Date of Award

January 2020

Document Type

Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Kirsten Bechtel

Abstract

Child physical abuse is a significant public health challenge with an incidence of approximately 6.4 hospitalized cases per 100,000 children. Many abused children, however, will go undiagnosed by physicians evaluating these injuries. Assessing whether a child has been abused is a high-stakes decision: a missed case leaves a child vulnerable to future injury, but an inaccurate diagnosis of abuse may be greatly disruptive and stigmatizing to children and their families. Previous research has established key physical examination and radiographic findings that are associated with abusive injury. A gap in the literature, however, is the role of additional injury circumstances and details, such as the immediate behavior of the caregiver, in distinguishing abuse from accidental injury. While physicians do use such circumstances of the injury in diagnostic decision-making, evidence of which of these specific elements are associated with abusive injury is limited, particularly in cases of children with abusive fractures.

In this thesis, we performed a retrospective medical record review of 303 children evaluated by child abuse evaluation team (Diagnosis, Admission, Reporting, and Treatment, or DART, team) at Yale-New Haven Hospital over a ten-year period. We extracted information regarding what we termed the "context of injury”: the elements related to the circumstances of the injury itself and the events leading to medical presentation for evaluation of the injury. We defined this to include caregivers present and the steps taken in seeking care for the injury. We hypothesized that certain elements of the context of injury (e.g. the presence of multiple caregivers or the child's mother at the time of injury, call to 911, call for medical advice) would be associated with accidental injury, while others (e.g. father, boyfriend or babysitter present at time of injury, delay >24 hours in seeking care) would be associated with abusive injury.

Consistent with our initial hypotheses, we found that the presence of the child's mother at the time of the injury was associated with an accidental mechanism of injury (p<0.001). Conversely, we identified several factors associated with abusive injury: a delay in seeking care >24 hours (p<0.001) and the presence of the father (p=0.005), mother's male partner (p=0.004), or a babysitter/daycare worker at the time of the injury (p=0.014). Surprisingly, while the presence of multiple caregivers was similar between cases of abuse and accident, there was an association between clinicians not knowing who caregivers were at the time of the injury and an abusive mechanism of injury.

These results suggest that certain historical elements of the context in which a child’s injury occurred may be associated with either abusive or accidental injury, and thus might provide valuable diagnostic information to clinicians when evaluating cases of suspected child abuse. However, these preliminary results should be interpreted with caution as these results were drawn from a cohort of children who were evaluated in the inpatient setting due to suspicion of abuse. Thus, they may not be applicable to a population of children presenting to general practitioners or an emergency department with head injuries or fractures.

Comments

This thesis is restricted to Yale network users only. It will be made publicly available on 09/10/2022

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