Unemployment and child abuse.

The employment state of men living in the homes of children at the time that child abuse was diagnosed was determined. The series included a wide range of abuse, including non-accidental injury, failure to thrive, neglect, and emotional deprivation. Two cohorts of children seen during 1974-9 and 1980-5 were compared; these periods were chosen because a large increase in unemployment began in Sheffield in 1980. Although the proportion of the men without work was significantly increased during the second period, this increase could not be ascribed to the rise in either long term or short term unemployment among those who had previously been in regular employment. It was accounted for by a rise in the proportions of single parent families and families in which the resident man had never had regular employment. This may reflect an increase in pregnancies among young mothers. There was no evidence to support the belief that the loss of a job in otherwise stable families leads to an increase in child abuse.     

Unusual injury? Recent injury in normal children and children with suspected non-accidental injury.

Four hundred normal children aged between 2 weeks and 11 years were examined to determine the prevalence and site of recent injury of any type. There was evidence of injury in 37% with a steady increase in prevalence to 60% by the end of the third year of life. Bruising of the hands and feet and of the lower legs was the most frequent type of injury. Head and facial injuries were most common between 18 months and 3 years (17% of children) but were rare at other ages. Injury to the lumbar region was unusual before 5 years but was present in 14% of children of school age. In 84 children of similar age where non-accidental injury was proved or suspected a different pattern of injury was present. Sixty per cent had injuries to the head and face; this increase in prevalence was seen at all ages. These children also had more frequent injuries in the lumbar region, particularly before the age of 5 years.     

Attendance of general practitioners at child protection case conferences.

OBJECTIVE--To investigate general practitioners'' attendance at and views on child protection conferences and their confidence in dealing with sexual abuse in children. DESIGN--Anonymous postal questionnaire sent to all general practitioners in Tower Hamlets and review of consecutive case conferences held by social services for three months in 1989. SETTING--Tower Hamlets health district. SUBJECTS--91 general practitioners, 56 of whom (62%) responded. MAIN OUTCOME MEASURES--Number of conferences attended, reasons for non-attendance, and reported confidence in dealing with sexual abuse. RESULTS--General practitioners estimated that 202 child protection conferences had been held in 1989 on their patients and that they had attended 85 of these. Information from social services for three months suggested that general practitioners had attended only nine of the 114 conferences reviewed. Timing of the conference was the most important reason for non-attendance. All respondents wanted access to the minutes of these conferences irrespective of their own attendance. Most general practitioners were very or moderately confident of their ability to detect child sexual abuse and non-accidental injury and to communicate with the family. CONCLUSION--More effort should be made to ensure that general practitioners are notified of case conferences and that the timing and location of conferences is compatible with their other commitments.     

Patterns of fractures in accidental and non-accidental injury in children: a comparative study.

The incidence and pattern of fractures in children who had been abused were compared with those of fractures sustained by children of similar ages in whom abuse had been excluded. From 1976 to 1982 there were 35 children with fractures resulting from child abuse, and all were aged under 5. Of the 826 children in the control group, seen from January to June 1981, 85% were aged over 5. Abused children were much more likely to have multiple fractures (p less than 0.001) and bruising of the head and neck (p less than 0.001). Fractures of the ribs were common in children who had been abused, and their presence, in the absence of major chest trauma, strongly suggested that abuse was occurring. Injuries to the long bones were invariably spiral or oblique fractures or subperiosteal new bone formation--both "gripping or twisting" injuries. Spiral fracture of the humeral shaft was significantly more common (p less than 0.001) in the group of abused children. Classic metaphyseal chip fractures were uncommon. One child in eight aged under 18 months who sustains a fracture may be a victim of child abuse.     

Non-accidental injury in children: what we do in Derby.

A scheme for dealing with cases of non-accidental injury in children in the Derby clinical area has been operating since 1971. A stable team of doctors, policemen, and social workers deal with each case. The parents are told at once that battering is suspected, and the police and social services department co-operate closely in establishing the facts, supporting the family, and protecting the child. A psychiatric assessment of the parents may help social workers decide on the long-term care of the child, and the forensic physician is invaluable if the case has to go to court. The team has made three recommendations about prevention and management of these cases: a specialist social service team should be set up to deal with these children and regain the skills and knowledge lost when children''s departments were abolished in 1971; babies should be routinely weighed naked in infant welfare clinics; and juvenile courts should be able to order a psychiatric report on the parents in care proceedings.     

Does home visiting prevent childhood injury? A systematic review of randomised controlled trials.

OBJECTIVE--To quantify the effectiveness of home visiting programmes in the prevention of child injury and child abuse. DESIGN--Systematic review of 11 randomised controlled trials of home visiting programmes. Pooled odds ratios were estimated as an inverse variance weighted average of the study specific odds ratios. SETTING--Randomised trials that were available by April 1995. SUBJECTS--The trials comprised 3433 participants. RESULTS--Eight trials examined the effectiveness of home visiting in the prevention of childhood injury. The pooled odds ratio for the eight trials was 0.74 (95% confidence interval 0.60 to 0.92). Four studies examined the effect of home visiting on injury in the first year of life. The pooled odds ratio was 0.98 (0.62 to 1.53). Nine trials examined the effect of home visiting on the occurrence of suspected abuse, reported abuse, or out of home placement for child abuse. Because of the potential for bias in outcome reporting in these studies, pooled effect estimates were not calculated. CONCLUSIONS--Home visiting programmes have the potential to reduce significantly the rates of childhood injury. The problem of differential surveillance for child abuse between intervention and control groups precludes the use of reported abuse as a valid outcome measure in controlled trials of home visiting.     

Predicting child abuse: signs of bonding failure in the maternity hospital.

Fifty children referred to the Park Hospital because of actual or threatened abuse were compared with 50 controls born at the same maternity hospital. Five factors were significantly more common in the abused group than among their controls: (a) mother aged under 20 at birth of first child, (b) evidence of emotional disturbance, (c) referral of family to hospital social worker, (d) baby''s admission to special care baby unit, (e) recorded concern over the mother''s ability to care for child. Thirty-five of the abused group had two or more of these factors compared with only five of the control group. As these data were collected from information recorded routinely at the maternity hospital, it is possible to identify most abusing families when the child is born. Such identification must lead to a comprehensive assessment of each case followed by constructive preventive action.     

Burn injuries inflicted on children or the elderly: a framework for clinical and forensic assessment

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the difference between battery and assault in U.S. law and the concepts of the phrase "child abuse" and "elder abuse." 2. Understand that state statutes vary and can define abuse narrowly or with great specificity, and that either definition has inherent problems for physicians treating victims of abuse and neglect. 3. Know where to find the state-specific legal criteria for child or elder abuse and neglect, along with the corresponding standards for mandatory reporting and physician accountability. 4. Understand the relevant law regarding physician-patient privilege and the repercussions of incorrect but good faith reporting and of failing to report suspected abuse or neglect of children or the elderly. 5. Understand that there are no pathognomic signs for inflicted burn injury. 6. Clinically assess burned pediatric or elderly patients within a framework that will minimize the risk of missing or inappropriately suspecting injuries that stem from abuse or neglect. SUMMARY: This article deals with burns inflicted on children and the elderly, two particularly vulnerable societal groups. Though inflicted burning is a relatively rare method of inflicting physical abuse, failure to diagnose it has far-reaching ramifications. These injuries pose both medical and forensic problems for physicians, along with unique ethical dilemmas. This article is a collaboration between surgeons and lawyers providing a holistic, workable approach to the management of inflicted burn injury. The authors first describe the legal considerations that must be appreciated by U.S. physicians, then they suggest a rational and balanced clinical approach to the assessment of burn injuries that may have been inflicted intentionally or negligently on children and the elderly.     

Expected Consequences of Disclosure Revealed in Investigative Interviews with Suspected Victims of Child Sexual Abuse

The current study explored the expected consequences of disclosure discussed by 204 5- to 13-year-old suspected victims of child sexual abuse during the course of investigative interviews conducted using the NICHD Investigative Interview Protocol. Expected consequences were mentioned in nearly half of all interviews, with older children and those alleging multiple incidents more likely to do so. Most consequences were mentioned spontaneously by children and most consequences were expected to befall the children themselves. The most common consequences were physical harm and feeling negative emotions for the child and jail/legal consequences for the suspect. Expecting consequences for the child or another family member were associated with delaying disclosure, but expecting consequences for the suspect was not related to delay. Results provide insight into developmental and socio-motivational influences on children's disclosure of negative events and are of considerable practical interest to legal and clinical professionals who must interview, treat, and evaluate children alleging sexual abuse.     

Generalising the Cinderella Effect to unintentional childhood fatalities

We investigated whether the repeatedly demonstrated increase in risk of child abuse and infanticide associated with living with a step parent generalized to cases of unintentional childhood fatal injury, the most common cause of death in children across the developed world. Reports were drawn from the Australian National Coroners' Information System (NCIS) on all cases of intentionally (n=32) and unintentionally (n=319) produced fatal injury in children aged under 5 years between 2000 and 2003. Even when using the most conservative possible analytic approach, in which all cases in which family type was unclear were classified as being from an ‘intact biological family’, step children under 5 years of age were found to be at significantly increased risk of unintentional fatal injury of any type, and of drowning in particular. Children from single-parented families were generally not found to be at significantly increased risk of intentional or unintentional fatal injury, while children who lived with neither of their biological parents were at greatest risk overall for fatal injury of any type.     

Malnutrition in infants receiving cult diets: a form of child abuse.

Severe nutritional disorders, including kwashiorkor, marasmus, and rickets, were seen in four children and were due to parental food faddism, which should perhaps be regarded as a form of child abuse. All disorders were corrected with more normal diets and vitamin supplements. In view of the potentially serious consequences of restricted diets being fed to children, families at risk should be identified and acceptable nutritional advice given. When children are found to be suffering from undernutrition due to parental food faddism a court order will normally be a necessary step in providing adequate treatment and supervision.     

Respiratory consultations in asthmatic compared with non-asthmatic children in general practice.

In a retrospective study we found that before a diagnosis of asthma had been made children with asthma had consulted their general practitioner more often with respiratory symptoms than children who were non-asthmatic under the age of four. In the second, third, and fourth years the number of consultations differed significantly between the two groups. Asthma should be suspected in any child who presents often with respiratory symptoms. This should lead to earlier diagnosis in most cases.     

The Long-Term Health Consequences of Child Physical Abuse,Emotional Abuse,and Neglect: A Systematic Review and Meta-Analysis

Background

Child sexual abuse is considered a modifiable risk factor for mental disorders across the life course. However the long-term consequences of other forms of child maltreatment have not yet been systematically examined. The aim of this study was to summarise the evidence relating to the possible relationship between child physical abuse, emotional abuse, and neglect, and subsequent mental and physical health outcomes.

Methods and Findings

A systematic review was conducted using the Medline, EMBASE, and PsycINFO electronic databases up to 26 June 2012. Published cohort, cross-sectional, and case-control studies that examined non-sexual child maltreatment as a risk factor for loss of health were included. All meta-analyses were based on quality-effects models. Out of 285 articles assessed for eligibility, 124 studies satisfied the pre-determined inclusion criteria for meta-analysis. Statistically significant associations were observed between physical abuse, emotional abuse, and neglect and depressive disorders (physical abuse [odds ratio (OR) = 1.54; 95% CI 1.16–2.04], emotional abuse [OR = 3.06; 95% CI 2.43–3.85], and neglect [OR = 2.11; 95% CI 1.61–2.77]); drug use (physical abuse [OR = 1.92; 95% CI 1.67–2.20], emotional abuse [OR = 1.41; 95% CI 1.11–1.79], and neglect [OR = 1.36; 95% CI 1.21–1.54]); suicide attempts (physical abuse [OR = 3.40; 95% CI 2.17–5.32], emotional abuse [OR = 3.37; 95% CI 2.44–4.67], and neglect [OR = 1.95; 95% CI 1.13–3.37]); and sexually transmitted infections and risky sexual behaviour (physical abuse [OR = 1.78; 95% CI 1.50–2.10], emotional abuse [OR = 1.75; 95% CI 1.49–2.04], and neglect [OR = 1.57; 95% CI 1.39–1.78]). Evidence for causality was assessed using Bradford Hill criteria. While suggestive evidence exists for a relationship between maltreatment and chronic diseases and lifestyle risk factors, more research is required to confirm these relationships.

Conclusions

This overview of the evidence suggests a causal relationship between non-sexual child maltreatment and a range of mental disorders, drug use, suicide attempts, sexually transmitted infections, and risky sexual behaviour. All forms of child maltreatment should be considered important risks to health with a sizeable impact on major contributors to the burden of disease in all parts of the world. The awareness of the serious long-term consequences of child maltreatment should encourage better identification of those at risk and the development of effective interventions to protect children from violence. Please see later in the article for the Editors'' Summary     

Fetal alcohol spectrum disorders among children in a Brazilian orphanage

Background: The objective was to investigate the frequency of fetal alcohol spectrum disorders (FASD) and ophthalmologic anomalies in orphanage children in Brazil. Methods: A prospective study was performed on 94 children living in an orphanage in Brazil. The children were examined by a multidisciplinary team consisting of specialists in pediatrics, neurology, psychology, neuropsychiatry, and ophthalmology. Results: The main reasons for living in the orphanage, in 61% of the children, were negligence, child abuse, and abandonment. Of all the children studied, 50% had mothers with known alcohol abuse and 47% had one or more diagnoses of neurodevelopmental/behavioral and/or cognitive deficits. General developmental delay was found in 18%, intellectual disability in 3%, cognitive impairment in 27%, attention‐deficit/hyperactivity disorder in 14%, and autism in 3%. Altogether 17% had FASD, comprising three children with fetal alcohol syndrome (FAS), six with partial FAS, and seven with alcohol‐related neurodevelopmental disorder. 16% had ophthalmological findings such as poor vision, strabismus, and dysmorphology of the optic nerves. Twenty‐eight children (30%) were adopted from the orphanage; of these, six had FASD (two FAS, three partial FAS, one alcohol‐related neurodevelopmental disorder), five had attention‐deficit/hyperactivity disorder, and eight had developmental delay. Conclusion: Nearly half of the children living in the orphanage had neurodevelopmental disorders and a considerable number showed signs of damage from prenatal alcohol exposure. A broader look at the problem of FASD in Brazil and other South American countries is desirable to document the burden of disease and provide data for targeting prevention efforts. Birth Defects Research (Part A) 103:178–185, 2015. © 2014 Wiley Periodicals, Inc.     

TUBERCULOUS BRONCHITIS IN CHILDREN

Of 63 children with primary pulmonary tuberculosis who were examined bronchoscopically without particular regard for the usual criteria for the procedure, 18 (28.5 per cent) had visible tuberculous bronchitis.Certain endobronchial lesions resolved spontaneously, others responded to bronchoscopic treatment, and still others persisted despite all efforts.X-ray observations and clinical signs were of limited value in determining prior to bronchoscopy which child would have visible bronchial disease.Bronchoscopy is essential for both diagnosis and treatment of these lesions.Tuberculous bronchitis should be suspected whenever a child who is being treated for pulmonary tuberculosis by conservative means does not improve.     

Child sexual abuse sequelae and body-image surgery

Child sexual abuse is common and damages the body image. Child sexual abuse survivors may request body-image surgery. Seven patients are described in whom child sexual abuse sequelae complicated body-image surgery. Two patients viewed their surgeons as similar to sexual abusers. Yet two patients were clearly, and two possibly, helped by the surgery. Surgeons can detect and manage such patients by (1) having a child sexual abuse therapist on hand for consultation, (2) adding "abuse" to the medical history form, (3) recommending to known or suspected child sexual abuse patients preoperative therapy or a self-help book, (4) obtaining specific permission for any body contact, (5) stating belief in abuse, if revealed, (6) explaining the surgery in unusual detail, (7) recognizing the high-risk child sexual abuse groups, and, (8) declining to operate on the angry child sexual abuse patient.     

Characteristics and Trends of Pediatric Traumatic Brain Injuries Treated at a Large Pediatric Medical Center in China, 2002–2011

Background

Pediatric traumatic brain injuries (TBIs) have not been well studied in China. This study investigated characteristics and trends of hospitalized TBIs sustained by Chinese children.

Methods and Findings

We analyzed 2002–2011 hospitalized TBI patients (0–17 years of age) treated at a large pediatric medical center in China. TBIs were defined using the International Classification of Diseases, Tenth Revision (ICD-10) codes. We examined age patterns across external causes of TBIs. We reported the trend of traffic-related TBIs for each year from 2002 to 2011. Of 4,230 TBI patients, 67.1% (95% CI: 65.4%–68.8%) were city residents and 28.8% (95% CI: 26.3%–31.3%) came from rural villages. Males had disproportionately more TBIs than females (65.2% vs. 34.8%). Falls, struck by/against objects, and traffic collisions were the top three external causes of TBIs for all age groups. Falls were the leading cause of TBI for all ages but peaked at 2 years of age. There were 125 TBIs in 0–2 year olds (5.9% of all TBIs in this age group) that were caused by suspected child abuse. Suspected child abuse was significantly more likely to occur in 0–1 year olds. The proportion of traffic -related TBIs increased significantly from 12.99% in 2002 to 19.68% in 2008 but dropped each subsequent year until it reached a level of 8.91% in 2011.

Conclusions

Our study confirms that falls, struck by/against objects and traffic collisions are the top external causes of TBIs in Chinese children. When compared with national data from the developed countries, gender patterns are similar, but the ranking of external causes is different. This is the first study to highlight the important role of suspected child abuse in causing TBIs in infants in China. TBIs caused by child abuse warrant further research and government attention as a social and medical problem in China.     

Vagus nerve stimulation in children with mitochondrial electron transport chain deficiencies

We retrospectively investigated outcome data for vagus nerve stimulation (VNS) in children less than 12 years of age with intractable seizures and mitochondrial disease. Five children with a mitochondrial disease, due to electron transport chain deficiency, were studied. Information was collected from clinic visits prior to, and subsequent to, VNS implantation. Data were collected by type and frequency of seizures, encephalogram and neuroimaging findings, and medication history. Four of the children had predominantly myoclonic seizures, while the other child had focal seizures with secondary generalization and myoclonic seizures. All five children did not have significant reduction in seizure frequency with VNS. VNS may not be an effective method to control myoclonic seizures in children with electron transport chain disorders.     

Alcohol and the fetus in the west of Scotland.

Forty children with the fetal alcohol syndrome were identified in the west of Scotland. All were growth retarded and had abnormal facial features, and all those who were tested were found to have neurological or developmental abnormalities. Two children died of associated physical defects. Most of the mothers were socially deprived, and all had drunk heavily while pregnant. Three women had subsequently died. These findings provide clear evidence that in the west of Scotland maternal alcohol abuse during pregnancy is a significant cause of morbidity and mortality in children.