Identifying Populations at Risk for Child Abuse: A Nationwide Analysis

Disparities in detection of suspected child abuse

BACKGROUND

Child abuse is a significant cause of injury and death among children, but accurate identification is often challenging. This study aims to assess whether racial disparities exist in the identification of child abuse.

METHODS

The 2010-2014 and 2016-2017 National Trauma Data Bank was queried for trauma patients ages 1-17. Using ICD-9CM and ICD-10CM codes, children with injuries consistent with child abuse were identified and analyzed by race.

RESULTS

Between 2010-2014 and 2016-2017, 798,353 patients were included in NTDB. Suspected child abuse victims (SCA) accounted for 7903 (1%) patients. Of these, 51% were White, 33% Black, 1% Asian, 0.3% Native Hawaiian/Other Pacific Islander, 2% American Indian, and 12% other race. Black patients were disproportionately overrepresented, composing 12% of the US population, but 33% of SCA patients (p < 0.001). Although White SCA patients were more severely injured (ISS 16-24: 20% vs 16%, p < 0.01) and had higher in-hospital mortality (9% vs. 6%, p = 0.01), Black SCA patients were hospitalized longer (7.2 ± 31.4 vs. 6.2 ± 9.9 days, p < 0.01) despite controlling for ISS (1-15: 4. 5.7 ± 35.7 vs. 4.2 ± 6.2 days, p < 0.01). In multivariate regression, Black children continued to have longer lengths of stay despite controlling for ISS and insurance type.

CONCLUSIONS

Utilizing a nationally representative dataset, Black children were disproportionately identified as potential victims of abuse. They were also subjected to longer hospitalizations, despite milder injuries. Further studies are needed to better understand the etiology of the observed trends and whether they reflect potential underlying unconscious or conscious biases of mandated reporters.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

III.

Child abuse and neglect in Brussels during the COVID-19-lockdown

BACKGROUND

It is likely that the circumstances during the COVID-19-lockdown in Belgium increased the incidence and prevalence of child abuse and neglect (CAN) due to exacerbated risk factors and new COVID-19-related stressors. However, traditional reporters had less contact with children which could lead to undetected cases of CAN.

OBJECTIVE

Gain insight into the number and profile of CAN reports filed to the Brussels Confidential Center of Child Abuse and Neglect (CCCAN) during the COVID-19-lockdown.

PARTICIPANTS AND SETTING

A dataset comprising 536 CAN reports from periods before (N = 442) and during the lockdown (N = 94).

METHODS

Characteristics about the report, reporter, victim and his/her family, perpetrator(s) and the trajectory with the CCCAN were registered. The number and characteristics of reports during the lockdown were compared to those of reports before the lockdown.

RESULTS

The number of advisory questions (p = .506, d = .377) and allegations (p = .095, d = 1.206) remained unchanged. During the lockdown, the risk assessment of advisory questions was higher (p = .011, d = .280), they evolved more into social exigency investigations (p < .001, φ = .246) and were referred more often to judicial authorities (p = .010, φ = .163). Allegations were filed more often by the helpline, police and judicial authorities (p < .001, φ = .590) during the lockdown and involved more Dutch-speaking (p = .016, φ = .166) victims.

CONCLUSIONS

The number of CAN reports remained the same during the lockdown but their profile changed.

Characterizing physical trauma in children and youth with special health care needs

BACKGROUND

Children and youth with special health care needs (CYSHCN) have or are at an increased risk for a chronic condition necessitating medical and related services beyond what children usually require. While evidence suggests that CYSHCN are at an increased risk of injury, little is known about this population within the trauma system. This study describes CYSHCN within the pediatric trauma system and examines patterns of injury risk (i.e., intent, place of injury, trauma type, and mechanism of injury) based on special health care need (SHCN) status.

METHODS

For this cross-sectional study, we used data from the 2018 National Trauma Data Bank to identify pediatric encounters (1-18 years, N = 115,578) and compare demographics (sex, race/ethnicity, insurance status, and age) by CYSHCN status using χ 2 and t tests. Children and youth with special health care needs encounters were compared with non-SHCN encounters using multinomial logistic regression models, controlling for demographics.

RESULTS

Overall, 16.7% pediatric encounters reported an SHCN. Children and youth with special health care needs encounters are older, and a higher proportion is publicly insured than non-SHCN encounters ( p < 0.001). Furthermore, CYSHCN encounters have a higher risk of assault (relative risk, 1.331) and self-inflicted (relative risk, 4.208) injuries relative to unintentional injury ( p < 0.001), as well as a higher relative risk of traumatic injury occurring in a private residence ( p < 0.01) than other locations such as school (relative risk, 0.894). Younger CYSHCN encounters have a higher risk of assault relative to unintentional injury when compared with non-SHCN encounters ( p < 0.01). Pediatric trauma encounters reporting mental health and alcohol/substance use disorder SHCN have a higher probability of self-inflicted and assault injuries than non-SHCN encounters ( p < 0.001).

CONCLUSIONS

These findings suggest that CYSHCN have different traumatic injury patterns than their non-SHCN peers, particularly in terms of intentional and private residence injury, and deserve a special focus for traumatic injury prevention.

LEVEL OF EVIDENCE

Prognostic/epidemiologic, level III.

National burden of pediatric abusive injuries: patterns vary by age

PURPOSE

Child abuse is often unrecognized by healthcare practitioners. This study sought to characterize pediatric abuse injury patterns and associated mortality rates in a nationwide cohort.

METHODS

The Kids' Inpatient Database (1997-2012) was queried for patients < 18 years old with a diagnosis of child abuse (utilizing ICD-9 codes for abusive head trauma [AHT], neglect, physical, emotional, sexual, and other abuse). Demographic factors, mortality, and injury patterns were compared with demographic factors using standard statistical tests.

RESULTS

 > 39,000 children were hospitalized for abuse from 1997 to 2012. The majority were Caucasian (36%), male (51%) and < 4 years old (70%). Most sustained physical abuse (53%), followed by AHT (14%), sexual (9%) and emotional abuse (2%). Multiple injuries were sustained by 44% of patients. Mortality was 4% (n = 1476). Burns (2%) and intrathoracic (2%) injuries had the highest mortality compared to other injuries (21% and 19%, respectively; both P < 0.001). Emotional abuse (5%) and neglect (1%) were highest in those ≥ 13 years old (both P  = 0.001).

CONCLUSION

Physical injuries are less common in adolescents (13-18 years) hospitalized for abuse. However, they are more likely to report emotional abuse and neglect, which has not been compared in previous studies. Intrathoracic injuries and AHT are associated with significant mortality.

Comparing fatal child abuse involving biological and surrogate parents

BACKGROUND

Nearly half of pediatric homicides younger than 5 years are attributable to child abuse. Parents are most commonly the perpetrators, but less is known about incidents involving biological versus surrogate parents. We sought to evaluate the characteristics of fatal child abuse involving biological and surrogate parents using the Georgia National Violent Death Reporting System, which we believe may differ in demographics and incident characteristics.

METHODS

This database was used to examine all homicides of children younger than 18 years from 2011 to 2017. Demographics and incident characteristics were analyzed using the existing National Violent Death Reporting System variables and incident narratives. Nonparametric and χ2 tests were used to compare fatal child abuse incidents involving biological and surrogate parents (e.g., adoptive, foster, step-parents, intimate partners of biological parent).

RESULTS

There were 452 pediatric homicides and 219 cases of fatal child abuse. Of all cases of fatal child abuse, 60% involved biological and 29% involved surrogate parents. Compared with children killed by biological parents, children killed by surrogate parents were older (4 vs. 3 years), more often male (71% vs. 51%), more likely to survive the initial injury and present to the emergency department before death (96% vs. 69%), and less likely to have a medical comorbidity (2% vs. 11%; all p < 0.05). Surrogate parents were more likely to be male (90% vs. 48%) and use a firearm (20% vs. 13%) to inflict the injury, both p < 0.05. The race/ethnicity of the child was not associated with the parent's relationship.

CONCLUSION

Child abuse accounts for half of all pediatric homicides. Parents are the most common perpetrators of fatal child abuse, but surrogate parent perpetrators are almost exclusively male and more likely to use firearms. Most children have a history of abuse, leaving an opportunity to intervene on potentially preventable deaths if abuse is identified in a timely fashion.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic, Level III.

Differential Diagnosis between Child Abuse and Infantile Cortical Hyperostosis: A Case Report and Literature Review

Child abuse is a major public health problem that can lead to critical consequences for the child and family. However, early identification of abuse may be difficult. An 8-month-old boy presented with extensive periosteal reaction in both upper and lower long bones. There was no specific history of injury. Caffey disease was initially considered as the diagnosis because the patient displayed fever and hyperostosis of multiple bones with elevated erythrocyte sedimentation rates and C-reactive protein and alkaline phosphatase levels. However, we suspected child abuse based on the clinical and radiological features. We eventually found out that the child had been injured through child abuse and were able to treat him. We report this case because child abuse cases may be confused with Caffey disease. This case report can, therefore, help distinguish between Caffey disease and child abuse.

Can we increase detection? A nationwide analysis of age-related fractures in child abuse

PURPOSE

The purpose of this study was to stratify fractures associated with child abuse in relation to the child's age.

METHODS

The Kids' Inpatient Database (1997-2012) was queried for all patients (<18 years old) with a diagnosis of fracture and child abuse. The primary outcome was age-related determinants of fracture distribution. Chi-squared analysis was used for statistical analysis where appropriate, with significance set at p < 0.05.

RESULTS

More than 39,000 children were admitted for child abuse, and 26% sustained fractures. Most were infants (median age 0 year [IQR 0-1]). 28% sustained multiple fractures, and 27% had skull fractures. By age, infants had the highest rate of multiple fractures (33% vs 16% 1-4 years), and the highest rate of closed skull fractures (33% vs 21% ages 1-4), while adolescents had more facial fractures (43% vs 11% ages 9-12), all p < 0.001. Multiple rib fractures were more commonly seen in infants (28% vs 8% ages 1-4), while children 5-8 years had the highest rates of clavicular fractures (7% vs 3% in infants), all p < 0.001.

CONCLUSION

Age-related fracture patterns exist and may be due to changing mechanism of abuse as a child grows. These age-related fracture patterns can help aid in healthcare detection of child abuse in hopes to thwart further abuse.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

Level III.

Child Abuse in Times of Crises: Lessons Learned

The COVID-19 pandemic has created conditions which heighten risk for child abuse. As key players in times of crisis, pediatric emergency medicine providers must be equipped with the tools to recognize, respond to, and mitigate risk of child abuse. An exploration of the scientific literature, stakeholder organization reports and lay press was undertaken to understand the impact of large-scale U.S. crises, including infectious disease, financial downturn, natural disaster, and violence, on child abuse risk and inform prevention strategies. Review of the literature suggests a relationship between crises and child abuse risk, though gaps in the research remain. We outline the role of pediatric emergency medicine providers in partnering with communities in organizing and advocating for systems that better protect children and strengthen families.

Identifying Abuse and Neglect in Hospitalized Children With Burn Injuries

BACKGROUND

The purpose of this study was to identify the pattern of injuries that relates to abuse and neglect in children with burn injuries.

METHODS

The Nationwide Readmissions Database for 2010-2014 was queried for all patients aged less than 18 y admitted with burn injuries. The primary outcome was child maltreatment identified at the index admission. The secondary outcome was readmission for maltreatment. A subgroup analysis was performed on patients without a diagnosis of maltreatment during the index admission. Multivariable logistic regression was performed for each outcome.

RESULTS

There were 57,939 admissions identified and 1960 (3.4%) involved maltreatment at the index admission. Maltreatment was associated with total body surface area burned >20% (odds ratio (OR) 2.79, P < 0.001) and burn of the lower limbs (OR 1.37, P < 0.001). Readmission for maltreatment was found in 120 (0.2%), and the strongest risk factor was maltreatment identified at the index admission (OR 5.11, P < 0.001). After excluding the patients with maltreatment identified at the index admission, 96 (0.17%) children were found to have a readmission for maltreatment that may have been present on the index admission and subsequently missed. The strongest risk factor was burn of the eye or ocular adnexa (OR 3.79, P = 0.001).

CONCLUSIONS

This study demonstrates that a portion of admissions for burn injuries in children could involve maltreatment that was undiagnosed. Identifying these at-risk individuals is critical to prevention efforts.