Combined rapid sequence MRI protocol and skull radiography as an alternative to head CT in the evaluation of abusive head trauma in children: a pilot study.

The aim of our pilot study was to compare the performance of the RS-MRI protocol combined with skull radiography versus CT for the detection of skull fractures, scalp hematomas, and intracranial hemorrhage in patients with abusive head trauma (AHT). Additionally, our study aimed to determine whether the presence of scalp hematoma predicts concurrent skull fracture. We conducted a pilot study through retrospective chart review of 24 patients between ages 0 and 15 months who experienced AHT and who received CT, MRI, and skull radiography between May 2020 and August 2021. Two blinded board certified neuroradiologists reviewed the skull radiographs alongside the rapid trauma MRI. Their impressions were documented and compared with findings derived from CT. Combination imaging detected ten out of the 12 skull fractures noted on CT (sensitivity 83.3%, specificity 100%, p=0.48). RS-MRI detected 15 out of the 16 intracranial hemorrhages detected by CT (sensitivity 93.75%, p >0.9). When scalp hematoma was detected on RS-MRI, nine out of the 12 had associated skull fractures when reviewed by radiologist 1 (sensitivity 75%, specificity 100%, p=0.22), and seven out of the 12 had associated skull fractures when reviewed by radiologist 2 (sensitivity 58%, specificity 92%, p=0.25). In pediatric patients with suspected AHT, we found that RS-MRI combined with skull radiographs was not significantly different than CT for the detection of skull fractures, scalp hematomas, and intracranial hemorrhage. This combination has the potential to replace the use of CT as a screening tool for abusive head trauma, while avoiding the risks of sedation often required for routine MRI.

Making Trauma Less Traumatic: Implementing Inpatient Pediatric Screening of Acute Stress Symptoms.

OBJECTIVES: Pediatric patients hospitalized for physical injury and trauma are at increased risk of developing acute stress disorder. Routine identification and referral for treatment of patients with psychological sequelae of traumatic injury were added to the accreditation requirements of the American College of Surgeons for pediatric trauma centers in 2022. We aimed to use quality improvement methodology with iterative interventions to increase psychological screening consults for admitted pediatric trauma patients to 80% in 6 months. METHODS: We planned a quality improvement intervention to increase identification of posttraumatic psychological symptoms in pediatric trauma patients. We created a Making Trauma Less Traumatic consultation service with a dedicated therapist to provide screening, treatment, and referral. Key interventions included education of key stakeholders and iterative improvements in consultation workflow. Our primary measure was frequency of eligible pediatric trauma patients who had consultation requests for posttrauma therapy during admission. We additionally monitored percent of patients with positive symptom screens and lost to follow-up. RESULTS: From September 2020 through November 2021, consults for eligible pediatric trauma patients improved from a baseline of 4.1% to a weekly mean of 100%. Of those screened, 32.7% had at least 1 symptom of acute stress. No families declined screening or therapy, though 29.5% were lost to intended follow-up. CONCLUSIONS: We present a successful model of implementing routine psychological screening of pediatric trauma patients utilizing a dedicated consultation service. A high number of admitted patients screened positive for symptoms during hospitalization. Families were accepting of the intervention though follow-up was challenging.

Implementation of the North Carolina Plan of Safe Care in Wake County, North Carolina.

BACKGROUND The Comprehensive Addiction and Recovery Act (CARA) of 2016 amended the Child Abuse Prevention and Treatment Act (CAPTA), reinforcing and revising the requirement that states develop policies and procedures to address the needs of substance-affected infants and their caregivers. North Carolina's program, the North Carolina Plan of Safe Care (NC POSC), was implemented in August 2017 and involves coordination between multiple agencies.METHODS We conducted a quality improvement project to assess implementation of the North Carolina Plan of Safe Care in Wake County through interviews with key stakeholders involved in program delivery including health care providers (n = 7), child protective services social workers (CPS; n = 14), and care managers at Care Coordination for Children (CC4C; n = 10). We also analyzed data on Plan of Safe Care notifications to Wake County CPS from January 2018 to October 2019.RESULTS Several key themes emerged in stakeholder interviews, including 1) lack of awareness of the program among health care providers; 2) gaps in information sharing and communication between agencies; 3) concerns regarding CPS notifications for all substance exposure types, including prenatal exposure to medication for opioid use disorder (MOUD); 4) common family needs and service referrals; 5) challenges engaging with families; 6) lack of knowledge among health care providers and CPS social workers regarding CC4C; and 7) benefits of the program for infants and families. From January 2018 to October 2019, 91% of notifications for substance-affected infants received by Wake County CPS as part of the NC POSC were screened-in for a maltreatment assessment. Of those screened-in, more than two-thirds (70%) involved prenatal marijuana exposure only.LIMITATIONS This project was limited to one county.CONCLUSIONS As NC POSC implementation continues, further consideration of the infrastructure and guidance available to address the implementation challenges identified by stakeholders will be essential to meeting family needs and promoting infant safety and well-being.

Prevalence of Injuries Among Medicaid Enrolled Infants Prior to Child Abuse and Neglect.

Prior research has identified common injuries among children who experience child maltreatment; however, most of this work has focused on inpatient settings and has excluded many cases of neglect. This study examines the prevalence of injuries that occur prior to a diagnosis of child maltreatment, as well as the proportion of children with well-child visits prior to the injury and child maltreatment diagnosis. Based on a secondary analysis of Medicaid data from four states, we found that among infants with 12 months of continuous enrollment (N = 4817), 30.6% of those diagnosed with maltreatment were previously diagnosed with an injury. Among infants diagnosed with child maltreatment, 88.4% had at least one well-child visit prior to the maltreatment diagnosis. Among children with a maltreatment diagnosis and a prior injury, 84% had at least one well-child visit preceding the injury. These results indicate that most children had at least one well-child visit prior to being diagnosed with child maltreatment or an injury, indicating opportunities for prevention.

Prenatal Substance Exposure and Child Maltreatment: A Systematic Review.

State and federal policies regarding substance use in pregnancy, specifically whether a notification to child protective services is required, continue to evolve. To inform practice, policy, and future research, we sought to synthesize and critically evaluate the existing literature regarding the association of prenatal substance exposure with child maltreatment. We conducted a comprehensive electronic search of PubMed, Web of Science, PsycInfo, CHINAL, Social Work Abstracts, Sociological Abstracts, and Social Services Abstracts. We identified 30 studies that examined the association of exposure to any/multiple substances, cocaine, alcohol, opioids, marijuana, and amphetamine/methamphetamine with child maltreatment. Overall, results indicated that substance exposed infants have an increased likelihood of child protective services involvement, maternal self-reported risk of maltreatment behaviors, hospitalizations and clinic visits for suspected maltreatment, and adolescent retrospective self-report of maltreatment compared to unexposed infants. While study results suggest an association of prenatal substance exposure with child maltreatment, there are several methodological considerations that have implications for results and interpretation, including definitions of prenatal substance exposure and maltreatment, study populations used, and potential unmeasured confounding. As each may bias study results, careful interpretation and further research are warranted to appropriately inform programs and policy.

Incidence of Injury, Maltreatment, and Developmental Disorders Among Substance Exposed Infants.

Recent changes to federal legislation created a requirement for states to address the needs of infants with prenatal substance exposure. Understanding clinical outcomes among substance exposed infants prior to these changes is important for establishing a baseline of risk and informing systems-level responses. Using North Carolina, Georgia, and Texas Medicaid data, we examined the incidence of inpatient and outpatient diagnoses for injury, maltreatment, and developmental disorders prior to age 12 months and compared types of diagnoses among substance exposed and unexposed infants. The cumulative incidence of maltreatment (1.2% vs. 0.2%) and developmental disorder (10.7% vs. 1.5%) diagnoses prior to age 12 months was significantly higher among substance exposed compared to unexposed infants. The incidence of injury diagnoses was similar (3.7% vs. 3.4%). We observed differences in types of maltreatment and injury diagnoses. For example, diagnoses for neglect were more common among substance exposed infants while diagnoses for physical abuse were more common among unexposed infants. Results provide insight for informing monitoring and intervention by medical and public health professionals.

Relevance of Abusive Head Trauma to Intracranial Hemorrhages and Bleeding Disorders.

BACKGROUND: Bleeding disorders and abusive head trauma (AHT) are associated with intracranial hemorrhage (ICH), including subdural hemorrhage (SDH). Because both conditions often present in young children, the need to screen for bleeding disorders would be better informed by data that include trauma history and are specific to young children. The Universal Data Collection database contains information on ICH in subjects with bleeding disorders, including age and trauma history. Study objectives were to (1) characterize the prevalence and calculate the probabilities of any ICH, traumatic ICH, and nontraumatic ICH in children with congenital bleeding disorders; (2) characterize the prevalence of spontaneous SDH on the basis of bleeding disorder; and (3) identify cases of von Willebrand disease (vWD) that mimic AHT. METHODS: We reviewed subjects <4 years of age in the Universal Data Collection database. ICH was categorized on the basis of association with trauma. Prevalence and probability of types of ICH were calculated for each bleeding disorder. RESULTS: Of 3717 subjects, 255 (6.9%) had any ICH and 206 (5.5%) had nontraumatic ICH. The highest prevalence of ICH was in severe hemophilia A (9.1%) and B (10.7%). Of the 1233 subjects <2 years of age in which the specific location of any ICH was known, 13 (1.1%) had spontaneous SDH (12 with severe hemophilia; 1 with type 1 vWD). The findings in the subject with vWD were not congruent with AHT. CONCLUSIONS: In congenital bleeding disorders, nontraumatic ICH occurs most commonly in severe hemophilia. In this study, vWD is not supported as a "mimic" of AHT.

Multiple Forensic Interviews During Investigations of Child Sexual Abuse: A Cost-Effectiveness Analysis.

In cases of suspected child sexual abuse (CSA) some professionals routinely recommend multiple interviews by the same interviewer because any additional details provided might improve decision-making and increase perpetrator convictions. We analyzed alternative policies about child interviewing to estimate the probability that a policy of all children receiving multiple interviews will increase criminal convictions and better protect children. Using decision analysis, we prepared a decision tree reflecting the structure through which a case of possible CSA passes through the health care, welfare, and legal systems with an estimated probability of conviction of the offender. We reviewed the CSA disclosure, criminal justice, and child welfare literature to obtain estimates for the median and range of rates for the steps of disclosure, substantiation, criminal charges, and conviction. Using the R statistical package, our decision analysis model was populated using literature-based estimates. Once the model was populated, we simulated the experiences of 1,000 cases at 250 sets of plausible parameter values representing different hypothetical communities. Multiple interviews increase the likelihood that an offender will be convicted by 6.1% in the average community. Simulations indicate that a policy in which all children seen for a CSA medical evaluation receive multiple interviews would cost an additional $100,000 for each additional conviction. We estimate that approximately 17 additional children would need to be interviewed on more than one occasion to yield one additional conviction. A policy of multiple interviews has implications for the children, for the costs of care, for protecting other children, and for the risk of false prosecution.

Has this prepubertal girl been sexually abused?

CONTEXT: The legal and social sequelae of interpreting genital findings as indicative of sexual abuse are significant. While the absence of genital trauma does not rule out sexual abuse, the physical examination can identify genital findings compatible with sexual abuse. OBJECTIVES: To determine the diagnostic utility of the genital examination in prepubertal girls for identifying nonacute sexual abuse. DATA SOURCES: Published articles (1966-October 2008) that appeared in the MEDLINE database and were indexed under the search terms of child abuse, sexual or child abuse and either physical examination; genitalia; female, diagnosis; or sensitivity and specificity; and bibliographies of retrieved articles and textbooks. STUDY SELECTION: Three of the authors independently reviewed titles of articles obtained from MEDLINE and selected articles for full-text review. DATA EXTRACTION: Two authors independently abstracted data to calculate sensitivity, specificity, and likelihood ratios for the diagnosis of nonacute genital trauma caused by sexual abuse in prepubertal girls. RESULTS: Data were not pooled due to study heterogeneity. The presence of vaginal discharge (positive likelihood ratio, 2.7; 95% confidence interval, 1.2-6.0) indicates an increased likelihood of sexual abuse. In the posterior hymen, hymenal transections, deep notches, and perforations prompt concerns for genital trauma from sexual abuse, but the sensitivity is unknown. Without a history of genital trauma from sexual abuse, the majority of prepubertal girls will not have a hymenal transection (specificity close to 100%). CONCLUSIONS: Vaginal discharge as well as posterior hymenal transections, deep notches, and perforations raise the suspicion for sexual abuse in a prepubertal girl, but the findings do not independently confirm the diagnosis. Given the broad 95% confidence intervals around the likelihood ratios for the presence of findings along with the low or unknown sensitivity of all physical examination findings evaluated, the physical examination cannot independently confirm or exclude nonacute sexual abuse as the cause of genital trauma in prepubertal girls.

Speak softly--and forget the stick. Corporal punishment and child physical abuse.

BACKGROUND: Previous studies have shown an association between spanking and child physical abuse. However, the relationship between more frequent and severe corporal punishment and abuse remains unknown. The objective of this study was to examine the associations between reported spanking, spanking frequency, or spanking with an object and the odds of physical abuse in a representative sample of mothers from North and South Carolina. METHODS: This study is a cross-sectional, anonymous telephone survey of adult mothers with children aged<18 years living in the Carolinas in 2002. The analysis was conducted in 2007. Survey responses were used to determine the association between corporal punishment (spanking, spanking frequency, and spanking with an object) and an index of harsh physical punishment consistent with physical abuse (beating, burning, kicking, hitting with an object somewhere other than the buttocks, or shaking a child aged<2 years). RESULTS: Mothers who report that the child was spanked are 2.7 (95% CI=1.2, 6.3) times more likely to report abuse. Increases in the frequency of reported spanking in the last year are also associated with increased odds of abuse (OR=1.03, 95% CI=1.01, 1.06). Mothers reporting spanking with an object are at markedly increased odds of reporting abuse (OR=8.9, 95% CI=4.1, 19.6). CONCLUSIONS: Although reported spanking increases the odds of reported physical abuse, the relationship between the reported hitting of a child with an object and reported abuse is much stronger. Reduction in this form of discipline through media, educational, and legislative efforts may reduce child physical abuse.

Accuracy of caregiver identification of developmental delays among young children involved with child welfare.

Underidentification of developmental delays among young children involved with child welfare/child protective services (CW) is problematic. Caregivers of young children involved with CW may help increase identification of young children with developmental delays, but the accuracy of caregiver identification in this population and whether this varies by caregiver type is not known. This study uses data from the National Survey of Child and Adolescent Well-Being to determine if (1) caregivers of young children involved with CW accurately identify children with developmental delays and (2) foster caregivers are better able to identify developmental delays compared with other caregivers. Close to half the children had a delay in language, cognitive, and/or adaptive behavior (45%). Overall sensitivity for caregiver identification was 35% (95% confidence interval [CI]: 29%, 41%); specificity was 84% (95% CI: 80%, 87%). After controlling for certain child and caregiver characteristics, in-home caregivers had 0.15 times the odds of identifying a child with a developmental delay compared with foster caregivers (95% CI 0.1, 0.4). Results suggest that caregiver identification of developmental delays is specific but not sensitive, and that foster caregivers were more likely to identify a child with a developmental delay compared with in-home caregivers. Policy implications include improving educational programs regarding child development and developmental services for foster, kinship, as well as in-home caregivers in the hopes of increasing sensitivity of caregiver identification of developmental delays for the population of young children involved with CW.