Oral health history in children referred to a child advocacy center in Norway

BACKGROUND

Some suspected child victims of physical or sexual abuse undergo dental forensic examinations at child advocacy centers (CACs) in Norway. Their oral health history has not previously been studied.

OBJECTIVE

This study aimed to compare oral health history of CAC children to matched children. Additionally, the oral health history of children exposed to sexual abuse was compared to children exposed to physical abuse.

PARTICIPANTS AND SETTING

The CAC cohort included 100 children, 3-16 years. The matched cohort, with no known history of abuse, included 63 children.

METHODS

The retrospective study analyzed registered data in the children's dental records.

RESULTS

CAC children were more likely than matched children to have caries experience in both primary and permanent teeth, with incidence rate ratio (IRR) 1.50 (95 % CI 1.01-2.25) and 1.92 (1.11-3.30). "Was Not Brought" to dental appointments was more than twice as likely, IRR 2.25 (1.31-3.86), in the CAC cohort. There were no significant differences in reports to the Child Protection Services or dental traumas. Suspected victims of sexual abuse had more caries, IRR 4.28 (2.36-7.77), and fillings, IRR 4.83 (2.55-9.16), in permanent teeth compared to suspected victims of physical abuse.

CONCLUSIONS

CAC children were more likely to have caries experience and not show up for dental appointments than the matched children. Sexual abuse suspected had four times more caries experience than physical abuse suspected. This study supports the need for addressing oral health in risk evaluations concerning child abuse, and provides valuable information to dental professionals and prosecuting authorities.

Amongst Norwegian paediatricians there is little agreement in management of cases of suspected child maltreatment

AIM

Child maltreatment is not unusual in our society but little is known about the medical management of cases in the Nordic countries. This study investigated physician knowledge and practice in cases of suspected physical and sexual abuse and neglect.

METHODS

Using a patient vignette questionnaire, we assessed paediatrician knowledge and clinical decision-making on paediatric wards at 17 hospitals in Norway. Experts and non-experts in child maltreatment responded to the survey which described six potential cases of physical and sexual abuse and neglect.

RESULTS

A total of 156 paediatricians, 67% of whom were female and with a mean age of 40, responded. There was a high level of unanimity in recognition of abuse, but wide variation and little consensus in clinical decision-making and adherence to national guidelines, with Fleiss kappa ranging from -0.002 to 0.468. In cases involving physical abuse concerns in infants and toddlers, less than half of all paediatricians reported they would order a full radiologic skeletal survey and head MRI/CT imaging, and less than 30% would plan follow-up consultations.

CONCLUSION

This study shows little agreement in the paediatric management of child maltreatment cases. These findings suggest the need for a national plan ensuring appropriate paediatric care for maltreated children.

Labial adhesion - diagnostics and treatment

BACKGROUND

Labial adhesion is relatively common, but the condition is little known among doctors and parents. The article assesses treatment in the specialist health service.

MATERIAL AND METHOD

The treatment and course are assessed in 105 girls in the age group 0 – 15 years who were referred to St. Olavs Hospital in the period 2004 – 14.

RESULTS

The majority of the girls (n = 63) were treated topically with oestrogen cream. In 26 of 51 girls (51 %) for whom the final result is known, the adhesion opened after one treatment. When 1 – 4 oestrogen treatments were administered, the introitus had opened completely in two out of three (65 %). Fewer than half of those who received supplementary surgical treatment achieved permanent opening.

INTERPRETATION

Treatment for labial adhesion had a limited effect in this study. As the literature suggests that the condition results in few symptoms and resolves spontaneously in virtually all girls in puberty, no compelling medical reason exists for opening the adhesion in asymptomatic girls. It is important that doctors are aware of the condition in order to prevent misdiagnosis and to provide parents with adequate information. For parents it is important to know that spontaneous resolution may result in soreness and dysuria. Knowledge of the condition can most likely prevent unnecessary worry.

Child maltreatment and quality of life: a study of adolescents in residential care

BACKGROUND

Childhood maltreatment is an important risk factor for mental and physical health problems. Adolescents living in residential youth care (RYC) have experienced a high rate of childhood maltreatment and are a high-risk group for psychiatric disorders. Quality of life (QoL) is a subjective, multidimensional concept that goes beyond medical diagnoses. There is a lack of research regarding the associations between childhood maltreatment and QoL. In the present study, we compare self-reported QoL between adolescents in RYC in Norway with and without maltreatment histories, and adolescents from the general population. We also study the impact of number of types of adversities on QoL.

METHODS

Adolescents aged 12-23 years living in RYC in Norway were invited to participate in the study; 400 participated, yielding a response rate of 67 %. Maltreatment histories were assessed through interviews with trained research assistants, and completed by 335 adolescents. Previous exposure to maltreatment was reported by 237 adolescents. The Questionnaire for Measuring Health-Related Quality of Life in Children and Adolescents (KINDL-R) was used. Nonexposed peers in RYC (n = 98) and a sample of adolescents from the general population (n = 1017) were used for comparison. General linear model analyses (ANCOVA) were conducted with five KINDL-R life domains as dependent variables. Linear regression was used to study the effect of number of types of adversities.

RESULTS

Exposed adolescents in RYC reported poorer QoL than peers in control groups. Compared with nonexposed peers in RYC, the 95 % confidence intervals for mean score differences on the KINDL-R subdomains (0-100 scale) were 1.9-11.4 (Physical Well-being), 2.2-11.1 (Emotional Well-being), -0.7-10.0 (Self-esteem), and 1.8-10.9 (Friends). Compared with the general population sample, the 95 % confidence intervals for mean score differences were 9.7-17.6 (Physical Well-being), 7.9-15.3 (Emotional Well-being), 3.6-12.5 (Self-esteem), and 5.3-12.8 (Friends). Number of types of adversities was associated with a poorer QoL score on all subdomains (Physical- and Emotional Well-being, Self-esteem, Friends, and School).

CONCLUSIONS

Childhood maltreatment was associated with a poorer QoL score. We suggest the use of QoL and maltreatment measures for all children and adolescents in RYC.

Previous maltreatment and present mental health in a high-risk adolescent population

Childhood maltreatment is known to increase the risk of future psychiatric disorders. In the present study, we explored the impact of experienced maltreatment on the prevalence and comorbidity of psychiatric disorders in a high-risk population of adolescents in residential care units. We also studied the impact of poly-victimization. The participants of the study were adolescents in residential care units in Norway (n=335, mean age 16.8 years, girls 58.5%). A diagnostic interview (Child and Adolescent Psychiatric Assessment Interview) was used, yielding information about previous maltreatment (witnessing violence, victim of family violence, community violence, sexual abuse) and DSM-IV diagnoses present in the last three months. Exposure to maltreatment was reported by 71%, and in this group, we found significantly more Asperger's syndrome (AS) (p=.041), conduct disorder (CD) (p=.049), major depressive disorder (MDD) (p=.001), dysthymia (p=.030), general anxiety disorder (GAD) (p<.001), and having attempted suicide (p=.006). We found significantly more comorbid disorders in the maltreated group. Poly-victimization was studied by constructing a scale comprised of witnessing violence, victim of family violence, victim of sexual abuse and household dysfunction. We found that poly-victimization was associated with significantly increased risk of MDD, GAD, AS, CD, and having attempted suicide (p<.01). The complexity of the clinical outcomes revealed in this study suggest that longer-term treatment plans and follow-up by psychiatric services might be needed to a greater extend than for the rest of the child and adolescent population, and that trauma informed care is essential for adolescents in residential youth care.

Sexually transmitted infections among women attending a Norwegian Sexual Assault Centre

OBJECTIVES

The objective was to describe the prevalence of sexually transmitted infections (STI) and blood-borne viruses (BBV), and prophylactic treatment offered to female postpubertal patients attending a Norwegian Sexual Assault Centre (SAC). We wanted to evaluate whether STIs diagnosed at the initial visit could have been assault-transmitted, and to explore whether background and assault characteristics were associated with diagnosed STI/BBV.

METHODS

We included postpubertal females ≥12 years of age attending the SAC within 1 week of the assault. Data were collected from records. We conducted a retrospective, descriptive study, and used logistic regression analysis.

RESULTS

Among 412 patients with a median age of 21 years, 35 patients had an STI (8.5%), two of which probably were assault-transmitted. Chlamydia trachomatis was the dominating agent, detected in 25 patients (6.4%). At serology screening, 3.7% tested positive for hepatitis C and/or hepatitis B core antibody. Patient age 16-19 years was associated with STI, while BBV positives were older. Non-Western assailant was associated with STI, while substance abuse was associated with STI and BBV. In order to prevent potential transmission of STI not identified at the initial visit, 91% accepted prophylaxis against bacterial STI, while antiviral prophylaxis was offered to less than one-fifth of the patients.

CONCLUSIONS

The C trachomatis prevalence among the sexual assault patients was lower than in a comparable clinical population. The STI was suspected to be assault-transmitted in only two cases.

[Sexual abuse of prepubertal children]

BACKGROUND

During the last 15 years, a considerable change has taken place regarding the understanding of anatomical and microbiological anogenital findings in children. At the end of the 1980s, abnormal findings were described in more than 50 % of allegedly abused children. Today such findings are described in 5 %. An important consequence of this change is that absence of abnormal findings should never be used to exclude abuse, not even abuse with anogenital penetration. The main reason for this change is increased knowledge about normal variation and healing after injury, as well as an improvement in standardisation of terminology.

MATERIAL AND METHODS

This paper is based on relevant literature published on this topic.

RESULTS AND CONCLUSIONS

During this period, several findings have been reclassified from abnormal to normal or non-specific. Examples of such findings are anal dilatation, large and gaping hymenal opening and narrow hymenal brim. Some of the previously reported cases of anogenital scarring are probably mis-classified normal structures. Research-based international classification scales are now established in order to aid the physician in diagnosing sexual abuse, and these are revised on a regular basis. It is currently common to classify medical findings into three main categories; normal/unspecific findings, indeterminate findings and diagnostic findings.

Anogenital human papillomavirus in non-abused preschool children

AIM

To estimate the prevalence of human papillomavirus (HPV) in anogenital samples from children selected for non-abuse.

METHODS

A letter of invitation was sent to 2731 girls and 1042 boys, all of them aged 5 or 6 y. Inclusion was based on self-selection, whereby parents who did not suspect any occurrence of sexual abuse of their child gave informed consent to participate. Several mechanisms were undertaken to exclude abused children. A complete examination was done of each child, including anogenital examination with a colposcope and microbiological sampling from the genitals and anus. Polymerase chain reaction (PCR) using primers MY09 and MY11 was used to identify HPV, and sequencing was done on each positive amplicon.

RESULTS

PCR was performed on 325 adequate specimens from 211 children enrolled. Seven samples from 5 girls were HPV-positive, making 2/161 (1.2%) of the anal and 5/164 (3.0%) of the genital specimens positive. HPV was not detected in any of the boys. In four girls strong associations with HPV 6 genotypes were found, while one girl probably had a mixed infection with HPV 6 and 16. Three girls (1.8%) had clinically detectable anogenital warts.

CONCLUSION

Since our results are comparable with a prevalence reported from allegedly abused children, and higher rates have been reported from the oral cavity in healthy children, we find detection of HPV unreliable as an indicator of sexual abuse in 5-6-y-old children. The rate of anogenital warts found in our study is comparable with a rate reported in abused children.

Genital anatomy in non-abused preschool girls

AIM

To describe the normal variations in genital anatomy in preschool girls selected for non-abuse.

METHODS

A total of 2731 girls aged 5 or 6 y were invited to take part in the study; 195 girls were recruited. Inclusion was based on self-selection, whereby parents who did not suspect any occurrence of sexual abuse of their children gave informed consent to participate. Several steps were taken to exclude abused girls and girls with previous accidental genital injuries. The genital examination, using a colposcope and a camera, was performed in supine position using a separation and traction technique, and in the prone knee-chest position.

RESULTS

A number of genital anatomical features and hymenal measurements were described and found consistent with previous studies. An important finding was outward folding of the posterior hymenal rim in many girls, a feature that could be difficult to distinguish from attenuation of the posterior hymen. A gaping hymenal orifice, previously suggested to be a supportive sign of sexual abuse, was fairly frequently found and significantly associated with a large horizontal hymenal diameter.

CONCLUSION

To distinguish between girls with outward folding of the posterior hymen and those with attenuated hymens, we recommend the use of the saline irrigation method. Even though normative hymenal measurement data now exist from a reasonable number of girls, these measurements should be used with caution in sexual abuse evaluations.

Anogenital bacteriology in non-abused preschool children: a descriptive study of the aerobic genital flora and the isolation of anogenital Gardnerella vaginalis

The purpose of the study is to describe the genital aerobic bacterial flora including Gardnerella vaginalis in girls and the occurrence of anal G. vaginalis in both genders. From a group of 3773 children, 278 (99 boys and 179 girls) with a mean age of 5.63 y (range: 5.13-6.73) were recruited. Inclusion in the study was based on self-selection, whereby parents who did not suspect any occurrence of sexual abuse of their child gave informed consent to participate. Several mechanisms were undertaken to exclude abused children. At least one bacterial species was isolated from the genitals of 59 (33.9%) girls. Most isolates (39 out of 99) were bacteria representing skin flora (staphylococci and coryneform organisms), with viridans streptococci and related organisms as the second most common group of isolates (31 out of 99). S. anginosus was the single most frequent bacterial species identified (17 isolates). Streptococcus pyogenes was isolated from the genitals of two girls, Streptococcus pneumoniae from one girl and Haemophilus influenzae from eight girls. G. vaginalis was not isolated from the genitals in any girl, but the organism was isolated from the anal canal in three children.

Perianal anatomy in non-abused preschool children

The purpose of this study was to describe the normal variation in perianal anatomy in preschool children, selected for non-abuse, and to compare the findings in two examination positions. A letter of invitation was sent to 3773 children, after which 305 children (103 boys and 202 girls) were recruited. Inclusion in the study was based on self-selection, whereby parents who did not suspect any occurrence of sexual abuse of their child gave informed consent to participate. The mean age of the children was 5.63 y (range: 5.13-6.75). An anal examination was performed in the left lateral position (LLP) and the prone knee-chest position (KCP), for approximately 30 s each. A colposcope and a camera were used. All data were systematically analysed for gender differences, and a paired sample test was used to compare findings in LLP and KCP. Venous congestion in LLP and external anal dilatation in both positions were significantly more common in girls, while midline depressions and smooth areas (both positions) were significantly more common in boys. External and total anal dilatation, midline smooth areas and depressions and the occurrence of a prominent anal verge were significantly more common in the KCP. The finding of total anal dilatation was rare.

CONCLUSION

We observed several gender and position differences in perianal anatomy, and most of these findings seem to be related to structure and tone in the anal muscles.

[A classification system of anogenital findings. A diagnostic tool in the assessment of sexually abused children]

The assessment of suspected sexual child abuse demands teamwork where the paediatrician plays a central role. From a juridical point of view, the task of the paediatrician is to evaluate the anatomic, microbiologic and forensic medical findings. In 1995, in order to improve the quality of this work, Norwegian paediatricians established a peer review group which meets on a regular basis. Based on available literature and the experience of the individual members, a classification system for anogenital findings has been developed. The findings are divided into five classes. Class one comprises findings frequently seen in children who have not been abused. Class two comprises findings not considered to be normal, but for which there could be many different causes. Classes three, four and five represent findings which are increasingly predictive with respect to injury penetration or attempted penetration. Since our knowledge of anogenital anatomy in children who have not been abused is limited, our classification system should be updated regularly.

[Sexually transmitted diseases, HIV infection and AIDS in Mudzi, Zimbabwe. A study of knowledge, attitudes and practice in a rural area in southern Africa]

We describe a study conducted in a rural area of Zimbabwe. We examined all patients who attend for treatment of a presenting sexually transmitted disease for a period of one month in 1989 and 1992. In addition we studied the knowledge of, attitudes towards and practices as regards HIV-infection and AIDS in 1992. The annual rate of sexually transmitted diseases was not different in the two periods studied. Most of the females with symptoms of sexually transmitted diseases were married and had been infected by their husbands. Most males too were married, but had been infected by prostitutes. There was a reduction in the proportion of patients who were employed as teachers, policemen or in the army. The use of condoms seems to have increased. Males were generally better informed about HIV-infection and AIDS than females were. As much as 26% of the females and 40% of the males had a close friend/relative who had died from AIDS and 69% of the females and 81% of the males had found it necessary to change their sexual behaviour after hearing about AIDS. Most people knew the most important parts of transmission, and about condoms as a means of protection, but the rate of sexually transmitted diseases remains very high. New strategies are needed in the preventive work.