Paediatric femur fractures at the emergency department: accidental or not?

Only a small proportion of all paediatric fractures is caused by child abuse or neglect, especially in highly prevalent long bone fractures. It can be difficult to differentiate abusive fractures from non-abusive fractures. This article focuses on femoral fractures in young children. Based on three cases, this article presents a forensic evidence-based approach to differentiate between accidental and non-accidental causes of femoral fractures. We describe three cases of young children who were presented to the emergency department because of a suspected femur fracture. Although in all cases, the fracture had a similar location and appearance, the clinical history and developmental stage of the child led to three different conclusions. In the first two cases, an accidental mechanism was a plausible conclusion, although in the second case, neglect of parental supervision was the cause for concern. In the third case, a non-accidental injury was diagnosed and appropriate legal prosecution followed. Any doctor treating children should always be aware of the possibility of child abuse and neglect in children with injuries, especially in young and non-mobile children presenting with an unknown trauma mechanism. If a suspicion of child abuse or neglect arises, a thorough diagnostic work-up should be performed, including a full skeletal survey according to the guidelines of the Royal College of Radiologists and the Royal College of Paediatrics and Child Health. In order to make a good assessment, the radiologist reviewing the skeletal survey needs access to all relevant clinical and social informatio

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

Prevalence of suspected child abuse in children with constipation: A case-control study

Background A possible association between child abuse and neglect (CAN) and functional constipation (FC) has been described in adults, however, limited data are available in children. Our objective was to determine the prevalence of suspected CAN in children with FC as compared with their healthy peers. Methods A case-control study was carried out in children aged 3-10 years. Children with FC were recruited at a tertiary outpatient clinic, and healthy controls were recruited at schools. Parents were asked to fill out questionnaires about the history and behaviour of their child, children were inquired using a semistructured interview about experienced traumatic events and sexual knowledge. The interview was scored by two independent observers. The prevalence of suspected CAN was determined according to the questionnaires and interview. Results In total, 228 children with FC and 153 healthy controls were included. Both groups were age and gender comparable (50% females, median age 6 years (not significant)). No significant difference in the prevalence of suspected CAN was found between children with FC and healthy controls (23.3% vs 30.1%, 95% CI 0.44 to 1.12, p=0.14), including a suspicion of sexual, emotional and physical abuse. Conclusion Suspected CAN was detected in both children with FC as in healthy controls. The possible association between CAN and FC in children could not be confirmed

The Diagnostic Utility of the Child Sexual Behavior Inventory for Sexual Abuse: A Systematic Review

Children with alleged child sexual abuse (CSA) need to be assessed systematically. The use of validated instruments during the assessment, like the Child Sexual Behavior Inventory (CSBI), could add diagnostic value. We aim to assess the diagnostic utility of the CSBI to differentiate between sexually abused and non-abused children. We conducted a systematic review. We searched the electronic databases MEDLINE and PsychInfo for studies comparing CSBI scores in sexually abused children and non-abused children (2–12 years old). Two independent reviewers extracted data and assessed the methodological quality. We included 7 (out of 1048) articles. The CSBI total scores were significantly higher in CSA-victims compared with non-abused children (in case–control settings). However, in children with suspected CSA, the results were ambiguous. One study reported significant differences. Another study reported weak diagnostic ability for the CSBI-3 in children with suspected CSA (a sensitivity and specificity of 0.50, with a positive predictive value of 0.28, and a negative predictive value of 0.72). Research on the diagnostic utility of the CSBI for suspected CSA is limited and shows disappointing results. Until more research is done, the CSBI should not be used on its own to differentiate between sexually abused and non-abused children

Assessments carried out by a child abuse and neglect team in an Amsterdam teaching hospital led to interventions in most of the reported cases

Aim: This study described cases of child abuse and neglect (CAN) that were reported to the multiagency CAN team at the Emma Children's Hospital in Amsterdam and the resulting interventions. Methods: We carried out a retrospective review of all cases that were reported to the CAN team from 1 January 2010 to 31 December 2012. Results: There were 27 prenatal cases, 92 referrals based on parental characteristics and 523 children. Overall, 1.2% of the children visiting the emergency department of our hospital, attending the outpatients department or being admitted were reported to the team. More than half of the referrals (55.1%) were confirmed as CAN. The most common diagnoses were as follows: witnessing intimate partner violence, physical neglect and emotional abuse. If CAN was confirmed an intervention was offered in 98.3% of cases. If a CAN diagnosis was undetermined or rejected, the figures were still 83.5% and 64.2%, respectively. Conclusion: Our results showed that CAN affected more than one in every 100 children visiting our hospital, and the expertise of our hospital-based CAN Team led to an intervention in the majority of the reported cases. The broad scope of problems that were encountered underlined the importance of a multidisciplinary CAN tea

Physical symptoms in very young children assessed for sexual abuse: a mixed method analysis from the ASAC study

So far, a recognizable pattern of clinical symptoms for child sexual abuse (CSA), especially in young male children, is lacking. To improve early recognition of CSA, we reviewed physical complaints, physical examination, and tests on sexually transmitted infections (STIs) in confirmed victims (predominantly preschool boys) of CSA from the Amsterdam sexual abuse case (ASAC). We retrospectively analyzed the outcomes of the primary assessment using mixed methods: descriptive analysis of physical complaints, physical exams, and STI tests from medical files and a qualitative analysis on expert's interpretations of physical complaints and children's behavior during physical examination. We included 54 confirmed CSA victims, median age 3.2 (0-6) years, 43 boys (80%), and 11 girls (20%). Physical complaints were reported in 50%, of which gastrointestinal and anogenital complaints were most common. None of the children showed CSA-specific genital signs at physical examination. Most prominent finding during physical examination was a deviant behavioral response (anxiety, withdrawal, too outgoing) in 15 children (28%), especially in children who experienced anal/vaginal penetration. Testing for STIs was negative. Conclusion: Physical complaints and physical signs at examinations were non-specific for CSA. Deviant behavioral reactions during physical examination were the most prominent finding. Precise observation of a child's behavior during physical examination is neede