Diagnostic Performance of Ultrafast Brain MRI for Evaluation of Abusive Head Trauma.

BACKGROUND AND PURPOSE: MR imaging with sedation is commonly used to detect intracranial traumatic pathology in the pediatric population. Our purpose was to compare nonsedated ultrafast MR imaging, noncontrast head CT, and standard MR imaging for the detection of intracranial trauma in patients with potential abusive head trauma. MATERIALS AND METHODS: A prospective study was performed in 24 pediatric patients who were evaluated for potential abusive head trauma. All patients received noncontrast head CT, ultrafast brain MR imaging without sedation, and standard MR imaging with general anesthesia or an immobilizer, sequentially. Two pediatric neuroradiologists independently reviewed each technique blinded to other modalities for intracranial trauma. We performed interreader agreement and consensus interpretation for standard MR imaging as the criterion standard. Diagnostic accuracy was calculated for ultrafast MR imaging, noncontrast head CT, and combined ultrafast MR imaging and noncontrast head CT. RESULTS: Interreader agreement was moderate for ultrafast MR imaging (κ = 0.42), substantial for noncontrast head CT (κ = 0.63), and nearly perfect for standard MR imaging (κ = 0.86). Forty-two percent of patients had discrepancies between ultrafast MR imaging and standard MR imaging, which included detection of subarachnoid hemorrhage and subdural hemorrhage. Sensitivity, specificity, and positive and negative predictive values were obtained for any traumatic pathology for each examination: ultrafast MR imaging (50%, 100%, 100%, 31%), noncontrast head CT (25%, 100%, 100%, 21%), and a combination of ultrafast MR imaging and noncontrast head CT (60%, 100%, 100%, 33%). Ultrafast MR imaging was more sensitive than noncontrast head CT for the detection of intraparenchymal hemorrhage (P = .03), and the combination of ultrafast MR imaging and noncontrast head CT was more sensitive than noncontrast head CT alone for intracranial trauma (P = .02). CONCLUSIONS: In abusive head trauma, ultrafast MR imaging, even combined with noncontrast head CT, demonstrated low sensitivity compared with standard MR imaging for intracranial traumatic pathology, which may limit its utility in this patient population.

Munchausen syndrome by proxy: a different kind of child abuse.

Munchausen syndrome by proxy (MSBP) continues to mystify health care professionals, law enforcement officials and the judicial system. Even though the first cases were described in 1977, it remains puzzling why a parent would want to induce fictitious symptoms and illnesses in a child. Many professionals do not consider MSBP as a diagnosis because the parent, usually the mother, is so convincing that she is a "good" mother, cares about and wants the best for her child. This article is offered to further educate physicians that MSBP exists, can present in the form of anything and should be considered as a diagnosis in cases that do not make medical sense. Case examples are provided, along with common and not so common presentations. MSBP is a form of severe child abuse that must be reported to Child Protection Service when a child is endangered. Physicians play a critical role in identifying these children and recommending the best course of action to the rest of the system.

Domestic violence: a health concern.

Domestic violence may be the single most common etiology for injuries in women presenting to the health care system. There is a national effort to begin to ask all female patients about family violence. Physicians have a responsibility to identify, educate and appropriately manage and/or refer patients in violent relationships.

Child abuse education: do not overlook dental professionals.

Dental professionals are mandated by law to report suspicions of child abuse and neglect (CAN), but surveys show dentists do not fulfill their obligation to report. Even though more than 50 percent of physical abuse occurs to the head and facial area, and more than 70 percent of child abuse and neglect fatalities are caused by injuries to the head and neck, dental professionals are often overlooked in efforts to educate the public on the problem. Pre-program questionnaires completed by dental professionals attending an educational program on identifying and reporting child abuse indicated that 70 percent had no previous training in identifying and reporting child abuse, 65 percent had suspected child abuse in their patients, but only 19 percent reported the abuse. As a result of this educational program, it is expected that some children in the state of Indiana will receive improved assessments by dentists and suspected child abuse and neglect will be reported to the proper agencies when identified.

Attorney attitudes regarding behaviors associated with child sexual abuse.

There appears to be a good deal of disagreement between professionals as to what constitutes child abuse. Attorneys as a group have been found to judge behaviors associated with child abuse more leniently than other abuse professionals. However, no one has discriminated between defense and prosecuting attorneys in these areas. It was hypothesized that because of divergent roles in child sexual abuse cases attitudes toward adult-child behaviors associated with sexual abuse would differ among attorney groups. Two prosecuting and two defense attorneys from every county in the state of Indiana were sent questionnaires. Participants were asked to indicate if a behavior was acceptable, inappropriate, or sexual abuse if it occurred on one or on multiple occasions. Prosecutors had more severe judgements than the defense attorneys on 32 of the 42 behaviors. They were more likely to indicate that a behavior was inappropriate or abuse. Cognitive dissonance theory is proposed as a possible explanation for these findings.

Components of child and parent interviews in cases of alleged sexual abuse.

Considerable discussion in child sexual abuse evaluation centers around minimizing the number of victim interviews, however, the completeness of one professional's interview is not always addressed. In this study, professionals (medical, social, law enforcement/legal, mental health) indicated what components they included in their interviews of sexual abuse victims and their parents. Components included: details of abuse, family relationships, school situation/performance, child's development (toilet training, bed wetting, language development, etc.), child's knowledge of body part names, child's knowledge of body part functions, child-rearing practices (bathing, sleeping), medical history (illnesses, surgery), behavior problems, psychological symptoms (nightmares, sadness), physical complaints (pain, discharge), parental teaching about sex, and child's access to sexually explicit television or magazines. Interview components varied by profession, consistent with expected professional bias. This study demonstrates some professional bias in interviewing children and parents and suggests that having a single interview or interviewer may not always be optimal for a thorough evaluation. Increased communication and teamwork among professionals, and cross-training among disciplines could facilitate both the recognition of appropriateness of some "multiple interviews" as well as provide efforts to consolidate interviews when possible.

Behavioral problems in alleged sexual abuse victims.

This study was conducted to compare the parental assessments of problem behaviors, using the Achenbach Child Behavior Checklist, among alleged sexual abuse victims (n = 81) and an age, race, and gender matched group of nonabused comparison subjects (n = 90). Alleged sexual abuse victims demonstrated significantly higher mean total behavior problem, internalizing and externalizing scores than the comparison sample. Subscale profiles were all in the direction consistent with withdrawal, impairment in social interaction, and sexual problems. Item comparison indicated that sexual abuse victims were more likely to be assessed as having some problem behaviors that have been reported as being indicative of sexual abuse. A significant difference was not obtained on several behaviors that have been previously reported as indicative of sexual abuse. These findings support concerns that sexual abuse victims do exhibit more problem behaviors, but caution must be exercised when interpreting individual behaviors because of their frequency in a nonabused sample.

Medical evaluation referral patterns for sexual abuse victims.

It has been recommended that all children suspected of being sexually abused should have medical evaluations. To better understand practices and perceptions of child sexual abuse medical evaluations, a survey was conducted of 579 professionals attending educational programs on child sexual abuse; 85.8% (N = 497) responded. Half (50%) of the respondents reported no previous training in child sexual abuse. Of the 336 nonphysician professionals, 194 (57.7%) were in positions where they make referrals of the victims, and 69% of these did not refer all of the children they saw for medical evaluations. The first referral choice for medical evaluation was most often to the victim's primary physician (57%). For those professionals who did not refer all alleged victims for medical evaluation, neither the victims' age, gender, nor accessibility to care were generally considered relevant in determining the decision to refer. However, the type of abuse and presence of physical and psychological symptoms were considered relevant in making the decision. The majority indicated that the findings of the medical exam were very useful in substantiating or refuting the allegation of abuse. Further training for both medical and nonmedical professionals is needed to increase awareness of the need for and implications of the medical evaluation if children are to receive comprehensive assessments. Physicians may play an active role in this process through education of professionals and provision of care.

Child abuse and mental health among adolescents in dependent care.

Do adolescents in dependent care who have been abused or neglected demonstrate more mental health problems than their nonabused peers? This study examined relationships of child abuse, depression, and self-esteem among 82 adolescents (mean age 14.5 years, 52% male, 82.9% white) living in a dependent care facility. Of these, 32 adolescents were victims of child abuse or neglect. Upon admission, 54 adolescents were identified as depressed on the Beck Depression Inventory. Initial scores on the depression and self-esteem instruments did not differ by age, race, or history of maltreatment, though trends among subtypes of abuse were identified. Females had significantly lower self-esteem and tended toward more depression. Repeat evaluation 6 months after admission revealed significant improvement in both depression and self-esteem scores for the entire sample. As a group, however, the maltreated adolescents did not demonstrate significant improvement in depression, and a history of neglect was associated with less improvement. Depression in this dependent care sample was common, however, we did not identify the maltreated adolescents as having significantly more problems with self-esteem or depression. For some adolescents, dependent care may be an appropriate and helpful alternative.

Behavioral risk, emotional risk, and child abuse among adolescents in a nonclinical setting.

In this replication study of adolescents in a nonclinical setting, the prevalence of reported problem behaviors, emotions, and abuse is evaluated, and the impact of abuse on multivariate emotional and behavioral risk is assessed. A total of 3998 students (69%) in a rural midwestern community in grades 7 to 12 participated in the study. Almost 20% of the students reported some form of physical and/or sexual abuse, with more girls than boys reporting sexual abuse (chi 2 = 48.5, P less than .001). Some problem behaviors (alcohol use) and emotions (trouble sleeping, difficulty with anger) were common among all adolescents and some were strongly associated with a history of abuse (especially, considering or attempting suicide, running away, laxative use, and vomiting to lose weight). Higher emotional and behavioral risk scores among abused students were confirmed. The effects of physical and sexual abuse on risk scores were independent and additive; no interaction was observed. An interaction of gender and sexual abuse on problem behavior was observed, with problem behavior being significantly greater among sexually abused boys. The results confirm increased risk of problem behaviors and negative feelings among abused adolescents when compared with nonabused peers, and better define influences of gender and abuse type on emotional and behavioral risks.

Pediatrics residents' attitudes about insulin-dependent diabetes mellitus and children with diabetes.

Nationwide, pediatricians provide a substantial portion of the health care of children with diabetes. Their beliefs and attitudes about diabetes and children with the illness have an important influence on their treatment decisions. The attitudes and beliefs of a 1988 sample of pediatrics residents were compared with data from a 1987 national survey of practicing pediatricians' beliefs and attitudes about children with insulin-dependent diabetes mellitus and about the disease itself. Pediatrics residents in their second and third years of training were considerably more negative about diabetes and diabetic children than were either the members of the national sample of practicing pediatricians or the residents' first-year colleagues.

Genitalia in human figure drawings: childrearing practices and child sexual abuse.

To replicate and explore the associations of drawing genitalia on a human figure, child-rearing practices, and a history of alleged sexual abuse, we designed a cross-sectional study of 109 alleged child sexual abuse victims, ages 3 through 8 years, and a group of 109 comparison children matched for age, sex, race, and socioeconomic status but with no history of abuse. A standardized format was used to collect drawings, administer the Peabody Picture Vocabulary Test, and gather background data on medical, developmental, and child-rearing issues. Seven alleged sexual abuse victims and one comparison child spontaneously drew genitalia (p = 0.02, one-tailed Fisher Exact Test, estimated relative risk 7.96). No differences in drawing maturity (Draw-A-Man score) were identified, although Peabody Picture Vocabulary Test scores were higher in comparison children (82.1 vs. 91.0, p less than 0.01). Neither drawing genitalia nor history of alleged sexual abuse were significantly associated with histories of medical problems, enuresis, encopresis, urinary tract infection, or child-rearing practices related to sleeping, nudity, bathing, sexual abuse education, or exposure to sexually explicit materials. The similar patterns of child-rearing practices in both samples should make professionals cautious in attributing allegations of abuse to specific child-rearing practices. This study confirms our previous report that the presence of genitalia spontaneously drawn on a child's drawing of a human figure is associated with alleged sexual abuse.

Emotional indicators in human figure drawings of sexually victimized and nonabused children.

A study was conducted to compare the presence of Koppitz' Emotional Indicators (EIs) and EI Categories in human figures drawn (HFDs) by alleged sexual abuse victims (ASA Vs) and nonabused children. We collected drawings from 65 ASA Vs and 64 comparison (presumably nonabused) subjects. No statistically significant differences in the presence of individual EIs were observed. Alleged sexual abuse victims tended to draw some indicators more often: "legs pressed together," "big hands," and "genitals." It also was observed that more "normal" children than expected drew some indicators, which suggests the possible need for revision of the definition of some indicators, specifically "omission of body." The ASA Vs more often scored an EI from the anxiety category (p = .05) than did comparison children. No significant differences in other categories were demonstrated. It was concluded that drawings from ASA Vs demonstrated anxiety more often than did drawings from comparison children, while specific indicators did not differ between groups.

Patterns of child sexual abuse knowledge among professionals.

To better understand knowledge and perceptions of child sexual abuse, a survey was conducted of 902 professionals attending child sexual abuse educational programs during 1986-1987. About half (50.8%) of the group reported seeing at least two child sexual abuse cases a month, while 20.5% reported seeing five or more. Almost half (48.9%) of the respondents reported previous formal training regarding child sexual abuse. Professionals were generally knowledgeable about child sexual abuse; however, at least 20% of the professionals were not knowledgeable about some items that are important in the identification of child sexual abuse and that might hamper the legal and medical investigation of a case. Those with formal training, more years of professional practice, and who see five or more victims per month answered more questions correctly, but the differences were not always statistically significant. Further training for both medical and non-medical professionals is needed to ensure appropriate care of child sexual abuse victims and to improve communication and coordination of efforts between professions.

Management of diabetes in pediatric resident continuity clinics.

General pediatricians provide comprehensive care for many children with insulin-dependent diabetes mellitus. To assess and improve our ambulatory training program, we first evaluated diabetes-specific care behaviors by residents in their continuity clinics and then introduced a structured visit encounter form. Based on established guidelines provided to the residents, a chart audit indicated appropriate measurement of glycosylated hemoglobin 40% of the time, cholesterol 90% of the time, urine protein 50% of the time, and thyroxine 66.7% of the time. Height was plotted 23% of the time, blood pressure was noted 66% of the time, and ophthalmologic referrals were documented 60% of the time. Requests for assistance from nonphysician members of a multidisciplinary diabetes team were minimal. After introduction of the structured visit encounter form, care behaviors did not improve. New training approaches to prepare general pediatric residents to provide excellent diabetes care are needed.

Pediatric endocrinologic recommendations, pediatric practice, and current pediatric training regarding care of children with diabetes.

Many pediatric diabetes patients are cared for by community-based pediatricians. Training for pediatricians in optimal diabetes care should be based on both the recommendations of pediatric endocrinologists regarding optimal care and the practices of general pediatricians. Pediatric endocrinologists, general pediatricians, and pediatric residency coordinators were surveyed to assess the consonance of current recommendations, practices, and training in pediatric diabetes care. Not surprisingly, pediatric endocrinologists recommended more subspecialty care than pediatricians reported practicing. A major difference between endocrinologists and pediatricians emerged in the area of psychosocial support. A total of 85% of endocrinologists answered that there should be a mental health diabetes team member, but only 37% of pediatricians reported often or sometimes working with one to develop care plans. Pediatricians who provide complete diabetes care for most of their patients measure frequent glycosylated hemoglobin levels, obtain yearly lipid measurements marginally less often, and use urinary glucose measurements more often than recommended by pediatric endocrinologists. According to the descriptions of most pediatric residency training programs, multidisciplinary teams include a pediatrician, an endocrinologist, and a dietician. However, 25% do not include a social worker or nurse and 70% do not include a psychologist. Although most training programs operate on the assumption that their trainees will ultimately share responsibility with a subspecialist for diabetes care, in 26% of programs residents saw no diabetics in their continuity clinics. Most residents do not participate in providing diabetes education.(ABSTRACT TRUNCATED AT 250 WORDS)

Abuse, feelings, and health behaviors in a student population.

Behavioral sequelae of child abuse are frequently cited, but there are few studies that examine the strength of association between behavioral effect and abuse for children in a nonclinical setting. Seven hundred twelve junior high school students (mean age, 13.5 years) were surveyed for self-report of personal experience with abuse, certain health behaviors, and self-esteem. Physical and/or sexual abuse was reported by 18.3% of students. Both types of abuse were associated with the following behaviors: running away; considering hurting oneself; suicide attempts; and the use of drugs, pot (marijuana), cigarettes, and laxatives. No clinically significant relationships were found between abuse and report of anger, sadness, or self-esteem. These data suggested that some feelings and behaviors were common among all adolescents sampled, while others were more common among abused adolescents. Recognition of strong associations should help direct clinical management. The results of this study confirm findings from some previous reports and indicate the need for further studies of children who are not in a clinical setting.