Child abuse and child abuse studies in Japan

Medical research on child abuse has a short history of only 20 years. However, the social and familial changes that have occurred since the Second World War have resulted in an increasing number of abused children throughout Japan. Reported cases represent only the tip of the iceberg, with many cases being ignored. This article discusses the history, definition, incidence, and social, familial, and psychopathology factors in the etiology of child abuse based on clinical experience and research surveys undertaken during the past 20 years. Suggestions for improving child abuse preventive and reactive services are also made.     

Uro-genital bleeding in pre-menarcheal girls: dilemmas of child abuse

Uro-genital bleeding in pre-menarcheal girls always raises concerns regarding child abuse. There are serious social issues involved; however, before labeling it as sexual abuse, all efforts must be made to rule out an organic pathology. We recently encountered two young girls of Afro-Caribbean origin who presented with vaginal bleeding with concerns from referring physicians about child/sexual abuse. On examination both had a rare condition of urethral prolapse. One of them underwent four-quadrant excision and the other was treated conservatively with urethral catherization.     

Intracranial bleeding from child abuse: The value of skull radiographs

Two infants with intracranial bleeding are described. Each had extensive evaluations aimed at uncovering vascular anomalies or bleeding diatheses. Plain skull radiographs that demonstrated fractures led to the correct diagnosis of child abuse. This report serves to emphasize the value of the plain skull radiograph in the evaluation of infants with intracranial bleeding.     

Child abuse as a result of enuresis

BACKGROUND: Enuresis is a frequent manifestation with important psychological and social consequences. The aim of the present study was to describe the types of child abuse as a result of enuresis, and to investigate the association of child abuse. METHODS: A cross-sectional field study was conducted between March 2001 and August 2001 in the 5-17-year-old age group, to identify risk factors and prevalence of enuresis in the province of Trabzon, Turkey. A face-to-face interview with 889 mothers was carried out. In the questionnaire, the existence, frequency, and risks factors of enuresis were questioned in detail and the parental reactions to the child's enuresis were widely investigated. RESULTS: The prevalence of nocturnal enuresis was 17.9% in the 5-17-year-old age group. It was also found out that of 154 mothers, 86.4% (n = 133) were involved in child abuse of different types. It was found that 40.6% of children who were abused as a result of their enuresis were neglected medically, 42.1% were spanked and 12.8% were beaten. CONCLUSIONS: The high prevalence of enuresis among Turkish children leads to a high frequency of neglect. The high frequency of other types of child abuse in Turkey can be taken as being punishment.     

Child abuse viewed through the hot-line in Osaka,Japan

Cases of child abuse identified by a hot-line telephone service and by a survey of health and welfare agencies are reported. Many consultations to the telephone hot-line were from mothers concerned about maltreating their own children. In such cases, the extent of abuse was often mild to moderate, and many of those mothers were troubled about child care in the relatively segregated context of the nuclear family. In only a few cases did the callers indicate that the children's life was in danger. In the administrative survey, however, deaths occurred in 5% of the cases, and the abused children frequently had physical and psychological symptoms. There were also more frequent and more serious family problems in the administrative survey compared to the telephone consultation cases. The findings of these surveys suggest that many children and parents are suffering from child abuse in Japan, that many cases are currently not being identified by health and welfare agencies, and that a wide range of measures, from protection of severely abused children to prevention of abuse, are necessary.     

Child sexual abuse: recognition and response when there is a suspicion or allegation

Child sexual abuse is a clear violation of children's rights with known lifelong devastating consequences. It occurs across all ages, sexes and cultures. Cases are underreported and may not be disclosed at first due to its secretive and hidden nature. It is clear that children do try to disclose but are not always heard or believed. In this paper we delve deeper into the recognition and response to suspected cases of child sexual abuse and the importance of working within a multidisciplinary team to best safeguard the victims. We emphasise the importance of asking questions in a direct, empathic and developmentally appropriate manner, such that the child feels believed and supported. The physical and behavioural changes are described in suspected cases and possible differential diagnoses. We propose a holistic model to the management and prevention of child sexual abuse based on the ecological approach to child maltreatment.     

Child abuse and neglect and the brain--a review

Developmental psychology and the study of behaviour and emotion have tended to be considered in parallel to the study of neurobiological processes. This review explores the effects of child abuse and neglect on the brain, excluding nonaccidental injury that causes gross physical trauma to the brain. It commences with a background summary of the nature, context, and some deleterious effects of omission and commission within child maltreatment. There is no post-maltreatment syndrome, outcomes varying with many factors including nature, duration, and interpersonal context of the maltreatment as well as the nature of later intervention. There then follows a section on environmental influences on brain development, demonstrating the dependence of the orderly process of neurodevelopment on the child's environment. Ontogenesis, or the development of the self through self-determination, proceeds in the context of the nature-nurture interaction. As a prelude to reviewing the neurobiology of child abuse and neglect, the next section is concerned with bridging the mind and the brain. Here, neurobiological processes, including cellular, biochemical, and neurophysiological processes, are examined alongside their behavioural, cognitive, and emotional equivalents and vice versa. Child maltreatment is a potent source of stress and the stress response is therefore discussed in some detail. Evidence is outlined for the buffering effects of a secure attachment on the stress response. The section dealing with actual effects on the brain of child abuse and neglect discusses manifestations of the stress response including dysregulation of the hypothalamic-pituitary-adrenal axis, and parasympathetic and catecholamine responses. Recent evidence about reduction in brain volume following child abuse and neglect is also outlined. Some biochemical, functional, and structural changes in the brain that are not reflections of the stress response are observed following child maltreatment. The mechanisms bringing about these changes are less clearly understood and may well be related to early and more chronic abuse and neglect affecting the process of brain development. The behavioural and emotional concomitants of their neurobiological manifestations are discussed. The importance of early intervention and attention to the chronicity of environmental adversity may indicate the need for permanent alternative caregivers, in order to preserve the development of the most vulnerable children.     

Electronic Health Record Tools to Identify Child Maltreatment: Scoping Literature Review and Key Informant Interviews

ObjectiveTo prevent missed cases and standardize care, health systems are beginning to implement EHR-based screens (EHR-CA-S) and clinical decision supports systems (EHR-CA-CDSS) for the identification and management of child maltreatment. This study aimed to 1) document the existing research evidence on the performance of EHR-CA-S and EHR-CA-CDSS and 2) examine clinical perspectives regarding the use of such tools and factors that affect uptake.MethodsWe searched MEDLINE, Embase, EBSCO, Scopus, and CINAHL databases for English language articles published prior to November 2021 that describe and/or evaluated an EHR-CA-S and/or EHR-CA-CDSS involving 0 to 18-year olds. We performed semistructured interviews with 20 individuals who have experience in identifying, evaluating, and/or treating child maltreatment and/or conducting research on these topics.ResultsOur search identified 574 articles; 16 met inclusion criteria. Studies examined screening, alerts and triggers, and quality improvement. None evaluated long-term clinical outcomes. Sensitivity ranged from 0.14 to 1.00, specificity from 0.865 to 1.00, positive predictive value from 0.03 to 1.00 and negative predictive value from 0.55 to 1.00. A variety of EHR-CA-S and/or EHR-CA-CDSS have been implemented at institutions in our sample. Interviewees cited missed cases, policy requirements, and the lack of standardization of care as impetuses for adopting these tools, yet expressed concerns regarding insufficient evidence, bias, and time-intensiveness of implementation.ConclusionsInterviewees and the literature agree that current evidence does not support adoption of a particular CA-S or CA-CDSS. Further refinement and research on EHR-CA-S and EHR-CA-CDSS is necessary for these tools to be feasibly implemented and sustained, reliable for clinical practice, and not cause any unintentional harms.     

892名卫校女生儿童期性虐待经历及其对心理健康的影响

目的 了解卫校女生儿童时期性虐待发生情况,探讨性虐待经历对学生心理健康的影响,为卫生、教育及其他相关部门制定预防儿童性虐待对策提供参考依据。方法 用自填式问卷,对一所卫校892名女生就有关儿童时期受性虐待经历进行不记名回顾性调查。结果 在被调查的892名女生中,有25．6％(2128／892)报告16岁以前经历过或非身体接触或身体接触的性虐待(身体接触的性虐待中包括被试图性交和被强行性交)。其中129人经历过身体接触的性虐待,占14．5％。52．6％的儿童首次性虐待经历发生在12岁及以下。与没有儿童期性虐待经历的女生比较,有儿童期性虐待经历的女生抑郁情绪量表得分高;健康状况自我感觉评价得分低;有性交行为比例高;在调查的近12个月里有自杀意念或自杀企图、参与或卷入斗殴、以及在调查近30天里曾吸烟饮酒的发生率均明显偏高。结论 儿童性虐待问题在我国并非少见。儿童期性虐待经历是影响受害者心理健康的一个重要因素。     

Child Sexual Abuse

ABSTRACT. Thirty-eight children, 0-17 years of age, suspected to have been sexually abused by a relative or an acquaintance were psychiatrically evaluated. The suspicions had developed in various ways: through accounts given by the child, through the child's contacts with a person suspected of having abused another child, through a witness or through conclusions drawn, for instance, from changes in behaviour or play patterns of the child. Genital fondling was the most common sexual act reported. The children usually described repeated abuse. The duration of the abuse situation was more than one year in the majority of the cases.     

Diagnostic findings in alleged sexual abuse: symptoms have no predictive value

AIMS: To describe demographic characteristics and trends, indications for referral and medical findings in children and young people seen for suspected sexual abuse. METHODS: Retrospective review of consecutive medical records over a 7-year period. RESULTS: A total of 2310 new patients were seen for concerns about sexual abuse and/or genital symptoms, resulting in 2162 genital examinations, of which 2134 were statistically analysed. The age ranged from 1 month to 17 years, with peaks at 3 and 14 years. Eighty-six percent were female. Most were referred by statutory authorities, with a marked reduction in referral numbers from 1997. Where a perpetrator was described, 97% were male and 92% were family members or friends. Medical findings diagnostic of sexual abuse were found in 130 cases (6%). Diagnostic findings were more likely to be found in adolescent girls. For the most part, physical symptoms were of no value in differentiating between those who had been sexually abused and those who had not. CONCLUSIONS: The demographics are concordant with the literature. The reduction in referrals may reflect changes in practice by statutory authorities. In pre-pubertal children, referrals were often made on the basis of physical symptoms, which have no predictive value in the diagnosis of sexual abuse.     

Rib fractures in infants: red alert! The clinical features, investigations and child protection outcomes

OBJECTIVE: To examine clinical features, investigation methods and outcomes of infants with rib fractures. METHODOLOGY: All infants aged 2 years or younger who presented over a 5-year period with documented rib fractures were identified from the medical records database of a tertiary referral paediatric hospital and data collected by retrospective chart review. Additional data regarding notifications and placements were obtained from the Department of Families Youth and Community Care, Queensland. RESULTS: Rib fractures were attributed to child abuse in 15 of 18 infants identified. The initial presentation in the abused infants was most often as a result of intracranial pathology and limb fractures. In four cases the rib fractures were incidental findings when abuse had not been suspected. Bone scintigraphy revealed eight previously undetected rib injuries in four cases. In three cases of abuse, the rib fractures were an isolated finding. Three of the infants with inflicted rib injuries were discharged home. In one such infant a significant re-injury occurred. Three returned home with implicated adults no longer in residence, and nine spent a mean period of 12 months in foster care. CONCLUSIONS: Rib fractures in infancy are usually caused by severe physical abuse. Accidental rib fractures are rare in infants and result from massive trauma. Rib fractures, multiple or single, may occur in isolation in abused infants. The implications of such injuries must be recognized to ensure appropriate, safe and consistent child protection outcomes. Bone scintigraphy is more sensitive than radiographs in the detection of acute rib fractures and should be performed in all cases of suspected infant abuse.     

Severe Child Abuse Presenting as Polymicrobial Bacteremia

ABSTRACT. Life-threatening polymicrobial bacteremia in a 71/2-year-old boy, was found to be caused by willful contamination of i.v. drips by the mother. The boy, as well as his diseased twin sister, had histories of long-lasting chronic otitis of unknown etiology. The importance of obvious pathologic psycho-social factors was overlooked, and diagnosis was only reached by close collaboration with clinical microbiologists.     

Differential diagnosis of child physical abuse: conditions that may be mistaken for child abuse

Child protection is one of the most difficult aspects of paediatric practice. Physical abuse is the commonest form of maltreatment identified by clinicians. Suspicious injuries are rarely accompanied by an admission of inflicted harm, even when this is the cause. Clinicians therefore must have a high index of suspicion and where injuries appear consistent with physical abuse or are inadequately explained they must follow safeguarding procedures. However, as for any clinical problem, there is a differential diagnosis to consider. Medical conditions can sometimes mimic signs suggestive of physical abuse. Other conditions can increase a child's vulnerability to specific injuries. In this article we discuss the differential diagnosis of bruising, fractures and head injuries which are the three commonest presenting features of physical abuse. Awareness of the differential diagnosis and appropriate assessment of the injured child can assist in reaching the correct diagnosis and therefore protect children from harm.     

Bruising and Physical Child Abuse

Bruising is one of the earliest, most common, and easily recognizable signs of physical child abuse and can signal escalating interpersonal violence within a household. Early detection of abuse through recognition of bruising coupled with appropriate intervention may help to prevent future and potentially more severe physical assaults. This article provides an overview of precise terminology and definitions, contusion pathology, development and appearance of bruises, characteristics of bruises suspicious for abuse, photographic documentation, techniques to help visualize bruising, conditions that may be confused with abusive bruising, and the difficulties encountered when attempting to estimate the age of bruises.     

Non-accidental fractures in infants: risk of further abuse

OBJECTIVES: To look for features of non-accidental fractures in infants aged under I year and assess the risk of subsequent morbidity and mortality. METHODOLOGY: A retrospective analysis of 99 children aged under 1 year who presented to the Mater Children's Hospital, Brisbane, between January 1990 and December 1993, and were found to have a fracture. The 99 infants were divided into non-accidental and accidental groups. Comparison was made between the two groups for age, sex and type of fracture. Deaths, subsequent injuries and child protection notifications until March 1997 were compared between groups. RESULTS: Of the 99 infants with fracture (64 males, 35 female), the skull and femur were the most prevalent sites of fracture. Twenty-six infants had fractures assessed as non-accidental. This group was younger but did not differ significantly in gender or site of fracture. Infants aged under 4 months had a significantly greater risk of their fracture being non-accidental (P = 0.0007). Subsequent substantiated child protection notifications occurred in nine of the non-accidental group and in one of the accidental group (P = 0.000001). There was no significant difference in the rate of subsequent notifications between those infants with abuse who were removed from their carers and those not removed. Subsequent injuries presenting to hospital occurred in 17 of the accidental group and three of the non-accidental group (P = 0.20). There were no deaths. CONCLUSION: Infants aged under 1 year with fractures have a high prevalence of abuse. The risk of abuse as cause for the fracture is greater in those aged under 4 months. Infants with non-accidental fractures have a high risk of further abuse even with intervention.