Chadwick’s Child Maltreatment 4e, Volume 1: Physical Abuse and Neglect

Chapter 1

OVERVIEW OF CHILD MALTREATMENT

John M. Leventhal, MD

Andrea G. Asnes, MD, MSW

Since 1962, when Kempe and colleagues first described the battered child syndrome,¹ it has become increasingly clear that child maltreatment, including physical abuse, neglect, sexual abuse, and emotional abuse, is far too common, has profound short- and long-term effects on children and families, and is extremely costly to society. It also has become clear that much greater attention and financial support will be necessary to increase dramatically the efforts aimed at preventing child maltreatment and supporting families.

Before the article by Kempe and colleagues, observant radiologists raised important questions about how major injuries, such as fractures, occurred in young children and hesitantly proposed that these injuries were the result of actions by the caregivers.²,³ Others, such as Adelson,⁴ wrote about the killing of children.

Kempe’s article, however, provided a major shift in the understanding of certain poorly explained childhood injuries that were seen by countless clinicians around the country. Whereas some clinicians had not recognized that parents and other caregivers were hurting their children, others likely had recognized the problem but had kept quiet about it because it was too painful and difficult to believe. Kempe and his coauthors provided information about both the clinical spectrum of the battered child syndrome and the first epidemiological study, in which 749 abused children were identified around the country. It seems very unlikely that anyone at that time could have foreseen what has been learned about the problem’s extent over the last five decades.

The recognition of abused children created new problems and questions for hospitals and clinicians. What is the home like where the child was abused? Is it safe to send the child home, and, if not, where should the child go? In response to these types of questions and others and the need to protect children, state and federal legislation in the 1960s and 1970s established child protective services (CPS) agencies in each state, and laws were passed mandating that physicians and other professionals report suspected abuse to CPS.

DEFINITIONS AND EPIDEMIOLOGY

Maltreatment of children includes neglect, physical abuse, sexual abuse, and emotional maltreatment. Neglect is defined as acts of omission and includes the failure to provide adequate nutrition, clothing, shelter, or supervision; abandonment; and failure to ensure that the child receives adequate healthcare, dental care, or education. Although neglect can be a single event, such as leaving a young child unsupervised in an unsafe setting, it often is a pattern of unsafe or inadequate care, such as a pattern of inadequate supervision or inadequate nutrition because of a serious mental health problem or substance abuse on the part of the caregiver. Clinicians must distinguish neglect from episodes of less serious failures to provide adequate care to a child, such as when a 10-month-old rolls off of a bed or a child has missed a few appointments for well-child care and has not received all of the recommended immunizations.⁵

Physical abuse is defined as acts of commission toward the child by a parent or caregiver. Such acts can result in harm to the child or they might intend to harm, although there may be no harm or only a minor injury. It can include injuries that occur when a child is physically punished severely or when a parent loses control and shakes a crying infant. Injuries that are suspicious for abuse or neglect must be distinguished from unintentional (or accidental) injuries. A specific form of child abuse, called medical child abuse, previously referred to as Munchausen Syndrome by Proxy, occurs when a caregiver causes injury to a child that involves unnecessary and harmful or potentially harmful medical care.⁶

Sexual abuse is the involvement of adults, older children, or adolescents in sexual activities with children who cannot give appropriate consent and who may not understand the significance of what is happening to them.⁷ Such activities violate family and societal taboos. Sexual abuse includes, for example, sexual touching of the genitalia, oral sex, attempted or actual sexual intercourse, including children in child pornography, or exposing children to child pornography. Although a 5-year age difference between victim and perpetrator is often used to decide whether sexual behaviors between two children should be considered sexual abuse, as opposed to sexualized play, it is often more helpful to examine how invasive and persistent the behaviors are by the older child and whether the younger child wanted the behaviors to stop and felt threatened.

Emotional (or psychological) maltreatment is a repeated pattern of damaging interactions between parent(s) and child that become typical of the relationship.⁸ This form of maltreatment occurs when a child repeatedly feels that he or she is unwanted, unloved, or worthless. It includes denigration, belittling, and ridiculing; it can also include actively rejecting the child or ignoring the child’s emotional needs. Although emotional maltreatment is likely the most common form of maltreatment, children are infrequently reported to CPS agencies for emotional maltreatment. Emotional maltreatment, however, often accompanies other types of abuse or neglect and plays a major role in the consequences of these types of maltreatment.

Much has been learned about the epidemiology of child maltreatment. Since 1976, each year in the United States, data have been collected from each state’s CPS agency to track the number of reports and substantiated cases. Since 1990, these data have been collected by the National Child Abuse and Neglect Data System (NCANDS). By the early 1990s, there were over 3 million reports nationwide, and approximately one third of these reports were substantiated, meaning that the local CPS agency had enough evidence to believe that child maltreatment had occurred.

From 1990 to 2009, there was a substantial decline in the yearly number of cases nationwide of substantiated sexual abuse (61% decline) and physical abuse (55% decline) and a 10% decline in cases of substantiated neglect.⁹,¹⁰ The decline in the occurrences of sexual and physical abuse is impressive and likely reflects real changes in how children are cared for in the United States. Some of the decrease in occurrence, however, may be due to other changes, such as the criteria used by CPS to substantiate reports of sexual abuse or how specific reports are categorized as abuse, neglect, or sexual abuse.¹¹

In 2011, 3 million children were reported to CPS agencies nationwide, and 677000 cases were substantiated as being victims of maltreatment.¹² Thus 9.1 per 1000 children were subjects of a substantiated report of maltreatment. Of these, 78.5% were caused by neglect, 17.6% by physical abuse, 9.1% by sexual abuse, 9.0% by emotional maltreatment, 2.2% by medical neglect, and 10.3% by other types of maltreatment, including abandonment or congenital drug addiction. These percentages add to more than 100%, indicating that children can suffer from more than one type of maltreatment.

In addition, approximately 1570 children died because of abuse or neglect. The majority of these children (81.6%) were younger than age 4 years, and 42.4% were younger than age 1 year. The number of fatalities related to maltreatment has decreased over the last several years. Experts, however, believe that deaths caused by abuse or neglect may be significantly undercounted,¹³ and as many as 2000 children may die each year because of maltreatment.¹⁴

The data from CPS agencies are based only on cases of child maltreatment that are actually recognized in the community and reported to and substantiated by CPS; therefore at least four other approaches have been used to examine the occurrence of child maltreatment, as follows:

—Prospective data collection in selected communities to identify cases of maltreatment, even if not reported to CPS. This approach has been used in four congressionally mandated national studies: the National Incidence Studies (NIS), which were conducted from 1979 to 1980 (NIS-1), 1986 to 1987 (NIS-2), 1993 to 1995 (NIS-3), and 2005-2006 (NIS-4).¹⁵ In each of these studies the number of identified victims of maltreatment has been substantially higher than the number of cases substantiated by CPS over the comparable time period.

—Asking adults about the details of how they have treated their children over a specific period, such as the previous month or year.¹⁶

—Asking children directly about their experiences of violence, including their experiences of maltreatment.¹⁷ These studies have shown that children can be asked directly by using sensitive and ethically appropriate approaches to questioning. Such studies have also shown that many children experience more than one type of violence in a year; in one study, 22% of children had experienced at least four different specific types of violence, and these children were at an increased risk of having mental health problems.¹⁷

—Asking adults about how they were treated during childhood.¹⁸ Using this last approach has been very helpful in gaining an understanding of the number of adults who have experienced different types of maltreatment during childhood. For example, numerous studies have asked adult women and men about their experiences of sexual abuse during childhood and adolescence. A review of studies of community samples in the United States and Canada found that the prevalence of sexual abuse reported by women was 2% to 62% and by men, 3% to 16%. Finkelhor¹⁸ suggested that a reasonable summary statistic for women would be 20% and for men, 5% to 10%.

MAJOR CHANGES IN RESPONDING TO CHILD MALTREATMENT

Since the legislation of the 1960s and 1970s, there have been major changes in how clinicians, CPS agencies, government, and society in general have responded to child maltreatment. Ten of these changes are discussed briefly in the following sections.

CHILD MALTREATMENT AS A BROADER TERM

First, the term child abuse was broadened and developed into a new, all-encompassing term child maltreatment. After the recognition of physical abuse came the recognition of neglect and, in the late 1970s and 1980s, the recognition of sexual abuse. All along, clinicians recognized the importance of the emotional aspects, which have become particularly important in understanding many of the short- and long-term consequences of maltreatment. Although an individual child may be reported for a single type of maltreatment (eg, physical abuse), it has become increasingly clear that children reported for one type of maltreatment often have suffered from other types as well.

UNDERSTANDING THE ETIOLOGY OF CHILD MALTREATMENT

The understanding of how abuse and neglect occur in families has changed over time. The initial focus was on parental psychopathology; however, a more helpful framework focuses on abnormalities in the parent-child relationship¹⁹ in the context of an ecological model of parenting.²⁰ Bavolek¹⁹ noted the following 4 abnormalities in the parent–child relationship that can lead to abuse or neglect:

—Lack of empathy toward the child’s needs

—The parent’s belief in physical punishment

—Parental role reversal

—Inappropriate parental expectations of the child

These parental thoughts, feelings, and behaviors need to be considered in an ecological model,²⁰ in which the parent-child relationship is viewed as existing in layers of systems, including the family, the extended family, the social setting, and the cultural context. How parents feel about and behave toward their child can be influenced by characteristics of the child (eg, unwanted), parent (eg, abused during childhood), family (eg, domestic violence), social setting (eg, poor housing), and cultural context (eg, violence in the neighborhood). In this more complex model no single factor leads to abuse or neglect; rather it is the accumulation of factors or stressors that can result in maltreatment.

This more complex approach to understanding parenting behaviors in general also can be used to target interventions to support the parent-child relationship. For example, isolated families can be helped by linking them to social supports, depressed parents can be prescribed antidepressants or helped with CBT, or drug-abusing parents can be provided with treatment services. Each level of treatment can relieve stresses that can influence how parents care for their children.

There have been less dramatic changes in understanding why adults and older children perpetrate sexual abuse. For sexual abuse to occur, at least two prerequisites are necessary: (a) the offender’s sexual arousal to children and (b) the willingness to act on this arousal.²¹ Studies examining risk factors for sexual offending against children are methodologically complicated. A common approach to understanding such behaviors has been to use a case-control study to examine personal, family, or social factors in sexual offenders compared with nonsexual offenders. Longitudinal studies in which children are followed into adolescence or adulthood have contributed to the understanding of sexual offending. In such studies, children with certain risk factors are compared to those without such risk factors; the frequency of sexual offending in each group is then examined over time. For example, in a longitudinal study the investigators sought to gain further insight into which boys who had been sexually abused went on to sexually abuse others.²² Of 224 boys who had been sexually abused and followed for 7 to 19 years, 26 (11.6%) committed sexual offenses. Compared to the nonoffenders, the sexual offenders were more likely to have experienced the following:

—Material neglect (odds ratio = 3.4)

—Lack of supervision (3.0)

—Sexual abuse by a female (3.1)

—Witnessing of serious family violence (3.1)

—Demonstrating cruelty to animals (7.9)

The results of such studies help investigators understand subgroups of sexually abused boys who are at high risk of becoming perpetrators.

THE MANDATED REPORTER

A third major change has been in the definition and expectations of mandated reporters. Over the years, the types of professionals identified in state statutes as mandated reporters have been expanded to include nearly all professionals who have contact with children. Thus, the list includes physicians, dentists, teachers, social workers, psychologists, police, clergy, and others. Lawyers are not included so that they can represent their clients without having to report them as well. Mandated reporters are expected to report both by telephone to a central hotline and in writing. Most state laws indicate that the mandated reporter must report if there is reasonable suspicion of abuse or neglect; mandated reporters do not have to be 100% certain. State statutes protect the reporter from being sued for reporting in good faith. The failure to report a suspected case can place a child at risk of a more serious occurrence of maltreatment, and this inaction can result in prosecution of the mandated reporter by the state.

THE ROLE OF CHILD PROTECTIVE SERVICES

A fourth change has been in the role of the CPS agency. In general, CPS agencies have been underfunded and staffed with inexperienced and undertrained workers. Efforts to improve the quality of the work provided by these agencies have occurred through federal and state legislation, in some cases as a result of lawsuits against the state agencies. In some states, the federal court has provided ongoing oversight of CPS agencies, and this has resulted in increased services for children and often increased funding from the state legislature. The passage of federal laws and the availability of federal funds also have influenced state practices, such as the timing of administrative case reviews or the amount of effort and actions taken by CPS in attempting to reunify maltreated children with their families or terminating parental rights so that a child can be adopted.

The modern CPS agency no longer just investigates cases of suspected maltreatment and places children in foster care; the scope of the work has become considerably more complex. For example, CPS must be able to investigate cases of suspected maltreatment in foster care; ensure that children in foster care, including many with complex medical needs, receive appropriate medical and psychological care; help adolescents transition out of the foster care system and into independent living arrangements; and help families with serious problems related to substance abuse or family violence. In a few states, CPS agencies have responded by expanding staff expertise (by having special consultation units that might include a nurse practitioner, an educational specialist, a substance abuse specialist, a domestic violence expert, and others) and by relying on expertise from the community to provide advice and consultation. In short, CPS has become more collaborative with the community and with its professionals.

In addition, many CPS agencies have expanded the scope of their work and no longer just focus on child protection (ie, investigating reports, making determinations of substantiation, placing children in foster care, and helping families to receive services). Instead, such agencies often have been given the responsibility for the state’s services related to child mental health and juvenile justice. The merging of these functions in a single agency has theoretical and practical benefits because there is overlap in the children and families served. For example, mental health services can be funded by the agency and targeted to families receiving protective services.

Some critics contend that the focus on investigations of suspected maltreatment has overly emphasized the investigation process and not focused enough on the needs of troubled children and families. In response to this concern, many CPS agencies are attempting to help families by triaging less serious cases to an alternative pathway that includes family engagement, less intensive investigation, and the provision of community-based services to help the family. Evaluation of this approach,²³ called differential response, has shown some positive results, although there are few randomized trials. Families assigned to the differential response pathway tend to be more satisfied than families in the investigative arm. Among families who participated in this pathway, there were fewer subsequent reports for maltreatment compared to families in the traditional pathway. Importantly, services were provided earlier to the families in the differential response pathway, although the availability of the correct kinds of services continues to be a problem. As these differential response programs go to scale in states’ CPS agencies, continued evaluations will be necessary. Clearly, for these programs to be successful there must be adequate community-based services so that families triaged from CPS can be helped.

COLLABORATIVE INVESTIGATIONS

A fifth major change concerns how cases are investigated. Over the last two decades, there has been a growing nationwide trend, particularly concerning cases of suspected sexual abuse and serious physical abuse, to have collaborative investigations between CPS and the police. Many states have passed legislation that supports the development of a multidisciplinary investigation team in each judicial district or region. The purposes of such teams are to ensure successful prosecution of cases and minimize secondary trauma to children and families. Teams comprise experts from the community, including CPS, police, and prosecutors; a physician or nurse practitioner with expertise in sexual abuse and physical abuse; forensic interviewers; mental health clinicians; and representatives from other agencies. Although little research has been done on the effectiveness of this approach, better coordination of investigations and clearly defined tasks seem to result in more skilled interviewing of the child, fewer interviews of the child by different investigators, more timely medical examinations and referrals for mental health treatment, more support for the family, and more complete investigations.

SYSTEMS OF CARE

The approach to providing care to maltreated children has evolved and now includes child abuse pediatricians, hospital-based child protection teams, regional or statewide medical evaluation and treatment services, and Children’s Advocacy Centers (CACs). Although pediatricians have taken an important lead related to child maltreatment since Kempe’s time and the American Academy of Pediatrics has had a specialty section on child abuse and neglect since 1990, recognition of the subspecialty of Child Abuse Pediatrics did not come about until 2006. In 2009, 191 pediatricians were recognized as board certified in the field. This certification means that child abuse, like other subspecialties of pediatrics, such as cardiology and gastroenterology, is now recognized by the American Board of Pediatrics and that training as a child abuse pediatrician will require a 3-year fellowship in approved training programs.

Hospital-based child protection teams have existed at many hospitals for many years, but recent attention to these programs has come about because of reports from the National Association of Children’s Hospitals and Related Institutions (NACHRI) (now called the Children’s Hospital Association) describing the role of children’s hospitals in child maltreatment and the sources of funding for these programs.²⁴,²⁵ As part of the report on the role of children’s hospitals, NACHRI proposed standards of excellence regarding the levels of services provided by hospital-based child protection programs. There also has been recent research examining the effectiveness of child protection teams.

In some states, the provision of evaluation and treatment services are coordinated at the state level so that all maltreated children are ensured of receiving the necessary services. For example, in Florida there are 24 regional Child Protection Teams that are available 24 hours per day to provide expert multidisciplinary evaluations. In North Carolina there is a statewide system (Child Medical Evaluation Program) that includes over 200 medical providers who receive special training and reimbursement for medical evaluations of abused children referred by CPS; in this program, about half the medical providers are community providers.

To help ensure that sexually abused children receive high-quality evaluations in collaboration with CPS and law enforcement, CACs, under the umbrella of the National Children’s Alliance, have been established in over 700 communities. CACs attempt to pull together the professionals in a community who are involved with the investigation, evaluation, and treatment of sexually abused children. These professionals include law enforcement, criminal justice, CPS, and medical and mental health clinicians. Despite the widespread establishment of CACs around the country, limited data document whether the coordination of services ensures better outcomes for children and families and higher rates of convictions. One study compared children receiving services at four well-established CACs with children receiving services in neighboring communities without CACs. These studies showed that CAC cases compared to non-CAC cases had more coordination of investigating professionals.²⁶,²⁷ There were no differences in the number of children who received more than two interviews,²⁶ but children seen at CACs were more likely to have forensic medical examinations.²⁷

OBTAINING INFORMATION FROM CHILDREN

Understanding the child’s own perspective of the suspected abuse, neglect, or sexual abuse has always been viewed as critical. A major change over the last three decades has been the increasing attention to research on children as reporters of their experiences, whether reporting to clinicians or investigators or in the courts, and the subsequent efforts to translate these research findings into practice. The major focus has been on how children report suspected sexual abuse. Researchers have investigated children’s short- and long-term memory, how children describe events that they experience or witness, and factors (such as the kinds of questions) that influence their reporting.²⁸,²⁹ Research has included laboratory-based and naturalistic studies. In laboratory studies, factors such as what an adult says or does can be manipulated to see how these changes influence children’s reports of what they heard or saw. In naturalistic studies, investigators often take advantage of witnessed events that happen to children. For example, children have been asked to report about a recent physical examination and, in particular, to report on whether the physician examined their genitals.³⁰

The findings from this research indicate that children (especially young ones) can be influenced to say that sexual abuse has occurred when it has not. Rulings by the courts that adults were imprisoned improperly, in part, by children’s limited statements, have provided an impetus to improve the interviewing of children about suspected sexual abuse. Studies have examined actual interviews and various approaches to interviewing, and there is now an evidence base supporting specific approaches to interviewing children about sexual or physical abuse. The most studied interview protocol is the NICHD protocol developed by Lamb and colleagues.³¹ Finding Words, which is an interviewing protocol with some similarities to the NICHD protocol, has been adopted by several states, but has been studied less extensively. In addition, forensic interviewers have been specially trained on how to interview children and ask children non-leading questions about their experiences. Few data are available about the quality of the interviews conducted by forensic interviewers in the field.

ATTENTION TO PREVENTION

A major focus has been directed toward prevention. Not surprisingly, it was difficult to focus on prevention when maltreated children were neither being appropriately recognized nor receiving the appropriate evaluation and treatment. Since the 1980s, however, there has been increasing attention to prevention.³² For child sexual abuse, these preventive efforts have targeted young children, who often are taught about good and bad touch. Research examining the effects of these programs has shown changes in the knowledge of children about these areas. It has been more difficult to show changes in behaviors,³³ but many clinicians are aware of children who disclosed ongoing sexual abuse after participating in such educational activities. Children who have participated in such programs also may be more likely to tell family members about attempted sexual abuse.

During the last two decades, there has been a renewed interest in the development of programs to prevent physical abuse and neglect.³⁴-³⁷ A major strategy has been the use of regular and frequent home visiting for socially high-risk, first-time mothers, beginning during pregnancy or shortly after the child’s birth and continuing through the first 2 or 3 years of the child’s life. The home visitors have been nurses, paraprofessionals, or, sometimes, trained volunteers. The home visitor uses a parenting curriculum, develops a therapeutic relationship with the parents, and aims to do the following:

—Provide advice about and model effective parenting

—Help parents develop parenting skills and good relationships with their infants

—Help parents understand appropriate expectations about their child’s development

—Help parents make good life decisions about important topics, such as returning to school, choice of day care, or leaving an abusive partner

—Recognize early problems related to family violence and maltreatment in the home

—Help ensure that the child receives appropriate medical care

—Help families link to appropriate community-based services, such as mental health services for the mother or developmental services for the child

Evaluations of the effectiveness of such prevention programs are methodologically complex and extremely costly to conduct. Rigorous evaluations of nurses providing the home visiting services have been conducted by Olds and colleagues.³⁸-⁴¹ In a series of randomized trials, these investigators have shown that in families receiving home visitations (from the prenatal period to the child’s second birthday) compared with those receiving standard care, there are lower rates of serious injuries to the child and, over time, lower rates of reports to CPS.³⁸-⁴¹ In addition, in a 15-year follow-up, mothers in the intervention group who were not married and were from households of low income at the time of enrollment had fewer children, fewer months receiving welfare benefits, and fewer arrests.³⁸ There were long-term benefits for the children as well. For example, adolescents whose mothers received home visitation and were unmarried and of low socioeconomic status had fewer arrests and fewer lifetime sex partners, smoked less frequently, and consumed less alcohol compared to adolescents of comparable mothers who did not get the intervention.⁴¹ These long-term results have helped to stimulate interest in early preventive services for socially high-risk children and families.

Other models of preventive services, such as Triple P, have been studied using randomized trials. Triple P is a population-based approach to providing parenting interventions at five different levels of support for families. The services aim to prevent developmental, behavioral, and emotional problems in children. This intervention has been studied in a randomized trial based on geographical regions. Compared to standard care, children in the intervention group had fewer substantiated cases of child maltreatment, fewer injuries due to child maltreatment, and fewer out-of-home placements. ⁴²

A few regional or state-level efforts have attempted to develop a comprehensive approach to providing prevention services. For example, over the last 15 years in the state of Connecticut, the Children’s Trust Fund has worked with the legislature to expand the home visiting program from 2 to 42 sites.⁴³ These sites include all 29 birthing hospitals and 13 additional sites in two urban communities. There are statewide policies and procedures manuals, an administrative structure including committees of supervisors and home visitors in the field, and an ongoing evaluation to track findings such as the yearly number of substantiated reports to CPS. All first-time mothers are screened for eligibility either prenatally or during the postpartum period in the hospital, and socially high-risk families (based on a screening measure) are offered the home visiting services. Each year about 2000 families receive weekly home-visiting services.

Since 2010, there has been a new interest in prevention by the federal government, and funding for home visiting to promote child development and to prevent maltreatment is available through the health care reform act (Patient Protection and Affordable Care Act or Affordable Care Act).⁴⁴ This funding has been aimed at developing and expanding statewide prevention programs using evidence-based interventions.

A MARKED INCREASE IN RESEARCH

A ninth change has been the marked increase in research focused on child maltreatment. This research has advanced the field in many important ways, including the following:

—Research has had important effects on practice. For example, studies have examined the range of normal genital⁴⁵ and anal⁴⁶ findings in children and compared the physical findings in nonsexually abused and sexually abused children.⁴⁷ Studies have examined the effects of interviewing children in different ways both in the laboratory settings,²⁹ where the experimental variables can be manipulated, and in the real-world settings of interviewing children about their actual experiences.⁴⁸ Other studies have examined accidental vs. abusive injuries.⁴⁹ A series of studies examining the evidence base of the association of specific injuries such as bruises or retinal hemorrhages has been conducted by the Welsh Child Protection Systematic Review Group using a meta-analytic approach.⁵⁰

—Research has contributed to describing the phenomenon of child maltreatment and the range of clinical presentations and findings.⁵¹-⁵³

—Research has had a profound effect on the understanding of the scope of the problem and the short- and long-term consequences of maltreatment.⁵⁴ These studies have made it increasingly clear that child maltreatment is not just a childhood problem.⁵⁵-⁵⁷

—Other topics have been addressed, but clearly need more attention. For example, few studies have examined the effectiveness of various kinds of mental health treatments for maltreated children⁵⁸,⁵⁹ and even fewer studies have examined the practices of CPS agencies, ways to improve them, and comparisons of alternative ways of practice.⁶⁰

—Although the research and the number of researchers focusing on child maltreatment have greatly increased, concern remains that not enough attention has been paid to the problem of child maltreatment by the National Institutes of Health (NIH) and other federal agencies that fund research. This lack of federal funding has made it difficult to conduct large and expensive research projects on child maltreatment and to attract researchers to the field of child maltreatment.

THE CONSEQUENCES EXTEND INTO ADULT LIFE

Over the last decades, there have been increasingly sophisticated research efforts to understand the consequences of maltreatment. The following three epidemiological approaches have been used to investigate this problem:

—A few investigators have used longitudinal cohorts to follow maltreated and comparison children over time and have investigated outcomes, such as developmental problems, juvenile or adult violence, mental health problems, and substance abuse.⁶¹

—A second approach has been to use a case-control design in which cases are adults with a specific problem such as depression, and controls are adults who do not have the problem.⁶² Researchers then ask both groups about childhood experiences, such as physical abuse or sexual abuse.

—A third approach has been to identify a sample of adults from a specific population, such as individuals from a geographic area or members of a health maintenance organization. The adults are asked about both their past experiences, such as physical abuse, and their current functioning, such as physical and mental health.⁵⁵-⁵⁷ Rates of the outcomes are then compared in the groups with and without certain past experiences.

These approaches have provided clear evidence that maltreatment has important long-term effects on physical and mental health, substance use or abuse, interpersonal relationships, perpetrating maltreatment, criminality, and parenting. For example, in the Adverse Childhood Experiences (ACE) Study, members of the Kaiser Health Plan in San Diego completed a questionnaire about health and eight adverse childhood experiences (or ACEs): emotional, physical, and sexual abuse, exposure to domestic violence, house-hold substance use, mental illness in the household, parental separation or divorce, and an incarcerated household member. Reports have shown strong relationships between the number of adverse childhood experiences and health and mental health outcomes, such as attempted suicide,⁵⁵ smoking,⁵⁶ and unintended pregnancies.⁵⁷ In the study on attempted suicide, adults who had four adverse childhood experiences were four times more likely to have attempted suicide in their lifetime compared with adults who reported no such childhood experience. For adults reporting at least seven such childhood experiences, the increased risk was 17-fold.⁵⁵

In addition to epidemiological studies concerning the consequences of child maltreatment, there has been increasing interest in how early experiences affect gene expression and the development of the brain and the neuroendocrine system.⁶³

CONCLUSION

The challenges of providing care to maltreated children and their families are clear. Early recognition of child maltreatment will help stop the maltreatment experienced by children, help families change their behaviors, and in some cases save lives. Once the maltreatment is recognized, appropriate medical and mental health services can help children and families begin to heal and understand what has happened to them. A long-term goal of such treatment is to reduce the physical and mental health consequences of maltreatment that can continue into adulthood. In addition to recognition and treatment, a major effort will be needed to expand preventive services so that all high-risk families and eventually all families with young children can receive appropriate preventive and supportive services.

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18.Finkelhor D. Current information on the scope and nature of child sex abuse. Future Child. 1994;4:31-53.

19.Bavolek SJ. The Nurturing Parenting Programs. Washington, DC: Office of Juvenile Justice and Delinquency Prevention, US Department of Justice; 2000.

20.Belsky J. The determinants of parenting: a process model. Child Dev. 1985;55:83-96.

21.Faller KC. Understanding Child Sexual Maltreatment. Newbury Park, CA: Sage Publications; 1993.

22.Salter D, McMillan D, Richards M, et al. Development of sexually abusive behaviour in sexually victimised males: a longitudinal study. Lancet. 2003;361:471-476.

23.Quality Improvement Center on Differential Response in Child Protective Services. Differential response in child protective services: a literature review. Children’s Bureau, US Department of Health and Human Services Administration for Children and Families; 2009. www.differentialresponseqic.org/assets/docs/quilit-review-sept-09/pdf. Accessed July 1, 2011.

24.National Association of Children’s Hospitals and Related Institutions. Defining the children’s hospital role in child maltreatment. http://www.wrcactoolkit.org/upload/Children’s%20Hospitals’%20role%20in%20child%20maltreatment.pdf. Accessed September 12, 2013

25.National Association of Children’s Hospitals and Related Institutions. Responding to child maltreatment: 2008 survey findings and trends. www.childrenshospitals.net/AM/Template.cfm?Section=Winter_2010&Template/CM/ContentDisplay.cmf&ContentID=42015. Accessed June 15, 2011.

26.Cross TP, Jones LM, Walsh WA, Simone M, Kolko D. Child forensic interviewing in Children’s Advocacy Centers: empirical data on a practice model. Child Abuse Negl. 2007;31:1031-1052.

27.Walsh WA, Cross TP, Jones LM, Simone M, Kolko D. Which sexual abuse victims receive a forensic medical examination? the impact of Children’s Advocacy Centers. Child Abuse Negl. 2007;31:1053-1068.

28.Eisen ML, Quas JA, Goodman GS, eds. Memory and Suggestibility in the Forensic Interview. Mahwah, NJ: Lawrence Erlbaum Associates; 2002.

29.Ceci SJ, Bruck M. Jeopardy in the Courtroom: A Scientific Analysis of Children’s Testimony. Washington, DC: American Psychological Association; 1995.

30.Saywitz KJ, Goodman GS, Nicholas E, Moan SF. Children’s memories of a physical examination involving genital touch: implications for reports of child sexual abuse. J Consult Clin Psychol. 1991;59:682-691.

31.Lamb ME, Orbach Y, Hershkowitz I, Esplin PW, Horowitz D. A structured forensic interview protocol improves the quality and informativeness of investigative interviews with children: a review of research using the NICHD investigative interview protocol. Child Abuse Negl. 2007;31:1201-1231.

32.Daro D, Donnelly AC. Charting the waves of prevention: two steps forward, one step back. Child Abuse Negl. 2002;26:731-742.

33.Leventhal JM. Programs to prevent sexual abuse: what outcomes should be measured? Child Abuse Negl. 1987;11:169-171.

34.Donelan-McCall N, Eckenrode J, Olds DL. Home visiting for the prevention of child maltreatment: lesson learned during the past 20 years. Pediatr Clin North Am. 2009;56:389-403.

35.Leventhal JM. Twenty years later: we do know how to prevent child abuse and neglect. Child Abuse Negl. 1996;20:647-653.

36.Leventhal JM. Prevention of child abuse and neglect: successfully out of the blocks. Child Abuse Negl. 2001;25:431-439.

37.Leventhal JM: Getting prevention right: maintaining the status quo is not an option. Child Abuse Negl. 2005;29:209-213.

38.Olds DL, Eckenrode J, Henderson CR, et al. Long-term effects of home visitation on maternal life course and child abuse and neglect: 15-year follow-up of a randomized trial. JAMA. 1997;278:637-643.

39.Kitzman H, Olds DL, Henderson CR Jr, et al. Effect of prenatal and infancy home visitation by nurses on pregnancy outcomes, childhood injuries, and repeated childbearing: a randomized controlled trial. JAMA. 1997;278:644-652.

40.Olds DL, Robinson J, O’Brien R, et al. Home visiting by paraprofessionals and by nurses: a randomized, controlled trial. Pediatrics. 2002;110:486-496.

41.Olds D, Henderson CR, Cole R, et al. Long-term effects of nurse home visitation on children’s criminal and antisocial behavior: 15-year follow-up of a randomized controlled trial. JAMA. 1998;280:1238-1244.

42.Prinz RJ, Sanders MR, Shapiro CJ, et al. Population-based prevention of child maltreatment: the U.S. Triple P System population trial. Prev Sci. 2009;10:1-12.

43.Foley-Schain K, Finholm V, Leventhal JM: Building a state-wide home visiting program from 2 to forty-two sites: a state agency’s perspective. Child Abuse Negl. 2011;35:283-286.

44.Patient Protection and Affordable Care Act. http://www.dol.gov/ebsa/healthreform/. Accessed August 10, 2011.

45.McCann J, Wells R, Simon M, Voris J. Genital findings in prepubertal girls selected for nonabuse: a descriptive study. Pediatrics. 1990;86:428-439.

46.McCann J, Voris J, Simon M, Wells R. Perianal findings in prepubertal children selected for nonabuse: a descriptive study. Child Abuse Negl. 1989;13:179-193.

47.Berenson AB, Chacko MR, Wiemann CM, Mishaw CO, Friedrich WN, Grady JJ. A case-control study of anatomic changes resulting from sexual abuse. Am J Obstet Gynecol. 2000;182:820-834.

48.Teoh YS, Yang PJ, Lamb ME, Larsson AS. Do human figure diagrams help alleged victims of sexual abuse provide elaborate and clear accounts of physical contact with alleged perpetrators? Appl Cognit Psychol. 2010;24:287-300.

49.Pierce MC, Kaczor K, Aldridge S, O’Flynn J, Lorenz DJ. Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics. 2010;125:67-74.

50.Welsh Child Protection Systematic Review Group. www.core-info.cardiff.ac.uk. Accessed July 15, 2011.

51.Thomas SA, Rosenfield NS, Leventhal JM, Markowitz RI: Long bone fractures in young children: distinguishing accidental injuries from child abuse. Pediatrics. 1991;88:471-476.

52.Roesler TA, Jenny C. Medical Child Abuse: Beyond Munchausen Syndrome By Proxy. Evanston, IL: American Academy of Pediatrics; 2008.

53.McIntosh N, Mok JYQ, Margerison A. Epidemiology of oronasal hemorrhage in the first 2 years of life: implications for child protection. Pediatrics. 2007;120:1074-1078.

54.Kendall-Tackett KA, Williams LM, Finkelhor D. Impact of sexual abuse on children: a review and synthesis of recent empirical studies. Psychol Bull. 1993;113:164-180.

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58.Deblinger E, Stauffer LB, Steer RA. Comparative efficacies of supportive and cognitive behavioral group therapies for young children who have been sexually abused and their nonoffending mothers. Child Maltreat. 2001;6:332-343.

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Chapter 2

SKELETAL AND VISCERAL RADIOLOGICAL IMAGING

Megan Marine, MD

Richard Gunderman, MD, PhD

HISTORY OF CHILD ABUSE

Child maltreatment was first studied and described by French physician, Ambroise Tardieu in the mid-1800s before the use of diagnostic x-rays. Tardieu was a pre-eminent forensic medical scientist who devoted a significant part of his career to trying to unveil the inexplicable nature of child abuse. His work, Etude Medico-Legale sur les Sevices et Mauvais Traitements Exerces sur des Enfants (Forensic Study on Cruelty and Ill-Treatment of Children), published in 1860, is a classic description of battered child syndrome. He reported 32 cases, 18 of which resulted in death. A tireless advocate for children, he also published articles on the terrible working conditions children endured in factories and mines, as well as sexual abuse and infanticide. Many of his colleagues and successors did not believe his allegations of physical and sexual abuse. Unfortunately victims continued to suffer in silence for nearly another century.¹

In 1946 John Caffey, pioneer of pediatric radiology, published the first systematic clinical and radiologic study of child abuse victims, reporting 6 children under age 2 years with extremity fractures and subdural hematomas.² Caffey’s junior associate, pediatrician Frederick Silverman, then detailed the radiographic findings of child abuse in 1953, describing both posterior rib fractures and metaphyseal lesions, two of the most specific injuries highly associated with abuse.³ Following Silverman’s collaboration with pediatrician and researcher Henry Kempe, the landmark article The Battered Child Syndrome, was published in the Journal of the American Medical Association in 1962, which led to the recognition of child abuse by the medical community.⁴

In 1972 Kempe founded The Kempe Center for the Prevention and Treatment of Child Abuse and Neglect. Twelve years later, Kempe was nominated for the Nobel Peace Prize for his contribution to child abuse prevention and treatment, and he is now considered one of the American pioneers of the detection, treatment, and prevention of child abuse. His efforts resulted in the adoption of abuse-reporting laws in all 50 US states.⁵ Currently, all 50 states, the District of Columbia, and the US Territories have mandatory child abuse and neglect reporting laws that require that suspicions of abuse be reported to a child protective services (CPS) agency.⁶

EPIDEMIOLOGY OF CHILD ABUSE

The Child Abuse Prevention and Treatment Act (CAPTA), as amended by the Keeping Children and Families Safe Act of 2003, defines child abuse and neglect as any recent act or failure to act on the part of a parent or caregiver that results in death, serious physical or emotional harm, sexual abuse or exploitation; or an act or failure to act that presents an imminent risk of serious harm.⁶

The Child Maltreatment Report released in December 2010 found a staggering 702 000 US children to be victims of child abuse and neglect in 2009.⁶ These numbers likely underestimate the extent of the problem, as reported cases understate the true incidence.⁷ Neglect accounted for the majority (78.3%) of victims. Physical abuse accounted for 17.8% of child victims, or 124 956 children. Sexual abuse was found in 9.5%; 7.6% were psychologically maltreated; and 2.4% were medically neglected. In addition, 9.6% of victims experienced such other types of maltreatment as abandonment or congenital drug addiction.⁶

Fatal abuse and serious abusive injuries are more common among children and infants younger than 2 years.⁸ Forty-nine states reported a total of 1 676 fatalities in 2009. Based on these data, a nationally estimated 1 770 children died from abuse and neglect in 2009.⁶

Infants from birth to age 1 year are the most vulnerable victims of abuse and neglect at a rate of 20.6 per 1000 children of the same age group, representing 12.6% of all abuse and neglect victims. One-third of all victims of maltreatment were younger than 4 years.6

The perpetrators of child abuse are most commonly parents (80.9%), and another 6.3% are other relatives of the victim.⁶ Child physical abuse affects children of all ages, genders, ethnicities, and socioeconomic groups; however, there are important risk factors, including socioeconomic status. Children in homes with annual incomes of less than $15 000 have 3 times the number of fatalities, 7 times the number of serious inflicted injuries, and 5 times the number of moderate inflicted injuries compared with children living in homes with annual incomes exceeding $15 000.⁹ Additional risk factors include maternal smoking, more than 2 siblings, low infant birth weight, and an unmarried mother.¹⁰ One study found that children living in households with unrelated adults were approximately 50 times more likely to die of inflicted injuries than were children residing with 2 biological parents.¹¹ Children with disabilities are also at an increased risk for physical abuse, found to be as substantial as 2.1 times higher according to the US Department of Health and Human Services.¹²

INTERNATIONAL PREVALENCE OF CHILD ABUSE

Violence against children happens in every country and society. Some is even allowed by national laws and is rooted in cultural, economic, and social practices. Violence occurs in the home, in educational settings, in care and justice systems, in places of work, and in the community. This includes modes of violence seen less commonly in the United States, such as child labor, exploitation of children, sexual violence, genital mutilation, as well as corporal punishment, which is legal in penal institutions in at least 77 countries.¹³

Prevalence studies of international child abuse have largely been limited to sexual abuse, as these children tend to be older and are more likely to remember their abuse.¹⁴ Additionally, international comparisons of child abuse can be difficult given the different laws, child welfare systems, and the very definition of child abuse, which varies across the world.¹⁵

According to the National Society for Prevention of Cruelty to Children, annual rates of reported and substantiated cases of child abuse indicate a lower incidence in specific countries, including Australia, Canada, and England. For example, in 2002-2003, Australia had 40 416 cases, or 6.8 per 1000 child population. In 1998, Canada had 61 000 cases, or 9.7 per 1000 child population. In 2002-2003, England had 30 200 cases, or 2.7 per 1000 child population. This compared to the United States in 2001 with a total of 492 108 cases, or 12.4 per 1000 child population.¹⁴

IMAGING OF CHILD ABUSE

The American College of Radiology (ACR) has specific imaging guidelines, or appropriateness criteria, for imaging in children of suspected physical abuse. In children less than age 24 months, x-ray skeletal survey and head computed tomography (CT)without contrast are usually appropriate radiologic procedures. In children older than age 24 months, the value of the skeletal survey is less and radiographs should be tailored to the suspected area of injury.⁷

The radiographic skeletal survey should be obtained using high-detail imaging and coned down to the area of interest for each body part. The survey consists of frontal and lateral views of the skull, lateral views of the cervical and thoracolumbosacral spine, and single frontal views of the chest and abdomen. Oblique views of the ribs should also be obtained to increase the sensitivity and specificity for detection of rib fractures. Additionally, frontal views of the long bones should be obtained, each separately, of the arms, forearms, thighs, legs, hands, and feet to improve image quality.⁷ Lateral views of the entire long bone are performed at our institution and were reportedly performed routinely at 16.8% of 107 participating children’s health care centers in 2004.¹⁶ Our experience demonstrates lateral radiographs of the long bone significantly increase detection and confidence levels of metaphyseal fractures.¹⁷

The ACR states that Tc-99m whole body bone scan may be appropriate if the skeletal survey is negative and high clinical suspicion remains.⁷

Additionally, head MRI may be appropriate if further evaluation is indicated from the head CT or there are neurologic signs and symptoms. In suspected thoracic and/or abdomen/pelvis injuries, CT chest and/or abdomen/pelvis with intravenous contrast is recommended.⁷

The American Academy of Pediatrics (AAP) currently recommends an x-ray skeletal survey with possible radionuclide bone scan for acute rib fractures and subtle non-displaced long bone fractures. For intracranial and extracranial injury, CT scan of the head and possibly head/neck magnetic resonance imaging (MRI) are recommended. CT scan with intravenous contrast of the abdomen is recommended for suspected abdominal injury. When a child is identified as a suspected victim of abuse, siblings and other child contacts of the suspected abuser should also be assessed for injuries.¹⁸

TYPES OF CHILD ABUSE

In the United States, neglect is the most common form of child maltreatment, implying the omission of care, education, supervision, protection, attention to medical needs, and physical and emotional support. Physical abuse is the second most common form of abuse and is the most relevant form with regard to medical imaging. Physical abuse includes such behaviors as beating, violently shaking, scalding, and biting.¹⁵ Bruises are the most common manifestation of physical abuse and skeletal fractures are the second most common.¹⁹ All organ systems are affected.

ROLE OF THE RADIOLOGIST

The pediatric radiologist plays an integral role in the detection, diagnosis, and legal proceedings in cases of child abuse. Recognizing injuries and having knowledge of the types of injuries associated with child abuse, particularly when the mechanism of trauma does not explain the findings, is extremely important. More than 80% of all identified child abuse-related injuries are detected through medical imaging.²⁰ The pediatric radiologist serves as an advocate for children’s welfare. Radiologists commonly provide expert testimony on what has been radiologically established and is supported on the basis of his/her professional experience and knowledge.²¹ Pediatric radiologists also routinely interpret post-mortem skeletal surveys for unexplained death in an infant or child, aiding in the determination of the cause of death to ensure proper handling of these cases by the legal system.²²

MANIFESTATIONS OF CHILD ABUSE

Common examples of musculoskeletal, neurologic, abdominopelvic, and thoracic non-accidental trauma manifestations follow.

MUSCULOSKELETAL FINDINGS

No single fracture is characteristic of child abuse; however, particular fractures strongly suggest it. Highly specific fractures include classic metaphyseal lesions (CMLs), posterior rib fractures, and scapula, spinous process, and sternal fractures. Those of moderate specificity include multiple fractures, fractures of different ages, epiphyseal separations, vertebral body fractures, digital fractures, and complex skull fractures. Low-specificity fractures for abuse include subperiosteal new bone formation, fractures of the clavicle and long bone shaft, and simple skull fractures.²³

Posterior and lateral rib fractures are considered to be caused by squeezing or compressive forces.²⁴ These fractures are not uncommonly multiple. When faced with multiple fractures, it is important to determine the ages of the fractures, as finding fractures of differing ages increases concern for child abuse. The timetable of radiographic changes include soft tissue swelling, followed by subperiosteal new bone formation as early as 4 days and always by 2 weeks, loss of fracture line and soft callus, hard bony callus, and bony remodeling peaking at 8 weeks. There is, however, considerable overlap, making the dating of fractures an inexact science relying on the radiologist’s personal clinical experience.²⁵ (Figures 2-1-a and b).

Figure 2-1-a. Girl, 3 months old, with multiple bilateral posterior and lateral healing rib fractures with hard bony callus formation.

Figure 2-1-b. Same patient as in 2-1a, 2 days later. Technetium 99m MDP bone scan demonstrates multiple bilateral rib fractures.

Repeat radiographs or skeletal survey performed approximately 2 weeks after the initial examination can provide additional information on the presence and age of child abuse fractures.²⁶ These should be performed when abnormal or equivocal findings are found on the initial study and when abuse is suspected on clinical grounds.²⁷ (Figures 2-1-c, 2-2-a and b).

Figure 2-1-c. Nineteen days later. Note the change in the appearance of the healing rib fractures. The proximal left humeral metaphyseal fracture now also noted.

Figures 2-2-a and b. Boy, 22 days old, with bilateral acute posterior rib fractures. On the right, 14 days later, the fractures now show bony callus formation.

A classic metaphyseal lesion occurs when an acceleration-deceleration and/or torsional force is applied to the immature primary spongiosa adjacent to a cartilaginous growth plate, the most immature portion of metaphysis.²⁸ These fractures are commonly referred to as corner or bucket-handle type fractures depending on the projection of the radiograph. (Figures 2-3-a to d, 2-4 and 2-5-a to c).

Sternal fractures have a higher specificity for child abuse but are uncommon, given the malleability of thorax at an early age. Mechanism of fracture is likely direct blow or forceful compression of chest.²⁹,³⁰

Figures 2-3-a and b. Girl, 5 months old, with slight irregularity of the proximal tibia metaphysis.

Figures 2-3-c and d. Follow-up radiographs 16 days later better demonstrate the healing proximal tibia classic metaphyseal lesion or bucket handle fracture.

Figure 2-4. Girl, 3 months old, with healing distal tibia and fibula metaphyseal fractures.

Figures 2-5-a and b. Boy, 20 months old, with acute distal radius CML. Normal left side is shown for comparison.

Figure 2-5-c. Same patient as in 2-5-b, with less commonly seen healing metacarpal fractures, moderately specific for child abuse.

Scapular fractures are also rare, thanks to their protective surrounding muscle and connective tissue. The mechanism is typically severe, high-energetic trauma. The acromion is the most common location for a fracture, which can result from indirect trauma such as shaking or when arm is turned onto back with significant force.³⁰ (Figures 2-6-a and b).