Inflicted injury versus accidental injury

Cutaneous Manifestations of Child Abuse & Neglect: Part I

Child abuse and neglect remains a significant cause of morbidity and mortality in children. Dermatologists may not fully conceptualize their crucial role in the evaluation of child abuse and neglect as both mandated reporters and experts in skin pathology. This CME summarizes the current information on cutaneous signs and clinical simulants of abuse for dermatologists so that dermatologists gain more insight into the skin examination for child abuse and neglect, develop confidence in their ability to distinguish dermatologic signs of accidental versus inflicted trauma, and more frequently consider abuse and neglect in their differential diagnosis.

Patterned Bruises From Abusive Squeezing

ABSTRACT

Bruising is the most common presentation of child physical abuse. Many patterns of abusive bruising result in positive or negative imprints of the implement used (eg, fingertips in "grab mark" contusions or hand in slap injury). However, bruising may also form along the lines of greatest anatomical stress (eg, gluteal cleft or pinna bruising). Bruising due to abusive squeezing also forms along lines of greatest anatomical stress, resulting in a negative imprint of the flexural folds of the hand. Four cases of children with this unique pattern of bruising due to abusive squeezing are presented. Recognition of these bruises as inflicted represents an opportunity for early identification and intervention in cases of child physical abuse.

Oral and dental signs of child abuse and neglect

AIM

The aim of this report is to identify the main oral and dental aspects of physical and sexual abuse and dental neglect in childhood, contributing to the precocious identification and diagnosis in a dental practice.

METHODS

The oral and dental manifestations were divided and classified according to the type of child abuse: physical abuse, sexual abuse, neglect.

PHYSICAL ABUSE

Several studies in the literature have shown that oral or facial trauma occurs in about 50% of physically abused children; the oral cavity may be a central focus for physical abuse. Oro-facial manifestations of physical abuse include bruising, abrasions or lacerations of tongue, lips, oral mucosa, hard and soft palate, gingiva, alveolar mucosa, frenum; dental fractures, dental dislocations, dental avulsions; maxilla and mandible fractures.

SEXUAL ABUSE

Although the oral cavity is a frequent site of sexual abuse in children, visible oral injuries or infections are rare. Some oral signs may represent significant indications of sexual abuse, as erythema, ulcer, vescicle with purulent drainage or pseudomembranus and condylomatous lesions of lips, tongue, palate and nose-pharynx. Furthermore, if present erythema and petechiae, of unknown etiology, found on soft and hard palates junction or on the floor of the mouth, can be certainly evident proofs of forced oral sex.

DENTAL NEGLECT

Oral signs of neglect are easily identifiable and are: poor oral hygiene, halitosis, Early Childhood Caries (ECC), odontogenous infections (recurrent and previous abscesses), periodontal disease, aptha lesions as a consequence of a nutritional deficiency status. Moreover, it is analyzed the assessment of bite marks because often associated with child abuse, the identification and collection of clinical evidence of this type of injury.

CONCLUSION

A precocious diagnosis of child abuse, in a dental practice, could considerably contribute in the identification of violence cases and in an early intervention.

Child abuse: skin markers and differential diagnosis

Reports of child abuse have increased significantly. The matter makes most physicians uncomfortable for two reasons: a) Little guidance or no training in recognizing the problem; b - Not understanding its true dimension. The most common form of child violence is physical abuse. The skin is the largest and frequently the most traumatized organ. Bruises and burns are the most visible signs. Physicians (pediatricians, general practitioners and dermatologists) are the first professionals to observe and recognize the signs of intentional injury. Dermatologists particularly, can help distinguish intentional injury from accidental, or from skin diseases that mimic maltreatment.

Child abuse and orthopaedic injury patterns: analysis at a level I pediatric trauma center

BACKGROUND

Child abuse is a serious threat to the physical and psychosocial well-being of the pediatric population. Musculoskeletal injuries are common manifestations of child abuse. There have been multiple studies that have attempted to identify the factors associated with, and the specific injury patterns seen with musculoskeletal trauma from child abuse, yet there have been no large studies that have used prospectively collected data and controlled comparisons. The purpose of our study was to describe the patterns of orthopaedic injury for child abuse cases detected in the large urban area that our institution serves, and to compare the injury profiles of these victims of child abuse to that of general (accidental) trauma patients seen in the emergency room and/or hospitalized during the same time period.

METHODS

This study is a retrospective review of prospectively collected information from an urban level I pediatric trauma center. Five hundred cases of child abuse (age birth to 48 mo) were identified by membership in our institution's Suspected Child Abuse and Neglect database collected between 1998 and 2007. These cases were compared against 985 general trauma (accidental) control patients of the same age group from 2000 to 2003. Age, sex, and injury type were compared.

RESULTS

Victims of child abuse were on average younger than accidental trauma patients in the cohort of patients under 48 months of age. There was no difference in sex distribution between child abuse and accidental trauma patients. When the entire cohort of patients under 48 months were examined after adjusting for age and sex, the odds of rib (14.4 times), tibia/fibula (6.3 times), radius/ulna (5.8 times), and clavicle fractures (4.4 times) were significantly higher in child abuse versus accidental trauma patients. When regrouping the data based on age, in patients younger than 18 months of age, the odds of rib (23.7 times), tibia/fibula (12.8 times), humerus (2.3 times), and femur fractures (1.8 times) were found to be significantly higher in the child abuse group. Yet, in the more than 18 months age group, the risk of humerus (3.4 times) and femur fractures (3.3 times) was actually higher in the accidental trauma group than in the child abuse group.

CONCLUSIONS

Patients who present to an urban level I pediatric trauma center and are victims of abuse are generally younger, and have an equal propensity to be male or female. It is important for the clinician to recognize that the age of the patient (younger or older than 18 mo and/or walking age) is an important determinant in identifying injury patterns suspicious for abuse. Patients below the age of 18 months who present with rib, tibia/fibula, humerus, or femur fractures are more likely to be victims of abuse than accidental trauma patients. Yet, when patients advance in age beyond 18 months, their presentation with long bone fractures (ie, femur and humerus) is more likely to be related to accidental trauma than child abuse.

LEVEL OF EVIDENCE

level III, prognostic study.

Can one accurately date a bruise? State of the science

Forensic nursing experts and other health professionals often testify regarding the injuries women and men receive from violence. Bruise discoloration can provide an opportunity for health professionals to grossly estimate the age of impact and determine if it is consistent with a given reported history. However, there is much confusion in the literature and clinical practice as to the accuracy of dating bruises. This article will demonstrate that using the color of the bruise as the primary criteria to determine its age is not the best practice. The limited available research and related literature on the topic are flawed and inconsistent. Finally, recommendations will be made for future research and clinical practice.

Assessment of abuse-related injuries: A comparative study of forensic physicians, emergency room physicians, emergency room nurses and medical students

A comparative study was made investigating whether emergency room physicians, emergency room nurses, forensic physicians, and interns are competent in describing, recognising and determining the possible cause of injuries. The injury assessment scores varied from good--adequate--fail and remained blank in various participant groups. Forensic physicians scored significantly better than emergency room staff and interns in the assessment of abuse-related injuries. There were almost no differences noted between emergency room physicians and emergency room nurses. For the functional group with more or less than 4 to 6 years of experience, no significant differences were noted for scoring good in all 5 cases. The fact that forensic physicians scored better than the emergency room staff is probably explained by the fact that almost all practicing forensic physicians have been officially qualified. Training in this field for all professionals involved in such assessment should be mandatory.

Cutaneous signs of child abuse

Maltreatment of children is a major public health crisis, and it is estimated that each year more than 3 million children are victims of abuse. Safeguarding the welfare of children is a priority, and it is the moral and ethical responsibility of healthcare professionals to detect cases of abuse and intervene appropriately to prevent further harm. Clinicians are often challenged to differentiate signs of child abuse from skin conditions that mimic maltreatment. Because cutaneous injury represents the most recognizable and common form of abuse, dermatologists are often called upon to help distinguish signs of intentional injury from skin conditions that mimic maltreatment. However, few resources specific to dermatologic signs of abuse exist to aid in diagnosis. A review of the literature will provide an educational resource to assist dermatologists and other clinicians in differentiating cutaneous signs of child abuse, including physical and sexual abuse, from mimickers of inflicted injury.

LEARNING OBJECTIVE

After completing this learning activity, participants should be able to distinguish signs of intentional injury from skin conditions that mimic maltreatment and understand the clinician's role in the diagnosis and reporting of cases of suspected child abuse.

Sensitivity of autopsy and radiological examination in detecting bone fractures in an animal model: Implications for the assessment of fatal child physical abuse

Skeletal injuries are often strong indicators of child abuse and their detection is therefore crucial. The aim of this study was to compare the sensitivity of three diagnostic approaches, namely autopsy, traditional (conventional) radiology, and computed tomography on "battered" piglets, in order to verify the sensitivity of each method, with respect to the true number of bone fractures assessed once the piglet was skeletonised (osteological control). Four newborn cadaver piglets who had died from natural causes were severely beaten post-mortem in every district of the body. Traditional radiography, computed tomography (CT) and autopsy were performed. The piglet was then macerated until skeletonised and the number of all fractures present recorded (osteological control). On the cranium, traditional radiology revealed only 35% circa of actual fractures, autopsy detected only 31% (P<0.01 for both comparisons versus osteological control), whereas CT imaging detected all fractures actually present. For ribs, radiology detected only 47% of all fractures present, and autopsy 65% circa (P>0.05 for both comparisons versus osteological control), while CT scans detected 34% (P<0.01). In suspected cases of fatal child abuse, we suggest that the bones of specific districts be directly analysed either at autopsy or by collecting specific diagnostic sites, such as parts of the rib cage, and subjecting them to maceration. The removed areas could be replaced with artificial material for cosmetic purposes. The authors stress the importance of combined radiological, CT scan, autopsy and osteological survey in the detection of perimortem bone fractures.

Cutaneous manifestations of child abuse

Dermatologists and child abuse are not frequently associated in the minds of most physicians. Yet the most common manifestations of child abuse are cutaneous. This article reviews cutaneous manifestations of physical abuse, including bruises, lacerations, abrasions, human bites, and burns. It also discusses ways that dermatologists can differentiate abusive injuries from accidental ones as well as from the many dermatologic conditions that can mimic child abuse. Finally, we review what actions the dermatologist should take when suspecting abuse in a patient.

Intentional avulsion fracture of the second cervical vertebra in a hypotonic child

Children uncommonly present with cervical fractures due to high-impact injuries. A 4-year-old child with developmental delay and chronic hypotonia presented to the hospital with acute onset of irritability and transient difficulty in walking. Lateral neck x-rays showed avulsion fracture of the second cervical vertebra. Neck magnetic resonance imaging study showed injury to the interspinal ligaments between the first and second cervical vertebrae in addition to confirming the acute avulsion fracture of C-2. The child was injured after he was thrown onto a bed from a distance of 1 to 2 ft according to his babysitter's admission. This is the first reported pediatric case presenting this type of inflicted fracture in a hypotonic child, although hypotonia may not have played a causal role.

Apparent life-threatening event or child abuse?

Children with apparent life-threatening events (ALTEs) often pose a diagnostic and management dilemma in a pediatric emergency department. Although the term ALTE is nonspecific and symptoms are vague, it may have alarming connotations and may signal serious life threatening conditions. It may be a subtle presentation of child abuse. We report an infant who was presented with an ALTE and subsequently determined to have subdural hematoma caused by nonaccidental injury.

Pediatric Homicides Related to Burn Injury: A Retrospective Review at the Medical University of South Carolina

Many burn injuries are mistakenly referred to as "accidents" because they occur suddenly and seem unpredictable and uncontrollable; however, injuries often occur in predictable patterns. We reviewed all pediatric forensic cases referred to the Medical University of South Carolina Forensic Pathology Section over a 28-year period from January 1975 to December 2002. There were 124 cases with 121 fire-related fatalities and three scald fatalities. Ninety of the burn victims were in the 0-5-year age group. The manner of deaths showed 108 accidents and 12 homicides (four undetermined). Eleven of 12 burn-related homicides occurred at the home with all of the victims in the 1-8-year age group. The perpetrator of the home fire homicides was the mother in five cases and the sister in one case (two undetermined). Homicide involved a vehicle fire in one case in which the father caused an explosion with an accelerant. The three scald death perpetrators were the father, mother's boyfriend, and an aunt.This retrospective study and review of the literature may reveal patterns useful for evaluation of manner of death. By recognizing scene characteristics, potential perpetrators, and children at risk, we can better classify pediatric burn-related fatalities.

Pediatric orthopedic trauma: principles of management

Musculoskeletal injuries in the pediatric population are unique and require a thorough evaluation by a trained specialist. Unlike adults, many of the injuries may be treated closed due to the amazing growth and remodeling potential of children. Special consideration should be taken in treating certain fracture patterns to prevent the long-term consequences of growth deformities and protect children from child abuse. It is the goal of this article to outline common orthopedic injuries in the pediatric population to facilitate proper care in the multidisciplinary evaluation and treatment of children.

U.S. Preventive Services Task Force. Screening for family and intimate partner violence: recommendation statement

This statement summarizes the U.S. Preventive Services Task Force (USPSTF) recommendations on screening for family and intimate partner violence based on the USPSTF's examination of evidence specific to family and intimate partner violence. It updates the 1996 recommendations contained in the Guide to Clinical Preventive Services, second edition. In 1996, the USPSTF found insufficient evidence to recommend for or against the use of specific instruments to detect domestic violence (a "C" recommendation according to 1996 grade definitions). The Task Force now uses an explicit process in which the balance of benefits and harms is determined exclusively by the quality and magnitude of the evidence. As a result, current letter grades are based on different criteria than those in 1996. Current explanations of the ratings and of the strength of overall evidence are given in Appendix A and in Appendix B, respectively. The complete information on which this statement is based, including evidence tables and references, is available in the summary article and in the Systematic Evidence Review, "Screening for Family and Intimate Partner Violence: Systematic Evidence Review for the U.S. Preventive Services Task Force." The USPSTF recommendations, the accompanying summary article, and complete Systematic Evidence Review are available through the USPSTF web site (http://www.preventiveservices.ahrq.gov). The summary article and the USPSTF recommendation statement are available in print through the AHRQ Publications Clearinghouse (call 1-800-358-9295 or e-mail ahrqpubs@ahrq.gov).

Pediatric ankle fractures: evaluation and treatment

Pediatric ankle fractures account for approximately 5% of pediatric fractures and 15% of physeal injuries. The biomechanical differences between mature and immature bones, as well as the differing forces applied to those bones, help explain the differences between adult and pediatric fractures. The potential complications associated with pediatric ankle fractures include those seen with adult fractures (such as posttraumatic arthritis, stiffness, and reflex sympathetic dystrophy) as well as those that result from physeal damage (including leg-length discrepancy, angular deformity, or a combination thereof). The goals of treatment are to achieve and maintain a satisfactory reduction and to avoid physeal arrest. A knowledge of common pediatric ankle fracture patterns and the pitfalls associated with their evaluation and treatment will aid the clinician in the effective management of these injuries.

Child abuse in Turkey: an experience in overcoming denial and a description of 50 cases

OBJECTIVE

To share the experiences of the first clinical multidisciplinary child abuse and neglect (CAN) team in Turkey with international child abuse community.

METHODS

The authors established the first Turkish CAN follow-up team at Dr. Behcet Uz Children's Hospital. Following a training program in five teaching hospitals in Izmir, the authors kept a record of every case diagnosed with CAN from these hospitals between 1996 and 1998. The demographic, epidemiologic, and medical features of this case series are summarized.

RESULTS

Fifty cases were diagnosed and followed-up. Seventy-six percent of patients were reported from Dr. Behcet Uz Children's Hospital. Age and sex distribution was 9.2 +/- 6.7 years and 46% male, 54% female, respectively. The offenders were only father in 38%, only mother in 28%, and multiple in 34%. More than three CAN risk factors were present in 94%. Of the children reported 44% survived, 14% died, and 42% were lost to follow-up. Sixteen percent were free of reabuse, and 42% survived with handicaps.

CONCLUSIONS

Child abuse and neglect is a reality in Turkey. The team's work increased pediatricians' awareness of CAN. Reporting these cases to Social Affairs Bureau was established for the first time in Turkey. Physicians in Turkey need training to diagnose and properly report CAN. The implemen tation of a national CAN prevention program is an urgent need for Turkey.

Intentional injuries among the young: presentation to emergency rooms, hospitalization, and death in Israel

PURPOSE

To study the incidence and outcome of intentional injuries requiring emergency room (ER) care among children and adolescents in a national sample.

METHOD

The population included 0- to 17-year-olds who presented to the ER for injuries in 23 hospitals over a 1-year period. A 6% to 9% random sample of days was selected in each hospital, and for each selected day the relevant ER record was reviewed for cause, nature, and outcome of injuries and sociodemographic information.

RESULTS

The annual incidence for intentional injuries resulting in ER visits was 19.6 in 10,000 children and adolescents aged 0 to 17 [95% confidence interval (CI) 17.4-21.8 in 10,000]. Fights/assaults constituted 54.1% of the presentations, abuse and rape, 10.3%, and self-inflicted injuries, 10.8%. Overall rates were higher among 10- to 17 year olds than at younger ages. The rates were higher among boys than girls for fights/assaults and abuse, whereas attempted suicide and rape were three times higher among girls than boys. Nearly twice as many Jewish children and adolescents presented to the ER for intentional injuries than Arab children and adolescents, with the ratio becoming even greater for attempted suicide. Of all the intentionally injured, 21.7% were hospitalized. The mortality rate was 1.1 in 100,000 (95% CI =.7-1.7/100,00) with no significant gender difference observed. No cases of suicide were reported for the Arab population.

CONCLUSIONS

Adolescents aged 10 years and older are at higher risk for intentional injuries than younger children. The ethnic differences evident in this study, especially for attempted and completed suicide, may be real or the result of differential disclosure of information owing to sociocultural norms or differential recording by health professionals.

Child abuse: clinical findings and management

PURPOSE

To provide an overview of the role of the nurse practitioner (NP) in identifying, reporting, and managing child abuse in primary care.

DATA SOURCES

Selected research, national guidelines, and the author's experience.

CONCLUSIONS

Child abuse is a complex phenomenon characterized by maladaptive behaviors between children and their parents.

IMPLICATIONS FOR PRACTICE

The role of the NP includes identification of families at risk, recognition of clinical findings of abuse, diagnosis of abuse, education for families identified at risk, and management of children diagnosed with abuse. The ultimate goal is the safe return of the child to a loving family.

A profile of the oro-facial injuries in child physical abuse at a children's hospital

OBJECTIVE

The aim of the present study was to determine the head, face and neck injuries associated with child abuse cases in the Cape Peninsula, Cape Town. South Africa.

METHOD

A retrospective, record-based analysis (n = 300) of non-accidental injuries at a Children's Hospital over a 5-year period (1992-1996) was carried out.

RESULTS

The mean age of the sample was 4.75 years--54.3% were boys and 45.7% were girls. Most of the crimes were committed in the child's own home (88.7%). Crimes were reported by mothers (48.7%), grandmothers (11.7%) and day hospitals (13%). Ninety percent of the perpetrators were known to the victim. The majority of the perpetrators were male (79%)--20% the perpetrators were the mother's boyfriend; 36% the father or step father, and in 12% the mother was responsible. Thirty-five percent of perpetrators were under the influence of alcohol or drugs when they committed the offence: 64.7% of cases suffered serious injuries, 48.7% had to be hospitalized, four children were critically injured and died. The head, face, neck, and mouth were the sites of physical injury in 67% of the 300 cases reviewed. The face was the most frequently injured (41%) part of the body, with the cheek being the most common site for the injury. The range and diversity of the oro-facial injuries included skull fractures, subdural hematomas, retinal hemorrhages, bruises, burns, and lacerations. Injuries to the mouth included fractured teeth, avulsed teeth, lacerations to the lips, frenum, tongue, and jaw fractures.

CONCLUSIONS

The main conclusions of this study were (i) under 2-year-old children were most at risk from abuse (36%); (ii) the number of the reported injuries to the oral cavity was extremely low (11%); and (iii) no dentists participated in the examination of any of the patients. Intra-oral injuries may be overlooked because of the medical examiner's unfamiliarity with the oral cavity. Oral health professionals should be consulted for diagnosis, advice and treatment.

Aberrant genital practices: an unrecognized form of child sexual abuse

The sexual abuse of children in the United States is a problem of epidemic proportions. Sexual abuse is defined as any activity with a child that is conducted for the sexual gratification of the perpetrator. Common examples of sexual abuse include vaginal intercourse; oral-genital contact; anal-genital contact; fondling; finger manipulation; and stimulation of the offender. Sexual abuse may also occur in less typical patterns in which children are subjected to aberrant genital care practices, typically by their parents. Three case studies illustrate examples of aberrant genital practices. This type of abuse can be identified in primary care settings by asking specific questions of parents and children. Examples of such questions are provided.

Minor pediatric injuries

Injuries are a common source of childhood morbidity and mortality. The initial evaluation should follow in a sequential fashion to determine the extent of injuries. Most minor injuries can be treated safely and cost-effectively in an office setting. The principles of wound care include adequate hemostasis, tissue debridement, removal of imbedded foreign bodies, and appropriate closure or coverage of the wound to optimize healing. Appropriate use of antibodies, tetanus prophylaxis, and rabies immunization will minimize complications. With proper selection and treatment, the outcome of children with minor injuries should be excellent.

Folk remedies and child abuse: a review with emphasis on caida de mollera and its relationship to shaken baby syndrome

OBJECTIVE

There were two objectives: first, to make the reader familiar with folk remedies that might be confused with child abuse; second, to challenge the idea existing in the literature that treatment for the Hispanic folk illness caida de mollera can cause the injuries seen in the shaken baby syndrome.

METHOD

Literature review and analysis with case application were used.

RESULTS

A wide variety of folk remedies with potential for confusion with child abuse were found to exist, and were described. Treatment for caida de mollera was found to consist of a number of gentle, nonviolent maneuvers quite different from the violent shaking believed to cause shaken baby syndrome.

CONCLUSIONS

Familiarity with folk remedies will help differentiate them from child abuse. The child protection community would benefit from realizing that treatment for caida de mollera is an improbable cause of shaken baby syndrome injuries.

Evaluation for possible physical or sexual abuse

In summary, child abuse requires a multidisciplinary approach. The clinician's role in obtaining the history and physical examination demands that one be familiar with interview technique, appropriate developmental milestones, normal genital anatomy, and the use of local community resources. Knowing that there are circumstances when the examination should be deferred to a specialized center or done under anesthesia is critical. Determining that a reasonable suspicion of abuse exists is the job of the clinician. The final determination of abuse is under the purview of the legal system.

The pathology of fatal child abuse

It is a sad indictment of human society that the abuse of children is such a prevalent and widespread problem. The acknowledgement that physical, emotional and sexual injury as well as intentional neglect can be inflicted upon the young by any person but especially by caregivers has been increasingly realised by the community. As a result, many professionals, especially in the medical sciences, are involved in the study and management of such cases with the ultimate goals of recognising children at risk, diagnosing those cases that have occurred, preventing initial or subsequent injury and bringing perpetrators to justice. The aim of this paper is to review recent published work on the pathology of abuse leading to death of the child. Particular reference is made to the patterns of observed physical damage as well as to the interpretation of those observations. Clearly many more children are abused than die directly as a result of that abuse, but pathologists are infrequently involved in the management of clinical abuse cases. Exceptions to this rule, of course, include assessment of biochemical changes in cases of Munchausen syndrome by proxy, diagnosis of infective lesions resulting from sexual assault as well as the interpretation of unexplained cutaneous lesions subsequently shown to be caused by physical assault (such as burns and bite marks). Cases of physical abuse are usually managed by pediatric specialists with assistance from radiologists, neurosurgeons and ophthalmologists, and it is important that effective communication be maintained by pathologists with these practitioners when investigating a case that has unfortunately culminated in death.

Recurrent "unexplained" scalp swelling in an eighteen-month-old child: an atypical presentation of angioedema causing confusion with child abuse

In this article, we demonstrate that angioedema may atypically present with noninflammatory scalp or facial swelling without recurrence on other parts of the body and without urticaria. In a young child, such a presentation exclusively with recurrent "unexplained" swellings over different parts of the scalp could erroneously be misconstrued as child abuse (blunt head trauma).

Risk factors for dropping out of a parenting education program

This study compared those who completed a clinic-based parenting program to dropouts in an attempt to identify risk factors for parents not completing the program. The program, aimed at mothers at risk for child maltreatment, was offered at three Seattle, Washington health centers providing comprehensive pediatric care to low-income families. We obtained baseline information from an intake questionnaire, the Nursing Child Assessment Teaching Scale (NCATS), and the Home Observation for Measurement of the Environment (HOME). Of the 172 enrollees, 124 (72%) completed the program. Univariate analyses showed that dropouts were more likely to be located at Clinic Site Three (42% vs. 10%, p < .001), teenaged (44% vs. 23%, p = .010), and African-American (56% vs. 32%, p = .010), and to have HOME scores less than 32 (57% vs. 33%, p = .023). There were no statistically significant differences between those who dropped out and those who didn't in marital status, education, referral rate to Child Protective Services prior to the start of parenting classes, or NCATS scores. Multivariate analyses showed that age less than 20 was significantly associated with dropping out when race and HOME scores were taken into account. There was significant interaction between age less than 20 and Clinic Site Three. These data suggest that program planners need to develop appropriate strategies to retain teenage mothers in parenting programs.

The identification and reporting of physical abuse by physicians: a review and implications for research

Identification and reporting of possible cases of child physical abuse are critical precursors to intervention with maltreating families. Professionals from a variety of disciplines are mandated to report suspected cases of child maltreatment. Unfortunately, not all physically abused children are identified or reported. This paper reviews the literature that has examined factors that may influence the identification and reporting of physical abuse by physicians. The literature review is preceded by an overview of the multistep, multibehavior process of identification and reporting. The factors that may influence identification and reporting are discussed according to their association with the case, physician, or setting. Future directions for research in the area of identification and reporting are suggested throughout the paper.

The combined effects of physical, sexual, and emotional abuse during childhood: long-term health consequences for women

The long-term health effects of physical, sexual, and emotional abuse during childhood were studied in a sample of 668 middle class females in a gynecologic practice who responded to a self-administered, anonymous questionnaire covering demographic information, family history, physical and psychological health, as well as stressful events and abusive experiences as a child. Half (53%) of the sample reported childhood abuse, with 28.9% recounting exposure to one type of abuse, 18.7% to two types of abuse, and 5.4% to all three types of abuse. In comparison to women not abused during childhood, the abused reported significantly more hospitalizations for illnesses, a greater number of physical and psychological problems, and lower ratings of their overall health. The greater the number of childhood abuses, the poorer one's adult health and the more likely one was to have experienced abuse as an adult. Thus, in addition to the deleterious psychological consequences of abuse described in the literature, physical health also appears to be adversely affected in women abused as children.

Morbidity and death due to child abuse in New Zealand

The purpose of this study was to explore under-diagnosis and racial bias among child abuse morbidity and mortality data from New Zealand. Computerized files of all intentional injury fatalities among children 16 years of age and under for 1978-87, and all hospital discharges for intentionally injured children 16 and under for 1988, were analyzed for evidence of physical abuse and sexual abuse. Among the 92 fatalities, only 21 of 68 deaths due to physical and/or sexual abuse were so coded. In both the mortality and the morbidity data, there was an association between the diagnosis of child abuse and race. In the case of fatalities, Maori and Samoan abuse victims were more likely to be assigned an E-code of E967 ("child battering and other maltreatment") than were "others" (p = 0.04), controlling for sex. In the case of hospitalizations, the association between E967 and whether or not the victim was European was significant for physical abuse only (p = 0.05). Assignment of N-code = 995.5 ("child maltreatment syndrome") as the reason for admission was significantly associated with race for those cases considered by us to have been abused, controlling for age (p = 0.002) or sex (p = 0.004).