REVIEW

CURRENT
OPINION Child maltreatment: a review of key literature
in 2013
Kimberly A. Schwartz a, Genevieve Preer b, Heather McKeag c, and
Alice W. Newton d

Purposes of review
This review summarizes new findings in the field of maltreatment, addressing epidemiology, physical
abuse, abusive head trauma, sexual abuse, sequelae, and prevention.
Recent findings
Many articles this year focus on establishing a framework for thinking about how to evaluate a child for
maltreatment, the consequences of maltreatment, and the current understanding of prevention efforts.
Interestingly, some research has helped to reinforce some concepts that were clinically appreciated,
especially related to retinal hemorrhages.
Summary
The volume, quality, and breadth of research relating to child maltreatment continue to improve and
expand our understanding of child abuse pediatrics. These authors summarize notable advances in our
understanding of child maltreatment over the past year.
Keywords
abusive head trauma, child maltreatment, child neglect, child physical abuse, child sexual abuse

INTRODUCTION maltreatment, it likely underestimates the true inci-

Child maltreatment literature has continued to dence of child abuse and neglect. Therefore, the
expand, with a focus on more accurate and effective scientific community continues to refine methods
ways to identify, diagnose, and prevent abuse. As for measuring and understanding rates of child
front-line clinicians become more attentive to maltreatment.
including child abuse in the differential diagnosis Farst et al. [6] used a large inpatient database,
of a child with unexplained injury, many often the Healthcare and Utilization Project Nationwide
undertake further evaluation for injuries prior to Inpatient Sample, to determine trends in hospital-
involving a child protection team. The American izations for severe abusive injuries from 1997 to
Academy of Pediatrics (AAPs) released several 2009. The rate of hospitalization for all children
clinical reports last year that are reviewed below 0–3 years for severe abusive injury was 2.36 (range
&& &&
to assist with these evaluations [1 –4 ]. Progress 2.10–3.01) per 10 000, and the rate did not signifi-
in assessing the sequelae and cost of child maltreat- cantly change over the last 14 years. Her team
ment continues this year, which helps in promoting assigned injury severity scores for 0–3-year-old
the urgency of prevention efforts. Finally, new data
on prevention efforts continue to hold promise. a
Child Protection Team, bDivision of Family Advocacy, Department of
Pediatrics, Boston Medical Center, cDepartment of Pediatrics, Tufts
University School of Medicine; Child Protection Program, Tufts Floating
MEASURING THE INCIDENCE OF Hospital for Children and dDepartment of Pediatrics, Harvard Medical
MALTREATMENT School; Child Protection Program, Massachusetts General Hospital,
Boston, Massachusetts, USA
The most ubiquitous information about trends in Correspondence to Alice W. Newton, MD, Department of Pediatrics,
child maltreatment comes from the National Child Massachusetts General Hospital, Room 516, 175 Cambridge St,
Abuse and Neglect Data System (NCANDS), which Boston, MA 02114, USA. Tel: +1 617 724 0285, fax: +1 617 724
counts child abuse reports to state agencies [5]. 5609, e-mail: anewton@partners.org
Because NCANDS relies on Child Protective Services Curr Opin Pediatr 2014, 26:396–404
(CPS) determination of a case to determine child DOI:10.1097/MOP.0000000000000102

www.co-pediatrics.com Volume 26  Number 3  June 2014

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Child maltreatment Schwartz et al.

low level of concern for abuse. Sentinel injuries were

KEY POINTS identified in 27.5% of the definitively abused
 The evidence base supporting the diagnosis of many infants, 8% of the intermediate concern, and none
forms of child physical and sexual abuse is growing of the nonabused infants. Bruising in a premobile
exponentially, with many AAP guideline statements infant, intraoral injury, such as frenulum tears or
about various forms of child maltreatment available to tongue bruising, and fractures were the identified
clinicians who care for children and families. sentinel injuries. The authors found that children
 Proper measurement techniques to assess child with sentinel injuries were 4.4 times more likely to
maltreatment numbers are critical to support funding have future abusive injuries. The importance of early
and prevention efforts. identification and protective intervention on behalf
of abused children cannot be overestimated.
 Prevention programs are crucial, but should not be
Early identification of abusive injuries is impera-
undertaken without proper outcome measures and an
understanding of the role that family violence plays in tive because of the risk of increased mortality with
child abuse. each recurrent abusive event. Deans et al. [9] describe
a mortality rate of 24.5% with recurrent nonacciden-
tal trauma compared with 9.9% mortality in a single
event of nonaccidental trauma. Abusive events esca-
children. It is important to recognize that infants late in severity at an alarming rate, and identification
had higher injury severity scores and higher rates of of abusive injuries at the onset may be lifesaving.
admission at 6.03 per 10 000 than the children aged
1–3 years.
Evaluation of fractures in children
&&
The AAP clinical report by Flaherty et al. [3 ] nicely
Child abuse report as risk for sudden delineates the evaluation of a child with fractures.
unexpected infant death Highlighted are fractures with high specificity for
The California Department of Public Health has a abuse, including posteriomedial rib fractures and
linked dataset that matches birth and death certi- classic metaphyseal lesions (corner/bucket-handle
ficates with CPS records. Dr Putnam-Hornstein et al. fractures). The differential for fracture includes pre-
[7] evaluated all infant deaths from 1999 to 2006 to existing medical conditions and bone diseases,
determine whether a CPS report was a meaningful such as osteogenesis imperfecta, osteopenia of pre-
risk factor for death from sudden infant death syn- maturity, vitamin D deficient rickets, osteomyelitis,
drome or sudden unexpected infant death (SUID). demineralization from disuse, scurvy (vitamin C
After adjustment for health and sociodemographic deficiency), copper deficiency, Menkes disease, and
risk factors, infants who had a previous CPS report chronic systemic disease. Close attention to the
had a three times higher risk of SUID than infants history provided to explain the injuries is imperative,
who were not reported. Although only a small frac- as is the developmental stage of the child. Family
tion of the infants who had CPS reports died, con- history may uncover concern for genetic disease,
sideration of more intense services for infants with whereas social history can help identify violence
reports may be necessary to prevent these SUIDs. within the home or a past history of working with
CPS. Laboratory studies are guided by the history
provided and the physical examination. If concern
CHILD PHYSICAL ABUSE arises for physical abuse based on the fracture at
Identification of child physical abuse continues to presentation, children under the age of 2 years
be a concern for healthcare providers working with should undergo a skeletal survey and head imaging
children and families, with literature addressing in those less than 1 year of age. The final reminder
early detection and diagnosis. from this report is the recommendation that all
children in the household should be screened
for maltreatment.
Early identification of child abuse
Identification of sentinel injuries is the cornerstone
of early detection of a child at risk for further abuse. Bruising, bleeding, and possible child abuse
&
Sheets et al. [8 ] reviewed 401 infants under the age The AAP also highlighted evaluation for bleeding
of 12 months, 200 of whom were definitively abused disorders as part of the differential for intracranial
&&
as diagnosed by their child protection team, 100 hemorrhage and bruising. Anderst et al. [1 ] com-
with intermediate concerns for abuse, and 101 con- posed a thoughtful review encompassing approach
trol infants seen by the child protection team with to children with suspected child abuse and evidence

1040-8703 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins www.co-pediatrics.com 397

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Office pediatrics

of bleeding. The history of trauma provided and et al. [14] described long-term negative cognitive
location of bruising help guide the laboratory test- outcomes in children spanked during childhood.
ing. A clear pathway for laboratory evaluation is For the primary care provider, review of proper dis-
provided and should be used as a guideline for cipline methods remains a critical part of anticipatory
indicated testing. All nonmobile children with guidance, and now there is more evidence that harsh
bruising should be evaluated for both child abuse discipline has deleterious effects throughout the
and bleeding disorder based on the risk of inflicted child’s life.
trauma in this age group and the timing of clinical
presentations of bleeding disorders at this age as ABUSIVE HEAD TRAUMA
well. The authors remind us that identification of
In 2009, the AAP issued a policy statement, which
a bleeding disorder does not rule out the possibility
supported the use of the term abusive head trauma
of child abuse in all cases.
(AHT) to describe inflicted injury in infants and
children that resulted from either violent shaking,
Caregiver fabricated illness in a child/ blunt impact, or a combination of both [15]. This
medical child abuse terminology has taken the place of shaken baby
In 2007, the AAP changed the framing of what was syndrome, a name that implies that the clinician
once called Munchausen syndrome by proxy to child knows the mechanism by which a child was injured.
abuse in a medical setting [10]. This year, Dr Flaherty The literature this year focuses on developing a more
&&
and Macmillan [2 ] have emphasized that ‘fabricated accurate understanding of the incidence of AHT,
illness in a child’ keeps the focus on the child victim predicting outcomes for patients and their families,
rather than the specific mindset or behaviors of the and ensuring that we consider other possible medical
caregiver. This clinical report shares practical guide- causes before making a diagnosis of child abuse.
lines for the indicators of possible fabricated illness.
Greiner et al. [11] also published a 15-item screening Epidemiology of abusive head trauma
instrument that was 94.7% sensitive and 95.6%
In 2008, experts in AHT working with the Centers
specific for medical child abuse with a score at least
for Disease Control (CDC) established guidelines for
4 in their small sample. Flaherty and Macmillan’s
&& researchers who wanted to measure and follow the
[2 ] AAP clinical report is helpful in that it provides a
incidence of AHT using International Classification
template for the complicated, extensive chart review
of Disease 9 (ICD 9) codes [16]. Berger et al. [17]
that is required in one of these cases. The authors
tested the accuracy of this approach, retrospectively
remind us that, even when reported, the children are
assessing hospital data at a large tertiary care hos-
not always protected. The involvement of a child
pital by using the CDC approach and comparing the
abuse pediatrician can be useful in assessing next
outcome with statistics drawn from the hospital
steps when considering caregiver fabricated illness
child protection program database. The authors
in a child/medical child abuse.
found that the ICD 9-based approach yielded a
sensitivity of 92% and a specificity of 96%, support-
Corporal punishment/harsh physical ing the use of the CDC’s approach.
punishment Shanahan et al. [18] also used these CDC guide-
With the shift of focus to the long-term outcomes of lines, measuring data across the United States from
childhood experiences and their relation to adult the Kids’ Inpatient Database (a nationwide database
health outcomes, harsh physical punishment was of nonrehabilitation hospital discharges of infants
&
explored by Afifi et al. [12 ]. The authors describe and children). Four years of data from multiple
harsh physical punishment as being pushed, states revealed an annual incidence of 33.4 cases
grabbed, shoved, slapped, or hit by a parent or adult (using CDC narrow guidelines) and 38.8 cases (using
in the home, and, for this study, was identified CDC broad guidelines) per 100 000 children below
separately from child physical abuse. Childhood 1 year old. Contrary to several other studies, the
experiences were correlated to adult physical health authors found no statistical impact on data collected
conditions that included arteriolosclerosis, hyperten- before or during the recession.
sion, hepatic disease, diabetes, cardiovascular dis- Niederkrotenthaler et al. [19] performed a
ease, gastrointestinal disease, arthritis, and obesity, similar analysis, finding that rates of AHT in infants
similarly to the ground-breaking Adverse Childhood below 1 year old (38.8 per 100 000) are significantly
Experiences study [13]. Findings revealed that harsh higher than in children aged 1–2 years (6.8 per
physical punishment independent of child physical 100 000). The authors compared AHT victims with
abuse was associated with higher odds of adult children who had accidental head injury, finding
physical health conditions. Additionally, MacKenzie that AHT victims were eight times more likely to die

398 www.co-pediatrics.com Volume 26  Number 3  June 2014

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Child maltreatment Schwartz et al.

and five times more likely to have a longer hospital differential diagnosis of retinal hemorrhage. Adams
&&
stay. As has been found in many other studies, et al. [23 ] performed a prospective study of 159
infants who are male and from lower socioeconomic patients admitted to a pediatric ICU (excluding those
status appear to be at higher risk; however, there was with suspected abuse or penetrating eye trauma).
no clear race association identified by the authors. Twenty-four (15.1%) children were found to have
Gumbs et al. [20], who used the CDC guidelines to retinal hemorrhaging, with 75% of these being mild
identify cases, studied AHT in military families. These (<5 hemorrhages) or moderate (5–20 hemorrhages).
authors found a rate of 39.2 cases per 100 000. Only children who had severe coagulopathy, leuke-
Increased risk was found in infants whose parents mia, or major witnessed trauma had numerous and
are in lower pay grades, whose mothers are deployed, widespread retinal hemorrhaging. Binenbaum et al.
or who are premature or who have birth defects. [24] also studied retinal hemorrhaging in a prospec-
tive study of children aged 3–17 with increased intra-
cranial pressure. The authors performed dilated
Perpetrators of abusive head trauma
&&
retinal examination on 100 children who on lumbar
Scribano et al. [21 ] studied 313 cases of AHT diag- puncture had an opening pressure of at least 20. Only
nosed at multiple hospitals over 5 years with iden- 16 of these children had retinal hemorrhages iden-
tified alleged perpetrators. This study revealed a tified, eight of whom had superficial retinal hemor-
similar pattern of perpetrator frequency to previous rhages adjacent to a swollen optic disc and eight of
studies, with biological fathers being most common, whom had splinter hemorrhages directly on the
followed by mother’s boyfriends, babysitters, bio- swollen optic disc. The authors point out that no
logical mothers, and other caregivers. Because of the case had significant retinal widespread and multi-
large study size, the authors were able to analyze the layer hemorrhage. They propose that elevated intra-
perpetrator relationship to child’s age and outcome. cranial pressure alone is not a common cause of
Authors found that, in older children above 1 year of retinal hemorrhaging.
age, nonparental caregivers were more likely to Recently, the media has focused on the validity
injure children; additionally, these caregivers were of ‘shaken baby syndrome,’ leading courts to recon-
more likely to be men. Importantly, the children sider and dismiss cases and leading researchers to
injured by nonparental caregivers sustained more study alternative diagnoses that are brought up in
serious injuries, and there was less likely to be any &
court. Thomas et al. [25 ] studied children less than
history of trauma provided by the caregiver. 2 years old who had accidental head injuries. In
their series of 149 cases, skull fractures with localized
Retinal hemorrhages: when to search for subdural bleeding were fairly common, but the cases
them that led to diffuse brain injury and neurologic seque-
&
Greiner et al. [22 ] examined the productivity of lae were rare. Most notably, these severe cases all had
automatically examining children’s retinas in cases an equally severe mechanism of injury involving
of possible abuse. The authors examined the Exami- significant forces. This supports the fact that minor
ning Siblings to Recognize Abuse Network database household falls very rarely lead to significant injury.
(a multicenter database of children who had been Child abuse pediatricians are sometimes faced
evaluated for abuse). Of 1692 patients who had with unexplained subdural hemorrhaging in chil-
undergone neuroimaging, 1122 had no findings dren with macrocrania and benign enlarged subar-
of AHT. Three-hundred fifty two of these children achnoid spaces [(BESS), sometimes referred to as
with negative neuroimaging underwent retinal external hydrocephalus]. Greiner et al. [26] retrospec-
examination by an ophthalmologist, with only tively studied 177 children who had been evaluated
two cases (0.6%) that were positive. These two cases for macrocrania, finding that in 108 of these children
had only a few retinal hemorrhages, a relatively enlarged subarachnoid space (BESS) was identified. In
nonspecific finding. We agree with these authors these children with BESS, only 5.6% had subdural
that, even in children with other signs of physical fluid of varying density identified. This does support
abuse, if neuroimaging is negative a dedicated that these children may be at higher risk, but the
retinal examination is not necessary. authors encourage evaluation for possible abuse in
any child with unexplained subdural hemorrhage.

Differential diagnosis of abusive head

trauma Predicting and ameliorating outcome in
The finding of significant retinal hemorrhages along victims of abusive head trauma
with signs of unexplained brain injury raises a con- Several studies looked at measurable laboratory or
cern for AHT. Several studies this year looked at the radiologic variables and their relationship to clinical

1040-8703 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins www.co-pediatrics.com 399

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Office pediatrics

outcome. Stewart et al. [27] studied a large number detail in the most recent AAP clinical report on the
of patients from several institutions in whom a subject. The authors outline five major concerns for
diagnosis of AHT had been made by a child protec- the provider presented with a case of suspected
tion team. The authors identified 148 of 412 infants sexual abuse that must be addressed: the child’s
with AHT who were sick enough on presentation to safety, reporting to the appropriate authorities,
prompt measurement of a blood gas and calculation the child’s mental health, timing of physical exam-
of a base deficit. These authors found a stepwise ination, and decision to collect forensic evidence.
association between elevation of base deficit and Most children with a history of sexual abuse
worse outcome. The need for cardiopulmonary have normal examinations [31]. Many forms of
recuscitation during initial resuscitation correlated sexual abuse do not cause scarring (fondling and
with worse outcome. The authors hypothesize that oral–genital contact) and, in the case of rare
base deficit is correlated with the presence of shock, physical findings, conditions that may mimic
which may lead to a worsening or secondary brain trauma should be separated from true traumatic
injury from hypoperfusion or hypoxia. lesions. The physical examination does not typically
Researchers in Japan looked at the correlation of confirm or refute sexual abuse. This important point
MRI findings with outcome. Tanoue et al. [28] found should be shared with the family prior to examin-
that the apparent diffusion coefficient (ADC) value ation – the examination rarely provides additional
from MRI studies on 14 infants was significantly information, sometimes information the family is
correlated with poor long-term outcomes in child counting on the physician to provide.
victims. The ADC map, which correlates with The timing or need for physical examination is
hypoxic–ischemic injury or severe traumatic brain based on physical symptoms and the need to rule
injury, may help guide clinicians in their discussion out injury. If a child is reporting pain or bleeding,
with families about what to expect as their infant physical examination would be indicated. On the
recovers. contrary, disclosure of abuse in the distant past
Risen et al. [29] compared outcome in AHT would be appropriate to refer to a specialty center
victims admitted to inpatient rehabilitation facili- for medical evaluation. Primary care providers
ties with age and sex-matched control children with should refer any child with disclosure of recent
nonAHT in a retrospective study from one institu- sexual contact, including the exchange of bodily
tion. Control and abused children had similar brain fluids, immediately to a specialty center or emer-
injuries. The authors, measuring independent gency department for forensic evidence collection,
ambulation and expressive speech, found that deferring examination in the primary care office.
infants and children who were victims of AHT were Timing of collection varies between states, but
able to make similarly significant gains in outcome. sexually transmitted infection and pregnancy pro-
In this study of 28 abused infants, the children who phylaxis, if indicated, are recommended within 72 h
were injured when they were less than 12 months after sexual contact.
had worse outcome than their matched nonabusive Child and family mental health is imperative to
controls. facilitate healing following disclosure of child sexual
abuse. Pediatricians should work with their local
child abuse pediatrician or community child advo-
CHILD AND ADOLESCENT SEXUAL ABUSE cacy center to ensure that patients who may have
Because of the high incidence of child sexual abuse, been sexually abused undergo complete sexual
coupled with the long shadow of negative out- abuse evaluations and are connected with appropri-
comes, pediatricians need to be familiar not only ate mental health providers.
with diagnosis, but also with appropriate response
and evaluation of children with concern for sexual
abuse [30]. As mandated reporters of suspected child SEQUELAE OF CHILD MALTREATMENT
abuse, pediatricians should review the recom- This year’s literature continued to expand our
mended medical evaluation of the child and ulti- understanding of the physiologic and psychiatric
mately facilitate greater support for the entire consequences of child maltreatment.
family.

Toxic stress
Suspected sexual abuse in the primary care Garner [32] reviews the effects of stress on the
setting developing brain. Citing the landmark studies by
&&
Jenny and Crawford-Jakubiak [4 ] delineate how to Felitti et al. [13] on Adverse Childhood Events,
address sexual abuse in the primary care office in Garner reviews the pathways by which these adverse

400 www.co-pediatrics.com Volume 26  Number 3  June 2014

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Child maltreatment Schwartz et al.

experiences, which include child abuse and neglect, which have been started without consideration of
can create toxic stress. It is now well accepted that how to measure the outcomes of such efforts. This
toxic stress can alter brain architecture in children year’s literature attempts to ameliorate this fact.
and lead to an array of undesirable adult health
outcomes ranging from liver cirrhosis and heart
failure to mental illness, sexually transmitted infec- The public health approach
tions, and infertility. Garner argues that prevention The pressing issue of child maltreatment prevention
efforts in childhood should aim to mitigate the is best understood through a public health lens, as
&&
deleterious and enduring effects of toxic stress, Covington argues in her review [37 ]. Child abuse
and cites home visiting programs as one promising and neglect typically has been approached from the
approach for reducing child maltreatment and its standpoint of identifying maltreated children and
attendant consequences by buffering children from preventing subsequent abuse. Covington contends
toxic stress and helping to build their resilience in that reframing child maltreatment from the public
the face of adverse experiences. health vantage point first requires improved surveil-
lance. In the United States, current statistics on
incidence of child maltreatment are collected on
Psychiatric diagnosis children who are already known to CPS or who have
Keeshin et al. [33] evaluated consecutive inpatient experienced severe abuse resulting in fatality. These
psychiatric admissions for 3–18-year-olds to deter- data fail to include children who are experiencing
mine whether a history of physical abuse, sexual maltreatment but are not known to CPS, or who are
abuse, or both conferred risk of cross-category psy- at high risk for first-time maltreatment. Further-
chiatric diagnoses (e.g., mood disorder and substance more, extant fatality data are often incomplete
abuse disorder), and therefore increased complexity. and may miss child maltreatment as the cause of
Sixty-two percent of the children who were both death. Covington proposes that utilizing innovative
physically and sexually abused were diagnosed with approaches to identify child maltreatment would
posttraumatic stress disorder. Having experienced afford a more complete understanding of the scope
both sexual and physical abuse multiplied the risk of the problem and guide prevention.
of cross-category comorbid psychiatric diagnoses. As Covington explains, knowledge of the epi-
Children who had been sexually abused were more demiology of maltreatment potentiates prevention
likely to have an increased number of medications efforts on several levels. Primary prevention focuses
prescribed on admission and increased likelihood of on interventions that decrease the risk of maltreat-
being placed on atypical antipsychotic medication ment for all children, whereas secondary prevention
compared with their nonabused counterparts. targets children who are understood to be at risk for
maltreatment but have not yet been maltreated.
Tertiary prevention attempts to prevent children
Calculating the monetary cost of who have already experienced maltreatment from
maltreatment being maltreated again. Many current prevention
Using an innovative method to calculate healthcare efforts, as reviewed below, have focused on secon-
costs associated with child maltreatment, Florence dary prevention for at-risk children through home
&
et al. [34 ] report that annual Medicaid costs visiting programs. Home visiting programs are one
incurred by children who are at risk for abuse or type of intervention that has shown promise in
neglect or known to be abused or neglected were proactively preventing child maltreatment rather
$2600 more per year than for comparison children. than reacting after it has taken place.
Overall, the authors estimate that costs associated Richmond-Crum et al. [38] argue that applying
with child maltreatment account for 9% of all Med- the public health framework to child maltreatment
icaid costs for children. These data, which build on necessarily includes a key role for public health
previously published studies from the same group departments. Health departments are uniquely
estimating the financial burden of child maltreat- situated to oversee surveillance, to initiate program
ment, highlight the wide-ranging implications of development, and to coordinate the work of govern-
child maltreatment [35,36]. ment agencies, community organizations, and other
stakeholders. Child maltreatment prevention efforts
in North Carolina are reviewed as a case study for
CHILD MALTREATMENT PREVENTION ways in which a multidisciplinary and multiagency
Child abuse pediatrics is a relatively new board approach spearheaded by public health leaders
certified specialty, and there have been many public can enhance both efficiency and efficacy in child
health efforts dedicated to the prevention of abuse, maltreatment prevention.

1040-8703 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins www.co-pediatrics.com 401

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Office pediatrics

Home visiting as secondary prevention Created in 2012, the network has formulated a
Home visiting programs are broadly defined as pro- comprehensive plan for research on the efficacy
grams that employ professionals or paraprofession- and implementation of home visiting programs in
als to meet with at-risk families and children in their the United States, with the goal of supporting and
homes in order to help build parental capacity and nurturing innovative approaches to research in this
meet resource needs. Although diverse in their growing area.
design, these programs generally share common Home visiting programs have now been eval-
goals of building parenting skills, improving child uated in the setting of multiple RCTs over the course
health outcomes, and preventing child maltreat- of the past decade. The United States Preventive
ment. Services Task Force (USPSTF) has performed a com-
The context for home visiting programs is sig- prehensive review of the results of RCTs of home
nificant in the United States, which in 2013 awarded visiting programs with specific reference to efficacy
close to $70 million to agencies in 13 states to fund of these interventions in decreasing child maltreat-
&&
home visiting efforts [39]. Similarly, in England, ment [43 ]. The review evaluates 10 RCTs published
home visiting efforts are expanding, and in 2015 between 2002 and 2012. All of the RCTs reviewed
a projected 13 000 families will be served by the focused on home visiting interventions for children
Family Nurse Partnership (FNP), a home visiting aged 0–5 years old, but had otherwise hetero-
program that aims to reach young, resource-poor, geneous methods, target populations, and follow-
&
first-time mothers [40 ]. Thus, the importance of up periods. Evidence from all of the RCTs reviewed
understanding the best and most effective ways to was rated as fair quality because of limitations in
implement home visiting programs cannot be over- methods or limited availability of methodological
emphasized, as Rubin et al. [41] argue in their information.
thoughtful opinion piece on this subject. Only five of the 10 RCTs reviewed by the USPSTF
&
For example, Browne and Jackson [40 ] argue, evaluated CPS involvement as a measure of child
home visiting programs that focus primarily on first- maltreatment. No significant differences between
time, low-income mothers may miss the majority of intervention and control arms were reported in
parents most likely to abuse their children. In their any of these studies. Secondary measures of child
persuasive analysis, the authors use data from a maltreatment were also measured in several of the
5-year prospective study of 14 252 English families studies, including emergency department utiliz-
to show that the characteristic most associated with ation, hospitalizations, and adherence to immuniz-
child maltreatment in this cohort was history of ations and well child care, with varying results
domestic violence, which conferred a relative risk between trials. Self-reported measures of harsh dis-
of 23.4 of child abuse or neglect. By contrast, first- ciplinary practices and physical abuse were com-
born children to mothers less than 21 years old pared in several of the trials, with three trials
who also had low socioeconomic status were com- reporting that self-reported harsh physical punish-
paratively protected, with a relative risk of 0.3 of ment was decreased in the intervention compared
being abused or neglected. The authors advocate with the control group.
for tailoring the FNP to focus on families with The overall picture from this review is of incon-
specific risk factors rather than offering this pro- sistent or small effects on secondary child maltreat-
gram to a broad swath of the population that may ment outcomes despite a range of innovative home
not in fact be positioned to benefit from this inter- visiting interventions evaluated. This trend contin-
vention. ues in other home visiting RCTs reported in 2013.
The cautionary notes struck by Rubin and RCTs of home visiting interventions in New Haven,
Browne offer a worthwhile context for understand- Connecticut [44], Rochester, New York [45], and
ing this year’s literature on the results of randomized Massachusetts [46] all failed to find statistically
controlled trials (RCTs) for home visiting programs significant differences in rates of CPS involvement.
in preventing child maltreatment. Home visiting Fergusson et al. [47], evaluating results of 9-year
interventions are heterogeneous in terms of design, follow-up of a home visiting RCT conducted in
scope, and length of follow-up, making direct New Zealand, found statistically significant differ-
comparison challenging. Outcome measurement ences in harsh parenting and physical punishment
suffers from lack of uniformity, and child maltreat- as reported by parents, although rates of CPS
ment is not always a primary outcome studied. The involvement were not reported.
challenges inherent in conducting research on In summary, although some benefits have been
home visiting programs are the focus of Duggan reported from well-designed, intensive interven-
et al.’s [42] comprehensive report on the newly tions, implications for child maltreatment preven-
formed National Home Visiting Research Network. tion should be interpreted cautiously.

402 www.co-pediatrics.com Volume 26  Number 3  June 2014

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Child maltreatment Schwartz et al.

13. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and
CONCLUSION household dysfunction to many of the leading causes of death in adults. The
The literature on child maltreatment from 2013 Adverse Childhood Experiences (ACE) Study. Am J Prev Med 1998; 14:245–
258.
reflects an attempt to refine the diagnosis and 14. MacKenzie MJ, Nicklas E, Waldfogel J, Brooks-Gunn J. Spanking and child
measurement of child abuse and neglect. Research- development across the first decade of life. Pediatrics 2013; 132:e1118–
e1125.
ers continue to find lifelong impact not only from 15. Christian CW, Block R; Committee on Child Abuse and Neglect, American
child sexual and physical abuse, but also from the Academy of Pediatrics. Abusive head trauma in infants and children. Pedia-
trics 2009; 123:1409–1411.
use of harsh physical punishment. Public health 16. Parks SE, Annest JL, Hill HA, Karch DL. Pediatric abusive head trauma:
experts are recognizing the importance of accurate recommended definitions for public health surveillance and research.
Control CfD. Atlanta, GA. 2012. http://www.acf.hhs.gov/sites/default/files/
measurements of abuse and neglect and coming to a cb/cm2012.pdf. [Accessed 20 February 2014]
greater understanding that family violence often 17. Berger RP, Parks S, Fromkin J, et al. Assessing the accuracy of the Interna-
tional Classification of Diseases codes to identify abusive head trauma: a
sets the stage for abuse and neglect of children. feasibility study. Inj Prev 2013. [Epub ahead of print]
18. Shanahan ME, Zolotor AJ, Parrish JW, et al. National, regional, and state
abusive head trauma: application of the CDC algorithm. Pediatrics 2013;
Acknowledgements 132:e1546–e1553.
19. Niederkrotenthaler T, Xu L, Parks SE, Sugerman DE. Descriptive factors of
None. abusive head trauma in young children: United States. Child Abuse Negl
2013; 37:446–455.
20. Gumbs GR, Keenan HT, Sevick CJ, et al. Infant abusive head trauma in a
Conflicts of interest military cohort. Pediatrics 2013; 132:668–676.
21. Scribano PV, Makoroff KL, Feldman KW, Berger RP. Association of perpe-
There are no conflicts of interest. && trator relationship to abusive head trauma clinical outcomes. Child Abuse
Negl 2013; 37:771–777.
This article significantly adds to the literature on perpetrator confessions, with a
look at the differences in perpetrator makeup for children older than 1 year as well
REFERENCES AND RECOMMENDED as an assessment of how perpetrator type is related to clinical outcome of the child
victim.
READING 22. Greiner MV, Berger RP, Thackeray JD, Lindberg DM. Examining siblings
Papers of particular interest, published within the annual period of review, have
& to recognize abuse I. Dedicated retinal examination in children evaluated
been highlighted as:
for physical abuse without radiographically identified traumatic brain injury.
& of special interest
&& of outstanding interest
J Pediatr 2013; 163:527–531.
The authors question the automatic reaction that many providers have in seeking
an ophthalmology evaluation in any case of possible abuse.
1. Anderst JD, Carpenter SL, Abshire TC; Section on Hemotology Oncology 23. Adams GG, Agrawal S, Sekhri R, et al. Appearance and location of retinal
&& Committee on Child Abuse and Neglect of the American Academy of && haemorrhages in critically ill children. Br J Ophthalmol 2013; 97:1138–
Pediatrics. Evaluation for bleeding disorders in suspected child abuse. 1142.
Pediatrics 2013; 131:e1314–e1322. This prospective study points out that retinal hemorrhages are rare in critically ill
A clinical report explaining the appropriate work-up for children presenting with children unless there is major trauma or an underlying bleeding dyscrasia.
bruising or intracranial hemorrhage. 24. Binenbaum G, Rogers DL, Forbes BJ, et al. Patterns of retinal hemorrhage
2. Flaherty EG, Macmillan HL; Committee On Child Abuse and Neglect. Care- associated with increased intracranial pressure in children. Pediatrics 2013;
&& giver-fabricated illness in a child: a manifestation of child maltreatment. 132:e430–e434.
Pediatrics 2013; 132:590–597. 25. Thomas AG, Hegde SV, Dineen RA, Jaspan T. Patterns of accidental
A clinical report explaining the way to conceive of caregiver-fabricated illness in a & craniocerebral injury occurring in early childhood. Arch Dis Child 2013;
child or medical child abuse. 98:787–792.
3. Flaherty EG, Perez-Rossello JM, Levine MA, et al., American Academy Of This study looks at accidental head trauma in children less than 2 years, supporting
&& Pediatrics Committee On Child Abuse and Neglect. Evaluating children with the fact that cases of severe injury with permanent neurologic sequelae are very
fractures for child physical abuse. Pediatrics 2014; 133:e477–e489. rare from accidental injury and occur in cases with correspondingly high-force
A clinical report describing the work-up and evaluation of children for fractures mechanisms (such as pedestrians struck by cars).
when physical abuse is considered. 26. Greiner MV, Richards TJ, Care MM, Leach JL. Prevalence of subdural
4. Jenny C, Crawford-Jakubiak JE; Committee on Child Abuse and Neglect, collections in children with macrocrania. AJNR Am J Neuroradiol 2013;
&& American Academy of Pediatrics. The evaluation of children in the primary 34:2373–2378.
care setting when sexual abuse is suspected. Pediatrics 2013; 132:e558– 27. Stewart CL, Holscher CM, Moore EE, et al. Base deficit correlates with
e567. mortality in pediatric abusive head trauma. J Pediatr Surg 2013; 48:2106–
A clinical report explaining the approach to children when there is a concern of 2111.
sexual abuse is considered. 28. Tanoue K, Aida N, Matsui K. Apparent diffusion coefficient values predict
5. US Department of Health and Human Services, Administration for Children, outcomes of abusive head trauma. Acta Paediatr 2013; 102:805–808.
Youth, and Families, Children’s Bureau. Child maltreatment 2012. 2012; 29. Risen SR, Suskauer SJ, Dematt EJ, et al. Functional outcomes in children with
http://www.acf.hhs.gov/sites/default/files/cb/cm2012.pdf. [Accessed 26 abusive head trauma receiving inpatient rehabilitation compared with children
February 2014] with nonabusive head trauma. J Pediatr 2014; 164:613–619; e2.
6. Farst K, Ambadwar PB, King AJ, et al. Trends in hospitalization rates and 30. Finkelhor D, Turner HA, Shattuck A, Hamby SL. Violence, crime, and abuse
severity of injuries from abuse in young children, 1997-2009. Pediatrics exposure in a national sample of children and youth: an update. JAMA Pediatr
2013; 131:e1796–e1802. 2013; 167:614–621.
7. Putnam-Hornstein E, Schneiderman JU, Cleves MA, et al. A prospective study 31. Adams JA. Guidelines for medical care of children evaluated for suspected
of sudden unexpected infant death after reported maltreatment. J Pediatr sexual abuse: an update for 2008. Curr Opin Obstet Gynecol 2008; 20:435–
2014; 164:142–148. 441.
8. Sheets LK, Leach ME, Koszewski IJ, et al. Sentinel injuries in infants evaluated 32. Garner AS. Home visiting and the biology of toxic stress: opportunities
& for child physical abuse. Pediatrics 2013; 131:701–707. to address early childhood adversity. Pediatrics 2013; 132 (Suppl 2):
Important article identfying concerning injuries in infants. S65–73.
9. Deans KJ, Thackeray J, Askegard-Giesmann JR, et al. Mortality increases with 33. Keeshin BR, Strawn JR, Luebbe AM, et al. Hospitalized youth and child abuse:
recurrent episodes of nonaccidental trauma in children. J Trauma Acute Care a systematic examination of psychiatric morbidity and clinical severity. Child
Surg 2013; 75:161–165. Abuse Negl 2014; 38:76–83.
10. Stirling J Jr, American Academy of Pediatrics Committee on Child Abuse and 34. Florence C, Brown DS, Fang X, Thompson HF. Healthcare costs associated
Neglect. Beyond Munchausen syndrome by proxy: identification and treat- & with child maltreatment: impact on medicaid. Pediatrics 2013; 132:312–
ment of child abuse in a medical setting. Pediatrics 2007; 119:1026–1030. 318.
11. Greiner MV, Palusci VJ, Keeshin BR, et al. A preliminary screening instrument An innovative methodology offers a new way to quantify the medical costs of child
for early detection of medical child abuse. Hospital Pediatr 2013; 3:39–44. maltreatment in the United States.
12. Afifi TO, Mota N, MacMillan HL, Sareen J. Harsh physical punishment in 35. Brown DS, Fang X, Florence CS. Medical costs attributable to child mal-
& childhood and adult physical health. Pediatrics 2013; 132:e333–e340. treatment a systematic review of short- and long-term effects. Am J Prev Med
Article associating harsh punishment with adverse adult health oucomes. 2011; 41:627–635.

1040-8703 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins www.co-pediatrics.com 403

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Office pediatrics

36. Fang X, Brown DS, Florence CS, Mercy JA. The economic burden of child 42. Duggan A, Minkovitz CS, Chaffin M, et al. Creating a national home visiting
maltreatment in the United States and implications for prevention. Child research network. Pediatrics 2013; 132 (Suppl 2):S82–S89.
Abuse Negl 2012; 36:156–165. 43. Selph SS, Bougatsos C, Blazina I, Nelson HD. Behavioral interventions and
37. Covington T. The public health approach for understanding and preventing && counseling to prevent child abuse and neglect: a systematic review to update
&& child maltreatment: a brief review of the literature and a call to action. Child the US Preventive services task force recommendation. Ann Intern Med 2013;
Welfare 2013; 92:21–39. 158:179–190.
A comprehensive and thorough explanation of the public health framework as it This review provides a thorough summary of recently published RCTs and
applies to child maltreatment; a necessary first read on this important topic. evaluates each using consistent and appropriately rigorous criteria, allowing
38. Richmond-Crum M, Joyner C, Fogerty S, et al. Applying a public health easy side-by-side comparison of a heterogeneous group of complex interven-
approach: the role of state health departments in preventing maltreatment tions.
and fatalities of children. Child Welfare 2013; 92:99–117. 44. Sadler LS, Slade A, Close N, et al. Minding the baby: enhancing reflectiveness
39. US Department of Health and Human Services. ‘HHS announces expansion to improve early health and relationship outcomes in an interdisciplinary home
of Maternal, Infant, and Early Childhood Home Visiting,’ 9/6/2013. http:// visiting program. Infant Ment Health J 2013; 34:391–405.
www.hhs.gov/news/press/2013pres/09/20130906a.html, [Accessed 14 45. Paradis HA, Sandler M, Manly JT, Valentine L. Building healthy children:
February 2014]. evidence-based home visitation integrated with pediatric medical homes.
40. Browne KD, Jackson V. Community intervention to prevent child maltreatment Pediatrics 2013; 132 (Suppl 2):S174–S179.
& in England: evaluating the contribution of the Family Nurse Partnership. 46. Easterbrooks MA, Bartlett JD, Raskin M, et al. Limiting home visiting effects:
J Public Health 2013; 35:447–452. maternal depression as a moderator of child maltreatment. Pediatrics 2013;
A thought-provoking analysis that quantifies the relative risk of a range of family 132 (Suppl 2):S126–S133.
characteristics associated with child maltreatment in a large prospective cohort. 47. Fergusson DM, Boden JM, Horwood LJ. Nine-year follow-up of a
41. Rubin DM, Curtis ML, Matone M. Child abuse prevention and child home home-visitation program: a randomized trial. Pediatrics 2013; 131:297–
visitation: making sure we get it right. JAMA Pediatr 2014; 168:5–6. 303.

404 www.co-pediatrics.com Volume 26  Number 3  June 2014

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.