Acute Sexual Assault in the Pediatric and Adolescent Population.

Children and adolescents are at high risk for sexual assault. Early medical and mental health evaluation by professionals with advanced training in sexual victimization is imperative to assure appropriate assessment, forensic evidence collection, and follow-up. Moreover, continued research and outreach programs are needed for the development of preventative strategies that focus on this vulnerable population. In this review we highlight key concepts for assessment and include a discussion of risk factors, disclosure, sequelae, follow-up, and prevention.

Curiosity and critical thinking: identifying child abuse before it is too late.

OBJECTIVE: We reviewed medical records to identify factors contributing to not recognizing child abuse in cases where it was subsequently identified. DESIGN/METHODS: Eighteen cases of delayed diagnosis of physical abuse were reviewed for qualitative themes. Missed abuse was defined by prior medical encounters that revealed findings concerning for physical abuse that were not recognized. RESULTS: Clinical limitations contributing to a delay in diagnosis included inattention to skin and subconjunctival findings, acceptance of inadequate explanations for injuries, no history obtained from verbal children, insufficient exploration of signs and symptoms, nonadherence to the maltreatment pathway, and incorrect diagnoses from radiologic examinations. System-based limitations included limited medical record access or completeness and admission to less-than-optimal settings. CONCLUSIONS: Having a greater index of suspicion for abuse may mitigate missed opportunities. With variability of medical training in child abuse, the factors we identified can be used as learning objectives for continuing medical education.

Occult abusive injuries in infants with apparently isolated skull fractures.

BACKGROUND: There is currently no consensus about which screening studies should be undertaken to identify abusive injuries in infants with apparently isolated skull fractures. Our objective was to determine rates of screening, rates of injury identification, and rates of reporting to child protective services among infants who underwent subspecialty evaluation for abuse after presenting with an apparently isolated skull fracture. METHODS: This was a retrospectively planned, secondary analysis of index children enrolled in a large network of children with concerns for physical abuse. For this analysis, we included infants (<12 months) who presented with signs and symptoms attributable to a skull fracture. We determined rates of skeletal survey, dedicated ophthalmologic examination and abdominal injury screening, rates of injury identification by testing and reports to child protective services. RESULTS: A total of 215 infants underwent abuse consultation for apparently isolated skull fractures. Skeletal surveys were performed in 201 subjects (93.4%) and identified additional fractures in 12 (5.6%; 95% confidence interval, 2.9-9.6%). Patient age, trauma history, and fracture type (simple/complex) were not sensitive predictors of finding additional fractures on skeletal survey. Only one additional fracture was associated with clinical signs or symptoms. Dedicated ophthalmologic examination was undertaken in 100 subjects (46.5%); one child had retinal hemorrhages. Hepatic transaminases were obtained in 135 subjects (62.7%), and 5 subjects (2.3%) had abdominal computed tomography. No abdominal injuries were identified. A total of 146 subjects (67.9%) were reported to child protective services. CONCLUSION: Infants with apparently isolated skull fractures are an important fraction of consultations for physical abuse. Additional fractures are identified in a small subset of the skeletal surveys completed in these children. LEVEL OF EVIDENCE: Epidemiological study, level IV.

Head injury depth as an indicator of causes and mechanisms.

OBJECTIVE: The goal was to measure differences in the causes, mechanisms, acute clinical presentations, injuries, and outcomes of children <36 months of age with varying "greatest depths" of acute cranial injury. METHODS: Children <36 months of age who were hospitalized with acute head trauma were recruited at multiple sites. Clinical and imaging data were collected, and caregivers underwent scripted interviews. Neurodevelopmental evaluations were completed 6 months after injury. Head trauma causes were categorized independently, and subject groups with varying greatest depths of injury were compared. RESULTS: Fifty-four subjects were enrolled at 9 sites. Twenty-seven subjects underwent follow-up neurodevelopmental assessments 6 months after injury. Greatest depth of visible injury was categorized as scalp, skull, or epidural for 20 subjects, subarachnoid or subdural for 13, cortical for 10, and subcortical for 11. Compared with subjects with more-superficial injuries, subjects with subcortical injuries more frequently had been abused (odds ratio [OR]: 35.6; P < .001), more frequently demonstrated inertial injuries (P < .001), more frequently manifested acute respiratory (OR: 43.9; P < .001) and/or circulatory (OR: 60.0; P < .001) compromise, acute encephalopathy (OR: 28.5; P = .003), prolonged impairments of consciousness (OR: 8.4; P = .002), interhemispheric subdural hemorrhage (OR: 10.1; P = .019), and bilateral brain hypoxia, ischemia, or swelling (OR: 241.6; P < .001), and had lower Mental Developmental Index (P = .006) and Gross Motor Quotient (P < .001) scores 6 months after injury. CONCLUSION: For children <3 years of age, head injury depth is a useful indicator of injury causes and mechanisms.