CDC: Majority of U.S. adults had troubled childhoods

USA TODAY
Updated 12/17/2010 8:18 PM

By Steven Reinberg HealthDay

 

Almost 60% of American adults say they had difficult childhoods featuring abusive or troubled family members or parents who were absent due to separation or divorce, federal health officials report.

 

In fact, nearly 9% said that while growing up they underwent five or more "adverse childhood experiences" ranging from verbal, physical or sexual abuse to family dysfunction such as domestic violence, drug or alcohol abuse, or the absence of a parent, according to the U.S. Centers for Disease Control and Prevention (CDC).

"Adverse childhood experiences are common," said study coauthor Valerie J. Edwards, team lead for the Adverse Childhood Experiences Team at CDC's National Center for Chronic Disease Prevention and Health Promotion. "We need to do a lot more to protect children and help families," she said.

About a quarter of the more than 26,000 adults surveyed reported experiencing verbal abuse as children, nearly 15% had been physical abused, and more than 12% — more than one in 10 — had been sexually abused as a child.

Since the data are self-reported, Edwards believes that the real extent of child abuse may be still greater. "There is a tendency to under-report rather than over-report," she said.

The findings are published in the Dec. 17 issue of the CDC's journal Morbidity and Mortality Weekly Report.

For the report, researchers used data from the Behavioral Risk Factor Surveillance System, which surveyed 26,229 adults in Arkansas, Louisiana, New Mexico, Tennessee and Washington. Edwards is cautious about extrapolating these results, but based on other data they probably are about the same in other states, she said.

While there were few racial or ethnic differences in reports of abuse, the report confirmed that women were more likely than men to have been sexually abused as children. In addition, people 55 and older were less likely to report being abused as a child compared to younger adults.

One theory why older people did not report as much childhood abuse is that since these takes a toll on health in adulthood, many of these older abuse victims may have died early, Edwards said. The CDC report, for example, notes that adverse childhood experiences are associated with a higher risk of depression, heart disease, diabetes, cancer, substance abuse and premature death. "So (childhood abuse) may be associated with years of life lost," she said.

There was no difference in the number of people reporting childhood abuse in any other age group, Edwards added.

Adverse childhood experiences included in the report included verbal abuse, physical abuse, sexual abuse, incarceration of a family member, family mental illness, family substance abuse, domestic violence and divorce.

According to the report, about 7.2% had had a family member in prison during their childhood and 16.3% had witnessed domestic violence in the family home. In addition, about 29% grew up in a home where someone abused alcohol or drugs. "These cases occur across all racial groups and ethnicities," Edwards noted.

Almost one in five respondents (19.4 percent) had lived as a child with someone who was depressed, mentally ill or suicidal, the report noted.

Although the volume of abuse and dysfunction is significant, such traumatic experiences cannot be used to describe a person or determine what that person will be, the researchers cautioned. Instead, they said, keeping track of these abusive experiences is important to gain a better understanding of them and their effect on society.

In addition, it's crucial to work harder to prevent abuse and household stress as well as finding better ways to identify and treat children at risk, they said.

"For adults who have had these experiences and feel they are still causing them problems, they are not alone and there is help available," Edwards said.

Dr. Lee M. Sanders, an associate professor of pediatrics at the University of Miami Miller School of Medicine said that "one of the things we don't realize when we look around at our neighborhoods and communities is that these problems are so common."

"That's something to be concerned about. That's something to take communal action on," he added.

Identifying and treating abuse early can prevent many serious health consequences later in life. Programs that provide quality care for children, as well as home visitation programs in early infancy and parenting programs, are part of the solution to this problem, Sanders said.

"These interventions are important not just because abuse is so common, but because of the lifelong health implications," Sanders said. "There is a connection of these events to lifelong implications, not just for mental health for adults, but also for physical health."

For example, a person who has several of these events is more likely to get cancer and heart disease, Edwards said. "This is serious and it's not just a quirk of statistics. It's a real relationship."

Video Series on: The A.C.E. Study - Adverse Childhood Experiences

ACE Study - 

Vincent Felitti, MD 

 

"We saw that things like intractable smoking, things like promiscuity, use of street drugs, heavy alcohol consumption, etc., these were fairly common in the backgrounds of many of the patients...These were merely techniques they were using, these were merely coping mechanisms that had gone into place."– Vincent Felitti, MD

When Dr. Vincent Felitti, head of the Department of Preventive Medicine at Kaiser Permanente in San Diego, began to delve into the reasons for the high dropout rate of patients who'd been successfully losing weight in Kaiser’s obesity program, he found to his surprise that a high proportion of those dropping out had histories of childhood abuse or neglect. Dr. Robert Anda, who had been doing research with the Centers for Disease Control and Prevention on the psychosocial origins of health-risk behaviors in patients at VA hospitals, heard Felitti speak about his findings, and in 1992 the two began to collaborate on the largest-scale study to date of the incidence and effects of childhood trauma, known as the Adverse Childhood Experiences (ACE) Study.

According to data collected from the over 17,000 Kaiser patients in this ongoing retrospective and prospective study, adverse childhood experiences, though well concealed, are unexpectedly common, have a profound negative effect on adult health and well-being a half century later, and are a prime determinant of adult health status in the United States.


The Origins of Addiction: Evidence from the Adverse Childhood Experiences Study  

Vincent J. Felitti, MD - Department of Preventive Medicine - Kaiser Permanente Medical Care Program

ABSTRACT:
A population-based analysis of over 17,000 middle-class American adults undergoing comprehensive, biopsychosocial medical evaluation indicates that three common categories of addiction are strongly related in a proportionate manner to several specific categories of adverse experiences during childhood. This, coupled with related information, suggests that the basic cause of addiction is predominantly experience-dependent during childhood and not substance-dependent. This challenge to the usual concept of the cause of addictions has significant implications for medical practice and for treatment programs....

Our overall findings, presented extensively in the American literature, demonstrate that:
• Adverse childhood experiences are surprisingly common, although typically concealed and unrecognized.
• ACEs still have a profound effect 50 years later, although now transformed from psychosocial experience into organic disease, social malfunction, and mental illness.
• Adverse childhood experiences are the main determinant of the health and social well-being of the nation....

Conclusion:
The current concept of addiction is ill founded. Our study of the relationship of adverse childhood experiences to adult health status in over 17,000 persons shows addiction to be a readily understandable although largely unconscious attempt to gain relief from well-concealed prior life traumas by using psychoactive materials 


The Relation Between Adverse Childhood Experiences and Adult Health: Turning Gold into Lead 

By Vincent J Felitti, MD  

The ACE Study reveals a powerful relation between our emotional experiences as children and our adult emotional health, physical health, and major causes of mortality in the United States. Moreover, the time factors in the study make it clear that time does not heal some of the adverse experiences we found so common in the childhoods of a large population of middle-aged, middle-class Americans. One doesn't "just get over" some things. 

Chronically Ill Children Are 88% More Likely to Suffer Physical Abuse, Swedish Researchers Find

ScienceDaily (Feb. 18, 2011) — Children with chronic health conditions are 88% more likely to suffer physical abuse than healthy children, according to research in the March issue of Acta Paediatrica. They are also 154% more likely to suffer a combination of physical abuse and exposure to intimate partner violence than their healthy school friends.

Researchers from Karlstad University, Sweden, analysed 2,510 questionnaires completed anonymously by children aged ten, 12 and 15 from 44 schools. Nearly one in four had at least one chronic health condition, including visual, hearing or speech problems, diabetes, mental illness, physical disabilities, allergies, weight issues, epilepsy or Attention Deficit Hyperactivity Disorder.

"Twelve per cent of all the children who took part in the survey said they had been physically abused, 7% had witnessed intimate partner violence and 3% had experienced both" says lead author Birgitta Svensson from the Department of Health and Environmental Sciences at the University. "But when we looked at children with chronic illness, the figures were significantly higher for physical abuse and for physical abuse combined with intimate partner violence."

Child physical abuse ranged from severe shaking, ear boxing and hair pulling by an adult to being severely beaten with a hand or device. Intimate partner violence was defined as a child seeing adults in their family hit each other.

"It is clear from our study that children with chronic health conditions face an increased risk of child physical abuse and intimate partner violence and that certain factors may unite this group, regardless of the nature or severity of their health problem" says Svensson.

"Further analysis showed that children with chronic health conditions faced an even higher risk of physical abuse when they were also born outside Sweden or lived in a low income family. The most vulnerable children were those that fell into all three categories."

Key findings of the study include:

Chronic health problems:

• 39% of the children reported chronic health problems -- 25% reported one, 10% reported two and 4% reported three or more. Children aged 15 reported significantly more chronic health problems than younger children.

All child physical abuse (with or without intimate partner violence):

• Having a chronic health condition raised the risk of physical abuse by 88%, as did being 15-years-old (+77%), male (+30%), born outside Sweden (+113%) and not living with both biological parents (+90%).

Child physical abuse only:

• 7% of the healthy children and 12% of the children with chronic health problems had suffered physical abuse only.
• Chronic health raised the risk of physical abuse only (+ 67%) as did being 15 (+37%) male (+49%) and born outside Sweden (+89%).
• Abuse rates increased with the number of chronic health conditions, from 10% for children with one to 16% for children with three or more.

Child physical abuse plus intimate partner violence:

• 2% of the healthy children and 5% of the children with chronic heath had suffered physical abuse and witnessed intimate partner violence.
• Chronic health raised the risk of experiencing both (+154%) as did being 15 (+192%), born outside Sweden (+128%) and not living with both biological parents (+314%).
• The chance of experiencing both increased with the number of chronic conditions, from 3.5% for children with one to 12% for children with three or more.

"This information, and the other trends identified by this study, will be very useful to anyone who works with children" concludes Svensson. "We are now taking our research a stage further to look at how families handle this internal conflict and at the professional support they need and receive."

Science Daily Link

MEDICAL NEWS: Domestic Abuse May Affect Reproductive Freedom

MedPage Today
By Kristina Fiore, Staff Writer, MedPage Today
Published: January 25, 2010
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

In some abusive relationships, men may use strategies to force women to become pregnant, including sabotaging their birth control, researchers reported.

In a cross-sectional study of women treated at five family clinics across northern California, about 20% of women said that their partner tried to coerce them into having a child, Elizabeth Miller, MD, of the University of California Davis, and colleagues reported online in the journal Contraception.

Beyond outright coercion, abusive partners also engaged in birth control sabotage, for example, poking holes in condoms and flushing birth control pills down the toilet.

"It was stunning to have this many women seeking reproductive health services saying, 'this has happened to me,'" Miller said.

To investigate a possible link between domestic violence and forced pregnancy, the researchers conducted a survey of 1,278 women ages 16 to 29 who sought care at the five family planning clinics in northern California.

More than half of the women surveyed -- 53% -- reported physical or sexual partner violence.

Approximately a third of the women who reported partner violence also reported pregnancy coercion or birth control sabotage.

Altogether, the effect of both partner violence and reproductive control nearly doubled a woman's odds of unintended pregnancy (OR 1.99, 95% CI 1.11 to 3.58).

Both pregnancy coercion and birth control sabotage were separately associated with unintended pregnancy as well (OR 1.83, 95% CI 1.36 to 2.46 and OR 1.58, 95% CI 1.14 to 2.20, respectively).

"The findings suggest that pregnancy coercion and birth control sabotage may be an aspect of partner violence that, given its relevance to reproductive health, should be identified by providers in clinical settings," the authors wrote.

Among the reasons men would want their partners to bear children: "It ranges from things like wanting to leave a legacy, to a straightforward desire for attachment, to having absolute control over her body," Miller said. "There are all of these elements to it."

Aisha Mays, MD, director of the Teen and Young Adult Clinic at San Francisco General Hospital who was not involved in the study, said pregnancy coercion is a growing problem that has been around for "quite some time" but is just now being recognized as a major health issue.
"It's about power and control," Mays said. "It's another way of saying, 'this girl's taken, this girl's mine.'"

Mays said she has seen cases in which a young mother who has a child with another partner will be forced by her new boyfriend to have another baby with him.

It's also a way for males to make their partners more dependent on them, according to Amy Bonomi, PhD, MPH, of Ohio State University.
"Women in abusive relationships are sometimes forced to bear children as a means to keep them dependent on their partner and sometimes as a means to justify additional -- and sometimes more severe -- abuse," Bonomi said.

Miller said the findings emphasize the need for family planning clinics to provide intervention programs to combat both reproductive control and partner violence.

Key strategies include advising women about "invisible" forms of birth control such as injectable and intrauterine contraceptives, as well as easy access to emergency contraception.

"If we can identify that reproductive control is going on," Miller said, "we can offer the woman methods for birth control that the partner can't mess with."
Mays added that physicians and counselors should talk about women's empowerment with regard to reproduction during reproductive health visits.
"It tends to be left out," Mays said. "We talk about getting the prescription [for birth control] and its side effects. But we really need to have a discussion around whether the girl is feeling ready for sex."

The study was limited by its cross-sectional design, which "precludes conclusions concerning temporality regarding associations observed among pregnancy coercion, birth control sabotage, and intimate partner violence with unintended pregnancy." Miller et al said additional studies are needed to clarify the chronology of reproductive control and partner violence, and how those factors might combine to affect risk for unintended pregnancy.

The study was supported by grants from the National Institute of Child Health and Human Development, a UC Davis Health System Research Award, and a Building Interdisciplinary Research Centers in Women's Health award.
The researchers reported no conflicts of interest.

This article was developed in collaboration with ABC News.

Primary source: Contraception
Source reference:  Miller E, et al "Pregnancy coercion, intimate partner violence and unintended pregnancy" Contraception 2010; DOI: 10.1016/j.contraception.2009.12.004.

MEDICAL NEWS: No Benefit Seen in Routine Screening for Domestic Abuse

MedPage Today
No Benefit Seen in Routine Screening for Domestic Abuse

By John Gever, Senior Editor, MedPage Today
Published: August 04, 2009
Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

Screening all women in medical clinics for intimate partner violence in a randomized trial did not reduce rates of abuse or improve their quality of life, researchers said. Among those for whom the screening revealed a history of abuse, recurrence of partner violence during 18 months of follow-up was reduced by a nonsignificant 18% (odds ratio 0.82, 95% CI 0.32 to 2.12) compared with control participants, according to Harriet L. MacMillan, MD, of McMaster University in Hamilton, Ontario, and colleagues. The study randomized more than 6,700 eligible and consenting women at 26 Ontario medical clinics to either screening before their medical evaluation, so that interventions could be recommended to women exposed to partner violence, or to completing the screening questionnaires after the clinic visit. Writing in the Aug. 5 Journal of the American Medical Association, the researchers found that quality of life scores improved somewhat more at the 18-month follow-up in the screened group -- from 52.1 to 58.5, compared with an increase from 50.6 to 52.7 in the control group (P<0.05). Depression scores were also modestly reduced. But when MacMillan and colleagues imputted outcomes for the more than 40% of participants in both groups who dropped out of the study during follow-up, these differences shrank to insignificance. The screened women also showed no reduction in after-effects of domestic violence, such as post-traumatic stress disorder and drug and alcohol problems, compared with the unscreened group. "These results do not provide sufficient evidence to support universal IPV screening in healthcare settings in the absence of an effective intervention to prevent or reduce intimate partner violence," the researchers concluded. The trial did not employ a specific intervention for those with positive screening results. Clinicians were informed of available local services for victimized women, but they provided referrals at their own discretion. In fact, the researchers said, "fewer than half [44%] of the screened-positive women reported having a discussion about violence with their clinician during their visit." MacMillan and colleagues said it may be argued that even small improvements in outcomes justify screening, particularly as the trial did not identify any specific harms to participants from the screening. For example, other researchers suggested last year that performing such screens on mothers bringing their children to pediatric clinics would be beneficial. (See Pediatricians Should Screen Moms for Domestic Violence) But the researchers pointed out that 87% of participants were not exposed to partner violence, suggesting a significant amount of wasted effort in the screening. They also noted that the screening had a false-positive rate of 11%, requiring additional clinical effort and opportunity costs to identify those with positive results who actually needed no intervention. In an accompanying editorial, Kathryn E. Moracco, PhD, MPH, of the University of North Carolina in Chapel Hill, N.C., and Thomas B. Cole, MD, MPH, a contributing editor at JAMA, suggested that the effectiveness of medical screening for partner violence can't be properly evaluated until there are clinic-based interventions with proven efficacy. "Specific interventions to prevent the recurrence of abuse for women at risk of violence should be implemented and rigorously tested, preferably in randomized trials, without further delay," they wrote. "The results of the [current study] should dispel any illusions that universal screening with passive referrals to community services is an adequate response to violence in intimate relationships," they contended. In the study, women presenting at 11 emergency departments, 12 family practice centers, and three ob/gyn clinics during an 18-month period beginning in July 2005 were nominally eligible to participate. Those younger than 18 or older than 64 were excluded, as were women who did not make their own appointments or who did not have a male partner in the past year. Participation was also limited to those who spoke English, were able to be alone, and were not seriously ill. These exclusions meant that, of more than 120,000 women presenting at these clinics, about 87,000 were ineligible. Another 13,000 either refused to provide information to determine eligibility or were missed by the investigators. About 1,500 more who were eligible declined to participate. That left about 6,700 to be randomized. The investigators designated certain days as "screening days" during which all eligible and consenting female patients were asked to complete the screening questionnaire before they saw clinicians. An equal number of days provided the nonscreened control, with participants completing the questionnaire after the clinic visit. The screening instrument was the Woman Abuse Screening Tool, with the Composite Abuse Scale used to determine exposure to violence during follow-up. Other outcomes such as PTSD, depression, and substance abuse were measured with standard instruments such as the Short Form-12 and Short Form-36. Quality of life was evaluated with the World Health Organization Quality of Life (WHOQOL)–Bref questionnaire. Of 2,733 screened patients, 347 had positive results. A similar proportion of the 2,948 patients in the control group who completed the questionnaires also had positive results. Those in the unscreened group could also be asked about domestic violence if the clinician chose. Participants were interviewed every six months afterward through the 18-month follow-up period. Attrition was steady, reaching 43% in the screened group and 41% in the control patients at the end of follow-up. Growth trajectories were calculated with a logistic model for abuse recurrence and with a linear model for quality of life. A secondary analysis used imputed observations based on partial follow-up data to compensate for the high attrition. The researchers found that, among the screened-positive women still in the study at 18 months, 8% had called a crisis hotline, while 9% had contacted a counseling or advocacy center for abused women, and 4% had sought refuge at a shelter during the follow-up period. Some 26% had talked with a psychologist or social worker. These figures were very similar to those in the control group whose screening results were positive. MacMillan and colleagues said it was notable that absolute improvements in most outcomes were seen in both groups relative to baseline. They speculated that participation in the study -- being asked about intimate partner violence and its effects -- may have been beneficial in itself. Every participant was given an information card with details on services for abused women in their communities. The authors also noted that the study began during a period when crime statistics indicated violence was at a high point, and "was likely to decrease over time regardless of any intervention." Besides the high loss to follow-up, limitations to the study included the reliance on participant self-report for baseline and follow-up data, as well as the carefully controlled trial conditions that would probably not occur in ordinary medical practice. They also noted that significant costs were involved to support the highly trained research assistants who ensured that women filled out the written screen and that positive results were delivered immediately to the clinicians. In addition, each clinician received specific training. Also, the study was conducted in Canada where women have universal access to most healthcare services. The study was funded by a grant from the former Ontario Women's Health Council (Ontario Ministry of Health and Long-Term Care).  MacMillan reported holding a Canadian Institutes of Health Research (CIHR) New Emerging Team grant from the Institutes of Gender and Health.

Primary source: Journal of the American Medical Association Source reference: MacMillan H, et al "Screening for intimate partner violence in health care settings: a randomized trial" JAMA 2009; 302: 493-501. Additional source: Journal of the American Medical Association Source reference: Moracco K, et al., "Preventing intimate partner violence: screening is not enough" JAMA 2009; 302: 568-69.

Impact of Exposure to Domestic VIolence on Children and young people

Stephanie Holt; Helen Buckley; Sadhbh Whelan;

Children's Research Centre, University of Dublin, Trinity College, Dublin, Ireland.

OBJECTIVE: This article reviews the literature concerning the impact of exposure to domestic violence on the health and developmental well-being of children and young people. Impact is explored across four separate yet inter-related domains (domestic violence exposure and child abuse; impact on parental capacity; impact on child and adolescent development; and exposure to additional adversities), with potential outcomes and key messages concerning best practice responses to children's needs highlighted. 

METHOD: A comprehensive search of identified databases was conducted within an 11-year framework (1995-2006). This yielded a vast literature which was selectively organized and analyzed according to the four domains identified above. 

RESULTS: This review finds that children and adolescents living with domestic violence are at increased risk of experiencing emotional, physical and sexual abuse, of developing emotional and behavioral problems and of increased exposure to the presence of other adversities in their lives. It also highlights a range of protective factors that can mitigate against this impact, in particular a strong relationship with and attachment to a caring adult, usually the mother. 

CONCLUSION: Children and young people may be significantly affected by living with domestic violence, and impact can endure even after measures have been taken to secure their safety. It also concludes that there is rarely a direct causal pathway leading to a particular outcome and that children are active in constructing their own social world. Implications for interventions suggest that timely, appropriate and individually tailored responses need to build on the resilient blocks in the child's life. PRACTICE 

IMPLICATIONS: This study illustrate the links between exposure to domestic violence, various forms of child abuse and other related adversities, concluding that such exposure may have a differential yet potentially deleterious impact for children and young people. From a resilient perspective this review also highlights range of protective factors that influence the extent of the impact of exposure and the subsequent outcomes for the child. This review advocates for a holistic and child-centered approach to service delivery, derived from an informed assessment, designed to capture a picture of the individual child's experience, and responsive to their individual needs.

PMID: 18752848 [PubMed - as supplied by publisher]

http://www.ncbi.nlm.nih.gov/pubmed/18752848?ordinalpos=7&itool=EntrezSystem2.PEntrez.P...

Doctors Overlook Signs of Child - In Pediatrics, Domestic Violence

MedPage Today

By Chris Emery, Contributing Writer, MedPage Today
Published: November 30, 2009
Reviewed by Zalman S. Agus, MD; Emeritus Professor
University of Pennsylvania School of Medicine and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner

Physicians often misdiagnose bone fractures caused by child abuse as accidental breaks, particularly if the child is male and the doctor is not a pediatrician, a new study found.

Of children who suffered fractures from abuse, about 20% had at least one previous medical visit during which a doctor missed signs of the problem (95% CI 15.8 to 26.0), according to a report published online Nov. 30 in Pediatrics. It took a median of eight days after the initial visit before doctors correctly assessed abuse during a subsequent examination.

Doctors were most likely to misdiagnose abusive fractures if the patients were boys, had breaks in the limbs, or were seen in a primary care setting or general emergency room, as opposed to a pediatric emergency department.

"This study is the first to report the frequency of delayed recognition of abusive fractures in children," Kathy Boutis, MD, MSc, of the Hospital for Sick Children, University of Toronto, and colleagues wrote. "One-fifth of children with abusive fractures were missed at initial physician visits, which is comparable to that reported for other types of abuse; however, we do not know how many cases of abusive fractures are never detected."

While fractures are common signs of child abuse and repeat injuries occur in 35% of child abuse cases, previous research suggested that doctors have difficulty distinguishing breaks caused by accidents from those resulting from abuse -- and thus miss a chance to prevent further abuse.

However, the frequency at which cases of abuse are overlooked was unknown.

The authors assessed 258 cases of children younger than 3 years treated for abusive fractures at Toronto Hospital for Sick Children between January 1993 and December 2007. The children had seen physicians previously for treatment of fractures. Of the children, 54 had a least one previous visit with a physician at which abuse was missed, the study found.

Abuse-related fractures were nearly twice as likely to be missed in boys as in girls. "Although the reason for this is unclear, injuries in general occur more often in boys, which may bias a clinician in assuming that the cause of a fracture is accidental," the authors wrote.

Of the 145 children with breaks to an extremity, 28% (95% CI 20.8 to 35.8) were cases of abuse that were overlooked. About a third of the cases of abuse that were missed on the initial visit were the result of physicians not diagnosing fractures from radiographs.

"This study suggests that front-line physicians should strongly consider consulting a radiologist when the presence of a fracture may lead to increased suspicion of abuse," the authors wrote.

They also suggested that physicians carefully check for other risk factors of abuse in children with fractures and that they err on the side of performing skeletal surveys for children who are at higher risk.

They cautioned that the study was retrospective, and that some cases of abuse may have been overlooked by the researchers because they were never referred to the child protection team at the hospital.

On the other hand, complex cases may not have been referred to the child abuse team, which may have elevated the estimate of the percentage of abuse cases that are overlooked on a child's initial physician visit for a fracture.

"However," the authors wrote, "child abuse is under-recognized, and there is also the possibility that we are underestimating the proportion of cases missed."

The study was funded by the Canadian Hospitals Injury Reporting and Prevention Program.

The authors reported no financial conflicts of interest.

Primary source: Pediatrics
Source reference:
Boutis K, et al "Delayed identification of pediatric abuse-related fractures" Pediatrics 2009; DOI: 10.1542/peds. 2008-3794.