<p>In this qualitative study with nonoffending caregivers of suspected child sexual abuse victims, we aimed to explore the perceived impact of sexual abuse discovery on caregivers and their families, and caregivers' attitudes about mental health services for themselves. We conducted semistructured, in-person interviews with 22 nonoffending caregivers of suspected sexual abuse victims &lt;13 years old seen at a child advocacy center in Philadelphia. Interviews were audio-recorded, transcribed, coded, and analyzed using modified grounded theory. Recruitment continued until thematic saturation was reached. We found that caregivers experienced significant emotional and psychological distress, characterized by anger, depressed mood, and guilt, after learning that their child may have been sexually abused. We identified four specific sources of caregiver distress: concerns about their child, negative beliefs about their parenting abilities, family members' actions and behaviors, and memories of their own past maltreatment experiences. Some caregivers described worsening family relationships after discovery of their child's sexual abuse, while others reported increased family cohesion. Finally, we found that most caregivers in this study believed that mental health services for themselves were necessary or beneficial to help them cope with the impact of their child's sexual abuse. These results highlight the need for professionals working with families affected by sexual abuse to assess the emotional and psychological needs of nonoffending caregivers and offer mental health services. Helping caregivers link to mental health services, tailored to their unique needs after sexual abuse discovery, may be an acceptable strategy to improve caregiver and child outcomes after sexual abuse.</p>

<p>The objective of this study was to describe caregiver perceptions about mental health services (MHS) after child sexual abuse (CSA) and to explore factors that affected whether their children linked to services. We conducted semi-structured, in-person interviews with 22 non-offending caregivers of suspected CSA victims&lt;13 years old seen at a child advocacy center in Philadelphia. Purposive sampling was used to recruit caregivers who had (n=12) and had not (n=10) linked their children to MHS. Guided by the Health Belief Model framework, interviews assessed perceptions about: CSA severity, the child's susceptibility for adverse outcomes, the benefits of MHS, and the facilitators and barriers to MHS. Interviews were audio-recorded, transcribed, coded, and analyzed using modified grounded theory. Recruitment ended when thematic saturation was reached. Caregivers expressed strong reactions to CSA and multiple concerns about adverse child outcomes. Most caregivers reported that MHS were generally necessary for children after CSA. Caregivers who had not linked to MHS, however, believed MHS were not necessary for their children, most commonly because they were not exhibiting behavioral symptoms. Caregivers described multiple access barriers to MHS, but caregivers who had not linked reported that they could have overcome these barriers if they believed MHS were necessary for their children. Caregivers who had not linked to services also expressed concerns about MHS being re-traumatizing and stigmatizing. Interventions to increase MHS linkage should focus on improving communication with caregivers about the specific benefits of MHS for their children and proactively addressing caregiver concerns about MHS.</p>

<p><strong>OBJECTIVE: </strong>To develop guidelines for performing initial skeletal survey (SS) in children &lt;24 months old with fractures, based on available evidence and collective judgment of experts from diverse pediatric specialties.</p>

<p><strong>METHODS: </strong>Following the Rand/UCLA Method, a multispecialty panel of 13 experts applied evidence from a literature review combined with their own expertise in rating the appropriateness of performing an SS for 525 clinical scenarios involving fractures in children &lt;24 months old. After discussion on the initial ratings, panelists re-rated SS appropriateness for 240 revised scenarios and deemed that SSs were appropriate in 191 scenarios. The panelists then assessed in which of those 191 scenarios SSs were not only appropriate, but also necessary.</p>

<p><strong>RESULTS: </strong>Panelists agreed that SS is "appropriate" for 191 (80%) of 240 scenarios rated and "necessary" for 175 (92%) of the appropriate scenarios. Skeletal survey is necessary if a fracture is attributed to abuse, domestic violence, or being hit by a toy. With few exceptions, SS is necessary in children without a history of trauma. In children &lt;12 months old, SS is necessary regardless of the fracture type or reported history, with rare exceptions. In children 12 to 23 months old, the necessity of obtaining SS is dependent on fracture type.</p>

<p><strong>CONCLUSIONS: </strong>A multispecialty panel reached agreement on multiple clinical scenarios for which initial SS is indicated in young children with fractures, allowing for synthesis of clinical guidelines with the potential to decrease disparities in care and increase detection of abuse.</p>

<p><strong>BACKGROUND: </strong>Clinical factors that affect the likelihood of abuse in children with femur fractures have not been well elucidated. Consequently, specifying which children with femur fractures warrant an abuse evaluation is difficult. Therefore the purpose of this study is to estimate the proportion of femur fractures in young children attributable to abuse and to identify demographic, injury and presentation characteristics that affect the probability that femur fractures are secondary to abuse.</p>

<p><strong>METHODS: </strong>We conducted a systematic review of published articles written in English between January 1990 and July 2013 on femur fracture etiology in children less than or equal to 5 years old based on searches in PubMed/MEDLINE and CINAHL databases. Data extraction was based on pre-defined data elements and included study quality indicators. A meta-analysis was not performed due to study population heterogeneity.</p>

<p><strong>RESULTS: </strong>Across the 24 studies reviewed, there were a total of 10,717 children less than or equal to 60 months old with femur fractures. Among children less than 12 months old with all types of femur fractures, investigators found abuse rates ranging from 16.7% to 35.2%. Among children 12 months old or greater with femur fractures, abuse rates were lower: from 1.5% - 6.0%. In multiple studies, age less than 12 months, non-ambulatory status, a suspicious history, and the presence of additional injuries were associated with findings of abuse. Diaphyseal fractures were associated with a lower abuse incidence in multiple studies. Fracture side and spiral fracture type, however, were not associated with abuse.</p>

<p><strong>CONCLUSIONS: </strong>Studies commonly find a high proportion of abuse among children less than 12 months old with femur fractures. The reported trauma history, physical examination findings and radiologic results must be examined for characteristics that increase or decrease the likelihood of abuse determination.</p>

<p><strong>OBJECTIVE: </strong>To develop guidelines for performing an initial skeletal survey (SS) for children &lt;24 months of age presenting with bruising in the hospital setting, combining available evidence with expert opinion.</p>

<p><strong>METHODS: </strong>Applying the Rand/UCLA Appropriateness Method, a multispecialty panel of 10 experts relied on evidence from the literature and their own clinical expertise in rating the appropriateness of performing SS for 198 clinical scenarios characterizing children &lt;24 months old with bruising. After a moderated discussion of initial ratings, the scenarios were revised. Panelists re-rated SS appropriateness for 219 revised scenarios. For the 136 clinical scenarios in which SS was deemed appropriate, the panel finally assessed the necessity of SS.</p>

<p><strong>RESULTS: </strong>Panelists agreed that SS is "appropriate" for 62% (136/219) of scenarios, and "inappropriate" for children ≥ 12 months old with nonpatterned bruising on bony prominences. Panelists agreed that SS is "necessary" for 95% (129/136) of the appropriate scenarios. SS was deemed necessary for infants &lt;6 months old regardless of bruise location, with rare exceptions, but the necessity of SS in older children depends on bruise location. According to the panelists, bruising on the cheek, eye area, ear, neck, upper arm, upper leg, hand, foot, torso, buttock, or genital area necessitates SS in children &lt;12 months.</p>

<p><strong>CONCLUSIONS: </strong>The appropriateness and necessity of SS in children presenting for care to the hospital setting with bruising, as determined by a diverse panel of experts, depends on age of the child and location of bruising.</p>