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Child Abuse

Child Abuse
MEDICAL DIAGNOSIS

Child
AND MANAGEMENT
Editors: Antoinette Laskey, MD, MPH, MBA, FAAP 4th Edition
Andrew Sirotnak, MD, FAAP

Abuse
�oroughly revised and expanded, the fourth edition covers the latest developments in
the field of child abuse and neglect. Written and edited by a vast array of leading experts
on child abuse and neglect, this practical, objective, evidence-based guide is an indispens-
able resource to pediatricians, family physicians, nurses, child protection professionals,
and all others who care for children who may have experienced abuse or neglect.
�is important resource helps professionals recognize maltreatment, respond, report
when appropriate, and partner to provide ongoing medical and psychological care.
Features hundreds of photographs and illustrations and a wealth of diagnostic,
MEDICAL

AND MANAGEMENT
MEDICAL DIAGNOSIS
radiographic, and management information.

New in the Fourth Edition! DIAGNOSIS

All-new chapters cover
⬤ Sentinel Injuries
Includes AND
⬤ Burns 34 chapters—
⬤ Environmental Neglect and Social
Determinants of Health 15 new! MANAGEMENT
⬤ Supervisory Neglect
⬤ Drug-Endangered Children
⬤ Medical Neglect and Obesity
⬤ Psychological Maltreatment
Antoinette Laskey, MD, MPH, MBA, FAAP
⬤ Interpersonal Violence Andrew Sirotnak, MD, FAAP

Edition
⬤ Human Tra�ficking and Sexual Exploitation via Electronic Media

4th
⬤ Caring for �ose Who Care: Vicarious Trauma and Burnout
⬤ Caring for Children in Out-of-Home Care
⬤ Trauma-Informed Care and Treatment 4th Edition
⬤ Identification of Child Maltreatment
⬤ Evidence-based Child Abuse and Neglect Prevention Programs
⬤ Creating Change �rough Advocacy Sirotnak
For other pediatric resources, visit the American Academy of Pediatrics at shop.aap.org.
Laskey

ISBN 978-1-61002-358-0
90000>

AAP
9 781610 023580
Child
Abuse
MEDICAL DIAGNOSIS AND MANAGEMENT
4th Edition
Editors
Antoinette Laskey, MD, MPH, MBA, FAAP
Professor of Pediatrics
Division Chief and Medical Director
Center for Safe and Health Families
University of Utah School of Medicine
Salt Lake City, UT

Andrew Sirotnak, MD, FAAP

Professor and Vice Chair for Faculty Affairs
Department of Pediatrics
University of Colorado School of Medicine
Director, Child Protection Team
Children’s Hospital Colorado
Aurora, CO
 American Academy of Pediatrics Publishing Staff
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Marketing, and Publishing
Mark Grimes, Vice President, Publishing
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Mary Louise Carr, MBA, Marketing Manager, Clinical Publications

Published by the American Academy of Pediatrics

345 Park Blvd

Itasca, IL 60143
Telephone: 630/626-6000
Facsimile: 847/434-8000
www.aap.org

The American Academy of Pediatrics is an organization of 67,000 primary care pediatricians, pediatric medical subspecialists, and
pediatric surgical specialists dedicated to the health, safety, and well-being of infants, children, adolescents, and young adults.
The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of care. Variations,
taking into account individual circumstances, may be appropriate.
Any websites, brand names, products, or manufacturers are mentioned for informational and
identification purposes only and do not imply an endorsement by the American Academy of Pediatrics (AAP).
The AAP is not responsible for the content of external resources. Information was current at the time of publication.
The publishers have made every effort to trace the copyright holders for borrowed material. If they have inadvertently overlooked any,
they will be pleased to make the necessary arrangements at the first opportunity.
This publication has been developed by the American Academy of Pediatrics. The authors, editors, and contributors are expert
authorities in the field of pediatrics. No commercial involvement of any kind has been solicited or accepted in the development of the
content of this publication. Disclosures: Dr Dias disclosed a safety monitoring board relationship with Allergan. Dr Dubowitz disclosed a
consulting relationship with Total Child Health and with Advanced Metrics. Dr Forkey disclosed family stock ownership with Precision Optics
Corporation. Dr Greenbaum disclosed a family safety monitoring board relationship with Retrophin and with Relypsa and a family consulting
relationship with Vifor and with Bristol-Myers Squibb. Dr McTavish disclosed a consulting relationship with the World Health Organization.
Dr Metz disclosed stock ownership in Vertex, Biogen, and Medtronic. The editors and many of the contributors to this book often provide expert
witness testimony in court cases involving alleged child abuse and may be reimbursed for these services.
Every effort has been made to ensure that the drug selection and dosages set forth in this text are in accordance with the current
recommendations and practice at the time of publication. It is the responsibility of the health care professional to check the
package insert of each drug for any change in indications and dosages and for added warnings and precautions.
Every effort is made to keep Child Abuse: Medical Diagnosis and Management consistent with the most recent advice and information
available from the American Academy of Pediatrics.
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© 2020 American Academy of Pediatrics
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847/434-8780 or email [email protected]). Third edition published 2009.

Printed in the United States of America

9-426/1019 1 2 3 4 5 6 7 8 9 10
MA0938
ISBN: 978-1-61002-358-0
eBook: 978-1-61002-359-7
Cover and publication design by Peg Mulcahy
Library of Congress Control Number: 2018967251
 Contributors
Amy R. Beck, PhD Kristine Campbell, MD, MSc, FAAP
Weight Management Program Associate Professor
Center for Children’s Healthy Division of Child Protection and
Lifestyles and Nutrition Family Health
Children’s Mercy Kansas City Department of Pediatrics
Associate Professor of Pediatrics University of Utah School of Medicine
UMKC School of Medicine Primary Children’s Hospital Center for
Kansas City, MO Safe and Healthy Families
Salt Lake City, UT
Elizabeth Benzinger, PhD
Ohio Bureau of Criminal Investigation Mary Case, MD
London, OH Professor
Department of Pathology
Molly Curtin Berkoff, MD, FAAP St Louis University Health Sciences Center
Associate Professor of Pediatrics St Louis, MO
Division of General Pediatrics and
Adolescent Medicine Antonia Chiesa, MD
Department of Pediatrics Associate Professor of Pediatrics
University of North Carolina at University of Colorado School of M
­ edicine
Chapel Hill Kempe Center for the Prevention and
Chapel Hill, NC Treatment of Child Abuse and Neglect
Children’s Hospital Colorado
Stephen C. Boos, MD, FAAP Aurora, CO
Associate Professor of Pediatrics
University of Massachusetts Medical Theresa M. Covington, MPH
School–Baystate Director, Within Our Reach
Springfield, MA Alliance for Strong Families and
Adjunct Associate Professor of Communities
Pediatrics Washington, DC
Tufts University School of Medicine Paige Culotta, MD, FAAP
Boston, MA Child Abuse Pediatrician
Children’s Hospital of New Orleans
Ryan Brown, MD, FAAP
Audrey Hepburn CARE Center
Clinical Associate Professor
New Orleans, LA
Department of Pediatrics
The University of Oklahoma College Allan R. De Jong, MD, FAAP
of Medicine Medical Director
Medical Director, Child Protection Team Children at Risk Evaluation (CARE)
The Children’s Hospital at OU Medical Program
Center Nemours/Alfred I. duPont Hospital
Oklahoma City, OK for Children
Wilmington, DE
Kara Byrne, PhD
Assistant Research Professor Stephanie A. Deutsch, MD, FAAP
College of Social Work Co-Medical Director
University of Utah Children at Risk Evaluation (CARE)
Salt Lake City, UT Program

iii
iv Contributors

Nemours/Alfred I. duPont Hospital Diana H. Fishbein, PhD

for Children Director, Program for Translational
Wilmington, DE Research on Adversity and
Neurodevelopment
Mark S. Dias, MD, FAAP, FAANS
Edna Bennett Pierce Prevention
Professor of Neurosurgery and
Research Center
Pediatrics
Professor, Department of Human
Penn State College of Medicine
Development and Family Studies
Penn State Health Children’s
The Pennsylvania State University
Hospital University Park, PA
Hershey, PA
Heather Forkey, MD, FAAP
Howard Dubowitz, MD, MS, FAAP Associate Professor
Professor Department of Pediatrics
Department of Pediatrics University of Massachusetts Medical School
University of Maryland School of Worcester, MA
Medicine
Baltimore, MD Jordan Greenbaum, MD
Institute on Healthcare and Human
Karen Farst, MD, MPH, FAAP Trafficking at the Stephanie V. Blank
Associate Professor and Section Chief Center for Safe and Healthy Children
for Children at Risk Children’s Healthcare of Atlanta
Department of Pediatrics Atlanta, GA
University of Arkansas for Medical International Centre for Missing and
Sciences Exploited Children
Little Rock, AR Alexandria, VA
Kenneth Feldman, MD, FAAP Sarah E. Hampl, MD, FAAP
Clinical Professor of Pediatrics General Pediatrics and Weight
University of Washington Management
Children’s Protection Program Center for Children’s Healthy Lifestyles
Seattle Children’s Hospital and Nutrition
Seattle, WA Children’s Mercy Kansas City
Amanda K. Fingarson, DO, FAAP Professor of Pediatrics
Child Abuse Pediatrics Program UMKC School of Medicine
Ann and Robert H. Lurie Children’s Kansas City, MO
Hospital of Chicago Suzanne B. Haney, MD, FAAP
Assistant Professor of Pediatrics Assistant Professor of Pediatrics
Northwestern University Feinberg University of Nebraska Medical Center
School of Medicine Children’s Hospital and Medical Center
Chicago, IL Omaha, NE
Martin A. Finkel, DO, FACOP, FAAP Tara L. Harris, MD, MS, FAAP
Professor of Pediatrics Assistant Professor of Clinical
Institute Codirector Pediatrics
Child Abuse Research Education & Division of Child Protection Programs
Service (CARES) Institute Department of Pediatrics
School of Osteopathic Medicine Indiana University School of Medicine
Rowan University Riley Hospital for Children
Stratford, NJ Indianapolis, IN
Contributors  v

M. Katherine Henry, MD, MSCE, FAAP Wendy G. Lane, MD, MPH, FAAP
Fellow Clinical Associate Professor
Department of Pediatrics Department of Epidemiology and
Perelman School of Medicine at the Public Health
University of Pennsylvania Department of Pediatrics
Safe Place: The Center for Child University of Maryland School of Medicine
Protection and Health Baltimore, MD
Division of General Pediatrics
Alex V. Levin, MD, MHSc, FRCSC,
Children’s Hospital of Philadelphia
FAAP, FAAO
Philadelphia, PA
Chief, Pediatric Ophthalmology and
Larissa Hines, MD, FAAP Ocular Genetics
Clinical Assistant Professor Wills Eye Hospital
Department of Pediatrics Philadelphia, PA
The University of Oklahoma College of
Daniel M. Lindberg, MD
Medicine
Associate Professor
Child Abuse Pediatrician
Department of Emergency Medicine
Child Protection Team
Department of Pediatrics
The Children’s Hospital at OU Medical
University of Colorado School of Medicine
Center
Attending Physician
Oklahoma City, OK
Kempe Center for the Prevention and
Brooks Keeshin, MD, FAAP Treatment of Child Abuse and Neglect
Assistant Professor Children’s Hospital Colorado
Department of Pediatrics Aurora, CO
University of Utah
Deborah Lowen, MD, FAAP
Center for Safe and Healthy Families
Associate Professor of Pediatrics
Primary Children’s Hospital
Vanderbilt University School of
Salt Lake City, UT
Medicine
Emily Killough, MD, FAAP Director, Center for Child Protection &
Child Abuse Pediatrician Well-Being
Division of Child Adversity and Vanderbilt University Medical Center
Resilience Nashville, TN
Children’s Mercy Kansas City
Assistant Professor of Pediatrics François M. Luyet, MD
Division of Child Abuse and Neglect Clinical Assistant Professor of Pediatrics
UMKC School of Medicine University of Wisconsin School of
Kansas City, MO Medicine and Public Health
University of Wisconsin Child
Barbara L. Knox, MD, FAAP Protection Program
Professor of Pediatrics University of Wisconsin American
University of Wisconsin School of Family Children’s Hospital
Medicine and Public Health Madison, WI
Medical Director, University of
Wisconsin Child Protection Harriet MacMillan, CM, MD, MSc,
Program FRCPC, FAAP
University of Wisconsin American Distinguished University Professor
Family Children’s Hospital Department of Psychiatry and
Madison, WI Behavioural Neurosciences
vi Contributors

Department of Pediatrics Mary E. Moffatt, MD, FAAP

Chedoke Health Chair in Child Professor of Pediatrics
Psychiatry University of Missouri Kansas City
Offord Centre for Child Studies School of Medicine
McMaster University Director, Child Abuse Pediatrics
McMaster Children’s Hospital/ ­Fellowship
Hamilton Health Sciences Division of Child Adversity and Resilience
Hamilton, Ontario, Canada Division of Emergency Medicine
Children’s Mercy Hospital, Kansas City
Kathi Makoroff, MD, MEd, FAAP Kansas City, MO
Mayerson Center for Safe and Healthy
Children Yair Morad, MD
Cincinnati Children’s Hospital Medical Department of Ophthalmology
Center Assaf Harofeh Medical Center
Associate Professor Tel Aviv University
University of Cincinnati College of Tel Aviv, Israel
Medicine
Wynne Morgan, MD
Cincinnati, OH
Assistant Professor
Shelly D. Martin, MD Department of Psychiatry
Child Abuse Pediatrician University of Massachusetts Medical
Brooke Army Medical Center School
San Antonio, TX Worcester, MA
Associate Clinical Professor of
Sandeep K. Narang, MD, JD, FAAP
Pediatrics
Associate Professor of Pediatrics
Uniformed Services University of the
Northwestern University Feinberg
Health Sciences
School of Medicine
Bethesda, MD
Division Head, Child Abuse Pediatrics
Jill McTavish, PhD Ann and Robert H. Lurie Children’s
Postdoctoral Fellow Hospital of Chicago
Department of Psychiatry and Chicago, IL
Behavioural Neurosciences
Shalon M. Nienow, MD, FAAP
McMaster University
Medical Clinic Director
Hamilton, Ontario, Canada
Chadwick Center for Children and
John D. Melville, MD, MS, FAAP Families
Associate Professor of Pediatrics Rady Children’s Hospital—San Diego
Medical University of South Carolina Clinical Assistant Professor
Charleston, SC Division of Pediatric Emergency Medicine
University of California San Diego
James Metz, MD, MPH, FAAP
San Diego, CA
Assistant Professor
Department of Pediatrics Sarah A. W. Northrop, MD, FAAP
University of Vermont Department of Pediatrics
Larner College of Medicine Brenner Children’s Hospital
Division of General Pediatrics, Assistant Professor of Pediatrics
ChildSafe Program Wake Forest School of Medicine
University of Vermont Children’s Hospital Wake Forest Baptist Health
Burlington, VT Winston-Salem, NC
Contributors  vii

Vincent J. Palusci, MD, MS, FAAP Edna Bennett Pierce Prevention

Professor of Pediatrics Research Center
New York University School of Medicine The Center for Healthy Children
New York, NY The Pennsylvania State University
University Park, PA
Sarah Passmore, DO, FAAP
Department of Pediatrics Brooke D. Saffren, OMS-IV
University of Oklahoma Philadelphia College of Osteopathic
Tulsa, OK Medicine
Philadelphia, PA
James G. Pawelski, MS
Director, State Advocacy Susan A. Scherl, MD, FAAP
American Academy of Pediatrics Professor
Itasca, IL Department of Orthopaedics
University of Nebraska Medical Center
Hillary W. Petska, MD, MPH, FAAP Attending Physician
Assistant Professor Section of Pediatric Orthopaedics
Department of Pediatrics Children’s Hospital and Medical Center
Medical College of Wisconsin Omaha, NE
Child Abuse Pediatrician
Child Advocacy and Protection Services Patricia G. Schnitzer, MS, PhD
Children’s Hospital of Wisconsin National Center for Fatality Review and
Milwaukee, WI Prevention
Washington, DC
Mary Clyde Pierce, MD, FAAP
Child Abuse Pediatrics Program, Lynn K. Sheets, MD, FAAP
Pediatric Emergency Medicine Professor
Ann and Robert H. Lurie Children’s Department of Pediatrics
Hospital of Chicago Medical College of Wisconsin
Professor of Pediatrics Medical Director
Northwestern University Feinberg Child Advocacy and Protection
School of Medicine Services
Chicago, IL Children’s Hospital of Wisconsin
Milwaukee, WI
Corey J. Rood, MD, FAAP
Child Abuse Pediatrician Lindsay Dianne Shepard, LCSW, MSW,
Assistant Professor of Pediatrics MSC
Medical Director, Child Abuse Pediatrics Program Manager
University of California Irvine Department of Pediatrics
Orange, CA University of Utah
Medical Director, Child Abuse and Therapist
Prevention Team Center for Safe and Healthy Families
Miller Children’s and Women’s Hospital Primary Children’s Hospital
Long Beach, CA Salt Lake City, UT
Emma Jane Rose, PhD Kirsten Simonton, MD, FAAP
Assistant Research Professor Assistant Professor of Pediatrics
Associate Director, Program for Northwestern University Feinberg
Translational Research on Adversity School of Medicine
and Neurodevelopment Attending Physician
viii Contributors

Division of Child Abuse Pediatrics Sasha Svendsen, MD, FAAP

Ann and Robert H. Lurie Children’s UMass Memorial Children’s Medical Center
Hospital of Chicago Westborough, MA
Chicago, IL University of Massachusetts Medical
School
Katherine Snyder, MD, MPH, FAAP Worcester, MA
Department of Pediatrics
Dell Medical School Brooke Sweeney, MD, FAAP
Medical Director, Weight Management
University of Texas at Austin
Services
Austin, TX
Children’s Mercy Kansas City
Jenna Spagnuolo, DCFI Clinical Assistant Professor of
Forensic Interviewer Supervisor ­Pediatrics
Child Abuse Program UMKC School of Medicine
Children’s Hospital of The King’s Kansas City, MO
Daughters Jonathan Thackeray, MD, FAAP
Norfolk, VA Chief Medical Community Health
Officer
Lisa Spector, MD, FAAP
Department of Medical Affairs
Professor of Pediatrics
Dayton Children’s Hospital
University of Central Florida
Professor and Vice Chair
Division Chief of Developmental and
Department of Pediatrics
Behavioral Pediatrics Wright State University Boonshoft
Nemours Children’s Hospital School of Medicine
Orlando, FL Dayton, OH
Suzanne P. Starling, MD, FAAP Kathryn Wells, MD, FAAP
Medical Director, Chadwick Center for Associate Professor and Section Head
Children & Families for Child Abuse and Neglect
Rady Children’s Hospital of San Diego Department of Pediatrics
Clinical Professor of Pediatrics, University of Colorado School
University of California San Diego of Medicine
San Diego, CA Aurora, CO
 With enduring gratitude to those who came before and laid the
foundation on which we were able to build and grow
and from whom we have learned so much
To my professional rocks APS, SPS, and TPH, who have helped
me grow into the professional I am
To ZWS, who has been there through it all and has turned into an
amazing professional in his own right
And to JGL, AGL, and DEL, without whom I could not achieve
all that I have set out to do
—ALL

To my colleagues, mentors, and peers, who have supported my

professional growth and leadership journey
To JWW and my family, who have provided
encouragement and sustained my resilience
And to all the students, fellows, and early career professionals who
inspire me as we learn together and care for children
—APS
 Contents
Foreword . ....................................................................................................................................................xv
Robert M. Reece, MD, FAAP

Acknowledgment ...............................................................................................................................................xvii
Introduction The Evolving Workforce............................................................................................................xix
Antoinette Laskey, MD, MPH, MBA, FAAP, and Andrew Sirotnak, MD, FAAP

Part 1: Physical Abuse

Chapter 1 Sentinel Injuries...........................................................................................................................3
Hillary W. Petska, MD, MPH, FAAP, and Lynn K. Sheets, MD, FAAP

Chapter 2 Cutaneous Manifestations of Child Abuse............................................................................... 19

Amanda K. Fingarson, DO, FAAP, and Mary Clyde Pierce, MD, FAAP

Chapter 3 Burns............................................................................................................................................47
Kenneth Feldman, MD, FAAP, and James Metz, MD, MPH, FAAP

Chapter 4 Skeletal Manifestations of Child Abuse..................................................................................103

Suzanne B. Haney, MD, FAAP, and Susan A. Scherl, MD, FAAP

Chapter 5 Visceral Manifestations of Child Abuse...................................................................................139

M. Katherine Henry, MD, MSCE, FAAP, and Daniel M. Lindberg, MD

Chapter 6 Maxillofacial, Neck, and Dental Manifestations of Child Abuse..........................................167

Ryan Brown, MD, FAAP, and Larissa Hines, MD, FAAP

Chapter 7 Abusive Head Trauma.............................................................................................................. 199

Stephen C. Boos, MD, FAAP, and Mark S. Dias, MD, FAAP, FAANS

Chapter 8 Ocular Manifestations of Child Abuse....................................................................................285

Brooke D. Saffren, OMS-IV; Yair Morad, MD; and Alex V. Levin, MD, MHSc,
FRCSC, FAAP, FAAO

Part 2: Sexual Abuse

Chapter 9 Taking Forensically Sound Histories in Cases of Alleged Sexual Abuse.............................309
Jenna Spagnuolo, DCFI, and Suzanne P. Starling, MD, FAAP

Chapter 10 Medical Evaluation of Suspected Sexual Abuse in Prepubertal Children.......................... 327

Molly Curtin Berkoff, MD, FAAP, and Martin A. Finkel, DO, FACOP, FAAP

Chapter 11 Medical Management of the Adolescent Who Has Experienced

Sexual Abuse or Assault..........................................................................................................383
Sarah A. W. Northrop, MD, FAAP, and Shalon M. Nienow, MD, FAAP

Chapter 12 Sexually Transmitted Infections in Child Sexual Abuse........................................................415

Allan R. De Jong, MD, FAAP, and Stephanie A. Deutsch, MD, FAAP

Chapter 13 The Role of Forensic Materials in Sexual Abuse and Assault............................................... 457
Kathi Makoroff, MD, MEd, FAAP; Jonathan Thackeray, MD, FAAP;
and Elizabeth Benzinger, PhD

xi
xii Contents

Part 3: Neglect
Chapter 14 Environmental Neglect and Social Determinants of Health............................................... 477
Wendy G. Lane, MD, MPH, FAAP, and Howard Dubowitz, MD, MS, FAAP

Chapter 15 Supervisory Neglect.................................................................................................................499

François M. Luyet, MD, and Barbara L. Knox, MD, FAAP

Chapter 16 Drug-Endangered Children..................................................................................................... 527

Karen Farst, MD, MPH, FAAP, and Kathryn Wells, MD, FAAP

Chapter 17 Failure to Thrive.......................................................................................................................565

Sarah Passmore, DO, FAAP, and Deborah Lowen, MD, FAAP

Chapter 18 Medical Neglect and Obesity...................................................................................................623

Emily Killough, MD, FAAP; Brooke Sweeney, MD, FAAP; Sarah E.
Hampl, MD, FAAP; and Amy R. Beck, PhD

Part 4: Other Forms of Maltreatment

Chapter 19 Psychological Maltreatment...................................................................................................655
Shelly D. Martin, MD, and Katherine Snyder, MD, MPH, FAAP

Chapter 20 Medical Child Abuse................................................................................................................. 673

Paige Culotta, MD, FAAP, and Jonathan Thackeray, MD, FAAP

Chapter 21 Interpersonal Violence............................................................................................................703

Tara L. Harris, MD, MS, FAAP

Chapter 22 Human Trafficking and Sexual Exploitation via Electronic Media...................................... 725
Jordan Greenbaum, MD, and Corey J. Rood, MD, FAAP

Part 5: Pathology of Child Maltreatment

Chapter 23 Pathology of Fatal Abuse........................................................................................................ 765
Mary Case, MD

Chapter 24 SIDS, SUID, and the Child Fatality Review Team Approach to
Unexpected Infant Death.........................................................................................................821
Vincent J. Palusci, MD, MS, FAAP; Theresa M. Covington, MPH; and Patricia G.
Schnitzer, MS, PhD

Part 6: Professional Issues in Child Maltreatment

Chapter 25 Photodocumentation...............................................................................................................861
John D. Melville, MD, MS, FAAP

Chapter 26 Reporting Abuse, Managing Uncertainty, and Other Legal Issues..................................... 875
Sandeep K. Narang, MD, JD, FAAP; Kristine Campbell, MD, MSc, FAAP;
and Kirsten Simonton, MD, FAAP

Chapter 27 Caring for Those Who Care: Vicarious Trauma and Burnout................................................921
Antonia Chiesa, MD, and Sasha Svendsen, MD, FAAP
Contents  xiii

Part 7: Outcomes
Chapter 28 Caring for Children in Out-of-Home Care.............................................................................943
Heather Forkey, MD, FAAP, and Wynne Morgan, MD

Chapter 29 Medical and Psychological Sequelae of Child Abuse and Neglect......................................987

Mary E. Moffatt, MD, FAAP

Chapter 30 Neurobiological Consequences of Childhood Maltreatment.............................................1019

Emma Jane Rose, PhD, and Diana H. Fishbein, PhD

Chapter 31 Trauma-Informed Care and Treatment............................................................................... 1059

Brooks Keeshin, MD, FAAP; Lindsay Dianne Shepard, LCSW, MSW, MSC; and
Kara Byrne, PhD

Part 8: Prevention
Chapter 32 Identification of Child Maltreatment................................................................................... 1093
Jill McTavish, PhD, and Harriet MacMillan, CM, MD, MSc, FRCPC, FAAP

Chapter 33 Evidence-based Child Abuse and Neglect Prevention Programs........................................1111

Lisa Spector, MD, FAAP

Chapter 34 Creating Change Through Advocacy..................................................................................... 1129

James G. Pawelski, MS

Index . ..................................................................................................................................................1141
 Foreword
“To study the phenomena of disease without books is to sail an uncharted sea, while
to study books without patients is not to go to sea at all.”
Sir William Osler

Clinicians who evaluate patients to determine whether they have been

harmed by neglect or sexual or physical maltreatment heed Olser’s
advice and use books along with peer-reviewed literature to complement
their direct contact with these patients. It is, therefore, essential that
authoritative books in the field of child abuse and neglect are available,
current, and evidence based. This fourth edition of Child Abuse: Medical
Diagnosis and Management continues its mission to present the best
research available synthesized by leading experts.
The preface in the first edition, published in 1994, stated the
“accumulation of understanding has appeared in such a diverse range
of clinical and research journals that it requires constant vigilance to
stay informed of recent advances. The practitioner needs an integrated
resource for the strictly medical information when confronting a new case
of child abuse.” This is true to an even greater extent 25 years and more
than 3,000 peer-reviewed articles published since Caffey’s seminal article
in 19461 and Kempe et al’s article in 1962.2 The relatively recent recognition
of child maltreatment as a major contributor to morbidity and mortality in
infancy, childhood, and adolescence has spawned the subspecialty of child
abuse pediatrics. This new edition of Child Abuse: Medical Diagnosis and
Management opens with a discussion of this evolving workforce.
In addition to the traditional core curriculum, comprehensively
presented in the first 26 chapters, appropriate attention is also given
to vicarious trauma and burnout, caring for the child in out-of-home
care, and the medical and psychological sequelae of child abuse and
neglect. The authors of the chapter on neurobiological consequences of
child maltreatment address the central importance of adverse childhood
experiences as critically significant in numerous adult pathologies. Finally,
the concluding section discusses prevention and advocacy, persistently
necessary approaches to the protection of children in a world fraught with
challenges from all quarters of our social order.
Thanks are due to those who contributed chapters, the editors who
selected them, and the American Academy of Pediatrics for publishing this
book.
Robert M. Reece, MD, FAAP

xv
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