Interpreting fractures in child maltreatment

All paediatricians and health professionals working with young children need to be aware of the potential for child abuse to be a cause of physical injuries, such as fractures. Clinical experience, Serious Case Reviews and research show us that maltreatment should be kept in mind, in order for investigations to be carried out where appropriate and to prevent further harm. Whilst accidental fractures are common, fractures may also be the sentinel injury that alerts professionals to the possibility of child abuse, presenting clinically or detected as an occult injury on imaging for other reasons or when investigating a case of suspected maltreatment. The health professional evaluating a child with any fracture should be aware of features that raise the suspicion of abuse as a cause and be familiar with current recommendations for further investigations. This article outlines the current research concerning abusive fractures in children. It offers guidance on how to optimize radiological investigations and avoid common pitfalls in clinical practice.     

The epidemiology of child maltreatment

Child maltreatment is a significant worldwide problem, with consequences that can include impaired physical and mental health throughout life, and adverse social and occupational effects that carry a heavy economic and social burden. One estimate of cost to the US economy in 2007, for example, was over US$100bn. In middle- and low-income countries, there have been fewer studies of incidence and prevalence, and the economic and social costs are harder to estimate. It is very difficult to obtain full case ascertainment even in the most severe forms of child maltreatment, and even for fatal cases. In general, self-reporting and surveys identify higher rates of child maltreatment than data from sources relating to official notification. This paper reviews the epidemiology of child maltreatment from a practical perspective, with a focus on factors in the social environment, and the clinical history and examination, that predict an increased risk of child maltreatment.     

The relation between child death and child maltreatment

The death of a child is a sentinel event in a community, and a defining marker of a society's policies of safety and health. Child death as a result of abuse and neglect is a tragic outcome that occurs in all nations of the world. The true incidence of fatal child abuse and neglect is unknown. The most accurate incidence data of such deaths have been obtained from countries where multi-agency death review teams analyse the causes of child fatalities, as is done in the United States and Australia.     

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.     

Interpreting physical signs of child maltreatment: ‘grey cases’ and what is ‘reasonably possible’

There is a growing evidence-base for physical signs of child maltreatment. However, health professionals sometimes find themselves in situations that are not clear cut, particularly when there is one suspicious injury in an otherwise normal child in a family where there are no risk factors for maltreatment present. This paper highlights such situations and guides the clinician through uncertainty to a consideration of whether or not the explanation for an injury is reasonably possible. This will be done by discussing the location, configuration and patterns of injury arising from low level falls, stairway falls, climbing into the bathtub, pacifiers or bottles, and being bitten by another child; explanations often proffered for an injury.     

Cultural issues in child maltreatment

Aims: Waves of immigration from the latter half of the 20th century have changed the cultural and ethnic mix of major regions of the world. Dynamic multicultural societies now are a reality across the Western world. The relationship and influence of these diverse cultures to the understanding and identification of child abuse and neglect is challenging and complex. Health professionals working with children from culturally and linguistically diverse groups often find themselves with the challenge of exploring and resolving the tension between definitions of harm in child protection practice and various cultural and child‐rearing practices. In this paper, we set out ways of thinking about the influence of culture when approaching and dealing with the suspicion of child maltreatment. Methods: We will explore how culture shapes the experiences of childhood, child‐rearing practices, and identify common barriers in working with children and families from culturally diverse backgrounds when presenting with child maltreatment. We will use case examples from Europe and Australia to illustrate the real life challenges of working in the area of child maltreatment across cultures. We will review the scientific literature exploring the nexus between culture and child maltreatment, identifying the gaps in the literature and highlight areas for future research. Results: We suggest a model for dealing with cultural issues in child maltreatment that is culturally competent and respectful. Conclusions: The model for cultural competency in child health and child protective services incorporates four domains for advocacy and action – individual, professional, organisational and systemic.     

Chylothorax associated with child abuse

We report a case of right chylothorax associated with physical abuse in a 10‐month‐old boy who presented with respiratory decompensation. Chylothorax was improved by thoracic drainage and nutrition management, such as fasting followed by medium‐chain triglyceride milk. Chest computed tomography on admission showed bilateral old rib fractures. Accordingly, physical abuse was suspected. Chylothorax of unknown cause in infancy, especially in those with coexisting rib fractures, must be scrutinized for child abuse.     

Risk factors for recurrence of maltreatment: a systematic review

Background

Children who have been maltreated are at increased risk of further maltreatment. Competent identification of those at highest risk of further maltreatment is an important part of safe and effective practice, but is a complex and demanding task.

Aim

To systematically review the research base predicting those children at highest risk of recurrent maltreatment.

Methods

Systematic review of cohort studies investigating factors associated with substantiated maltreatment recurrence in children.

Results

Sixteen studies met the inclusion criteria. The studies were heterogeneous. A variety of forms of maltreatment were considered. Four factors were most consistently identified as predicting future maltreatment: number of previous episodes of maltreatment; neglect (as opposed to other forms of maltreatment); parental conflict; and parental mental health problems. Children maltreated previously were approximately six times more likely to experience recurrent maltreatment than children who had not previously been maltreated. The risk of recurrence was highest in the period soon after the index episode of maltreatment (within 30 days), and diminished thereafter.

Conclusions

There are factors clearly associated with an increased risk of recurrent maltreatment, and these should be considered in professional assessments of children who have been maltreated. A comprehensive approach to risk assessment, including but not solely based on these factors, is likely to lead to interventions which offer greater protection to children.     

Risk factors of parents abused as children: a mediational analysis of the intergenerational continuity of child maltreatment (Part I)

BACKGROUND: This study provides an exploration of factors implicated in the intergenerational cycle of child maltreatment. Families with newborns where at least one of the parents was physically and/or sexually abused as a child (AP families) were compared in terms of risk factors to families where the parents had no childhood history of victimization (NAP families). The mediational properties of risk factors in the intergenerational cycle of maltreatment were then explored. METHODS: Information was collected by community nurses as a part of the 'health visiting' service. Data was collated across 4351 families, of which 135 (3.1%) had a parent who self-reported a history of abuse in childhood. The health visitor visited each family at home when the child was 4 to 6 weeks of age to assess the presence of risk factors. RESULTS: Within 13 months after birth, 9 (6.7%) AP families were referred for maltreating their own child in comparison to 18 (.4%) NAP families. Assessments found a significantly higher number of risk factors for AP families. Mediational analysis demonstrated that the presence of three significant risk factors (parenting under 21 years, history of mental illness or depression, residing with a violent adult) provided partial mediation of the intergenerational continuity of child maltreatment, explaining 53% of the total effect. CONCLUSION: Prevention may be possible, once a history of parental childhood abuse has been identified, by offering services in priority to those families where a parent is under 21 years, has a history of mental illness/depression and/or there is a violent adult residing in the household. However, it must also be acknowledged that these factors do not provide a full causal account of the intergenerational transmission and consideration should be given to additional factors, such as parenting styles (see Part II of this mediational model, Dixon, Hamilton-Giachritsis, and Browne, 2004).     

Assessment and follow-up of suspected child abuse in preschool children with fractures seen in a general hospital emergency department

OBJECTIVE: To evaluate the emergency department assessment and follow-up of possible child abuse in children with fractures. METHODS: A retrospective audit was conducted of children up to 3 years of age who presented with a fracture to a general hospital emergency department over a 2-year period. RESULTS: In the 98 cases included, there was no documentation of complete physical examination in 57% of cases, whether the injury was witnessed in 54%, or time of injury in 18%. In 27% of cases the history documented was too brief to assess consistency of the injury with the history. Seventy-five per cent of children with known prior injuries did not have their past history documented. In 80% of all cases there was no indication that the emergency department doctor had considered the possibility of child abuse. Emergency doctors did not recognize four out of 16 cases (25%) with inconsistent histories. There was poor follow-up of patients in whom abuse was suspected: 46% of children less than 2 years had neither a skeletal survey nor bone scan. Patients referred to a paediatrician by the emergency department were significantly more likely to have a skeletal survey performed and to have the diagnosis of child abuse confirmed. CONCLUSIONS: Emergency department staff in a general hospital do not document or assess for all of the indicators of child abuse in a high-risk population and they do not document consideration of the diagnosis in the majority of cases. Emergency department staff need more training and more resources to allow for full assessment of child abuse. Suspected child abuse cases should be referred to a paediatrician to improve investigation and follow-up.     

Children of substance-using mothers: child health engagement and child protection outcomes

Aim: Maternal substance use has been associated with a range of child risk factors. The study investigated the relationship between engagement with child health services and child protection outcomes for children of substance‐using mothers. Methods: The sample comprised 119 children of mothers who disclosed opiate, amphetamine or methadone use during a maternity admission between 2000 and 2003. Statutory child protection agency and child health engagement information for the first 2 years of life was obtained. The relationship between type of maternal substance use, child health engagement and child protection outcomes was examined. Results: Of study group infants, 72% were engaged with child health services during the first 2 years of life. Chi‐squared analysis showed no significant relationship between child health engagement and child protection reports. Child health engagement was associated with decreased substantiated child protection notifications for children of methadone using mothers, but not for children of illicit substance users. Conclusions: Almost a quarter of identified children of substance‐using mothers are not accessing standard child health services in their first 2 years of life. This study provides support for increased attention to the provision of child health services for children of methadone using mothers. Further research into effective intervention strategies for children of illicit substance‐using mothers is indicated.     

Attributions and behaviours of parents abused as children: a mediational analysis of the intergenerational continuity of child maltreatment (Part II)

BACKGROUND: This study extends previous research (Dixon, Browne, & Hamilton-Giachritsis, 2004) by exploring the mediational properties of parenting styles and their relation to risk factors in the intergenerational cycle of child maltreatment. Families with newborns where at least one of the parents was physically and/or sexually abused as a child (AP families) were compared, in terms of parents' attributions and behaviour, to families where the parents had no childhood history of victimization (NAP families). METHODS: Information was collected from 4351 families (135 AP families) by community nurses as part of the 'health visiting' service. The same health visitor visited each family twice at home when the child was 4 to 6 weeks and 3 to 5 months of age, to assess behavioural indicators of positive parenting. RESULTS: Within 13 months after birth, 9 (6.7%) AP families were referred for maltreating their own child in comparison to 18 (.4%) NAP families. Assessments found a significantly higher number of risk factors and measures indicating poor parenting for AP families. Mediational analysis found that intergenerational continuity of child maltreatment was explained to a larger extent (62% of the total effect) by the presence of poor parenting styles together with the three significant risk factors (parenting under 21 years, history of mental illness or depression, residing with a violent adult). The three risk factors alone were less explanatory (53% of the total effect). CONCLUSION: This study provides an explanation for why a minority of parents abused in childhood go on to maltreat their own infant, evidencing poor parenting styles and mediating risk factors. Hence, prevention may be enhanced in AP families by the promotion of 'positive parenting' in addition to providing additional support to young parents, tackling mental illness/depression and domestic violence problems.     

Child maltreatment 2002: Recognition, reporting and risk

BACKGROUND: Child abuse is a major cause of morbidity and mortality in the USA and in all other countries which have studied its incidence. It is the second leading cause of death of children in the USA. To decrease the incidence of child abuse and improve the welfare of children there must be international efforts to recognize, and report child abuse and to decrease those risk factors, which place children in jeopardy. In the USA, reports of child maltreatment have decreased each year since 1994 after nearly two decades of increase. The increase was associated with the passage of laws that mandated reporting child maltreatment and increased recognition of maltreatment. RESULTS: Several theories have been proposed to explain the decrease. These include: improved economy with decreased caretaker stress and more vulnerable children in day-care, imprisonment of offenders, treatment of victims to prevent reactive abuse, decreased use of corporal punishment, earlier recognition and reporting, prevention programs including home visitors and less corporal punishment in schools. If early recognition is to occur there must be clearly defined and uniform laws that define abuse and the significant consequences to mandated reporters for failure to report. The laws must be concise, understandable and contain medically based definitions of abuse. A bruise should be considered a significant injury. The use of an instrument on a child, for any reason should be reportable as abusive. Society must be taught that a child's head and its contents are particularly susceptible to trauma. Heads should not be slapped, shaken, or struck. The purpose of a report of suspect maltreatment should be to obtain services for families. Without proper services, abuse will reoccur and victims will become victimizers. Any sexual act, including pornography, involving a child who is unable to give consent constitutes reportable sexual abuse. Recognition of what constitutes abuse would be simplified if all countries adopted laws that forbid corporal punishment in schools and homes. Parenting education, which offers alternatives to the use of corporal punishment and anger and stress management skills, should be universal and begun in preschool. In the older child, topics would include conflict management tactics, mate selection, child development, child health, and pregnancy planning. DISCUSSION: Professional knowledge of child maltreatment is inadequate. This multidisciplinary topic must be incorporated into the undergraduate and graduate curricula in medicine and other professions dealing with children. Child victims are unable to represent themselves. In most other childhood diseases the parents rise up in arms to lobby for their children's rights and raise money for research, professional education and clinical services. In child maltreatment, government and private organizations must take on this task. The valuable resources of Federal Public Health Services become available when child maltreatment is declared to be a disease. Other countries should emulate countries that have eliminated corporal punishment of children. Countries that do not protect children from maltreatment including the ravages of war must be seen as perpetrators of child maltreatment and answerable to the international community. One may adhere to the adage that one is not one's brother's keeper. This should never be applied to children. As the world's most precious resource, we must be the keepers of all children.     

Analysis of child abuse cases admitted in pediatric service in Japan II. Backgrounds of child abuse in non-low birth-weight infants

Child abuse of 126 non-low birth-weight (non-LBW) cases reported front pediatric clinics of major hospitals in Japan in 1986 were examined. Compared to LBW infants abused children's medical problems were few (25.4%) but the presence of step-parents and a history of rearing outside the home were evident (41.3%). The abuse of a child with medical problems by real parents showed similar characteristics to abuse of LBW, occurring at 0–1 and 4 years and two types of abuser's problems were apparent; one problem was the lack of child rearing ability and the other was the inability to cope with the stress involved in child rearing. In abuse of a child by step-parents, most abusers expressed emotional problems with their abused children. Child abuse by a real parent following a period of non-home care occurred soon after the child returned home, and abusers complained that the abused child did not take to its real parents. Abuse of a child without medical problems by real parents occurred at or around birth and indicated a poor ability to rear a child due to parental problems or low tolerance to cope with child rearing. Abuse both of a child and siblings by real parents implied a deficiency of understanding and inability in child rearing due to parental problems that may have resulted in abuse of the children at 0–1 year. It seems that two processes are critical in non-LBW child abuse as well as LBW child abuse. Namely, an inability of parents to raise children and an inability to cope with the problem of their children, especially as a result of communication problems. It is important to detect risk factors for disturbing parent-child communication at an early stage and attempt to improve it.     

The needs of the abused child in the community

ABSTRACT. The development of community awareness of child abuse has followed medical awareness and is specifically concerned with prevention and early intervention. Contact between community services and 304 infants from a birth cohort in a poor socio-economic status, multi-ethnic urban municipality was documented to investigate how these services could provide effective community approaches to the problem. While perinatal and medical services provided fragmented care, the Maternal and Child Health Service was the only agency to contact all families, including those of the 21 abused or "at risk'infants.
It is suggested that such local universal services should form the basis of a community approach to the needs of the abused or "at risk'child.     

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.     

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.