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The article refutes the idea that gender-affirming care (GAC) is child maltreatment and shows how withholding GAC is harmful to children and amounts to state-sanctioned medical neglect and emotional abuse. Topics discussed include reason that GAC has been reified in numerous reputable professional guidelines, guiding questions used in the diagnosis of medical neglect, and ways to advocate for transgender and gender diverse (TGD) youth.

Adolescents with chronic pain can at times present with disability out of proportion to diagnostic workup. This is also a defining feature of medical child abuse (MCA). The aim of this study was to identify themes from the clinical narratives of adolescents with chronic pain that may indicate concern for MCA. This qualitative, retrospective study at an academic children's hospital between 2011 and 2019 identified 37 adolescents aged 13–18 years old with chronic pain and varying levels of concern for MCA. Conventional, inductive content analysis was used to identify themes from the medical records of all patients, which were reviewed by an interdisciplinary panel of experts. Themes were organised into three tiers related to the level of concern for MCA: 'Green zone' themes including fatigue or sleep problems, psychosocial distress, and social withdrawal were common among all patients. 'Yellow zone' themes including fragmented care, caregiver catastrophising, caregiver misrepresentation, medical provider exasperation, and sick identity were more common among patients in whom medical providers raised concern for MCA. A single 'red zone' theme, reportable harm to the child, was only present in patients diagnosed by a child abuse paediatrician as having MCA. A visual display of the results is provided for further research and clinical application. [ABSTRACT FROM AUTHOR]

OBJECTIVE: We sought to develop and validate a list of ICD-10-CM codes identifying abusive head trauma (AHT). METHODS: Subjects included all children under 2 years with head trauma seen in the emergency department or admitted to one of 5 medical centers. Cases were classified as AHT, accidental head injury, or indeterminate based on chart review of the medical record. ICD-10-CM code list to identify cases of AHT was developed based on prior head injury code lists. Sensitivity and specificity of the final code list were calculated. RESULTS: There were 2883 patients in the study population of whom 524 had AHT, 2123 had accidental injury, and 236 were indeterminate cases. The final list of AHT codes had a sensitivity of 76.1% (95% CI 72.5-79.8) and a specificity of 98.5% (95% CI 98.0-99.0) when limiting analyses to the groups with identified cause of injury (accidental vs abusive). Misclassification of cases based on codes resulting in false positives and false negatives was due to coding errors. CONCLUSIONS: The list of ICD-10-CM codes can be utilized to identify and track cases of AHT at a national level in large administrative datasets though likely underestimates true injury burden. [ABSTRACT FROM AUTHOR]

The aim of this study was to examine the frequency with which child abuse pediatricians (CAPs) assess consultations as low versus high likelihood of abuse. In this retrospective secondary analysis of data from the Examining Siblings to Recognize Abuse (ExSTRA) study, the likelihood of abuse score for 2890 consultations at 20 medical centers was collected. Descriptive statistics were used to examine the percentage of cases representing low versus high likelihood of abuse (i.e., score of 1–4 vs. 5–7 on a 7-point scale). Linear and logistic regression analyses were used to examine score variability between medical centers. Overall, fifty-three percent of cases were assessed as low likelihood of abuse, suggesting that CAPs were equally as likely to assess a high versus low likelihood of abuse. The percentage of cases representing low likelihood of abuse differed significantly (P <.001) between medical centers after controlling for patient age, sex, race/ethnicity, twin/triplet status, injury types, and injury severity. The variability between CAP assessments at different medical centers is discussed, along with potential contributors to this variability and directions for future work. [ABSTRACT FROM AUTHOR]

OBJECTIVES: The objective of this study was to describe the outcomes of implementing a high-risk bruise screening pathway in a pediatric emergency department (ED). METHODS: A retrospective observational study was performed of children aged 0 to,48 months who presented to the ED between December 1, 2016, and April 1, 2019, and had bruising that is high-risk for physical abuse on a nurse screening examination. A high-risk bruise was defined as any bruise if aged,6 months or a bruise to the torso, ears, or neck if aged 6 to,48 months. Records of children with provider-confirmed high-risk bruising were reviewed. RESULTS: Of the 49 726 age-eligible children presenting to the ED, 43 771 (88%) were screened for bruising. Seven hundred eighty-three (1.8%) of those children had positive screen results and 163 (0.4%) had provider-confirmed high-risk bruising. Of the 8635 infants aged,6 months who were screened, 48 (0.6%) had high-risk bruising and 24 of 48 (50%) were classified as cases of likely or definite abuse. Skeletal surveys were performed in 29 of 48 (60%) infants, and 11 of 29 (38%) had occult fracture. Of the 35 136 children aged 6 to,48 months who were screened, 115 of 35 136 (0.3%) had high-risk bruising and 32 of 115 (28%) were classified as cases of likely or definite abuse. CONCLUSIONS: High-risk bruising was rarely present. When infants aged,6 months were evaluated per recommendations, occult fracture was identified in one-third of patients. The screening pathway could help other institutions identify occult injuries in pediatric ED patients. [ABSTRACT FROM AUTHOR]

The objective of this study was to evaluate disparities in skeletal survey (SS) use for pediatric. head injury patients in the emergency department (ED). This was a multi-site retrospective. cohort study of children <24 months with concern for head injury and injury on head CT from. 7/1/12 - 1/1/22. We determined adjusted associations between SS completion and race, ethnicity, language for care, insurance type, and income, with sub-analysis of children <6 months and with complex injury. We evaluated occult fracture prevalence. Two-hundred seventy children met criteria and 88 had SS. No statistical association was found between skeletal survey completion and race or ethnicity, language for care, private insurance, median census tract income, or in sub-analyses. Two of 88 (2.3%) patients had occult fracture; both had risk factors for NAT. In conclusion, no statistical association was found between SS completion and demographics. Occult fracture was uncommon. SS use can likely be decreased in lower risk patients., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Drs. Crumm and Brown provide legal consultation and testimony for child abuse cases.

Background: Though child abuse pediatrics has been a board-certified subspecialty for 15 years, there are few formalized board preparation resources available., Objective: The purpose of this project was to establish a multiple-choice question bank with sufficient validity evidence for use in preparation for the child abuse pediatrics board examination., Participants and Setting: The question bank was distributed via an electronic child abuse pediatrics mailing list. Participants completing the entire question bank included 27 board-certified child abuse pediatricians (CAPs), 19 board-eligible CAPs, and 18 CAP fellows., Methods: We used Messick's framework to conduct the validity investigation, which includes five components: content evidence, response process, internal structure, relation to other variables, and consequences. Item analyses included difficulty index, discrimination index, and distractor analysis. We used Cronbach's alpha to estimate internal consistency reliability. We conducted linear regressions of scores on the question bank compared to in-training exam scores and career stage., Results: Eighty-four participants completed part of the question bank, and 64 completed the entire question bank. Of the original 117 questions ("items"), 94 met inclusion criteria. The mean score among board-certified CAPs was 80 %, and among participants reporting passing third-year ITE scores was 81 %. Correlation coefficient of scores on this question bank by career stage was r = 0.94, and by year of fellowship was r = 0.99. Cronbach's alpha for internal consistency reliability was 0.83., Conclusions: This multiple-choice question bank is the first question bank with a robust validity investigation for use by child abuse pediatrics trainees., Competing Interests: Declaration of competing interest The authors report no conflict of interest related to this work., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Objectives: Previous research has shown racial, ethnic, and socioeconomic disparities in provider medical evaluations and reporting to child protective services (CPS) and law enforcement (LE) for cases of suspected child physical abuse. Our hospital standardized evaluation and reporting of high-risk bruising using a clinical pathway. We aimed to assess whether standardization impacted disparity., Methods: We performed a retrospective observational study including children evaluated in the emergency department who had a social work consult for concern for child abuse or neglect between June 2012 and December 2019. From this group, we identified children with high-risk bruising. We compared outcomes (receipt of skeletal survey, CPS report, or LE report) before and after implementation of a standard bruising evaluation pathway to determine how the intervention changed practice among various racial, ethnic, and socioeconomic groups., Results: During the study period, 2129 children presented to the ED and received a social work consult for child abuse or neglect. Of these, 333 had high-risk bruising. Children without private insurance had a higher risk of having a CPS (adjusted relative risk, 1.32; 95% confidence interval, 1.09-1.60) or LE (adjusted relative risk, 1.48; 95% confidence interval, 1.11-1.97) report prepathway, but not after pathway implementation. No significant associations were seen for race or ethnicity., Conclusions: A standardized clinical pathway for identification and evaluation of high-risk bruising may help to decrease socioeconomic disparities in reporting high-risk bruising. Larger studies are needed to fully evaluate disparities in assessment and reporting of child abuse., Competing Interests: Disclosure: Drs. Crumm, Brown, and Schlatter provide consultation and testimony in child abuse cases. The other authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Both medical child abuse (MCA) and central sensitization (CS) may present in adolescents with chronic pain, disability, high healthcare utilization, and unremarkable medical evaluations., Objective: This study aimed to identify themes in the clinical narratives of adolescents with chronic pain that may help differentiate MCA from CS., Participants and Setting: Participants were 28 adolescents (ages 13-18 years) with chronic pain referred to either the Child Abuse Pediatrics team or the Pediatric Pain Medicine team at a tertiary children's hospital between 2011 and 2019, and diagnosed with MCA or CS, respectively., Methods: This was a qualitative, retrospective study. Qualitative themes were derived through a process of inductive content analysis utilizing open coding, grouping, and secondary review by an interdisciplinary panel of experts. The relative prevalence of each code, theme, and overarching category was examined between groups to identify areas of convergence and divergence., Results: Several themes appeared to be more prevalent in the MCA group (n = 9) compared to the CS group (n = 19). These included sick identity, homeschooling, caregiver with mental health disorder, maternal catastrophizing, maternal misrepresentation, persistence in healthcare-seeking, mandated reports made, medical neglect, and unnecessary and harmful medical care., Conclusions: This exploratory work identified themes from the clinical narratives of adolescents with chronic pain that may help differentiate MCA from CS. A visual reference, two illness scripts, and management recommendations are presented to aid pediatric providers in facilitating appropriate referrals for adolescents with chronic pain and disability out of proportion to diagnostic workup., (Copyright © 2022. Published by Elsevier Ltd.)

Child abuse is a broad term that includes, but is not limited to, physical or emotional harm, neglect, sexual abuse, and exploitation. In 2018 in the United States, there were nearly 700,000 victims of such maltreatment, of which 1700 children died. The majority of deaths occur in infants and toddlers under 3 years of age. While clinical signs and symptoms may raise suspicion for inflicted injury, such as bruising in young infants, imaging often plays a central role in identifying and characterizing nonaccidental trauma. The purpose of this article is to discuss the array of inflicted traumatic injuries to the thorax in children. Rib fractures are among the most common and telling features of physical abuse, especially in infants. The locations of such fractures and differences in appearance while healing will be presented, along with potential mimics and pitfalls. Less typical fractures seen in abuse will also be reviewed, including those of the sternum, clavicle, spine, and scapula. Finally, uncommon injuries to the lungs, heart and esophagus will also be considered., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Children of teenage parents are at increased risk for child maltreatment but there is limited information about the risks teenage parenthood poses for maltreatment recurrence after prior Child Protective Service (CPS) involvement., Objective: Determine whether children born to teenage parents are at increased risk of maltreatment re-referral to CPS compared to children born to older parents., Participants and Setting: Children under 6 years with substantiated reports of parental maltreatment between 2002 and 2018 were identified from National Child Abuse and Neglect Data System (NCANDS) data., Methods: Youngest known parental age at child's birth, in years, was categorized as <20, 20-24, 25-29, or ≥30 (referent group). The number of re-referrals within 5 years was the outcome of interest. Negative binomial regression analyses assessed whether being born to a teen parent was associated with a greater risk of re-referral., Results: In a study population of 2,680,961 children, having a teen parent, one aged 20-24 years, or 25-29 years at birth was associated with 19% (95% CI 1.18-1.19), 16% (95% CI 1.16-1.17), and 11% (95% CI 1.11-1.12) greater risk of re-referral compared to having a parent aged 30 years or older adjusting for child age, gender, race-ethnicity, state, and initial maltreatment type., Conclusion: The small, but significant increased risk for re-referral to CPS for child maltreatment in young children with at least one teenage or young parent at the time of birth compared to children with older parents suggests that specifically targeting young parents with appropriate services when initially referred to CPS may help reduce the risk of maltreatment recurrence., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Abstract: We describe 3 infants with skull fractures that involved more than 1 skull bone. On further evaluation, 2 of the 3 infants had additional fractures at other sites of the body and the third infant had concerning bruising of the face. Although an accidental mechanism of injury was initially given as the history in each case, law enforcement investigations led all 3 fathers to confess to crushing their infants' skulls out of frustration. These crushes were caused by their arms or hands. Bilateral skull fractures or those involving more than 1 skull bone can be seen in falls as well as in crush injuries. A crush-like pattern of injury, in the absence of a clear and plausible accidental mechanism, should raise concerns for possible physical abuse especially in nonambulatory infants., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Aim: We sought to determine the frequency and patterns of delayed medical care seeking for young children with skull fractures., Methods: We identified accidental skull fractures <4 years old, 2011-2012. Child abuse paediatricians abstracted retrospective data and paediatric radiologists re-reviewed images. 'Delays' were defined as presentation at ≥6 h. 'Minor accidents' included falls <4 feet and low force trauma, while 'major accidents' included higher height falls and major force events. We studied the frequency and duration of care delays, the signs or symptoms leading to care, and the duration of delays after signs or symptoms developed., Results: Two hundred and ten children had accidental skull fractures. Delays were less likely with major accidents (4.9%), than with minor accidents (25.8%) (RR = 0.32 [0.15-0.70]). Children came to care for scalp swelling (STS) (39%), the injury event (36.2%), altered consciousness (15.2%) and vomiting (10.5%). Delayed onset of STS (78.6%) caused most delayed care. Early STS was firm, (17.6%) versus delayed (5.0%), as opposed to soft or fluctuant., Conclusion: Delayed care seeking is common for minor, but not major accidental infant and toddler skull fractures. Most followed delayed onset of signs and symptoms. Delayed care seeking alone should not imply child abuse., (© 2020 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)