Child maltreatment: variation in trends and policies in six developed countries

Pattern and medical care of child victims of sexual abuse in Ekiti, south-western Nigeria

BACKGROUND

Child sexual assault (CSA) is a global health problem which affects many children and is often under-reported in developing countries. Data on CSA are few in these countries.

AIMS AND OBJECTIVES

This study aimed to review the pattern and medical care of victims of CSA in a tertiary hospital over a 39-month period.

METHODS

This is a retrospective, descriptive study. Case files of 28 cases of CSA were retrieved from those of 6535 patients seen in the paediatric out-patient department of Ekiti State University Teaching Hospital between 1 January 2010 and 31 March 2013.

RESULTS

Victims of CSA accounted for 0.43% of new patients seen during the period under review with a yearly increase over that time. Victims were all female with a median age of 11.5 years and the age range was 4-17. They all had genito-urinary findings and 3.6% had an anal tear. The assailants were all male, mostly adults. A school-teacher and school-friends were the perpetrators in 3.6% and 10.8% of cases, respectively. All were screened for HIV, but only 60.7% were screened for hepatitis B and C. Only 60.7% received HIV post-exposure prophylaxis and none was given prophylaxis against viral hepatitis B and C. Of those eligible for post-exposure emergency contraception, only 43.8% received it. Antibiotics and analgesics were routinely given in 89.3% cases. Only one of the patients attended for follow-up. None had repeat serological screening tests. The police were involved in 60.7% of cases but there was no prosecution.

CONCLUSION

Perpetrators of CSA are protean and, in the study area, there are gross inadequacies in the care provided for victims. Standard treatment protocols and additional training for health-care providers involved in the management of CSA victims are required.

Multiple injuries in a 3-year-old Nigerian girl: an extreme form of physical abuse

Physical abuse and other forms of child maltreatment occur worldwide. However, in developing countries such as Nigeria they are not often considered in the differential diagnosis. A 3-year-old girl is presented who sustained injuries including traumatic teeth extraction, multiple bruises, femoral shaft fracture and haemorrhage resulting in severe anaemia as a result of physical assault by her father. This case underscores the need for the implementation of appropriate legislation to combat child maltreatment in Nigeria.

The prevalence and impact of child maltreatment and other types of victimization in the UK: findings from a population survey of caregivers, children and young people and young adults

OBJECTIVES

To measure the prevalence of maltreatment and other types of victimization among children, young people, and young adults in the UK; to explore the risks of other types of victimization among maltreated children and young people at different ages; using standardized scores from self-report measures, to assess the emotional wellbeing of maltreated children, young people, and young adults taking into account other types of childhood victimization, different perpetrators, non-victimization adversities and variables known to influence mental health.

METHODS

A random UK representative sample of 2,160 parents and caregivers, 2,275 children and young people, and 1,761 young adults completed computer-assisted self-interviews. Interviews included assessment of a wide range of childhood victimization experiences and measures of impact on mental health.

RESULTS

2.5% of children aged under 11 years and 6% of young people aged 11-17 years had 1 or more experiences of physical, sexual, or emotional abuse, or neglect by a parent or caregiver in the past year, and 8.9% of children under 11 years, 21.9% of young people aged 11-17 years, and 24.5% of young adults had experienced this at least once during childhood. High rates of sexual victimization were also found; 7.2% of females aged 11-17 and 18.6% of females aged 18-24 reported childhood experiences of sexual victimization by any adult or peer that involved physical contact (from sexual touching to rape). Victimization experiences accumulated with age and overlapped. Children who experienced maltreatment from a parent or caregiver were more likely than those not maltreated to be exposed to other forms of victimization, to experience non-victimization adversity, a high level of polyvictimization, and to have higher levels of trauma symptoms.

CONCLUSIONS

The past year maltreatment rates for children under age 18 were 7-17 times greater than official rates of substantiated child maltreatment in the UK. Professionals working with children and young people in all settings should be alert to the overlapping and age-related differences in experiences of childhood victimization to better identify child maltreatment and prevent the accumulative impact of different victimizations upon children's mental health.

Children in the public benefit system at risk of maltreatment: identification via predictive modeling

A growing body of research links child abuse and neglect to a range of negative short- and long-term health outcomes. Determining a child's risk of maltreatment at or shortly after birth provides an opportunity for the delivery of targeted prevention services. This study presents findings from a predictive risk model (PRM) developed to estimate the likelihood of substantiated maltreatment among children enrolled in New Zealand's public benefit system. The objective was to explore the potential use of administrative data for targeting prevention and early intervention services to children and families. A data set of integrated public benefit and child protection records for children born in New Zealand between January 1, 2003, and June 1, 2006, was used to develop a risk algorithm using stepwise probit modeling. Data were analyzed in 2012. The final model included 132 variables and produced an area under the receiver operating characteristic curve of 76%. Among children in the top decile of risk, 47.8% had been substantiated for maltreatment by age 5 years. Of all children substantiated for maltreatment by age 5 years, 83% had been enrolled in the public benefit system before age 2 years. This analysis demonstrates that PRMs can be used to generate risk scores for substantiated maltreatment. Although a PRM cannot replace more-comprehensive clinical assessments of abuse and neglect risk, this approach provides a simple and cost-effective method of targeting early prevention services.

Mothers in methadone treatment and their involvement with the child protection system: a replication and extension study

OBJECTIVES

Although a high level of involvement with the child protection system has been identified in families where parental substance use is a feature, not all such parents abuse or neglect their children or have contact with the child protection system. Identifying parents with substance-use histories who are able to care for their children without intervention by the child protection system, and being able to target interventions to the families who need them the most is important. This study interviewed a relatively large sample of mothers about their histories, their children and their involvement with the child protection system. We hypothesized that mothers in opioid pharmacological treatment who are involved with child protection services are different in characteristics to those mothers who are not involved.

METHODS

One hundred and seventy-one women, with at least one child aged under 16 years, were interviewed at nine treatment clinics providing pharmacological treatment for opioid dependence across Sydney, Australia.

RESULTS

Just over one-third of the women were involved with child protection services at the time of interview, mostly with children in out-of-home care. Logistic regression analyses revealed that factors which significantly increased the likelihood of the mother being involved with the child protection system were: (1) having a greater number of children, (2) being on psychiatric medication, and (3) having less than daily contact with her own parents.

CONCLUSIONS

This study replicates and extends the work of Grella, Hser, and Huang (2006) and the limited literature published to date examining the factors which contribute to some substance-using mothers becoming involved with the child protection system while others do not. The finding that mental health problems and parental supports (along with the number of children) were significantly associated with child protection system involvement in this study, indicates a need for improved interventions and the provision of treatment and support services if we are to reduce the involvement of the child protection system with these families.

Cross-country comparison of victimisation-related injury admission in children and adolescents in England and Western Australia

Background

A single, standardised measure of victimisation-related (VR) injury admission in hospital administrative datasets could allow monitoring of preventive and response strategies and international comparisons of policy. Consistency of risk factors and incidence rates for a measure of victimisation-related injury in different countries with similar access to healthcare services would provide indirect evidence for measure validity.

Methods

Cohorts were derived from hospital administrative data for children aged less than 18 years who were admitted for acute injury to hospitals in England or Western Australia (WA) in 2000 to 2008. We compared the effects of age, sex and deprivation on the annual incidence of acute admission for VR injury defined by a cluster of ICD-10 codes reflecting characteristics that should alert clinicians to consider victimisation as a cause of injury. Four subcategories comprised codes specifically indicating child maltreatment, assault, undetermined cause, or adverse social circumstances.

Results

The incidence of VR injury followed a similar ‘J’-shaped association with age in both countries with increasing rates from 10 years onwards and peaks in infancy and in 16–17 year-olds. In both countries, rates increased with deprivation. Girls had lower rates than boys except in the 11–15 age group where girls had higher rates than boys in WA but not in England. Adjusted incidence rates were similar in both countries for children aged 3 to 15 years old, but were higher in WA compared with England in children under 3 years old and in those aged 16–17 years. Higher rates in WA in 16–17 year-olds were explained by more admissions coded for the subcategories of adverse social circumstances, and to a lesser extent, assault, than in England. Children less than 3 years old were more often coded specifically for maltreatment in WA than in England.

Conclusions

The similarities in risk factors and in the adjusted rates of victimisation-related injury admission in both countries suggest that the VR cluster of ICD-10 codes is measuring a similar underlying problem. Differential use of coding subcategories highlights the need to use the entire VR cluster for comparisons across settings.

Intimate partner violence

• IPV is an underrecognized problem that occurs in all countries, cultures, and socioeconomic groups. • IPV has an enormous impact on personal health, and economic and social well-being. • IPV may occur in heterosexual and LGBTQ relationships and may be perpetrated by either sex. • Canadian data from 1999 show about equal proportions of men and women had been victims of physical (seven and eight per cent, respectively) and psychological (18 and 19 per cent, respectively) IPV in the previous five years. • Exposure to IPV has deleterious effects on children and other family members. • Some populations are at greater risk or have special needs for IPV. These include immigrant women, Aboriginal women, LGBTQ communities, people with ALs, pregnant women, dating adolescents, older people, alcohol and other substance abusing people, low-income people, and those without a current partner (that is, IPV perpetrated by a former partner). • Mental health problems associated with IPV include depression, anxiety disorders, chronic pain syndromes, eating disorders, sleep disorders, psychosomatic disorders, alcohol and other substance abuse, suicidal and self-harm behaviours, nonaffective psychosis, some personality disorders, and harmful health behaviours, such as risk taking and smoking. As IPV is a major determinant of mental health, it is of vital importance to mental health professionals. • Physical health problems associated with IPV include death, a broad range of injuries, reproductive disorders, gastrointestinal disorders, chronic pain syndromes, fibromyalgia, poor physical functioning, and lower health-related quality of life. Sexually transmitted diseases, unwanted pregnancies and physical inactivity are also increased. • Children's exposure to IPV may have short- and long-term health impacts on the child, especially mental health effects. • Perpetrators of IPV most frequently have personality disorders, but substance abuse and other types of mental illness or brain dysfunction may also occur.

Trends in prevalence and characteristics of post-neonatal cerebral palsy cases: a European registry-based study

The present paper aims to analyze trends over time in prevalence of cerebral palsy of post-neonatal origin, to investigate whether changes are similar according to severity and to describe the disability profile by etiology. Post-neonatal cases, birth years 1976 to 1998, were identified from the Surveillance of Cerebral Palsy in Europe collaboration (19 population-based registries). A recognized causal event occurring between 28 days and 24 months of age was considered to define the cases. Trends in prevalence were explored using graphical methods (Lowess and Cusum control chart) and modeled with negative binomial regressions. Over the study period, 404 cases were identified as post-neonatal cases (5.5% of the total). Mean prevalence rate was 1.20 per 10,000 live births (95% CI [1.08-1.31]). A significant downward trend was observed (p=0.001), with an accentuated decrease in the 1990 s. The prevalence of severe cases which account for around one third of the total also significantly decreased over time (p<0.001). In 46% of cases, an infectious aetiology was reported; the corresponding prevalence significantly decreased since 1989. No significant decrease was observed for the rate of cases due to a vascular episode or of traumatic origin. Our results emphasize the need of large population-based surveillance systems to reliably monitor trends in prevalence in rare subgroups of children like those with acquired cerebral palsy. The decrease of the overall prevalence as well as those of the most severe cases may be partly due to public health actions targeted to prevent such events.

Trends in reports of child maltreatment in the Northern Territory, 1999-2010

OBJECTIVE

To examine trends in reports of child maltreatment to the Northern Territory Department of Children and Families among Aboriginal and non-Aboriginal children.

DESIGN, SETTING AND SUBJECTS

A historical cohort study using administrative data collections of notifications and substantiated cases of maltreatment among children aged from 0 to 17 years.

MAIN OUTCOME MEASURES

Annual rates of notification and substantiation of different types of child maltreatment.

RESULTS

From 1999 to 2010, the overall annual rates of notification for maltreatment of Aboriginal children showed an average increase of 21% (incidence rate ratio [IRR], 1.21; 95% CI, 1.19-1.24). The greatest increases were in notifications for neglect and emotional abuse. There were parallel increases in rates of substantiated cases of maltreatment. Among non-Aboriginal children, the overall annual rates of notification also increased (IRR, 1.10; 95% CI, 1.07-1.14); however, changes in annual rates of substantiated cases for all types of maltreatment were not statistically significant.

CONCLUSION

There have been considerable increases in both notifications and substantiated cases of child maltreatment, most prominently among Aboriginal children. It is possible that the observed increases reflect increasing incidence of maltreatment; however, they are also consistent with a mix of increased surveillance, improved service access, changes in policy and a shift in public attitudes.

Administrative data linkage as a tool for child maltreatment research

Linking administrative data records for the same individuals across services and over time offers a powerful, population-wide resource for child maltreatment research that can be used to identify risk and protective factors and to examine outcomes. Multistage de-identification processes have been developed to protect privacy and maintain confidentiality of the datasets. Lack of information on those not coming to the attention of child protection agencies, and limited information on certain variables, such as individual-level SES and parenting practices, is outweighed by strengths that include large and unbiased samples, objective measures, comprehensive long-term follow-up, continuous data collection, and relatively low expense. Ever emerging methodologies and expanded holdings ensure that research using linked population-wide databases will make important contributions to the study of child maltreatment.

Multi-exposure and clustering of adverse childhood experiences, socioeconomic differences and psychotropic medication in young adults

Purpose

Stressful childhood experiences have negative long-term health consequences. The present study examines the association between adverse childhood experiences, socioeconomic position, and risk of psychotropic medication in young adulthood.

Methods

This register-based cohort study comprises the birth cohorts between 1985 and 1988 in Sweden. We followed 362 663 individuals for use of psychotropic medication from January 2006 until December 2008. Adverse childhood experiences were severe criminality among parents, parental alcohol or drug abuse, social assistance recipiency, parental separation or single household, child welfare intervention before the age of 12, mentally ill or suicidal parents, familial death, and number of changes in place of residency. Estimates of risk of psychotropic medication were calculated as odds ratio (OR) with 95% confidence intervals (CIs) using logistic regression analysis.

Results

Adverse childhood experiences were associated with increased risks of psychotropic medication. The OR for more than three adverse childhood experiences and risk of psychotropic medication was for women 2.4 (95% CI 2.3–2.5) and for men 3.1 (95% CI 2.9–3.2). The risk of psychotropic medication increased with a higher rate of adverse childhood experiences, a relationship similar in all socioeconomic groups.

Conclusions

Accumulation of adverse childhood experiences increases the risk of psychotropic medication in young adults. Parental educational level is of less importance when adjusting for adverse childhood experiences. The higher risk for future mental health problems among children from lower socioeconomic groups, compared to peers from more advantaged backgrounds, seems to be linked to a higher rate of exposure to adverse childhood experiences.

Variation in recorded child maltreatment concerns in UK primary care records: a cohort study using The Health Improvement Network (THIN) database

OBJECTIVES

To determine variation over time and between practices in recording of concerns related to abuse and neglect (maltreatment) in children's primary care records.

DESIGN

Retrospective cohort study using a United Kingdom representative primary care database.

SETTING

448 General Practices.

PARTICIPANTS

In total 1,548, 972 children (<18 y) registered between 1995 and 2010.

MAIN OUTCOME MEASURES

Change in annual incidence of one or more maltreatment-related codes per child year of registration. Variation between general practices measured as the proportion of registered children with one or more maltreatment-related codes during 3 years (2008-2010).

RESULTS

From 1995-2010, annual incidence rates of any coded maltreatment-related concerns rose by 10.8% each year (95% confidence interval 10.5, 11.2; adjusted for sex, age and deprivation). In 2010 the rate was 9.5 per 1000 child years (95%CI: 9.3, 9.8), equivalent to a prevalence of 0.8% of all registered children in 2010. Across all practices, the median prevalence of children with any maltreatment-related codes in three years (2008 to 2010) was 0.9% (range 0%-13.4%; 11 practices (2.5%) had zero children with relevant codes in the same period). Once we accounted for sex, age, and deprivation, the prevalence for each practice was within two standard errors of the grand mean.

CONCLUSIONS

General Practitioners (GPs) are far from disengaged from safeguarding children; they are consistently and increasingly recording maltreatment concerns. As these results are likely to underestimate the burden of maltreatment known to primary care, there is much scope for increasing recording in primary care records with implications for resources to respond to concerns about maltreatment. Interventions and policies should build on this evidence that the average GP in the UK is engaged in child safeguarding activity.

Risk of maltreatment-related injury: a cross-sectional study of children under five years old admitted to hospital with a head or neck injury or fracture

Objectives

To determine the predictive value and sensitivity of demographic features and injuries (indicators) for maltreatment-related codes in hospital discharge records of children admitted with a head or neck injury or fracture.

Methods

Study design: Population-based, cross sectional study. Setting: NHS hospitals in England. Subjects: Children under five years old admitted acutely to hospital with head or neck injury or fracture. Data source: Hospital Episodes Statistics, 1997 to 2009. Main outcome measure: Maltreatment-related injury admissions, defined by ICD10 codes, were used to calculate for each indicator (demographic feature and/or type of injury): i) the predictive value (proportion of injury admissions that were maltreatment-related); ii) sensitivity (proportion of all maltreatment-related injury admissions with the indicator).

Results

Of 260,294 childhood admissions for fracture or head or neck injury, 3.2% (8,337) were maltreatment-related. With increasing age of the child, the predictive value for maltreatment-related injury declined but sensitivity increased. Half of the maltreatment-related admissions occurred in children older than one year, and 63% occurred in children with head injuries without fractures or intracranial injury.

Conclusions

Highly predictive injuries accounted for very few maltreatment-related admissions. Protocols that focus on high-risk injuries may miss the majority of maltreated children.