Objective 1) Examine the relationship between previous adverse childhood experiences and somatic complaints and health problems in early adolescence, and 2) examine the role of the timing of adverse exposures. Design Prospective analysis of the Longitudinal Studies of Child Abuse and Neglect interview data when children were 4, 6, 8, 12 and 14 years old. Setting Children reported or at risk for maltreatment in the South, East, Midwest, Northwest, and Southwest United States LONGSCAN sites Participants 933 children. Main Exposures Eight categories of adversity (psychological maltreatment, physical abuse, sexual abuse, neglect, caregiver’s substance use/alcohol abuse, caregiver’s depressive symptoms, caregiver treated violently, and criminal behavior by household member) experienced during the first 6 years of life, the second six years of life, the most recent 2 years, and overall adversity Outcome Measures Child health problems including poor health, illness requiring a doctor, somatic complaints and any health problem at age 14. Results More than 90% of the youth had experienced an adverse childhood event by age 14. There was a graded relationship between adverse childhood exposures and any health problem, while 2 and ≥3 adverse exposures were associated with somatic complaints. Recent adversity uniquely predicted poor health, somatic complaints and any health problem. Conclusions Childhood adversities, particularly recent adversities, already impair the health of young adolescents. Increased efforts to prevent and mitigate these experiences may improve the health of adolescents and adults.

Clinicians had some degree of suspicion that approximately 10% of the injuries they evaluated were caused by child abuse. Clinicians did not report all suspicious injuries to child protective services, even if the level of suspicion was high (likely or very likely caused by child abuse). Child, family, and injury characteristics and clinician previous experiences influenced decisions to report.

Fractures are common injuries caused by child abuse. Although the consequences of failing to diagnose an abusive injury in a child can be grave, incorrectly diagnosing child abuse in a child whose fractures have another etiology can be distressing for a family. The aim of this report is to review recent advances in the understanding of fracture specificity, the mechanism of fractures, and other medical diseases that predispose to fractures in infants and children. This clinical report will aid physicians in developing an evidence-based differential diagnosis and performing the appropriate evaluation when assessing a child with fractures. Pediatrics 2014;133:e477-e489 INTRODUCTIONFractures are the second most common injury caused by child physical abuse; bruises are the most common injury. 1 Failure to identify an injury caused by child abuse and to intervene appropriately may place a child at risk for further abuse, with potentially permanent consequences for the child. 2-4 Physical abuse may not be considered in the physician' s differential diagnosis of childhood injury because the caregiver may have intentionally altered the history to conceal the abuse. 5 As a result, when fractures are initially evaluated, a diagnosis of child abuse may be missed. 3 In children younger than 3 years, as many as 20% of fractures caused by abuse may be misdiagnosed initially as noninflicted or as attributable to other causes. 3 In addition, fractures may be missed because radiography is performed before changes are obvious or the radiographic images are misread or misinterpreted. 2 However, incorrectly diagnosing physical abuse in a child with noninflicted fractures has serious consequences for the child and family. To identify child abuse as the cause of fractures, the physician must take into consideration the history, the age of the child, the location and type of fracture, the mechanism that causes the particular type of fracture, and the presence of other injuries while also considering other possible causes. DIFFERENTIAL DIAGNOSIS OF FRACTURES Trauma: Child Abuse Versus Noninflicted InjuriesFractures are a common childhood injury and account for between 8% and 12% of all pediatric injuries. [6][7][8] In infants and toddlers, physical FROM THE AMERICAN ACADEMY OF PEDIATRICSGuidance for the Clinician in Rendering Pediatric Care by guest on May 11, 2018 http://pediatrics.aappublications.org/ Downloaded from abuse is the cause of 12% to 20% of fractures. 9 Although unintentional fractures are much more common than fractures caused by child abuse, the physician needs to remain aware of the possibility of inflicted injury. Although some fracture types are highly suggestive of physical abuse, no pattern can exclude child abuse. 10,11 Specifically, it is important to recognize that any fracture, even fractures that are commonly noninflicted injuries, can be caused by child abuse. Certain details that can help the physician determine whether a fracture was caused by abuse rather than unintentional injury include the hist...

Adverse environmental exposures, including child abuse and other household dysfunction, are associated with poor child health even at an early age, although our data do not support a dose-response relationship.

Decisions about reporting to child protective services are guided by injury circumstances and history, knowledge of and experiences with the family, consultation with others, and previous experiences with child protective services.

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Primary care providers report most, but not all, cases of suspected child abuse that they identify. Past negative experience with CPS and perceived lack of benefit to the child were common reasons given by providers for not reporting. Education increases the probability that providers will report suspected abuse.

Pediatrician experience with child protective services (CPS) and factors associated with identifying and reporting suspected child physical abuse were examined by a survey of members of the American Academy of Pediatrics (AAP). Respondents provided information about their demographics and experience, attitudes and practices with child abuse. They indicated their diagnosis and management of a child in a purposely ambiguous clinical vignette. Pediatricians who had received recent child abuse education were more confident in their ability to identify and manage child abuse. High confidence in ability to manage child abuse and positive attitude about domestic violence screening and value of anticipatory guidance predicted that pediatricians would have high suspicion that the child in the vignette was abused and that they would report the child to CPS. Future efforts to improve medical intervention in child abuse should focus on physician attitudes and experience, as well as cognitive factors.