evaluation of Suspected Child Physical Abuse. Pediatrics. 2007;119:1232-41. 2. Morad Y, Kim YM, Armstrong DC, Huyer D, Mian M, Levin AV. Correlation Between Retinal Abnormalities and Intracranial Abnormalities in the Shaken Baby Syndrome. Am J Ophthalmol. 2002;134:354-359. 3. Plunkett J. Fatal Pediatric Head Injuries Caused by Short-Distance Falls. Am J Forensic Med Pathol. 2001;22:1-12. 4. Gilles EE, McGregor ML, Levy-Clarke G. Retinal Hemorrhage Asymmetry in Inflicted Head Injury: A Clue to Pathogenesis? J Pediatr. 2003:143:494-9. 5. Lantz PE, Sinal SH, Staton CA, Weaver Jr RG. Evidence based case report: Perimacular retinal folds from childhood head trauma. BMJ. 2004;328:754-756. 6. Goldsmith W, Plunkett J. Biomechanical analysis of the causes of traumatic brain injury in infants and children. Am J Forensic Med Pathol. 2004;25:89-100. 7. Obi E, Watts P. Are there any pathognomonic signs in shake baby syndrome? J AAPOS. 2007;11:99-100. 8. Brown S, Levin AV, Ramsey D, Serbanescu I. Natural animal shaking: A model for inflicted neurotrauma in children? J AAPOS. 2007;11:85-86. 9. Binenaum G, Forbes BJ, Raghupathi R, Judkins A, Rorke L, Marguiles SS. An animal model to study retinal hemorrhages in nonimpact brain injury. J AAPOS. 2007;11:84-85. 10. Raghupathi R, Margulies SS. Traumatic axonal injury after closed head injury in the neonatal pig. J Neurotrauma. 2002;19:843-845. 11. Raghupathi R, Mehr MF, Helfaer MA, Margulies SS. Traumatic axonal injury is exacerbated following repetitive closed head injury in the neonatal pig. J Neurotrauma. 2004;21:307-316. 12. Prange MT, Coats B, Duhaime AC, Margulies SS. Anthropomorphic simulations of falls, shakes, and inflicted impacts in infants. J Neurosurg. 2003;99:143-150.

John Gilbert Galaznik, M.D. (Pediatrician) Student Health Center University of Alabama School of Medicine, Tuscaloosa Campus Box 870360 Tuscaloosa, Alabama 35487-0360 (205) 348-6262

Disclosure: I am a medical consultant on cases involving allegations of physical abuse to infants and small children. I have testified in both civil and criminal cases.

Conflict of Interest:

None declared

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Ex-assistant principal charged with child neglect in case of boy who shot teacher

The Associated Press

Signs stand outside Richneck Elementary School in Newport News, Va., Jan. 25, 2023. Denise Lavoie/AP hide caption

Signs stand outside Richneck Elementary School in Newport News, Va., Jan. 25, 2023.

NEWPORT NEWS, Va. — A former assistant principal at a Virginia elementary school has been charged with felony child neglect more than a year after a 6-year-old boy brought a gun to class and shot his first-grade teacher .

A special grand jury in Newport News found that Ebony Parker showed a reckless disregard for the lives of Richneck Elementary School students on Jan. 6, 2023, according to indictments unsealed Tuesday.

Parker and other school officials already face a $40 million negligence lawsuit from the teacher who was shot, Abby Zwerner. She accuses Parker and others of ignoring multiple warnings the boy had a gun and was in a "violent mood" the day of the shooting.

Criminal charges against school officials following a school shootings are quite rare, experts say. Parker, 39, faces eight felony counts, each of which is punishable by up to five years in prison.

The Associated Press left a message seeking comment Tuesday with Parker's attorney, Curtis Rogers.

Shots - Health News

'say something' tip line in schools flags gun violence threats, study finds.

Court documents filed Tuesday reveal little about the criminal case against Parker, listing only the counts and a description of the felony charge. It alleges that Parker "did commit a willful act or omission in the care of such students, in a manner so gross, wanton and culpable as to show a reckless disregard for human life."

Newport News police have said the student who shot Zwerner retrieved his mother's handgun from atop a dresser at home and brought the weapon to school concealed in a backpack.

Zwerner's lawsuit describes a series of warnings that school employees gave administrators before the shooting. The lawsuit said those warnings began with Zwerner telling Parker that the boy "was in a violent mood," had threatened to beat up a kindergartener and stared down a security officer in the lunchroom.

The lawsuit alleges that Parker "had no response, refusing even to look up" when Zwerner expressed her concerns.

When concerns were raised that the child may have transferred the gun from his backpack to his pocket, Parker said his "pockets were too small to hold a handgun and did nothing," the lawsuit states.

Architecture

With gun control far from sight, schools redesign for student safety.

A guidance counselor also asked Parker for permission to search the boy, but Parker forbade him, "and stated that John Doe's mother would be arriving soon to pick him up," the lawsuit stated.

Zwerner was sitting at a reading table in front of the class when the boy fired the gun, police said. The bullet struck Zwerner's hand and then her chest, collapsing one of her lungs. She spent nearly two weeks in the hospital and has endured multiple surgeries as well as ongoing emotional trauma, according to her lawsuit.

Parker and the lawsuit's other defendants, which include a former superintendent and the Newport News school board, have tried to block Zwerner's lawsuit.

They've argued that Zwerner's injuries fall under Virginia's workers' compensation law. Their arguments have been unsuccessful so far in blocking the litigation. A trial date for Zwerner's lawsuit is slated for January.

Prosecutors had said a year ago that they were investigating whether the "actions or omissions" of any school employees could lead to criminal charges.

What schools can (and can't) do to prevent school shootings

Howard Gwynn, the commonwealth's attorney in Newport News, said in April 2023 that he had petitioned a special grand jury to probe if any "security failures" contributed to the shooting. Gwynn wrote that an investigation could also lead to recommendations "in the hopes that such a situation never occurs again."

It is not the first school shooting to spark a criminal investigation into school officials. For instance, a former school resource officer was acquitted of all charges last year after he was accused of hiding during the Parkland school massacre in 2018.

Chuck Vergon, a professor of educational law and policy at the University of Michigan-Flint, told The AP last year that it is rare for a teacher or school official to be charged in a school shooting because allegations of criminal negligence can be difficult to prove.

More often, he said, those impacted by school shootings seek to hold school officials liable in civil court.

• elementary school

Stop COVID Cohort: An Observational Study of 3480 Patients Admitted to the Sechenov University Hospital Network in Moscow City for Suspected Coronavirus Disease 2019 (COVID-19) Infection

Collaborators.

• Sechenov StopCOVID Research Team : Anna Berbenyuk ,  Polina Bobkova ,  Semyon Bordyugov ,  Aleksandra Borisenko ,  Ekaterina Bugaiskaya ,  Olesya Druzhkova ,  Dmitry Eliseev ,  Yasmin El-Taravi ,  Natalia Gorbova ,  Elizaveta Gribaleva ,  Rina Grigoryan ,  Shabnam Ibragimova ,  Khadizhat Kabieva ,  Alena Khrapkova ,  Natalia Kogut ,  Karina Kovygina ,  Margaret Kvaratskheliya ,  Maria Lobova ,  Anna Lunicheva ,  Anastasia Maystrenko ,  Daria Nikolaeva ,  Anna Pavlenko ,  Olga Perekosova ,  Olga Romanova ,  Olga Sokova ,  Veronika Solovieva ,  Olga Spasskaya ,  Ekaterina Spiridonova ,  Olga Sukhodolskaya ,  Shakir Suleimanov ,  Nailya Urmantaeva ,  Olga Usalka ,  Margarita Zaikina ,  Anastasia Zorina ,  Nadezhda Khitrina

Affiliations

• 1 Department of Pediatrics and Pediatric Infectious Diseases, Institute of Child's Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
• 2 Inflammation, Repair, and Development Section, National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom.
• 3 Soloviev Research and Clinical Center for Neuropsychiatry, Moscow, Russia.
• 4 School of Physics, Astronomy, and Mathematics, University of Hertfordshire, Hatfield, United Kingdom.
• 5 Biobank, Institute for Regenerative Medicine, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
• 6 Institute for Regenerative Medicine, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
• 7 Chemistry Department, Lomonosov Moscow State University, Moscow, Russia.
• 8 Department of Polymers and Composites, N. N. Semenov Institute of Chemical Physics, Moscow, Russia.
• 9 Department of Clinical and Experimental Medicine, Section of Pediatrics, University of Pisa, Pisa, Italy.
• 10 Institute of Social Medicine and Health Systems Research, Faculty of Medicine, Otto von Guericke University Magdeburg, Magdeburg, Germany.
• 11 Institute for Urology and Reproductive Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
• 12 Department of Intensive Care, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
• 13 Clinic of Pulmonology, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
• 14 Department of Internal Medicine No. 1, Institute of Clinical Medicine, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
• 15 Department of Forensic Medicine, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
• 16 Department of Statistics, University of Oxford, Oxford, United Kingdom.
• 17 Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom.
• 18 Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.
• 19 Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, United Kingdom.
• 20 Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.
• PMID: 33035307
• PMCID: PMC7665333
• DOI: 10.1093/cid/ciaa1535

Background: The epidemiology, clinical course, and outcomes of patients with coronavirus disease 2019 (COVID-19) in the Russian population are unknown. Information on the differences between laboratory-confirmed and clinically diagnosed COVID-19 in real-life settings is lacking.

Methods: We extracted data from the medical records of adult patients who were consecutively admitted for suspected COVID-19 infection in Moscow between 8 April and 28 May 2020.

Results: Of the 4261 patients hospitalized for suspected COVID-19, outcomes were available for 3480 patients (median age, 56 years; interquartile range, 45-66). The most common comorbidities were hypertension, obesity, chronic cardiovascular disease, and diabetes. Half of the patients (n = 1728) had a positive reverse transcriptase-polymerase chain reaction (RT-PCR), while 1748 had a negative RT-PCR but had clinical symptoms and characteristic computed tomography signs suggestive of COVID-19. No significant differences in frequency of symptoms, laboratory test results, and risk factors for in-hospital mortality were found between those exclusively clinically diagnosed or with positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RT-PCR. In a multivariable logistic regression model the following were associated with in-hospital mortality: older age (per 1-year increase; odds ratio, 1.05; 95% confidence interval, 1.03-1.06), male sex (1.71; 1.24-2.37), chronic kidney disease (2.99; 1.89-4.64), diabetes (2.1; 1.46-2.99), chronic cardiovascular disease (1.78; 1.24-2.57), and dementia (2.73; 1.34-5.47).

Conclusions: Age, male sex, and chronic comorbidities were risk factors for in-hospital mortality. The combination of clinical features was sufficient to diagnose COVID-19 infection, indicating that laboratory testing is not critical in real-life clinical practice.

Keywords: COVID-19; Russia; SARS-CoV-2; cohort; mortality risk factors.

© The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: [email protected].

Publication types

• Observational Study
• Research Support, Non-U.S. Gov't
• Hospitalization
• Middle Aged

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• 20-04-60063/Russian Foundation for Basic Research

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• v.13(4); 2020 Dec

Responding to Basic and Complex Cases of Child Abuse: a Comparison Study of Recent and Current Child Advocacy Studies (CAST) Students with DSS Workers in the Field

Jennifer parker.

1 Child Protection Training Center, University of South Carolina Upstate, 160 E. St. John Street, Spartanburg, SC 29306 USA

Lynn McMillan

2 Center for Child Advocacy Studies, University of South Carolina Upstate, Spartanburg, SC USA

Stacey Olson

Susan ruppel, victor vieth.

3 Zero Abuse Project, St. Paul, MN USA

In an effort to improve the training of future child protection professionals, more than 70 universities and graduate schools in the United States have implemented Child Advocacy Studies (CAST) minors or graduate programs. In order to assess the efficacy of these programs, 46 current and recent graduates of a CAST minor and 43 child protection professionals currently employed by a Department of Social Services (DSS) were given two vignettes. The first vignette involved a clear case of sexual abuse and the second vignette involved a more complex case involving polyvictimization. The students were asked to identify various systems that needed to be involved, potential corroborating evidence, risk and protective factors, and types of victimization. In the case of sexual abuse, the current CAST students and CAST graduates performed at the same level as DSS caseworkers. On the more complex polyvictimization scenario, the current CAST students and CAST graduates performed significantly better than all levels of DSS caseworkers in identifying systems that respond to child maltreatment and in identifying psychological and emotional abuse. The results of this study suggests that undergraduate CAST minors may be an effective model for improving the knowledge and skills of future child protection professionals in responding to complex cases of maltreatment.

Inadequate training for future child protection professionals at the undergraduate and graduate level is widely cited in the literature (Vieth 2006 ). In a search of the websites of 1416 universities and colleges, researchers found that only 29% (410) of these web sites had any course work addressing issues of child maltreatment. Not one of the 1416 universities or colleges had a concentration, much less a minor on child maltreatment (Johnson 2015 ).

In a qualitative study, researchers interviewed 166 frontline child protection professionals about their education. The vast majority of respondents indicated very little undergraduate or graduate training on child abuse. In fact, most respondents indicated they had no training on child abuse cases before entering the field. As one example, a sheriff’s deputy with a bachelor’s degree in criminal justice reported he has handled more than 600 child sexual abuse (CSA) cases in his career but his entire training was “on the job” (Vieth 2013 ).

n a study on the undergraduate training of nursing students, researchers found that 75% of the programs had not developed violence-based student competencies and 68% of the programs did not evaluate violence content (Woodtli and Breslin 2002 ). Of the 359 undergraduate nursing programs reporting classroom hours on child abuse, 62% reported 2–4 h of training and 18% reported only 1 h of classroom instruction on child abuse or readings only (Woodtli and Breslin 2002 ).

Inadequate training may be particularly noticeable in newer or emerging areas of child protection. A qualitative study of social workers found that all of these workers felt inadequately trained to effectively respond to the needs of children who were victimized by online images of their sexual abuse (Martin 2016 ).

A number of studies also confirm inadequate training in graduate schools. A study of American Psychological Association (APA) accredited graduate programs found that many of the programs “fall far short” of guidelines proposed by the APA for minimal levels of competence in handling child maltreatment cases (Champion et al. 2003 ). The study finds the lack of graduate training for psychology students “contradicts the rapidly expanding literature on responding to maltreatment and the demands of this interdisciplinary, professional endeavor” (Champion et al. 2003 , p.215).

Discussing her educational background, psychologist Anna Salter writes:

“In the two years I spent at Tufts getting a Masters Degree in Child Study and the five years I spent at Harvard getting a Ph.D. in Psychology and Public Practice, there was virtually nothing on child sexual and physical abuse in any course I took. I had one lecture on the victims of child abuse, but not a single lecture anywhere on offenders. Ironically, many of the lectures were on maladies so rare I’ve yet to see them in twenty years of practice” (Salter 2003 , p. 2). A dozen years after this dreary assessment, scholars were continuing to call for improving the training of mental health professionals handling cases of child sexual abuse (Kenny and Abreu 2015 ).

Medical training similarly fails to train on topics relevant to addressing child abuse. In a 2018 study of 263 family residency programs, only 27% provided training on trauma-informed care and even then, it was less than five hours annually (Dichter et al. 2018 ). In the field of pediatrics, the reality is that “more than 40 years after the diagnosis of battered child syndrome entered the literature, our pediatric residency programs do not have a significant education requirement for preventing, recognizing, or managing child abuse” (Botash 2003 , p. 239).

Poor training increases the risk for egregious errors. In one study, for example, researchers found that 31% of shaken baby cases were not recognized by the physicians who first evaluated these victims (Jenny et al. 1999 ). The ability of medical professionals to “correctly identify genital and anal findings and interpret medical findings” in possible instances of child sexual abuse is “significantly associated” with “(t)raining, discipline, and clinical experience….” (Adams et al. 2012 , p. 392). In an analysis of hundreds of health care facilities, medical professionals were failing to properly evaluate for occult fractures in approximately half of child physical abuse cases (Wood et al. 2015 ).

In a national survey of pediatricians, researchers found “(t)hose who had received some child abuse” training in the field “expressed more confidence in their ability to identify and manage child abuse” (Flaherty et al. 2006 , p. 366). However, 22% of the pediatricians who had received field training did not feel adequately trained (Flaherty et al. 2006 ). The researchers concluded “(g)reat variability in self-reported training and experience were noted in the current study, suggesting these variations may be partially responsible for previously observed problems in identification and reporting of child abuse” from pediatricians (Flaherty et al. 2006 , p. 367).

U.S. Attorney General’s Task Force Recommendations for Undergraduate/Graduate Reform

The United States Attorney General’s Task Force on Children Exposed to Violence has called for a “national initiative to promote professional education and training on the issue of children exposed to violence at home, in their neighborhood, and in schools” (USDOJ 2012 , p. 5). The task force specifically urges academic institutions to “include curricula in all university undergraduate and graduate programs to ensure that every child and family serving professional receives training in multiple evidence-based methods for identifying and screening children for exposure to violence” (USDOJ 2012 , p. 6). The Attorney General’s Task Force included sexual abuse of children in its definition of violence (USDOJ 2012 ).

Child Advocacy Studies (CAST)

Child Advocacy Studies (CAST) is a national initiative designed to improve the undergraduate and graduate training of future child protection professionals entering the fields of social work, criminal justice, psychology, nursing, medicine, education, law, victim advocacy, and spiritual care. In a collaboration between Winona State University and the National Child Protection Training Center (now the Zero Abuse Project), an interdisciplinary twenty-one credit minor was developed and implemented (Johnson 2015 ). CAST programs were also developed for graduate programs including law schools, medical schools, and seminaries (Vieth et al. 2019 ).

Students completing the CAST medical school course were significantly better prepared to recognize signs of child maltreatment, to report suspected abuse, and to recommend or secure services than were students in a comparison group (Knox et al. 2013 ). CAST medical students are more likely to report suspicions of abuse even when they are not certain (Pelletier and Knox 2017 ). CAST medical students are also likely to be more accurate in identifying abuse than are students who did not receive CAST education (Pelletier and Knox 2017 ). Medical students completing the CAST course also have a significant decrease in attitudes supporting the physical discipline of children (Bartholomew et al. 2018 ).

As of this writing, only one study has examined the impact of CAST on undergraduate students. In a survey of CAST graduates, 80% were working in a field where the CAST minor was relevant (Osgood 2017 ). A full 100% of the CAST alumni agreed or strongly agreed the program better prepared them to recognize and respond to instances of child maltreatment (Osgood 2017 ).

The purpose of the current study was to compare the responses of recent graduates or upper level students of the CAST minor program with the responses of child protection professionals currently employed in the field to a reported case of child maltreatment. This is the first study to compare the knowledge or abilities of recent CAST graduates with professionals already in the field (Tables ​ (Tables1 1 and ​ and2 2 ).

Means and SEM for the number of system responses identified by the five affiliation groups

**CAST graduates ( p  < .03) performed significantly better than all three levels of DSS caseworkers. *Current CAST students ( p  < .09) were trending toward significance

Means and SEM for the number of psychological/emotional abuse identified by the five affiliation groups

*Current CAST students ( p  < .05) and **CAST graduates (p < .001) performed significantly better than all three level of DSS caseworkers

Forty-six recent graduates and senior students of the University of South Carolina Upstate Child Advocacy Studies (CAST) program and 43 child protection professionals currently employed by Department of Social Services (DSS) participated in the study. Participants were given a brief overview of the study followed by questions and consent to participate. Participants received two short case scenarios. After reading the cases they were asked to complete a brief questionnaire (Appendix 1 ) responding to each case in terms of various systems involved, corroborating evidence, risk and protective factors, and types of victimization. Participants provided basic demographic information without personal identifiers. One hour was allocated for each group to complete the questionnaire. Data were grouped according to the five groups: current CAST students, CAST graduates, DSS workers with less than one year experience, DSS workers with 1–2 years’ experience, and DSS workers with 3+ years’ experience. A coding system (Appendix 2 ) was developed to evaluate responses and two independent raters analyzed the results.

Case Scenario 1 (Involving Sexual Abuse)

One case scenario involved a child making a statement of sexual abuse. Specifically, a child reports to his teacher that his grandfather sexually abused him on a camping trip two weekends earlier. The actual scenario is as follows:

Third grade teacher, Jill Jones, had just dismissed her class for the weekend when she noticed that one of her students, Carl, was still sitting at his desk. Earlier that day, he shared with the class that his grandfather was taking him camping again this weekend. Ms. Jones assumed Carl was excited about the camping trip and so was puzzled now by his somber demeanor. When she asked, “are you OK?”, Carl explained that “two weekends ago my Grandpa took me to Camp Whitewater. We camped and went fishing and I caught lots of fish. I had lots of fun except that, in the middle of the night, Grandpa started to touch my privates. He then told me to lick his pee pee. I licked his pee pee until it threw up.” Ms. Jones knew that Deputy Jack Miller, their school resource officer, would still be in the building and she contacted him.

Case Scenario 2 (Involving Poly-Victimization)

The second scenario was much more complex involving multiple forms of abuse or poly-victimization (Turner et al. 2010 ) as well as more than one child victim as well as at least one adult victim. The maltreatment included possible abusive head trauma of an infant, domestic violence in which the mother was beaten and cut, issues of child neglect of both the infant and a seven year old child who may have witnessed and experienced abuse in the home, developmental delays, emotional abuse, and multiple ACE factors (Felitti and Anda 2010 ) including mental illness, drug usage, and parents with a history of childhood abuse.

This specific scenario is as follows:

On June 18, 2015 at 2134 hours, 911 dispatch received a hang up call from the address 815 Sycamore Street. 911 operator Thomas Jones phoned the residence but there was no response. At 2138 hours, 911 dispatch receive a call from 817 Sycamore Street alleging a domestic dispute next door. The caller, neighbor Betty Cranbrook, reported that she heard yelling by both the homeowners at 815 Sycamore Street. She indicated that Johnny Folsum and his wife, June, have lived next door to her in this working class neighborhood for approximately 9 months and Betty is increasingly concerned about escalating arguments in the home. Betty has seen an infant in the home and there have been toys for an older child in the front yard recently. Betty thinks the Folsums are drug dealers. They seem very private and rarely wave or speak to her. Betty has not called in prior disputes because she thought it was none of her business but tonight’s dispute was so loud that she heard it from her 2 nd story bedroom while she was watching television. Officer Wayne Johnson arrived at 815 Sycamore at 2155 hours. When he approached the residence, he heard loud yelling from inside the residence primarily by the female resident. Officer Johnson knocked on the door but no one answered. After several attempts to announce his presence, Officer Johnson entered the residence through the unlocked front door. Inside he found Johnny Folsum yelling at his wife, June. An infant, approximately 6 months of age, was lying motionless on the floor in the living room. Neither parent was making any attempt to administer aid to the infant. Officer Johnson notified dispatch to send an ambulance to the scene, as well as a detective. Johnny Folsum had redness and swelling on his right knuckles and scratches on his forearm. June Folsum had redness and swelling developing around both her eyes, redness around her neck, and a large laceration on the right side of her neck. Officer Johnson verbally attempted to calm both parties and instructed them to sit on the couch. The ambulance arrived at 2212 hours and promptly transported the infant to the local hospital. Detective Lila Smith arrived and upon hearing crying in another part of the home, she located a 7 year female child hiding in a bedroom closet. Detective Smith placed this child in emergency protective custody and notified child protective services (CPS). She then transported the child to the local children’s shelter and was met there by CPS investigator Jenny Hill. During the investigation, June Folsom reported a history of depression (untreated) since she was a teenager. Her father was incarcerated and she lived with her mother and stepfather. Her stepfather drank heavily, had violent outbursts, and sexually abused June. June experienced difficult pregnancies, followed by postpartum depression, with both children. She graduated high school and has mostly been a stay-at-home mother. The 7 year-old daughter has developmental delays. Johnny Folsom was raised in a strict religious household with both parents and several siblings. He graduated from high school and immediately began employment with a local manufacturing company where he remains employed today.

Case Scenario 1 (Sexual Abuse Only)

In responding to the vignette involving simply a report of sexual abuse, there were no significant differences found between the CAST groups (current CAST students, CAST graduates) and the DSS caseworker groups (DSS workers with less than one year experience, DSS workers with 1–2 years’ experience, and DSS workers with 3+ years’ experience).

Case Scenario 2 (Poly-Victimization)

There were no significant differences in identifying risk and protective factors or corroborating evidence. There were, however, significant differences with respect to identifying systems that needed to be responding to the case and also types of victimization involved.

Systems Response

A significant effect of affiliation was found F (4, 82) = 2.896, p  = .027. As shown in Table ​ Table1, 1 , CAST graduates identified and listed significantly more systems involved or likely to be involved in response to the case than DSS workers employed for less than a year ( p  = .021), on the job between 1 and 2 years ( p  = .012), or more than three years ( p  = .027).

Victimization

A significant effect of affiliation was found for type of victimization specific to psychological/emotional abuse, F (4, 82) = 5.777, p  < .001. As shown in Table ​ Table2, 2 , CAST graduates identified significantly more psychological/emotional abuse than DSS workers employed for less than a year ( p  = .003), between 1 and 2 years ( p  < .001), or more than three years ( p  = .001). Current CAST students identified significantly more psychological/emotional abuse than DSS workers employed for less than a year ( p  = .046), between 1 and 2 years ( p  = .004), or more than three years ( p  = .018).

The two case scenarios differed in terms of case complexity and the amount of detail provided. The poly-victimization case presented a more complex scenario and was more detailed in terms of relationships, prior history, and the scene encountered by first responders. On this more complex scenario, the CAST graduates performed significantly better than all levels of DSS caseworkers, specific to identifying systems that respond to child maltreatment. CAST graduates and current CAST students performed significantly better than all levels of DSS caseworkers in identifying psychological and emotional abuse.

The areas where no significant differences were found (corroborating evidence and risk/protective factors) suggest that CAST graduates and current CAST students performed on par with all levels of DSS caseworkers. It should be noted, though, that the vignettes did not include photographs of the potential crime scenes, transcripts of forensic interviews, suspect interrogations or interviews with other witnesses. Additional details would have presented greater opportunities to identify potential corroborating evidence and risk and protective factors, as well as differences in knowledge and ability between the CAST students and graduates and professionals already in the field.

The scenario involving a child sexual abuse only was less complex in presentation of a child’s initial disclosure and revealed no background information or investigation results. There were no significant differences between CAST graduates, current CAST students, and all levels of DSS caseworkers, meaning that the current CAST students and CAST graduates performed at the same level as all three categories of DSS caseworkers.

The findings from this study suggest that current students and recent graduates of the Child Advocacy Studies program are well prepared to enter the DSS workforce in that they are on par with new and seasoned caseworkers in terms of identifying systems that respond to child maltreatment, corroborating evidence, risk and protective factors (individual, family, and community), and types of victimization. If a future study involves more detailed information about the children and parents in a family, as well as photographs of potential crime scenes, medical and mental health reports and other evidence or information, greater differences might develop.

The findings also suggest that in a more complex child abuse scenario, CAST students are better equipped to identify and respond to these complexities. Again, the addition of more case information and transcripts of witness interviews would provide a more complete assessment of these potential differences.

The limitations of this study include that it was done at only one CAST university. There may be differences in CAST instruction or curriculum at other universities that may yield different results. Moreover, the scenario only compared the CAST students to caseworkers in the field. The similarities or differences in this study may or may not be the same if we compared students to law enforcement officers or other members of a multi-disciplinary team. Also, the study was primarily a pencil and paper analysis of the abilities of CAST students, CAST graduates, and professionals in the field. It did not test actual skills in interviewing children or adults, collaborating with law enforcement or other members of an MDT discussion, assessing a large volume of information, developing a case plan or other skills needed in the child protection workforce.

In addition to testing these results with a more elaborate case scenario or a simulation exercise, future studies might include whether CAST preparation to enter the DSS workforce results in: 1) job satisfaction or retention; 2) better outcomes for children and families; or 3) revisions to DSS caseworker training.

Appendix 1: Survey given for both CASE #1 and CASE #2

• List all systems (agencies, organizations) currently involved in this case:
• List any additional systems likely to become involved as the case investigation progresses:
• Briefly state the role of each system responding to this case scenario:
• List all potential evidence for the investigation of this case:
• List all factors in this case that contribute to risk of child maltreatment:
• List all factors in this case that may act as a buffer to protect children from maltreatment:
• List all possible forms of victimization based on initial case information:
• I am a current CAST student and I have completed CAST 301, 401, 402 and 499 (internship).
• I graduated in _____________ (insert graduation year) with a minor in CAST.
• i. I am a (circle one): supervisor; case worker
• ii. I work in (circle one): investigations; treatment; foster care; other_______________

Please circle gender option

• My gender is: Male Female

(Categories from APSAC Handbook, Chapter 3 along with CAC and Family)

• Child Protective Services
• Law Enforcement
• Health Care/Medical
• Mental Health/Therapy
• Legal (attorneys, courts, GALs)
• Education/Child Care/Other Community-based providers
• b. List any additional systems likely to become involved as the case investigation progresses:
• Child Protective Service.
• Law Enforcement.
• Health Care/Medical.
• Mental Health/Therapy.
• Legal (attorneys, courts, GALs).
• Education/Child Care/Other Community-based providers.

(open coding)

CASE Scenario (polyvictimization)

• 911 call tape
• Photographs
• Statements (neighbor, mother, father, 7yo child)
• Reports (EMS, ER/other hospital/forensic medical, CAC)
• Physical evidence at scene (list)

CASE Scenario (sexual abuse)

• Registration records at campground
• Witness who may have seen/heard something at campground
• Incriminating statements grandfather made to others referencing the camping trip
• Physical evidence (photos of weekend, fish in freezer, receipts for purchases, fishing license, fishing equipment, etc)
• Semen stains on sleeping bag, tent, boy’s or grandfather’s clothing

(Using Factors from CDC – code for total # identified)

Individual Risk Factors

• Children younger than 4 years of age
• Special needs that may increase caregiver burden (e.g., disabilities, mental retardation, mental health issues, and chronic physical illnesses)
• Parents’ lack of understanding of children’s needs, child development and parenting skills
• Parents’ history of child maltreatment in family of origin
• Substance abuse and/or mental health issues including depression in the family
• Parental characteristics such as young age, low education, single parenthood, large number of dependent children, and low income
• Non-biological, transient caregivers in the home (e.g., mother’s male partner)
• Parental thoughts and emotions that tend to support or justify maltreatment behaviors

Family Risk Factors

• Social isolation
• Family disorganization, dissolution, and violence, including intimate partner violence
• Parenting stress, poor parent-child relationships, and negative interactions

Community Risk Factors

• Community violence
• Concentrated neighborhood disadvantage (e.g., high poverty, residential instability, high unemployment rates, high density of alcohol outlets), and poor social connections.

Risk and Protective Factors

• b. List all factors in this case that may act as a buffer to protect children from maltreatment:

Family Protective Factors

• Supportive family environment and social networks (supported by research)
• Nurturing parenting skills
• Stable family relationships
• Household rules and child monitoring
• Parental employment
• Adequate housing
• Access to health care and social services
• Caring adults outside the family who can serve as role models or mentors

Community Protective Factors

• Communities that support parents and take responsibility for preventing abuse

(# of victimizations identified)

CASE Scenario (poly-victimization)

• Child neglect by caregiver
• Child physical abuse by caregiver
• Child sexual abuse by caregiver
• Child psychological/emotional abuse
• Child witness to violent crime
• Child exposure to pornography
• Intimate partner violence
• Adult psychological/emotional abuse
• Animal abuse
• Child sexual abuse.
• Child exposure to pornography.

Compliance with Ethical Standards

On behalf of all authors, the corresponding author states that there is no conflict of interest.

The University of South Carolina Institutional Review Board (USC IRB) has determined that the referenced research study is not subject to the Protection of Human Subject Regulations.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

• Adams J, Starling SP, Frasier LD, Palusci VJ, Shapiro RL, Finkel M, Botash A. Diagnostic accuracy in child sexual abuse medical evaluation: Role of experience, training, and expert case review. Child Abuse & Neglect. 2012; 36 :383–392. doi: 10.1016/j.chiabu.2012.01.004. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Bartholomew, I., Knox, M., Dynes, M., Hunter, K., & Gnanasambanthan, Y. (2018). Impact of education about physical punishment of children on the attitudes of future physicians. Manuscript submitted for publication .
• Botash AS. From curriculum to practice: Implementation of the child abuse curriculum. Child Maltreatment. 2003; 8 (4):239–241. doi: 10.1177/1077559503257960. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Champion KM, Shipman K, Bonner BL, Hensley L, Howe AC. Child maltreatment training in doctoral programs in clinical, counseling, and school psychology: Where do we go from here? Child Maltreatment. 2003; 8 :211–217. doi: 10.1177/1077559503254139. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Dichter ME, Teitelman A, Klusaritz H, Maurer DM, Cronholm PF, Doubeni CA. Trauma-informed care training in family medicine residency programs: Results from a CERA survey. Family Medicine. 2018; 50 (8):617–622. doi: 10.22454/FamMed.2018.505481. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Felitti VJ, Anda RF. The relationship of adverse childhood experiences to adult medical disease, psychiatric disorders and sexual behavior: Implications for healthcare. In: Lanius RA, Vermeten E, Pain C, editors. The impact of early life trauma on health and disease: The hidden epidemic. Cambridge: Cambridge Medicine; 2010. p. 77. [ Google Scholar ]
• Flaherty EG, Sege R, Price LL, Christoffel KK, Norton DP, O’Conner KG. Pediatrician characteristics associated with child abuse identification and reporting: Results from a national survey of pediatricians. Child Maltreatment. 2006; 11 (4):361–369. doi: 10.1177/1077559506292287. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Jenny C, Hymel KP, Ritzen A, Reinert SE, Hay TC. Analysis of missed cases of abusive head trauma. JAMA. 1999; 281 (7):621–626. doi: 10.1001/jama.281.7.621. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Johnson L. An innovative approach to providing collaborative education to undergraduate students in the area of child maltreatment. Journal of Interpersonal Care. 2015; 29 (3):271–272. doi: 10.3109/13561820.2014.947361. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Kenny MC, Abreu RL. Training mental health professionals in child sexual abuse: Curriculum guidelines. Journal of Child Sexual Abuse. 2015; 24 :572–591. doi: 10.1080/10538712.2015.1042185. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Knox M, Pelletier H, Vieth V. Educating medical students about adolescent maltreatment. International Journal of Adolescent Medicine and Health. 2013; 25 (3):301–308. doi: 10.1515/ijamh-2013-0066. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Martin J. Child sexual abuse images online: Implications for social work training and practice. British Journal of Social Work. 2016; 46 :372–388. doi: 10.1093/bjsw/bcu116. [ CrossRef ] [ Google Scholar ]
• Osgood AK. Lessons learned from student surveys in a child advocacy studies (cast) program. Journal of Child & Adolescent Trauma. 2017; 10 :261–266. doi: 10.1007/s40653-016-0087-y. [ CrossRef ] [ Google Scholar ]
• Pelletier HL, Knox M. Incorporating child maltreatment training into medical school curricula. Journal of Child & Adolescent Trauma. 2017; 10 (3):267–274. doi: 10.1007/s40653-016-0096-x. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Salter AC. Predators: Pedophiles, rapists, and other sex offenders 2. New York: Basic Books; 2003. [ Google Scholar ]
• Turner HA, Finkelhor D, Omrod R. Poly-victimization in a national sample of children and youth. American Journal of Preventive Medicine. 2010; 38 (3):323–330. doi: 10.1016/j.amepre.2009.11.012. [ PubMed ] [ CrossRef ] [ Google Scholar ]
• United States Department of Justice, Attorney General’s Task Force on Children Exposed to Violence. (2012). Report of the Attorney General’s Task Force on Children Exposed to Violence 5 . Retrieved from http://www.justice.gov/defendingchildhood/ . Last viewed February 18, 2019.
• Vieth V. Unto the third generation: A call to end child abuse in the United States within 120 years. Journal of Aggression, Maltreatment & Trauma. 2006; 12 :5–54. doi: 10.1300/J146v12n03_02. [ CrossRef ] [ Google Scholar ]
• Vieth, V. (2013). The view from the trenches: Recommendations for improving South Carolina’s response to child sexual abuse based on insight from frontline child protection professionals . Published as part of the “silent tears” assessment of the South Carolina child protection system. Retrieved from Gundersen health system: http://www.gundersenhealth.org/ncptc/publications-resources/silent-tears . Last visited February 18, 2019.
• Vieth, V., Goulet, B., Knox, M., Parker, J., Johnson, L., Steckler-Tye, K., & Cross, T. (2019). Child advocacy studies (CAST): A national movement to improve the undergraduate and graduate training of child protection professionals . Mitchell Hamline Law Review (In press).
• Wood JN, French B, Song L, Feudtner C. Evaluation for occult fractures in injured children. Pediatrics. 2015; 136 (2):232–240. doi: 10.1542/peds.2014-3977. [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Woodtli AM, Breslin ET. Violence-related content in the nursing curriculum: A follow-up national survey. Journal of Nursing Education. 2002; 41 :340–359. [ PubMed ] [ Google Scholar ]

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