Andrea G Asnes

Yale-New Haven Hospital, New Haven, Connecticut, United States

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Publications (20)47.76 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Research in child abuse pediatrics has advanced clinicians' abilities to discriminate abusive from accidental injuries. Less attention, however, has been paid to cases with uncertain diagnoses. These uncertain cases - the "gray" cases between decisions of abuse and not abuse - represent a meaningful challenge in the practice of child abuse pediatricians. In this study, we describe a series of gray cases, representing 17% of 134 consecutive children who were hospitalized at a single pediatric hospital and referred to a child abuse pediatrician for concerns of possible abuse. Gray cases were defined by scores of 3, 4, or 5 on a 7-point clinical judgment scale of the likelihood of abuse. We evaluated details of the case presentation, including incident history, patient medical and developmental histories, family social histories, medical studies, and injuries from the medical record and sought to identify unique and shared characteristics compared with abuse and accidental cases. Overall, the gray cases had incident histories that were ambiguous, medical and social histories that were more similar to abuse cases, and injuries that were similar to accidental injuries. Thus, the lack of clarity in these cases was not attributable to any single element of the incident, history, or injury. Gray cases represent a clinical challenge in child abuse pediatrics and deserve continued attention in research.
    No preview · Article · Nov 2015 · Child abuse & neglect
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    ABSTRACT: To assess the accuracy of International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM), codes in identifying cases of child physical abuse in 4 children's hospitals. We included all children evaluated by a child abuse pediatrician (CAP) for suspicion of abuse at 4 children's hospitals from January 1, 2007, to December 31, 2010. Subjects included both patients judged to have injuries from abuse and those judged to have injuries from accidents or to have medical problems. The ICD-9-CM codes entered in the hospital discharge database for each child were compared to the decisions made by the CAPs on the likelihood of abuse. Sensitivity and specificity were calculated. Medical records for discordant cases were abstracted and reviewed to assess factors contributing to coding discrepancies. Of 936 cases of suspected physical abuse, 65.8% occurred in children <1 year of age. CAPs rated 32.7% as abuse, 18.2% as unknown cause, and 49.1% as accident/medical cause. Sensitivity and specificity of ICD-9-CM codes for abuse were 73.5% (95% confidence interval 68.2, 78.4), and 92.4% (95% confidence interval 90.0, 94.0), respectively. Among hospitals, sensitivity ranged from 53.8% to 83.8% and specificity from 85.4% to 100%. Analysis of discordant cases revealed variations in coding practices and physicians' notations among hospitals that contributed to differences in sensitivity and specificity of ICD-9-CM codes in child physical abuse. Overall, the sensitivity and specificity of ICD-9-CM codes in identifying cases of child physical abuse were relatively low, suggesting both an under- and overcounting of abuse cases. Copyright © 2015 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.
    No preview · Article · Aug 2015 · Academic pediatrics
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    ABSTRACT: Child abuse and neglect is common in the United States, and victims often present to emergency departments (EDs) for care. Most US children who seek care in EDs are treated in general EDs without specialized pediatric services. We aim to explore general ED providers' experiences with screening and reporting of child abuse and neglect to identify barriers and facilitators to detection of child abuse and neglect in the ED setting. We conducted 29 semistructured interviews with medical providers at 3 general EDs, exploring experiences with child abuse and neglect. Consistent with grounded theory, researchers coded transcripts and then collectively refined codes and identified themes. Data collection and analysis continued until theoretical saturation was achieved. Barriers to recognizing child abuse and neglect included providers' desire to believe the caregiver, failure to recognize that a child's presentation could be due to child abuse and neglect, challenges innate to working in an ED such as lack of ongoing contact with a family and provider biases. Barriers to reporting child abuse and neglect included factors associated with the reporting process, lack of follow-up of reported cases, and negative consequences of reporting such as testifying in court. Reported facilitators included real-time case discussion with peers or supervisors and the belief that it was better for the patient to report in the setting of suspicion. Finally, providers requested case-based education and child abuse and neglect consultation for unclear cases. Our interviews identified several approaches to improving detection of child abuse and neglect by general ED providers. These included providing education through case review, improving follow-up by Child Protective Services agencies, and increasing real-time assistance with patient care decisions. Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
    Full-text · Article · Jul 2015 · Annals of emergency medicine
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    ABSTRACT: The relationship between risk factors and Child Protective Services (CPS) outcomes in families who participate in home visiting programs to prevent abuse and neglect and who are reported to CPS is largely unknown. We examined the relationship between parental risk factors and the substantiation status and number of CPS reports in families in a statewide prevention program. We reviewed CPS reports from 2006 to 2008 for families in Connecticut's child abuse prevention program. Six risk factors (histories of CPS, domestic violence [DV], mental health, sexual abuse, substance abuse, and criminal involvement) and the number of caregivers were abstracted to create risk scores for each family member. Maltreatment type, substantiation, and number of reports were recorded. Odds ratios were calculated. Of 1,125 families, 171 (15.6%) had at least one CPS report, and reports of 131 families were available for review. Families with a substantiated (25.2%) versus unsubstantiated (74.8%) first report had a high number of paternal risk factors (OR=6.13, 95% CI [1.89, 20.00]) and were more likely to have a history of maternal DV (OR=8.47, 95% CI [2.96, 24.39]), paternal DV (OR=11.23, 95% CI [3.33, 38.46]), and maternal criminal history (OR=4.55; 95% CI [1.32, 15.60]). Families with >1 report (34.4%) versus 1 report (65.6%) were more likely to have >3 caregivers, but this was not statistically significant (OR=2.53, 95% CI [0.98, 6.54]). In a prevention program for first-time families, DV, paternal risk, maternal criminal history, and an increased number of caregivers were associated with maltreatment outcomes. Targeting parental violence may impact child abuse prevention. Copyright © 2014 Elsevier Ltd. All rights reserved.
    No preview · Article · Dec 2014 · Child Abuse & Neglect
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    ABSTRACT: This article highlights five important aspects of the clinical problem of evaluating young children who are suspected of having abusive head trauma: 1) the clinical questions to be addressed, 2) challenges when evaluating young children with suspected abuse, 3) key aspects of clinical practice and data collection, 4) a framework for decision-making and 5) key articles in the literature that can help inform a sound clinical decision about the likelihood of abuse.
    No preview · Article · Dec 2014 · Pediatric Radiology
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    ABSTRACT: Technologies are not always successfully implemented into practice. This study elicited experiences of acute care providers with the introduction of technology and identified barriers and facilitators in the implementation process. A qualitative study using one-on-one interviews among a purposeful sample of 19 physicians and nurses within 10 emergency departments and intensive care units was performed. Grounded theory, iterative data analysis and the constant comparative method were used to inductively generate ideas and build theories. Five major categories emerged: decision-making factors, the impact on practice, technology’s perceived value, facilitators and barriers to implementation. Barriers included negative experiences, age, infrequent use and access difficulties. A positive outlook, sufficient training, support staff and user friendliness were facilitators. This study describes strategies implicated in the successful implementation of newly adopted technology in acute care settings. Improved implementation methods and evaluation of implementation processes are necessary for successful adoption of new technology.
    No preview · Article · Nov 2014 · Journal of Medical Engineering & Technology
  • Rebecca L. Moles · Andrea G. Asnes
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    ABSTRACT: Uncertainty in the diagnosis of abuse can have profound implications for the health and safety of the child, the emotional burden of a family, and investigative and criminal proceedings. A logical algorithm for addressing physical and sexual abuse cases that details aspects contributing to the uncertainty may aid the clinician in making a diagnosis and in communicating the crucial details to the relevant investigative agencies. This article defines and discusses uncertainty in the realms of physical and sexual abuse, and suggests an approach to managing uncertainty while still providing valuable information for the medical and child protective service systems.
    No preview · Article · Oct 2014 · Pediatric Clinics of North America
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    ABSTRACT: Purpose: Although capnography is being incorporated into clinical guidelines, it is not used to its full potential. We investigated reasons for limited implementation of capnography in acute care areas and explored facilitators and barriers to its implementation. Methods: A purposeful sample of physicians and nurses in emergency departments and intensive care units participated in semistructured interviews. Grounded theory, iterative data analysis, and the constant comparative method were used to analyze the data to inductively generate ideas and build theories. Results: Nineteen providers were interviewed from 5 hospitals. Six themes were identified: variability in use of capnography among acute care units, availability and accessibility of capnography equipment, the evidence behind capnography use, the impact of capnography on patient care, personal experiences impacting use of capnography, and variable knowledge about capnography. Barriers and facilitators to use were found within each theme. Conclusions: We observed varied responsiveness to capnography and identified factors that work to foster or discourage its use. These data can guide future implementation strategies. A deliberate strategy to foster utilization, mitigate barriers, and broadly accelerate implementation has the potential to profoundly impact use of capnography in acute care areas with the goal of improving patient care.
    Full-text · Article · Jun 2014 · Journal of Critical Care
  • Elizabeth Y. Rawson · Andrea G. Asnes

    No preview · Conference Paper · Oct 2013
  • Andrea G Asnes · John M Leventhal

    No preview · Article · Jul 2013 · The Journal of pediatrics
  • Andrea G Asnes · John M Leventhal

    No preview · Article · Jan 2013
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    ABSTRACT: Objective: Hospital discharge databases are being increasingly used to track the incidence of child physical abuse in the United States. These databases use International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes to categorize illnesses and injuries in hospitalized patients. We assessed the accuracy of the assignment of these codes for cases of child physical abuse. Study design: Participants were all children (N = 133) evaluated by a child abuse pediatrician (CAP) for suspicion of abuse at Yale-New Haven Children's Hospital from January 1, 2007-December 31, 2010. These children included both those judged to have injuries from abuse and those judged to have injuries accidental/medical in nature. We compared the ICD-9-CM codes entered in the hospital discharge database for each child with the decisions made by the CAPs, as documented in their child abuse registry. The CAPs' decisions were considered to be the gold standard. Sensitivity and specificity were calculated. Medical records were reviewed for cases in which the ICD-9-CM codes disagreed with the CAP's decision. Results: In 133 cases of suspected child physical abuse, the sensitivity and specificity of ICD-9-CM codes for abuse were 76.7 % (CI 61.4%, 88.2%) and 100% (CI 96.0%, 100%), respectively. Analysis of the 10 cases of abuse not receiving ICD-9-CM codes for abuse revealed that errors in physician documentation (n = 5) and in coding (n = 5) contributed to the reduction in sensitivity. Conclusions: Despite high specificity in identifying child physical abuse, the sensitivity of ICD-9-CM codes is 77%, indicating that these codes underestimate the occurrence of abuse.
    No preview · Article · Jul 2012 · The Journal of pediatrics
  • Paula Schaeffer · John M Leventhal · Andrea Gottsegen Asnes
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    ABSTRACT: Published protocols for forensic interviewing for child sexual abuse do not include specific questions about what prompted children to tell about sexual abuse or what made them wait to tell. We, therefore, aimed to: (1) add direct inquiry about the process of a child's disclosure to a forensic interview protocol; (2) determine if children will, in fact, discuss the process that led them to tell about sexual abuse; and (3) describe the factors that children identify as either having led them to tell about sexual abuse or caused them to delay a disclosure. Forensic interviewers were asked to incorporate questions about telling into an existing forensic interview protocol. Over a 1-year period, 191 consecutive forensic interviews of child sexual abuse victims aged 3-18 years old in which children spoke about the reasons they told about abuse or waited to tell about abuse were reviewed. Interview content related to the children's reasons for telling or for waiting to tell about abuse was extracted and analyzed using a qualitative methodology in order to capture themes directly from the children's words. Forensic interviewers asked children about how they came to tell about sexual abuse and if children waited to tell about abuse, and the children gave specific answers to these questions. The reasons children identified for why they chose to tell were classified into three domains: (1) disclosure as a result of internal stimuli (e.g., the child had nightmares), (2) disclosure facilitated by outside influences (e.g., the child was questioned), and (3) disclosure due to direct evidence of abuse (e.g., the child's abuse was witnessed). The barriers to disclosure identified by the children were categorized into five groups: (1) threats made by the perpetrator (e.g., the child was told (s)he would get in trouble if (s)he told), (2) fears (e.g., the child was afraid something bad would happen if (s)he told), (3) lack of opportunity (e.g., the child felt the opportunity to disclose never presented), (4) lack of understanding (e.g., the child failed to recognize abusive behavior as unacceptable), and (5) relationship with the perpetrator (e.g., the child thought the perpetrator was a friend). Specific reasons that individual children identify for why they told and why they waited to tell about sexual abuse can be obtained by direct inquiry during forensic interviews for suspected child sexual abuse. When asked, children identified the first person they told and offered varied and specific reasons for why they told and why they waited to tell about sexual abuse. Understanding why children disclose their abuse and why they wait to disclose will assist both professionals and families. Investigators and those who care for sexually abused children will gain insight into the specific barrier that the sexually abused child overcame to disclose. Prosecutors will be able to use this information to explain to juries why the child may have delayed his or her disclosure. Parents who struggle to understand why their child disclosed to someone else or waited to disclose will have a better understanding of their child's decisions.
    No preview · Article · May 2011 · Child abuse & neglect
  • Andrea Gottsegen Asnes · John M Leventhal

    No preview · Article · Jan 2011 · JAMA Pediatrics
  • John M Leventhal · Kimberly D Martin · Andrea G Asnes
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    ABSTRACT: The goal was to use a national database to determine the incidence of abusive traumatic brain injuries (TBIs) and/or fractures and the frequency of abuse versus accidents among children <36 months of age. We used the 2006 Kids' Inpatient Database and classified cases into 3 types of injuries, that is, (1) TBI only, (2) TBI and fracture, or (3) fracture only. Groups 2 and 3 were divided into 3 patterns, that is, (1) skull fractures, (2) skull and nonskull fractures, or (3) nonskull fractures. For each type and pattern, we compared abuse, accidental falls, other accidents, and motor vehicle accidents. The incidence of TBIs and/or fractures attributable to abuse was 21.9 cases per 100,000 children <36 months of age and 50.0 cases per 100,000 children <12 months of age. In the abuse group, 29.9% of children had TBIs only, 28.3% TBIs and fractures, and 41.8% fractures only. Abused children were younger and were more likely to be enrolled in Medicaid. For TBI only, falls were more common than abuse in the first 2 months of life but abuse was more common from 2 to 7 months. For TBI and skull fracture, falls were more common during the first year of life. For skull fracture only, almost all injuries were attributable to falls. There was overlap in TBIs and fractures attributable to abuse. Among <12-month-old children, TBIs and/or fractures attributable to abuse occurred in 1 of 2000. Falls occurred more commonly than abuse, even among very young children.
    No preview · Article · Jul 2010 · PEDIATRICS
  • John M Leventhal · Janet L Murphy · Andrea G Asnes
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    ABSTRACT: To describe a clinical approach to the recognition of overt and latent concerns of parents and children when children are evaluated for suspected sexual abuse by medical examiners. Description of a clinical approach. We describe 10 concerns-six of parents: (1) should we believe our child?; (2) worries about the child's body; (3) expressing emotions; (4) why the child delayed in telling; (5) how to talk to my child; (6) when will the perpetrator be arrested?; and four of children: 7) who will know about this?; (8) protecting one's parents; (9) worry about one's own body; and (10) what about my sexuality? We believe that by addressing these concerns in the medical evaluation of suspected sexual abuse, clinicians can help families focus on important issues, including ensuring the child's safety, acknowledging family members' feelings, and arranging counseling for the child and parents.
    No preview · Article · Mar 2010 · Child abuse & neglect
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    Andrea G Asnes · John M Leventhal
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    ABSTRACT: • The management of child maltreatment is never easy, but considering and reporting suspected cases of child abuse and neglect are important clinical skills and obligations of a pediatric clinician. • Use of the stepwise approach and the conceptual framework set forth in this article is likely to help the pediatric practitioner move from concern to action in a way that assures children's safety and also serves families best. • The clinical approach described in this article is based not on research evidence, but rather on the practical experience gleaned from years working as pediatric experts in child abuse.
    Preview · Article · Feb 2010 · Pediatrics in Review
  • Andrea Gottsegen Asnes · John M. Leventhal
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    ABSTRACT: After reading this chapter and answering the discussion questions that follow, you should be able to Identify types of child maltreatment and discuss the scope of the problem from a global perspective. Discuss the challenges of establishing a universally acceptable operational definition of child maltreatment. Analyze risk factors for child maltreatment, including those that relate to the child, parents, family, and society. Evaluate measures for prevention of child maltreatment at the individual child level, parent–child relationship level, community and societal levels.
    No preview · Chapter · Dec 2008
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    John M Leventhal · Kimberly D Martin · Andrea G Asnes
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    ABSTRACT: The goal was to assess the proportion of children with fractures attributable to abuse and the incidence of fractures caused by abuse among children <36 months of age who were hospitalized in the United States. We used the Kids' Inpatient Database, which has discharge data on 80% of acute pediatric hospitalizations in the United States, for 3 time periods (1997, 2000, and 2003). Fractures attributable to abuse in children <36 months of age were identified by both an International Classification of Diseases, Ninth Revision, Clinical Modification code for fracture and a diagnosis external-cause-of-injury code for abuse. Weighted estimates of the incidence were calculated. Among children <36 months of age who were hospitalized with fractures, the proportions of cases attributable to abuse were 11.9% in 1997, 11.9% in 2000, and 12.1% in 2003. The proportions of cases attributable to abuse decreased with increasing age; for example, in 2003, the proportions attributable to abuse were 24.9% for children <12 months of age, 7.2% for children 12 to 23 months of age, and 2.9% for children 24 to 35 months of age. In 2003, the incidence of fractures caused by abuse was 15.3 cases per 100000 children <36 months of age. The incidence was 36.1 cases per 100000 among children <12 months of age; this decreased to 4.8 cases per 100000 among 12- to 23-month-old children and 4.8 cases per 100000 among 24- to 35-month-old children. The Kids' Inpatient Database can be used to provide reasonable estimates of the incidence of hospitalization with fractures attributable to child abuse. For children <12 months of age, the incidence was 36.1 cases per 100000, a rate similar to that of inflicted traumatic brain injury (25-32 cases per 100000).
    Preview · Article · Sep 2008 · PEDIATRICS
  • Andrea Gottsegen Asnes · Ambika Shenoy
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    ABSTRACT: These vignettes do not include every difficult encounter confronted by the pediatric practitioner. They are offered as examples of an approach to handling such encounters. A unifying theme in these cases is the clinician's obligation to take responsibility for diffusing and ameliorating challenging, awkward, and frustrating interactions with families. Individual practitioners may choose different words than those we have offered. What matters is that clinicians see the role they have in improving relationships with families when relationships are stressed. Pediatric practitioners may not always feel generous, sympathetic, caring, or contrite when interacting with challenging families. Clinicians, however, need to treat these families with generosity, sympathy, care, and sometimes, contrition. Doing so is not only an obligation, but often results in a positive outcome to an initially negative encounter. Copyright © 2008 by the American Academy of Pediatrics. All rights reserved.
    No preview · Article · Jul 2008 · Pediatrics in Review

Publication Stats

160 Citations
47.76 Total Impact Points


  • 2008-2015
    • Yale-New Haven Hospital
      • Department of Laboratory Medicine
      New Haven, Connecticut, United States
    • Yale University
      • Department of Pediatrics
      New Haven, Connecticut, United States