Showing posts with label abuse. Show all posts
Showing posts with label abuse. Show all posts

Monday, October 12, 2015

An Ugly Reality: A Study of Developmental Behavior Of Children Born From Sexual Violence


By: Lydia Furman, MD,  Assistant Editor

      In a recently released study in Pediatrics, Dr. Rouhani et al. (doi: 10.1542/peds.2014-3373) presented us with a must read article about the burdens and experiences of women who are raising children conceived through sexual violence in the Democratic Republic of Congo (DRC) (ref here).  My first thought on reading this incredible article was that one does not need to go to the Democratic Republic of Congo (DRC) to meet women who are raising children conceived through sexual violence. Their conclusions are logical and intuitive, yet ground breaking, and I believe I can apply their “lessons” in my own practice. These authors interviewed over 700 women who are raising a child conceived through sexual assault. They used a specific method of locating hard-to-reach populations, called respondent driven sampling, in which ten initial identified women each recruited three other women, who then recruited three other women, and so on until the full population was identified.
      Please read the article to immerse yourself in the study, because likely you will find other parts of the work more meaningful than what captured me. What impressed me most was the extraordinary resilience of the women and of the maternal-child relationship.  Over one third of women reported that their community stigmatized their child, and over one third reported that their community stigmatized them personally. “Perceived acceptance of the child” by spouse, community and family seemed surprisingly low to me, given that the entire community was exposed to known, ongoing and multiple sexual assaults. Yet, despite all of this, 80.5% of women had “positive regard” (questions drawn from the Parental Stress Scale) for their child and 73.0% had “high attunement” (defined as “…awareness of, sensitivity to, and responsiveness to the child’s needs…”). So in the face of incomprehensible stress and challenge, including seeing their assailant and recalling the assault when looking at their child, the great majority of women are raising their children with engagement and kindness, as best one can understand. The authors’ multivariate analysis examines this question quantitatively and expands understanding further.
      While the upheaval in The DRC is notorious for the horror of widespread sexual violence, utilized as a weapon of war, the problems that women must face in raising a child who is the product of a rape respect no geographic boundaries. An issue that clinicians practicing in the US may have to recognize among women raising a child conceived through sexual violence is the complex racism of skin tone, which rears its ugly head when mother and child have obviously different skin colors or eye colors, prompting family or non-family members to ask about paternity. In the United States (US) it may be more possible for women to avoid stigma by non-acknowledgement of the sexual violence (e.g. by asking for non-inclusion of the information in the child’s medical record), but this does not permit future providers to treat the mother optimally (since she may have depression, anxiety, or other sequelae that are then not recognized), and this also makes support of any discussion she may want or need to have about conceiving in the setting of sexual violence   almost impossible.
       While Dr. Rouhani and colleagues studied a population in whom approximately 40% of women experienced sexual violence, it is sobering to realize that the Centers for Disease Control and Prevention (CDC) reports that “nearly one in five (18.3%) of women (in the US) … reported experiencing rape at some time in their lives” (http://www.cdc.gov/ViolencePrevention/pdf/SV-DataSheet-a.pdf ). While a continent and world away for some, this is a reality we cannot ignore. Ultimately prevention is the best cure, but in the meantime, removing stigma is critical.  Work is underway to support de-stigmatization of sexual violence in the DRC, for example through the Harvard Humanitarian Initiative (http://hhi.harvard.edu/sites/default/files/publications/women-in-war-stigmatization.pdf), and a brief search reveals relatively limited initiatives in the US, most primarily focused on domestic violence (for example, Triumph, a network for survivors of domestic violence, http://www.seethetriumph.org/). We have work to do, and the superb research of Dr. Rouhani and colleagues in the DRC is a wakeup call to all of us.

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Monday, July 13, 2015

Checking for Occult Fractures in the Setting of Abuse: Not the Automatic One Might Expect


By: Lewis First, MD, MS; Editor-in-Chief  

     We have certainly seen studies in our journal and others strongly demonstrating the importance of checking for occult fractures in children who are victims of physical abuse or in infants who have non-accidental traumatic brain injuries given the yield of finding such fractures in these injured children. So does it happen as a standard of diagnostic evaluation?  
      Sadly no—at least as per the study results reported by Wood et al. (doi: 10.1542/peds.2014-3977) in a retrospective study of more than 2500 abused children from more than 350 hospitals released this week in our journal.  The authors looked at inter-hospital variations and identified a variety of factors at the child and hospital level that influence the probability that occult fractures are or are not sought after. 
      For example, a smaller hospital with less young injured patients may be less apt to think about checking for occult fractures than one that is larger and sadly sees more of these patients.  The bottom line is that many injured children as a result of abuse and non-accidental injury are not being evaluated for occult fractures despite the importance of doing so.   
     How important is this?  Dr. Kristine Campbell, a specialist in the prevention of child abuse and neglect further comments on the ramifications of what this study suggests in an accompanying commentary (doi: 10.1542/peds.2015-0694).Hopefully forgetting to think about and in turn diagnose occult fractures does not happen in your local emergency room or in your practice when patients with alleged abuse are being evaluated –and if for some reason, you need a reminder to get a skeletal survey, this study and commentary should provide the painful reminder you need.

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Monday, June 15, 2015

Victimization of Children and Weapon Involvement: Some Alarming Statistics

By: Lewis First, MD, MS; Editor-in-Chief  

Texas A&M University-Com
      With so much attention on firearms and firearm safety in the news, the epidemiologic data on the prevalence of weapons involved in youth victimization seems to have been lacking—until now!   
      Mitchell et al. (doi: 10.1542/peds.2014-3966) have shared data on a national survey of children exposed to violence and report an astounding finding—more than 17.5 million children and teens are exposed to violence in which a weapon is involved—meaning they have served as witnesses or victims.  More than 2 million children and teens report they have been directly assaulted in incidents where guns or knives were used.
       Perhaps those on the fence regarding strengthening our gun-safety practices will jump off that fence and recognize the need to do all we can to restrict youth access as well as exposure to firearms so that the mental health repercussions of being victimized by these weapons and the people using them can be reduced as much as possible.   
     There is a lot of important information in this study worth sharing with those who are making decisions regarding gun control in your state or region—so do not hesitate to share this important study wherever it can make a difference.

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Tuesday, April 7, 2015

An Assault Injury May Lead to Subsequent Firearm Violence


By: Lewis First, MD, MS; Editor-in-Chief 
         
     Our heart goes out to teens who are victims of physical assault injuries that present to emergency departments for further evaluation and treatment.  But what happens after the assault compared to teens who are not assaulted?  Carter et al. (doi: 10.1542/peds.2014-3572) performed a prospective cohort study involving drug-using assaulted teens who presented to an urban Level 1 emergency department and compared them to a similar group of drug using teens who had not been assaulted and then followed both groups over the next two years  (collecting data on their well-being every 6 months).   
      Sadly there was a 40% increase in firearm violence in the assaulted group compared to the non-assaulted group—most having a firearm violent event within 6 months of the initial assault incident.  The authors take this finding further and identify risk factors that can further predict firearm violence in the assaulted group.
     What can we learn from this study?  We might want to do more than simply deal with the assault injuries themselves in the ED or in follow-up in a primary care setting—but instead try to intervene with more supportive services to these troubled youth in regard to helping  them with their substance abuse, mental health needs, need for revenge and /or desire to possess a firearm.  Obviously the goal is to do even more prevention work on firearm violence with teens even before this type of assault injury occurs—and Drs. Judith Schaechter and Eliot Nelson, experts on injury prevention from firearms share some important thoughts on this topic in an accompanying commentary (doi: 10.1542/peds.2015-0693). In this era of advocating for pediatrician inquiry into firearm access in homes with children and teens, this study and commentary are well worth your time and attention.

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