Educational paper: Imaging child abuse: the bare bones

Fractures are reported to be the second most common findings in child abuse, after skin lesions such as bruises and contusions. This makes careful interpretation of childhood fractures in relation to the provided clinical history important. In this literature review, we address imaging techniques and the prevailing protocols as well as fractures, frequently seen in child abuse, and the differential diagnosis of these fractures. The use of a standardised protocol in radiological imaging is stressed, as adherence to the international guidelines has been consistently poor. As fractures are a relatively common finding in childhood and interpretation is sometimes difficult, involvement of a paediatric radiologist is important if not essential. Adherence to international guidelines necessitates review by experts and is therefore mandatory. As in all clinical differential diagnoses, liaison between paediatricians and paediatric radiologists in order to obtain additional clinical information or even better having joint review of radiological studies will improve diagnostic accuracy. It is fundamental to keep in mind that the diagnosis of child abuse can never be solely based on radiological imaging but always on a combination of clinical, investigative and social findings. The quality and interpretation, preferably by a paediatric radiologist, of radiographs is essential in reaching a correct diagnosis in cases of suspected child abuse

Preface

AimThis was a one-year follow-up of families referred to support services after the parents visited the emergency department due to intimate partner violence, substance abuse or a suicide attempt. Its aim was to evaluate the well-being of any children. MethodsData on families identified a year earlier by the Amsterdam protocol were gathered from child protective services and parent and child self-reports in two Dutch regions from 2012-2015. ResultsWe included 399 children (52%) boys with a median age of eight years (range 1-18) in the study using child protective services data. Of the 101 families who participated in the first measurement, 67 responded one year after the parent's emergency department visit. The results showed that 20% of the children had no or minor problems, voluntary support services were involved in 60% of cases and child protective services were involved in 20%. Compared to their first assessment a year earlier, the children's psychosocial problems had not increased, but this could have been an underestimation due to selective responses. ConclusionThe Amsterdam protocol was valuable in referring families to voluntary support services, but given the ongoing problems in some families, professionals need to carefully monitor whether support services are sufficiently effectiv

High prevalence of non-accidental trauma among deceased children presenting at Level I trauma centers in the Netherlands

PURPOSE: Between 0.1—3% of injured children who present at a hospital emergency department ultimately die as a result of their injuries. These events are typically reported as unnatural causes of death and may result from either accidental or non-accidental trauma (NAT). Examples of the latter include trauma that is inflicted directly or resulting from neglect. Although consultation with a forensic physician is mandatory for all deceased children, the prevalence of fatal inflicted trauma or neglect among children is currently unclear. METHODS: This is a retrospective study that included children (0–18 years) who presented and died at one of the 11 Level I trauma centers in the Netherlands between January 1, 2014, and January 1, 2019. Outcomes were classified based on the conclusions of the Child Abuse and Neglect team or those of forensic pathologists and/or the court in cases referred for legally mandated autopsies. Cases in which conclusions were unavailable and there was no clear accidental cause of death were reviewed by an expert panel. RESULTS: The study included 175 cases of childhood death. Seventeen (9.7%) of these children died due to inflicted trauma (9.7%), 18 (10.3%) due to neglect, and 140 (80%) due to accidents. Preschool children (< 5 years old) were significantly more likely to present with injuries due to inflicted trauma and neglect compared to older children (44% versus 6%, p < 0.001, odds ratio [OR] 5.80, 95% confidence interval [CI] 2.66–12.65). Drowning accounted for 14 of the 18 (78%) pediatric deaths due to neglect, representing 8% of the total cases. Postmortem radiological studies and autopsies were performed on 37 (21%) of all cases of childhood death. CONCLUSION: One of every five pediatric deaths in our nationwide Level I trauma center study was attributed to NAT; 44% of these deaths were the result of trauma experienced by preschool-aged children. A remarkable number of fatal drownings were due to neglect. Postmortem radiological studies and autopsies were performed in only one-fifth of all deceased children. The limited use of postmortem investigations may have resulted in missed cases of NAT, which will result in an overall underestimation of fatal NAT experienced by children. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s12024-021-00416-7

Zelfbeschadiging bij kinderen en adolescenten

Self-harm among children and adolescents is a prevalent health issue. Definitions of self-harm differ, and the distinction between attempted suicide or self-harm is often unclear. A recent large population-based cohort study on self-harm among children and adolescents aged 10-29 years showed a sharp increase in the incidence of self-harm, especially in girls aged 13-16 years. It also showed an inequality in treatment offered, depending upon the socio-economic profile of the region in which the patient presented.We illustrate the problem of self-harm by presenting a clinical case, and provide advice on when to suspect self-harm and how to proceed when self-harm is suspected. Furthermore, we show that a similar increase in incidence of self-harm to that which has taken place in the UK has also been signaled in the Netherlands. Self-harm is associated with an increased risk of death by suicide and other causes of unnatural death. Evidence for therapeutic options for self-harm is limited

Results of the implementation of a new screening protocol for child maltreatment at the Emergency Department of the Academic Medical Center in Amsterdam

This study examines the results of the implementation of a new screening protocol for child maltreatment (CM) at the Emergency Department (ED) of the Academic Medical Center in Amsterdam, The Netherlands. This protocol consists of adding a so called 'top-toe' inspection (TTI), an inspection of the fully undressed child, to the screening checklist for child maltreatment, the SPUTOVAMO. We collected data from all patients 0-18 years old directly after introduction (February 2010) and 9 months later. Outcome measures were: completion of the screening and reasons for non-adherence. Data were collected on age, gender, reason for visiting the ED (defined by International Classification of Disease, ICD), presence of a chronic illness, type of professional performing the TTI and admission during week or weekend days. In February 560 and in November 529 paediatric patients were admitted. In February the complete screening protocol was performed in 42% of all children, in November in 17%. A correlation between completion of the SPUTOVAMO and having a TTI performed was found. Older age and presence of a chronic illness influenced the chance of having both SPUTOVAMO and TTI performed negatively. The completion rate of SPUTOVAMO was influenced by ICD code. Completion of TTI was influenced by type of investigator. The best performing professional was the ED physician followed by the paediatrician followed by the ED nurse. The reasons for not performing a TTI were not documented. Refusal of the TTI by a patient or parent was reported three times. Implementation of this new screening protocol for CM was only mildly successful and declined in time. A negative correlation between older child age and having a chronic illness and completion of the screening was found. A practical recommendation resulting from this study could be that, if CM screening protocols prove to be effective in detecting CM, regular training sessions have to be held. Filling out the checklist is something that could be performed by ED nurses. Performing a TTI is perhaps easier for the ED physicians to make part of their daily routin

Clinical practice: recognizing child sexual abuse—what makes it so difficult?

Recognizing child sexual abuse (CSA) in children is difficult, as there can be many hurdles in the assessment of alleged CSA. With this paper, we try to improve the recognition of CSA by discussing: (1) the difficulties regarding this matter and (2) the diagnostic evaluation of alleged CSA, combining both practical clinical recommendations based on recent research. Children are restrained to disclose CSA due to various reasons, such as fears, shame, and linguistic or verbal limitations. Associations between CSA and urogenital or gastrointestinal symptoms, internalizing and externalizing behavioral problems, post-traumatic stress symptoms, and atypical sexual behavior in children have been reported. However, these symptoms are non-specific for CSA. The majority of sexually abused children do not display signs of penetrative trauma at anogenital examination. Diagnosing a STI in a child can indicate CSA. However, other transmission routes (e.g., vertical transmission, auto-inoculation) need to be considered as well. Conclusion: The assessment consists of medical interview and child interview (parents and child separate and together) with special attention to the child’s development and behavior (problems), psychosocial situation and physical complaints, the child’s mental health, and the child’s trauma history; anogenital examination should be done in all cases of alleged CSA. The examination should be documented by photo or video graphically. Recent research suggests that videography may be the preferred method, and testing on STIs. The assessment should be done multidisciplinary by experienced professionals. Health-care professionals who care for children need to know how child protective agencies and law enforcement are organized. In case there are concerns about a child’s safety, the appropriate authorities should be alarmed.What is Known:• Sexual abuse in children often remains unrecognized in the majority of cases.What is New:• Research suggests that videographic documentation is preferred above photographic documentation for anogenital examination; observations of children’s behavioral reactions during examinations might be valuable in the evaluation of suspected sexual abuse; nucleic acid amplification testing can be used on vaginal swabs or urine samples for chlamydia and gonorrhea; the CRIES-13 and the CAPS-CA can be used to assess trauma-symptoms in children after sexual abuse

New hospital-based policy for children whose parents present at the ER due to domestic violence, substance abuse and/or a suicide attempt

Child maltreatment is a major social problem with many adverse consequences, and a substantial number of maltreated children are not identified by health care professionals. In 2010, in order to improve the identification of maltreated children in hospitals, a new hospital-based policy was developed in Amsterdam, The Netherlands. This policy was adapted from another policy that was developed in The Hague, the Netherlands, in 2007. In the new Amsterdam policy, all adults presenting at the emergency department due to domestic violence, substance abuse, and/or a suicide attempt are asked whether they have any children in their care. If this is the case, parents are urged to visit the outpatient pediatric department together with all of their children. During this visit, problems are evaluated and voluntary referrals can be arranged to different care organizations. If parents refuse to cooperate, their children are reported to the Dutch Child Abuse Counseling and Reporting Centre. The two aims of this study are to describe (1) characteristics of the identified families and (2) the referrals made to different voluntary and involuntary care organizations during the first 2 years after implementation of the policy. Data were collected from medical records. One hundred and six children from 60 households were included, of which 68 children because their mother was a victim of domestic violence. Referrals to care organizations were arranged for 99 children, of which 67 on a voluntary basis. The Amsterdam policy seems successful in arranging voluntary support for the majority of identified childre

Screening methods to detect child maltreatment: high variability in Dutch emergency departments

In the Netherlands, screening for child maltreatment is mandatory in all emergency departments but it is unclear which screening methods are being used. As a first step towards implementation of a universal screening method across all emergency departments, we assessed the currently used screening methods. To provide an overview of the screening methods for child maltreatment across all emergency departments in the Netherlands and to assess their empirical substantiation. We surveyed all emergency departments in the Netherlands using a questionnaire on screening methods. All screening checklists used in emergency departments were assembled and compared with the literature. 85 hospitals with an emergency department were approached, 80 of which completed the questionnaire and 77 provided copies of their screening checklists. All participating hospitals use a screening checklist, 41% a screening physical examination, 60% a screening based on parental risk factors and 3% a retrospective review of all charts. The empirical substantiation for these screening methods is largely lacking, and at least 73% of the hospitals use a checklist that has not been reported in the literature. Large variations in screening methods exist across emergency departments in the Netherlands, most of which are not based on empirical evidenc