Update on child physical abuse, sexual abuse, and prevention

Illicit drug exposure in patients evaluated for alleged child abuse and neglect

BACKGROUND

Substantiation of drug exposure in cases with alleged maltreatment is important to provide proper treatment and services to these children and their families. A study performed at University of Iowa Hospitals and Clinics showed that 30% of pediatric patients with burn injuries, which were due to child maltreatment, were also exposed to illicit drugs.

OBJECTIVE

The children presenting to the University of Iowa Hospitals and Clinics with alleged maltreatment have been tested for illicit substances since 2004. The objective of this study was to analyze the presence of illicit drug exposure in the pediatric subpopulation admitted to pediatric inpatient and outpatient units for an evaluation for abuse/neglect.

DESIGN AND METHODS

The study design is a retrospective chart review. Using hospital databases, every pediatric chart with a child abuse/neglect allegation was retrieved. The association between risk factors and clinical presentation and illicit drug test result was assessed. Excel and SAS were used for statistical analysis. Institutional review board approval was obtained to conduct this study.

RESULTS

Six hundred sixty-five charts met study inclusion criteria for child abuse/neglect allegation. Of those, 232 cases were tested for illicit drugs between 2004 and 2008 per the testing protocol. Thirty-four cases (14.7%) tested positive on a drug test. Positive test rates based on clinical presentation were 28.6% (18/63) in neglect cases, 16.1% (5/31) in cases with soft tissue injuries, 14.3% (4/28) in burn injuries, 10.0% (2/20) in cases with sexual abuse, 7.1% (2/28) in cases with fractures, and 4.8% (3/62) in abusive head trauma cases. There were long-term abuse findings in 129 children (55.6%). Logistic regression analysis revealed that positive drug testing was most significantly associated with clinical symptoms suggesting physical abuse or neglect versus sexual abuse (odds ratio [OR] = 6.70; 95% confidence interval [CI], 1.26-35.49; P = 0.026), no or public health insurance versus those with private insurance (OR = 4.49; 95% CI, 1.47-13.66; P = 0.008), history of parental drug abuse versus those without parental history of drug abuse (OR = 3.42; 95% CI, 1.38-8.46; P = 0.008), and history of domestic violence versus those without a history of domestic violence (OR = 2.81; 95% CI, 1.08-7.30; P = 0.034).

CONCLUSIONS

The results of this study showed that an illicit drug screening protocol used in the assessment of children evaluated for child abuse identified almost 15% of the population of allegedly abused and neglected children who were tested according to a protocol being exposed to illicit drugs. Thus, routine drug testing of at least children assessed for neglect and nonaccidental burn and soft tissue injuries, children with a history of either parental drug use or domestic violence is recommended.

The efficacy of hair and urine toxicology screening on the detection of child abuse by burning

Abuse by burning is estimated to occur in 1 to 25% of children admitted with burn injuries annually. Hair and urine toxicology for illicit drug exposure may provide additional confirmatory evidence for abuse. To determine the impact of hair and urine toxicology on the identification of child abuse, we performed a retrospective chart review of all pediatric patients admitted to our burn unit. The medical records of 263 children aged 0 to 16 years of age who were admitted to our burn unit from January 2002 to December 2007 were reviewed. Sixty-five children had suspected abuse. Of those with suspected abuse, 33 were confirmed by the Department of Health and Human Services and comprised the study group. Each of the 33 cases was randomly matched to three pediatric (0-16 years of age) control patients (99). The average annual incidence of abuse in pediatric burn patients was 13.7+/-8.4% of total annual pediatric admissions (range, 0-25.6%). Age younger than 5 years, hot tap water cause, bilateral, and posterior location of injury were significantly associated with nonaccidental burn injury on multivariate analysis. Thirteen (39.4%) abused children had positive ancillary tests. These included four (16%) skeletal surveys positive for fractures and 10 (45%) hair samples positive for drugs of abuse (one patient had a fracture and a positive hair screen). In three (9.1%) patients who were not initially suspected of abuse but later confirmed, positive hair test for illicit drugs was the only indicator of abuse. Nonaccidental injury can be difficult to confirm. Although inconsistent injury history and burn injury pattern remain central to the diagnosis of abuse by burning, hair and urine toxicology offers a further means to facilitate confirmation of abuse.

Attention-deficit/hyperactivity disorder symptoms and child maltreatment: a population-based study

OBJECTIVE

To examine whether symptoms of attention-deficit/hyperactivity disorder (ADHD) during childhood are associated with child maltreatment.

STUDY DESIGN

The study sample consisted of 14 322 participants in the National Longitudinal Study of Adolescent Health. We used logistic regression and propensity score matching to examine the relationship, adjusting for demographic, socioeconomic, and familial risk factors for child maltreatment.

RESULTS

Inattentive type, by criteria of Diagnostic and Statistical Manual of Mental Disorders Fourth Edition, was significantly associated with the likelihood of supervision neglect (odds ratio [OR]: 1.6; 95% confidence interval [CI]: 1.2-2.2), physical neglect (OR: 2.1; 95% CI: 1.4-3.1), physical abuse (OR: 1.6; 95% CI: 1.1-2.3), and contact sexual abuse (OR: 2.6; 95% CI: 1.5-4.5). To a lesser extent, hyperactive type was associated with the likelihood of supervision neglect (OR: 1.5; 95% CI: 1.1-2.0) and physical abuse (OR: 1.3; 95% CI: 1.0-1.6). The association between hyperactive type and physical neglect or contact sexual abuse was not significant. The results from the propensity score matching were similar.

CONCLUSIONS

Childhood ADHD symptoms were associated with self-reported child maltreatment. Health care providers should be alert to the potential for child maltreatment among children with ADHD symptoms, especially those with inattentive symptoms.

Evaluating nurses' knowledge and skills in the detection of child abuse in the Emergency Department

This commentary paper highlights the issue of child abuse and the important role that nursing staff working in the Emergency Department (ED) can play in halting the cycle of abuse. Child abuse is a worldwide problem that is occurring with increasing frequency. In fact, in Australia over the last 5 years the number of child protection referrals has more than doubled. As well as the immediate physical damage child abuse causes, it can also escalate to result in more serious injury and death. Furthermore, children who are abused in their early years of life are at increased risk of a range of adverse long-term developmental problems. Research has demonstrated that there is a significant lack of detection of suspected cases of child abuse in the ED. In fact the true incidence of children presenting to hospital EDs with abuse is difficult to determine, and many cases remain undetected. Nursing staff are perfectly positioned to detect the signs that a child may be at risk of abuse. However, in order to identify these signs it is essential that ED nurses have the knowledge and skills necessary to do so. Failure to consider the possibility of abuse will mean that the appropriate diagnosis is not made and the child is returned to an abusive environment. Therefore, this paper offers ED nurses recommendations for future directions in research and interventions to improve the detection of child abuse in Western Australia.