| | Physical abuse: Recognition and reportingAbstract This article provides primary care providers, including pediatric nurse practitioners, with a framework for understanding the dynamics of child abuse, recognizing physical abuse injuries, and reporting concerns of suspected physical abuse to child protective services. Three children die in America every day as a result of child abuse or neglect. Many children who have severe injuries at the time that physical abuse is diagnosed have previously presented with less severe injuries, and physical abuse was overlooked. Physical assessment for children presenting with bruises, bite marks, burns, skeletal injuries, abdominal trauma, and head injuries will be discussed. Prompt recognition and reporting of physical abuse injuries by primary care providers is imperative for the protection of children.
Childhood traditionally is viewed as a time of carefree fun and innocence. However, for thousands of children, violence is a part of everyday life. The violence does not occur in a war-torn village or on crime-ridden streets but rather in their own homes at the hands of adults who are supposed to love and care for them. This article provides primary care providers, including nurse practitioners, with a framework for understanding the dynamics of child abuse, recognizing physical abuse injuries, and reporting concerns of suspected physical abuse to child protective services.
Prevalence  The National Clearinghouse on Child Abuse and Neglect (2003) states that in 2001, 3 million reports were made to child protective services (CPS) concerning the welfare of 5 million children. Approximately 67% of these referrals were scre-ened-in, meaning that CPS determined that there was sufficient concern to warrant investigation (National Clearinghouse of Child Abuse & Neglect). More than half of the screened-in referrals were made by professionals, including doctors, nurses, teachers, law enforcement officers, and counselors. In 2001, approximately 903,000 children were substantiated by CPS to be victims of child maltreatment. Nineteen percent of the children suffered physical abuse. According to Prevent Child Abuse America (2003), three children die in America every day as a result of child abuse or neglect. Nearly half of the deaths involve children who are younger than 1 year, and 85% of the deaths are of children who are younger than 6 years. Homicide is the leading cause of injury-related deaths for children younger than 5 years (Zenel & Goldstein, 2002). Definition State and federal legislation both define child abuse and neglect. Federal legislation provides guidelines for states by identifying a minimum set of behaviors or acts that define physical abuse, neglect, and sexual abuse (National Clearinghouse of Child Abuse & Neglect, 2003). The Federal Child Abuse Prevention and Treatment Act (CAPTA) defines child abuse and neglect as any recent act or failure to act on the part of a parent or caretaker that results in death, serious physical or emotional harm, sexual abuse or exploitation, or an act or failure to act that presents an imminent risk of serious harm to a child (National Clearinghouse of Child Abuse & Neglect). CAPTA states that physical abuse is characterized by the infliction of physical injury as a result of punching, beating, kicking, biting, burning, shaking, or otherwise harming a child. CAPTA additionally states that the parent or caretaker may not have intended to harm the child; rather, the injury may have resulted from overdiscipline or physical punishment (National Clearinghouse of Child Abuse & Neglect). Columbus Children's Hospital's definition of physical abuse has been adopted by the Ohio Chapter of the American Academy of Pediatrics Committee on Child Abuse and Neglect (Johnson, 2002) (see Box 1). Box 1 Definition of physical abuse, Children's Hospital, Columbus, Ohio
•Tissue damage caused by a parent, guardian, or custodial caretaker, for any reason, including reaction to an unwanted behavior, is child abuse and must be reported to proper authorities.
•Tissue damage includes bruises, burns, tears, punctures, fractures, rupture of organs, and disruption of functions.
•Tissue damage can be caused by impact, pinching, shaking, penetration, heat, a caustic chemical, or a drug.
•Temporary redness (erythema) of the hands or buttocks caused by a caretaker's hand, though not condoned, may not necessitate reporting as child abuse.
•Temporary redness or tissue damage caused by a caretaker's hand to any other part of the body other than the hands or buttocks is child abuse.
•Physical discipline should not be used on children who are younger than 18 months or abnormal developmentally, emotionally, or physically.
•The use of an instrument on any part of the body is child abuse.
Data from Johnson (2002). Risk factors Child abuse crosses all socioeconomic, ethnic, religious, and educational boundaries. It is difficult to identify personality traits or life experiences in the adult population that are associated with child abuse, and these traits are not predictive of a single person's likelihood of abusing a child (Nagler, 2002). Examining psychosocial profiles of known abusers can be used to identify potential risk factors (see Box 2). Box 2 Parental/caretaker risk factors for child abuse
•History of child abuse/neglect as a child
•Lack of social supports/social isolation
•Poor impulse control
•Unrealistic developmental expectations of the child
•Adolescent or young parent
•Mental illness/depression/developmental delay
•Substance abuse
•Domestic violence
•Poverty
•Unemployment
•Low education
•Single-parent home with mother head of household
•Previous involvement with child protective services
•Role reversal in the parent-child relationship
Data from Chaney, 2000, Frederickson, 1999, Nagler, 2002, Peck and Priolo-Kapel, 2002, Santucci and Hsiao, 2003. Certain children are statistically at greater risk for child abuse (see Box 3). The majority of children who are physically abused are younger than 3 years; as a child ages, the risk of abuse decreases (Mayer & Burns, 2000). Inconsolable crying tends to be the precipitating factor for physical abuse in infants; toilet-training issues tend to precipitate physical abuse in toddlers (Chaney, 2000, Peck and Priolo-Kapel, 2002). Prematurity, developmental delay, physical disability, or a chronic medical condition can alter parent-child bonding, impair the child's ability to meet parental expectations, and exhaust parental financial and emotional resources, placing the child at increased risk for child abuse (Kini & Lazoritz, 1998). Children with behavior problems are at increased risk of child abuse, as are children living in foster care (Herendeen, 2002). Box 3 Factors placing children at increased risk of child abuse
•Age (infants and preschoolers are at increased risk)
•Prematurity
•Developmental delay/disability
•Congenital anomalies or other medical condition
•Behavior problems
•Placement in foster care
Data from Chaney, 2000, Herendeen, 2002. It is important for the primary care provider to understand that parental and child risk factors alone should not be used to make a diagnosis of physical abuse. However, when evaluating for possible abuse, it is important to be aware of potential risk factors. Herendeen (2002 states that child abuse is generally repetitive and tends to escalate over time. Many children who have severe injuries at the time that physical abuse is diagnosed have previously presented with less severe injuries and physical abuse was overlooked (Chaney, 2000). Prompt recognition and reporting of physical abuse injuries by primary care providers is imperative to the protection of children. Assessment of physical abuse Taking the history When a child presents with a physical injury, it is vital to obtain a complete history from the parent or caretaker accompanying the child. Inquire how, when, and where the injury occurred. Allow the caretaker to lead the interview with a narrative of the injury (Mayer & Burns, 2000). Obtain a complete timeline of the injury, noting any delay in seeking medical care (Herendeen, 2002). Begin the timeline with the last time the child appeared to be healthy or uninjured. Find out who was present when the injury occurred and if anyone witnessed the injury. When exploring the history given for the injury, it is important to remember that certain indicators are of concern for physical abuse (Cheung, 1999, Herendeen, 2002, Kemp, 2002) (see Box 4). Box 4 Indicators of physical abuse by history
•No history given for the injury
•Inconsistent/conflicting history given by caretakers
•History/injury is inconsistent with the developmental level of the child
•History is inconsistent with the injury
•Delay in seeking medical care
•Doctor shopping
Data from Chaney, 2000, Herendeen, 2002. If age and development allow, question the child directly about how the injury occurred. Whenever possible, interview the child alone without the accompanying parent or caretaker. Use direct, open-ended, and nonleading questions when talking with the child (Herendeen, 2002). It is important to obtain a complete medical history, including present illness, review of systems, medical history, family medical history, and history of injury-related disorders (Mayer & Burns, 2000). A family tree provides invaluable information regarding the family—for example, the current living situation, number of siblings, and number of partners the mother has had children with (Hornor, 2002). Families also should be screened for psychosocial risk factors (see Box 5). Box 5
•Maternal age at birth of first child
•Paternal age at birth of first child
•Marital status of parents
•Mother's current employment status
•Father's current employment status
•Educational level of parents
•Past or present drug and/or alcohol concerns for parents
•History of physical/sexual abuse or neglect within the family—mother and/or father victimized as child
•Previous involvement with child protective services
•History of the child being placed with relatives or in foster care
•Parental mental retardation concerns
Data from Hornor, G. (2002). The physical examination When there is a concern of possible physical abuse, a thorough physical examination should be conducted. Physical findings should be documented in objective and specific terminology (Chaney, 2000). Body diagrams and color photography should be used to document physical findings (Chaney). Describe the location, distribution, depth, color, size, and shape of cutaneous findings such as bruises, burns, lacerations, and abrasions (Cheung, 1999). Findings associated with physical abuse include lacerations, bruises, burns, fractures, bite marks, abdominal injuries, and head injuries (Chaney). During the physical examination, the child's behavior should be assessed for normal growth and development and appropriateness for the child's age. Note the child's personal hygiene. Bruises Bruises are perhaps the most common presentation of physical abuse (Herendeen, 2002, Mayer and Burns, 2000). Bruises result from a crushing injury or direct blow that causes leaking of blood into surrounding tissues (Herendeen). The bruise size and depth are influenced by the force of impact, the size of disrupted blood vessels, the vascularity and connective tissue density, and underlying body organs (Mayer & Burns). When examining bruises and lacerations, it is important to consider the location, shape, and pattern. Bruises on surfaces of the body over boney prominences such as shins, knees, and foreheads often are seen that result from normal play and most likely are accidental (Herendeen, 2002, Kini and Lazoritz, 1998, Mayer and Burns, 2000). Bruises on protected, padded areas of the body where there is more underlying fatty tissue are concerning for inflicted injury, such as the buttock, face, and genitalia, and especially the earlobe, neck, upper lip, and philtrum (Kini & Lazoritz; Mayer & Burns). It is important to note the shape and pattern of the bruise. Bruises that can be identified as produced by known objects such as belts or hangers or bruises that are sharply delineated, such as loop marks or crescentic marks, are suspicious for abuse (Kini & Lazoritz, 1998) (see Figure 1, Figure 2). Patterns left by the human hand often can be identified (Kini & Lazoritz) (see Figure 3). Abrasions, lacerations, or swel-ling accompanying the bruises may be helpful in determining etiology and timing. No definite guidelines exist for dating bruises. Bruises usually initially appear to be red and swollen and gradually change to purple, blue, green, and yellow as the blood is reabsorbed (Herendeen, 2002). Most bruises disappear in 2 to 4 weeks (Johnson, 1990). Bruise color is most helpful in determining whether the injury occurred from a single incident or on multiple occasions. Bruises of multiple colors, especially on the same body surface, are indicative of repeated trauma (Herendeen). Prothrombin, prothrombin time, bleeding time, and platelet count tests should be ordered to rule out a bleeding disorder when bruises are of concern for physical abuse (Herendeen, 2002, Johnson, 1990). The location and severity of the bruises, as well as the presence of accompanying symptoms, will determine the need for a more complete child abuse work-up, including skeletal survey, head computed tomography (CT) scan, ophthalmology consult, abdominal CT scan, and/or gastrointestinal profile. Altemeier (2001) points out the importance of evaluating the age of the child and developmental milestones when determining etiology of bruising; bruising in nonambulatory children is of concern for abuse. Sugar, Taylor, and Feldman (1999), as well as Labbe and Caouette (2001), found accidental bruising in children younger than 9 months of age to be rare. Bite marks Bites are of concern because of the potential for infection. Initially, it is important to determine if the bite is human or animal in origin. Animal teeth tend to be pointed and narrow, resulting in puncture marks to the skin. Human bites cover a larger surface area and tend to tear or crush. There is never an accidental reason for a child to present with an adult bite mark (Kini & Lazoritz, 1998). Therefore, when a child presents with a human bite mark, it is vital to determine if it is a bite from a child or an adult. If the space between the canines is greater than 3 cm, the bite was most likely by an adult (Herendeen, 2002, Kini and Lazoritz, 1998, Lee et al. 2002). Burns Burns result from a thermal injury to the skin and subcutaneous tissue. The causal mechanism may be scalds (hot liquids), flame contact (hot solid objects), electrical, or chemical (Mayer & Burns, 2000). Burn injuries are classified by the depth of the injured skin (superficial, partial, or full thickness), and the size of the burn is calculated from the percentage of body surface area involved (Mayer & Burns). Burn injury appearance is dependant on the site of the burn, the age of the child, and the presence or absence of clothing (Kini & Lazoritz, 1998). The most common cause for childhood burns, accidental or inflicted, is hot liquid resulting in a scald burn (Kini & Lazoritz). Approximately 10% to 25% of pediatric burns result from abuse, and most occur in children younger than 3 years (Herendeen, 2002, Mayer and Burns, 2000). It is vital to evaluate the history, pattern, location, and characteristics of the burn when determining if the injury is accidental or inflicted (Herendeen). Accidental burns, such as spills, tend to have a typical burn pattern: the worst burn is at the highest point of body contact, and the severity of the burn decreases as the spilled liquid runs down the body, cooling, and leaving a less severe injury (Mayer & Burns, 2000). Accidental burns from contact with hot liquids tend to weave an irregular burn pattern with patches and numerous splash marks (Kini & Lazoritz, 1998). Certain patterns of burn injury are characteristic of physical abuse (Cheung, 1999, Mayer and Burns, 2000, Peck and Priolo-Kapel, 2002). Stocking or glovelike burn patterns of the hands or feet, especially bilateral, are suggestive of immersion injury (Cheung) (see Figure 4). Immersion burn injuries result from the child being dunked in hot liquid. Immersion burns have sharply delineated edges between burned and unburned skin and are of a uniform depth (Peck & Priolo-Kapel). Scald burns to the perineum and lower extremities should raise suspicions of possible inflicted injury resulting from immersion in a hot liquid (Kini and Lazoritz, 1998, Mayer and Burns, 2000, Peck and Priolo-Kapel, 2002). Immersion burns typically result in a flexion burn pattern due to the child's joints being held in flexion as a result of fear, pain, or anger when immersed in the hot liquid, yielding areas of sparing as the result of flexion (Peck & Priolo-Kapel). Splash burns resulting from a hot liquid being thrown on a victim are possible but uncommon in children (Peck & Priolo-Kapel, 2002). Inflicted splash burns are difficult to differentiate from accidental splash burns, but accidental splash burns tend to involve the upper extremities, face, and trunk. Contact burns result from direct contact with a hot object. Peck and Priolo-Kapel (2002) state that inflicted contact burns tend to result in a more sharply defined pattern with a recognizable shape and are deeper. Accidental contact burn patterns tend to be less well defined because of the child's ability to move away from the hot object in response to pain, resulting in a more superficial burn (Peck & Priolo-Kapel). Cigarette burns are somewhat common in children (Herendeen, 2002). Accidental cigarette burns are typically superficial as a result of the child brushing up against the cigarette (Herendeen). Inflicted cigarette burns are often full-thickness burns with a sharply circumscribed edge and measuring 7 to 8 cm in diameter (Herendeen). Photographic documentation of the burn is essential when there is a concern of possible inflicted injury. Skeletal surveys should be obtained for children younger than 2 years when there is suspicion of abusive burn injury; when the child is between the ages of 2 and 5 years, the survey should be performed selectively based on history and physical examination (Peck & Priolo-Kapel, 2002). Assessment of water temperature is essential when evaluating burns resulting from hot water (Herendeen, 2002). The depth of the burn is dependant on the exposure time, the part of the body burned, the child's age, and the water temperature (Herendeen). It is important for law enforcement and/or CPS to measure water temperature at the injury site and compare it with the history of the injury (Herendeen). Water heaters typically are set between 120°F and 150°F (Mayer & Burns, 2000). Water is comfortable for bathing at 101°F and becomes uncomfortable at 109°F to 118°F (Mayer & Burns). Herendeen (2002) states that with water at 120°F, it would take 3 minutes to obtain a full-thickness burn. Cutaneous mimickers When assessing for physical abuse, it is important to remember that there are cutaneous mimickers of child physical abuse. Mongolian spots, predominantly seen in Black, Asian, Latino, and American Indian babies, are blue-green areas of pigmentation typically found on the buttocks (Mudd & Findlay, 2004). They can also be found on other parts of the body. Mongolian spots can be mistaken for bruises. Accurate documentation of Mongolian spots by the primary care provider can aid in differentiating them from bruises (Mudd & Findlay). Reassessing the child in a week also can help in differentiating Mongolian spots from bruises; Mongolian spots will not change, and bruises should change or disappear in a week. Erythema multiforme minor is an acute, self-limited reactive erythema thought to be caused by a hypersensitivity reaction to drugs or infectious agents (Mudd & Findlay, 2004). Mudd and Findlay state that the ecchymotic lesions can be mistaken for bruises and raise concerns of inflicted trauma. It is important to obtain a medical history including current and recent medications the child has ingested, along with recent infections. Henoch-Schonlein Purpura (HSP), anaphylactoid purpura, or allergic vasculitis also can be mistaken for bruising, especially in the early stages of the disease (Mudd & Findlay, 2004). Mudd and Findlay state that early HSP lesions appear urticarial but evolve into a nonthrombocytopenic, palpable, purpuric rash typically distributed around the buttocks and extensor surfaces of the arms and legs. HSP should be considered especially in boys between the ages of 2 and 7 years with a history of an upper respiratory infection within the past month (Mudd & Findlay). Bullous impetigo, usually caused by staphylococcus and/or strep, is a skin infection that can mimic burns (Mudd & Findlay, 2004). Bullous impetigo in its localized form can be mistaken for cigarette burns and scald burns in a more extensive infection (Mudd & Findlay). Skeletal injuries Any fracture in a nonambulatory child, typically before the age of 1 year, is of concern for possible abuse (Herendeen, 2002). Approximately 56% to 60% of fractures in children aged 1 year and younger are nonaccidental (Willman, Bank, & Senac, 1997). Multiple fractures or fractures in different stages of healing are of concern for abuse (Cheung, 1999). Fractures that are highly suggestive of abuse are classic metaphyseal lesions, rib fractures (especially posterior), scapular fractures, sternal fractures, and fractures of the spineous processes (Nimkink & Kleinman, 2001). Fractures with a moderate specificity for abuse include epiphyseal separations, vertebral body fractures and subluxations, digital fractures, and complex skull fractures (Nimkink & Kleinman). Fractures that are most likely accidental include clavicular fractures, long bone shaft fractures (in children older than 1 year), and linear skull fractures (Nimkink & Kleinman). Most long bone fractures of the femur and humerous in infants younger than 1 year are inflicted (Nimkink & Kleinman). This correlation decreases as the child ages (Nimkink & Kleinman). Spiral fractures of the tibia can occur in newly ambulatory children with minor accidental trauma (Herendeen, 2002). A skeletal survey should be obtained when a child presents with a fracture that is of concern for abuse. A full child abuse work-up may be needed depending on the location and number of fractures. Abdominal trauma Blunt abdominal trauma is the second most frequent cause of death in abused children (Herendeen, 2002, Kini and Lazoritz, 1998). Most victims of abdominal trauma are between the ages of 6 months and 3 years (Mayer & Burns, 2000). Children who suffer blunt abdominal trauma often have very little external pathology; therefore, caregivers delay in seeking medical care. Presenting symptoms often are obscure, including irritability, vomiting, lethargy, abdominal distension, anemia, or shock (Herendeen; Kini & Lazoritz). Multi-organ involvement is possible and is of great concern for child abuse in the absence of history of extreme trauma. Abdominal trauma, even single organ involvement, rarely occurs from a simple fall. Following medical stabilization of the child, an abdominal CT scan, skeletal survey, urinalysis, and liver enzymes should be ordered (Herendeen; Kini & Lazoritz). A full child abuse work-up should be initiated. Head injury Inflicted head injury (Shaken Baby Syndrome [SBS]) is the leading cause of death as a result of physical abuse injuries (Smith, 2003, Wallis and Goodman, 2000, Wyszynski, 1999). Inflicted head injury usually occurs in children younger than 2 years, and is most common in infants younger than 6 months (Smith; Wallis & Goodman; Wyszynski). SBS may be seen in children up to 5 years of age (Smith). Wallis and Goodman state that inflicted head trauma should be considered in any child younger than 2 years of age who presents with a subdural hematoma, retinal hemorrhages, and a history that is inconsistent with the degree of injury. Herendeen (2002) states 60% of inflicted head injury perpetrators are primary caregivers, and more than 30% of symptomatic children with inflicted head injury are misdiagnosed at first evaluation. Fussiness and crying are the most frequent stimulus reported by caregivers for the shaking. Caffey (1972) described “whip-lash shaken infant syndrome,” which suggested that the subdural hemorrhage and retinal hemorrhages were a result of rotational deceleration forces to the head from repetitive violent shaking, rupturing bridging blood vessels in the subdural space and between the layers of the retina. Listman and Bechtel (2003) state that children who are severely shaken suffer severe deceleration injury to the brain and may have evidence of diffuse cerebral edema and diffuse axonal injury. This can appear as a reversal of the differentiation between the gray and white matter, known as the reversal sign (Listman & Bechtel). Listman and Bechtel (2003) state that controversy exists regarding whether shaking alone or shaking and impact cause the injuries. Impact injuries typically result in a contusion, fracture, or hemorrhage. Skull fractures that should raise a concern of possible child abuse are multiple, complex, depressed, diastatic, or cross suture lines (Herendeen, 2002). Classic findings in inflicted head trauma (SBS) are subdural hematoma, cerebral edema, and retinal hemorrhages (Herendeen, 2002). The child may present with symptoms such as lethargy, poor feeding, irritability, vomiting, seizures, respiratory changes, or altered level of consciousness (Herendeen, 2002, Listman and Bechtel, 2003). Symptoms vary based on the severity of the injury. Often no injuries are present on physical examination. Retinal hemorrhages are noted in 60% to 95% of children with abusive head injuries and are virtually diagnostic of abusive head injury (SBS) (Herendeen; Listman & Bechtel). Other frequent findings in children with inflicted head injury as a result of shaking (SBS) include posterior and anterolateral rib fractures and metaphyseal fractures (Herendeen, 2002, Kemp, 2002, Listman and Bechtel, 2003). When abusive head injury is suspected, a CT scan of the head is the most rapid, reliable diagnostic tool (Herendeen, 2002, Kemp, 2002, Listman and Bechtel, 2003). Magnetic resonance imaging (MRI) can detect small extra-axial fluid collections not appreciated on CT scans, diffuse axonal injury, and can more accurately estimate the time the injury occurred (Listman & Bechtel). An ophthalmology consult should be obtained to evaluate the retinas for hemorrhage. A skeletal survey, bleeding profiles, and a full child abuse work-up should be completed. Implications for practice It is imperative for primary care providers, including pediatric nurse practitioners, to recognize physical abuse and respond appropriately. Early recognition and reporting of physical abuse can be effective in preventing repeated abuse of the abuse of other children (Johnson, 2002). The effects of child abuse are difficult to measure. The shattered bond and trust between child and parent is impossible to quantify. Physical sequelae are more easily measured and can range from subtle changes in learning, motor, or behavior to blindness, mental retardation, or death (Nagler, 2002). Nagler (2002) states physically abused girls are at higher risk for anger, depression, and post-traumatic stress– related problems. Boys with a history of physical abuse are more likely to suffer from depression and to exhibit threatening behavior (Nagler). MacMillan, Fleming, and Streiner (2001) studied a population of more than 7000 Ontario residents and found that those with a reported history of childhood physical abuse had higher lifetime rates of anxiety disorders, alcohol abuse, and antisocial behavior. Heim & Nemeroff (2001) found that human and animal studies showed that early life stress, such as child abuse, may lead to neurobiologic changes that predispose to psychiatric and behavioral illness. Given the significant sequelae of physical abuse, both physical and psychological, it is imperative that primary care providers recognize physical abuse in their pediatric patients and intervene appropriately. Early recognition, treatment, and reporting of physical abuse can help to decrease the negative effects on the victim, both physical and emotional. Obviously, physical abuse victims need to receive prompt medical care to assess and treat their injuries. Mental health counseling for physical abuse victims of preschool age and older should be a vital component of the plan of care. Both federal and state laws define child abuse and neglect. Primary care providers, including pediatric nurse practitioners, have a legal, ethical, and moral responsibility to report concerns of suspected child abuse to the proper child protective service and law enforcement agency. It is the medical professional's responsibility to understand the child abuse reporting laws of their state and the proper reporting procedure. Professionals are immune from legal and civil liability when reporting concerns of child abuse. Failure to report concerns of child abuse to child protective services is a violation of the law, and medical providers can be prosecuted. Timely recognition and reporting of physical abuse, as well as appropriate medical and mental health treatment, can be facilitated by the primary care provider. Primary care providers, including pediatric nurse practitioners, play a vital role in the protection of our children. References ReferencesAltemeier, 2001.
1.
Altemeier WA.
Interpreting bruises in children.
Pediatric Annals. 2001;9:517–520. Caffey, 1972.
2.
Caffey J.
On the theory and practice of shaking infants: Its potential residual effects of permanent brain damage and mental retardation.
American Journal of Diseases in Children. 1972;124:161–169. Chaney, 2000.
3.
Chaney SE.
Child abuse: Clinical findings and management.
Journal of the American Academy of Nurse Practitioner. 2000;12:467–471. Cheung, 1999.
4.
Cheung KK.
Identifying and documenting findings of physical child abuse and neglect.
Journal of Pediatric Health Care. 1999;13:142–143.
Full-Text PDF (460 KB)
|
CrossRef
Frederickson, 1999.
5.
Frederickson D.
Matreatment of children.
Journal of Child and Family Nursing. 1999;2:393–402. MEDLINE Heim and Nemeroff, 2001.
6.
Heim C, Nemeroff CB.
The role of childhood trauma in the neurobiology of mood and anxiety disorders: Preclinical and clinical studies.
Biological Psychiatry. 2001;49:251–254. Herendeen, 2002.
7.
Herendeen P.
Evaluation of physical abuse in children: Solid suspicion should be your guide.
Advance for Nurse Practitioners. 2002;10:32–38. MEDLINE Hornor, 2002.
8.
Hornor G.
Child sexual abuse: Psychosocial risk factors.
Journal of Pediatric Health Care. 2002;16:187–192. Abstract | Full Text |
Full-Text PDF (85 KB)
|
CrossRef
Johnson, 1990.
9.
Johnson CF.
Inflicted injury versus accidental injury.
Pediatric Clinics of North America. 1990;37:791–813. MEDLINE Johnson, 2002.
10.
Johnson CF.
Child maltreatment 2002: Recognition, reporting and risk.
Pediatrics International. 2002;44:554–560. MEDLINE |
CrossRef
Kemp, 2002.
11.
Kemp AM.
Investigating subdural haemorrhage in infants.
Archives of Diseases in Children. 2002;86:98–101. Kini and Lazoritz, 1998.
12.
Kini N, Lazoritz S.
Evaluation for possible physical or sexual abuse.
Pediatric Clinics of North America. 1998;45:205–217. Abstract | Full Text |
Full-Text PDF (976 KB)
|
CrossRef
Labbe and Caouette, 2001.
13.
Labbe J, Caouette G.
Recent skin injuries in normal children.
Pediatrics. 2001;108:271–276. Lee et al. 2002.
14.
Lee LY, Ilan J, Mulvey T.
Human biting of children and oral manifestations of abuse: A case report and literature review.
Journal of Dentistry for Children. 2002;5:92–95. Listman and Bechtel, 2003.
15.
Listman DA, Bechtel K.
Accidental and abusive head injury in young children.
Current Opinion in Pediatrics. 2003;15:299–303. MEDLINE |
CrossRef
MacMillan et al. 2001.
16.
MacMillan HL, Fleming JE, Streiner DL.
Child abuse and lifetime psychopathology in a community sample.
American Journal of Psychiatry. 2001;158:1878–1883.
CrossRef
Mayer and Burns, 2000.
17.
Mayer BW, Burns P.
Differential diagnosis of abuse injuries in infants and young children.
The Nurse Practitioner. 2000;25:15–37. MEDLINE |
CrossRef
Mudd and Findlay, 2004.
18.
Mudd S, Findlay J.
The cutaneous manifestations and common mimickers of physical child abuse.
Journal of Pediatric Health Care. 2004;18:123–129. Abstract | Full Text |
Full-Text PDF (656 KB)
|
CrossRef
Nagler, 2002.
19.
Nagler J.
Child abuse and neglect.
Current Opinion in Pediatrics. 2002;14:251–254. MEDLINE |
CrossRef
National Clearinghouse on Child Abuse and Neglect, 2003.
20.
National Clearinghouse on Child Abuse and Neglect. (2003). Child maltreatment 2001: Summary of key findings. Retrieved December 12, 2003, from http://nccanch.acf.hhs.gov Nimkink and Kleinman, 2001.
21.
Nimkink K, Kleinman PK.
Imaging of child abuse.
Radiology Clinics of North America. 2001;4:843–864. Peck and Priolo-Kapel, 2002.
22.
Peck MD, Priolo-Kapel D.
Child abuse by burning: A review of the literature and an algorithm for medical investigations.
The Journal of Trauma Injury, Infection, and Critical Care. 2002;53:1013–1021. Prevent Child Abuse America, 2003.
23.
Prevent Child Abuse America .
Child abuse prevention month 2003 facts. Chicago: Author; 2003;. Santucci and Hsiao, 2003.
24.
Santucci KA, Hsiao AL.
Advances in clinical forensic medicine.
Current Opinions in Pediatrics. 2003;15:304–307. Smith, 2003.
25.
Smith J.
Shaken baby syndrome.
Orthopaedic Nursing. 2003;22:196–205. MEDLINE |
CrossRef
Sugar et al. 1999.
26.
Sugar NF, Taylor JA, Feldman KW.
Bruises in infants and toddlers: Those who don't cruise rarely bruise.
Archives of Pediatric and Adolescent Medicine. 1999;153:399–403. Wallis and Goodman, 2000.
27.
Wallis WH, Goodman G.
Neurotrauma in infants: Shaken impact syndrome (inflicted head injury).
Critical Care Nursing Clinics of North America. 2000;12:489–497. MEDLINE Willman et al. 1997.
28.
Willman KY, Bank DE, Senac M.
Restricting the time of injury in fatal inflicted head injuries.
Child Abuse and Neglect. 1997;21:929–940. MEDLINE |
CrossRef
Wyszynski, 1999.
29.
Wyszynski ME.
Shaken baby syndrome: Identification, intervention, and prevention.
Clinical Excellence for Nurse Practitioners. 1999;3:262–267. MEDLINE Zenel and Goldstein, 2002.
30.
Zenel J, Goldstein B.
Child abuse in the pediatric intensive care unit.
Critical Care Medicine. 2002;30:s515–s521.
CrossRef
 Reprint requests: Gail Hornor, MS, RNC, CPNP, Children's Hospital, 700 Children's Dr, Columbus, OH 43205
PII: S0891-5245(04)00173-7 doi:10.1016/j.pedhc.2004.06.009 © 2005 The National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved. | |
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