Screening injured children for physical abuse or neglect in emergency departments: a systematic review

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.

A validated Screening instrument for Child Abuse and Neglect (SCAN) at the emergency department

The objective of this study is to develop and validate a screening instrument for the recognition of child maltreatment in the emergency department (ED). Existing data on screening questions and outcomes (diagnosis of child maltreatment) from three large observational screening studies at eight different EDs in the Netherlands were harmonized. A multivariate logistic regression was performed to develop the Screening instrument for Child Abuse and Neglect (SCAN). The SCAN was validated by performing a cross-validation and calculating the discriminative ability. A total of 24,963 patients were included. Out of the potential screening questions the following questions were included in the final instrument: is the injury compatible with the history, and does it correspond to the child's developmental level? (aOR 10.40, 95% CI 5.69-19.02), was there an unnecessary delay in seeking medical help? (aOR 3.45, 95% CI 1.73-6.88) and is the behaviour/interaction of the child and parents (carers) appropriate? (aOR 14.67, 95% CI 7.93-27.13). The SCAN had a pooled AUC of 0.75 (95% CI 0.63-0.87) in the cross-validation. The question "Are there other signals that make you doubt the safety of the child and/or family?" (available in only one of the original datasets, OR 182.9; 95% CI 102.3-327.4) was by consensus added to the final SCAN.

CONCLUSION

This validated and brief Screening instrument for Child Abuse and Neglect (SCAN) is designed to improve early recognition of child maltreatment in the ED. A positive screening result of the SCAN warrants a thorough work-up for child maltreatment, including a top-toe examination, if necessary additional diagnostics and adequate safety measures.

WHAT IS KNOWN

• Screening instruments increase the detection of possible cases of child maltreatment in the emergency department and support health care professionals to identify these cases. • The application of different screening instruments led to the need for one brief validated instrument.

WHAT IS NEW

• This study presents a validated and brief Screening instrument for Child Abuse and Neglect (SCAN), consisting of four questions. • The SCAN supports professionals in detecting signals of child maltreatment, and a positive screening result should lead to a thorough work-up, including a top-toe examination, complete history, additional diagnostic tests and consultation of a child abuse expert.

BMI moderates the association between adverse childhood experiences and COPD

OBJECTIVES

Cigarette smoking and obesity are leading risk factors for chronic obstructive pulmonary disease (COPD). Although studies have established an association between adverse childhood experiences (ACEs) and COPD, few studies have examined whether this association is moderated by cigarette smoking or body mass index (BMI). This cross-sectional study examined the association between ACEs and COPD, and whether cigarette smoking or BMI moderates this association.

METHODS

Data for this study came from the 2019 Behavioral Risk Factor Surveillance System survey. An analytic sample of 75,700 adults aged 18-79 years (50.7% female) were analyzed using binary logistic regression. The outcome variable investigated was self-reported physician-diagnosed COPD, and the main explanatory variable was ACEs.

RESULTS

Of the 75,700 respondents examined, 8.1% had COPD. About one in three (33.6%) respondents had no ACEs, 23.1% had one ACE, and about one in five (20.2%) had four or more ACEs. In the multivariable binary logistic regression, we found that the association between ACEs and COPD differs by BMI status. Controlling for the effects of other factors, the association between ACEs and COPD is strongest for respondents who are obese (AOR = 1.41, 95% CI = 1.04-1.91).

CONCLUSIONS

The findings of this study demonstrate that ACEs are associated with COPD later in adulthood, and BMI moderated this association. The findings of this study add to the number of studies demonstrating the adverse impact of ACEs on chronic health outcomes among adults.

How often do nurses suspect violence and domestic violence in local emergency medical communication centre? A cross-sectional study

OBJECTIVE

To assess the extent of violence that is revealed by screening at first contact with a local out-of-hours emergency medical communication centre (LEMC; Norwegian 'Legevaktsentral').

DESIGN

Cross-sectional study.

SETTING

Arendal LEMC, covering 10 municipalities in south-eastern Norway. All contacting patients (telephone or personal attendance) were asked by nurse whether the encounter was related to violence.

SUBJECTS

All first patient encounters at Arendal LEMC.

MAIN OUTCOME MEASURES

Number and proportion of cases where the nurses suspected violence, both domestic violence and other violence. Incidence rate of violence, age and gender distribution of patients, time of day and reason for encounter.

RESULTS

Violence was suspected in 336 of 103,467 first patient encounters (0.3%), of which 132 (0.1%) was domestic violence. Patients were female in 50.6% of all violence cases, and in 79% of domestic violence cases. Incidence rates were 137 per 100,000 person-years for all violence, and 53 for domestic violence.

CONCLUSIONS

This study indicates violence may be revealed in three of 1000 first encounters to an LEMC when nurses screen systematically for domestic or other violence.Key points    Violence as underlying reason for encounter with primary care emergency health services is probably often not discovered by health personnel.   • We examined how often nurses reveal violence upon first contact when systematically asking all patients.  • Violence was suspected in 0.3% of cases, and domestic violence in 0.1%.  • Among patients with disclosed domestic violence, 79% were female.

Caregiver Reports of Infant Distress and Injury in Abused Infants

OBJECTIVES

To determine whether in infants evaluated for physical abuse, medical encounters for infant distress are correlated with physical abuse or a history of sentinel injuries.

STUDY DESIGN

This retrospective, case-control analysis of infants aged <12 months evaluated for physical abuse identified demographic characteristics, prior injuries, and medical encounters for infant distress. Variables were compared between abused infants and nonabused infants with and without sentinel injuries. A nonparametric recursive classification tree analysis assessed interactions between variables.

RESULTS

Infant distress was associated with abuse (67.9% vs 44.7%; P = .008; OR, 2.6; 95% CI, 1.3-5.2). Infants with sentinel injuries had higher rates of infant distress (74.1% vs 42.4%; P ≤ .001) and crying (81.5% vs 62.7%; P = .012). Previous falls (32.6% vs 18.1%; P = .03) and nonsentinel injuries (18.2% vs 5.4%; P = .002) also were associated with abuse, although sentinel injuries were the most important predictor of abuse, followed by infant distress.

CONCLUSIONS

Infants with medical encounters for distress and injury may be at higher risk for abuse and may benefit from intensive educational and support services for their caregivers. Additional research evaluating the most effective interventions for caregivers of fussy infants is needed.

Early recognition of child abuse through screening indicators at the emergency department: experience of a tertiary urban pediatric hospital

Background

Emergency Departments play a pivotal role in detecting cases of child abuse. Despite the efforts made in the past decades on the need for a screening method for the early detection of abuse victims, a unique instrument shared by the international scientific community has not been made. These instruments should be able to help recognizing whether it is necessary to further investigate the child’s condition. The aim of the study is to illustrate the screening indicators in use since 2010 in the Emergency Department of the Bambino Gesù Children’s Hospital to early recognise the victims of abuse and the modifying process of the screening tool undertaken over the years.

Methods

We retrospectively analyzed the process that led to the editing of the indicators of child abuse in use nowadays at the Bambino Gesù Children's Hospital. We codified three clinical pathways to apply in case of suspected abuse. Furthermore, we investigated the medical records of screening-positive accesses in the Paediatric Emergency Department of the Bambino Gesù Children's Hospital from January 2008 to October 2020.

Results

An estimation of positive screening, regarding the type of abuse suspected, and the number of accessed in ED was made, resulting in a cohort of 956 patients. In 2010 we created a list of 14 items grouped in three clusters: anamnestic declarations or incongruences, carelessness/neglect and evident lesions at physical examination. Positivity to one of the items allows the actuation of the investigating protocol named as clinical pathway.In 2013, after three years of experience, the criteria were edited to increase specificity. The application of screening led to a median number of 82 suspected cases/year from 2013 to 2020.

Conclusion

A screening tool is essential and productive for the early recognition of victims of abuse. An in-deep analysis of suspected cases through a standardized method, such as the clinical pathway, allowed reaching the diagnosis in a more accurate and precise manner.

Do Victims of Abusive Head Trauma Visit Emergency Departments More Often Than Children Hospitalized for Fever? A Case-Control Study

OBJECTIVE

During the first years of life, infant crying is a common trigger of abusive head trauma (AHT). Emergency department (ED) use by AHT victims before visits for child abuse symptoms is not well known, particularly for infant crying. Furthermore, diagnosis could be missed. In the same period, fever is a common reason for hospitalization unconnected with AHT. The main goal of our study was to compare the ED use by AHT victims before visits for child abuse symptoms and by children of the same age hospitalized for fever.

METHODS

We conducted a retrospective case-control study from 2011 to June 2018 in a French hospital. We compared cases of AHT selected using the International Classification of Diseases and control subjects hospitalized in the general pediatric unit for fever without immunodeficiency matched in age. Univariate and multivariate analyses were performed.

RESULTS

Among the 75 victims of AHT, 5 had at least 1 previous ED visit not linked with abuse. None had visited for infant crying. Among the control subjects, 34 had at least 1 previous ED visit, including 6 for infant crying. Among the 57 dyads of controls and cases living in the hospital's area, the controls had significantly more previous ED visits than the cases (P < 0.001). There were more male infants among the cases (72% vs. 55%, P = 0.033).

CONCLUSIONS

Our study suggests that AHT victims had no more ED visits before visits for child abuse symptoms, particularly not for infant crying.

Recognition of child maltreatment in emergency departments in Europe: Should we do better?

OBJECTIVES

To evaluate the different policies to recognize child maltreatment in emergency departments (EDs) in Europe in order to define areas of improvement.

METHODS

A survey was conducted on the recognition of child maltreatment in EDs in European countries with a focus on screening methods, parental risk factors, training and hospital policies. The survey was distributed through different key members from the EUSEM, REPEM and the EuSEN. A summary score based on the NICE guideline (4 questions on child characteristics, 4 questions on parental characteristics and 5 questions on hospital policy) was calculated.

RESULTS

We analysed 185 completed surveys, representing 148 hospitals from 29 European countries. Of the respondents, 28.6% used a screening tool, and 31.8% had guidelines on parental risk factors. A total of 42.2% did not follow training based on child characteristics, and 57.6% did not follow training on parental characteristics. A total of 71.9% indicated that there was a need for training. 50.8% of the respondents reported a standardized policy for the detection of child maltreatment. Translating the survey results to NICE summary scores of the EDs in Europe, we found that 25.6% (34/133) met most, 22.6% (30/133) met some and 51.9% (69/133) met few of the NICE guideline recommendations. More specifically, with respect to hospital policies, 33.8% (45/133) met most, 15.0% (20/133) met some and 51.1% (68/133) met few of the NICE guideline recommendations.

CONCLUSION

There is high variability regarding policies for child maltreatment detection and only a quarter of the EDs met most of the NICE guideline recommendations for child maltreatment. There is a need for the use of screening tools, training of ED staff and implementation of local hospital policies.

Medical Visits From Birth to 6 Months Predict Child Maltreatment Diagnoses Up to Age 5

Electronic health record data for pediatric members of Kaiser Permanente Southern California were used to identify key variables (ie, the number of emergency department visits and the number of providers) available in early infancy (0-6 months) placing children at higher risk of a maltreatment diagnosis in the first 5 years of life. The analytic sample included 96 462 children age 0 to 5 years born from January 1, 2009, to June 30, 2018. Poisson regression showed that children with ≥2 emergency department visits from birth to 6 months were at twice the risk of a maltreatment diagnosis before age 2 and 5 years compared with those children with no emergency department visits. Children with more continuity of primary care providers (0-5 providers) in the first 6 months of life were at lower risk of a maltreatment diagnosis at 2 years and 5 years than those children who saw multiple providers (6+). Information about medical utilization in early infancy may help physicians and other medical providers identify children at higher risk of maltreatment and prevent future incidents.

Child maltreatment by non-accidental burns: interest of an algorithm of detection based on hospital discharge database

OBJECTIVES

To build a detection algorithm of non-accidental pediatric burns (NAB) using hospital resumes from the French Hospital Discharge Database (HDD) and to describe cases with no judicial or administrative report.

MATERIALS AND METHODS

Children aged 0-16 years old hospitalized at the University Hospital of Tours from 2012 to 2017 with a coded burn were included. "Probable" or "possible" HDD cases of NAB were defined based on the International Classification of Diseases 10th version codes during the inclusion stay or the previous year. A chart review was performed on all the HDD cases and HDD non cases matched on sex and age with a 1:2 ratio. Performance parameters were estimated for three clinical definitions of child maltreatment: excluding neglect, including neglect in a restrictive definition, and in a broad definition. For clinical cases, report to the judicial or administrative authorities was searched.

RESULTS

Among the 253 included children, 83 "probable" cases and 153 non-cases were analyzed. Sensitivity varied from 48 (_95%CI [36-60], excluding neglect) to 90% [55-100] and specificity from 70 [63;77] to 68% [61;74]. The proportion of clinical cases with no report without justification varied from 0 (excluding neglect) to > 85% (with the broadest definition); all corresponded to possible isolated neglect.

CONCLUSION

The performances of the algorithm varied tremendously according to the clinical definition of child maltreatment. Neglect is obviously complex and tough to clinically detect. Training for healthcare professionals and qualitative studies on obstacles to report should be added to this work.

Perception of Physical Child Abuse Among Parents and Professionals in a French Emergency Department

France has not prohibited all forms of corporal punishment, and the point at which an act is regarded as physical abuse is not clearly determined. The aim of our study was to compare perception of a caregiver's violent behavior toward his child by professionals and parents in an emergency department and determine characteristics associated with that perception. A cross-sectional study was conducted from November 2013 to October 2014 in the emergency department of the pediatric university hospital in Bordeaux, France. An anonymous self-administered questionnaire, including vignettes describing hypothetical situations of violent interaction between a parent and child, and items related to sociodemographic and family characteristics, was administered to professionals and parents. Vignettes included varying child's age and behavior, frequency of caregiver's behavior, hitting with/without an object, and targeted child's body part. Violent behavior was restricted to hitting for reasons of feasibility. Respondents were asked to rate the acceptability of situations on a 100-mm visual analog scale. Analyses were multivariate mixed Poisson regressions. A total of 1,001 participants assessed the vignettes. Participants were predominantly females (64%), married or living with a partner (87%), with a median age of 34 years. Professionals assessed vignettes as acceptable significantly more than parents (mean rating 2.8 times higher; p < .001). For both professionals and parents, all vignette characteristics were significantly associated with acceptability. Parents who had a child below 1 year old, those who had visited an emergency department many times in the past year, and those who had fewer children were less tolerant. Such findings indicate the need for additional research to better appreciate consequences and severity of violent behavior toward children, and the need to educate parents and professionals.

Sentinel surveillance of child maltreatment cases presenting to Canadian emergency departments

Background

The Canadian Hospitals Injury Reporting Prevention Program (CHIRPP) is a sentinel surveillance program that collects and analyzes data on injuries and poisonings of people presenting to emergency departments (EDs) at 11 pediatric and eight general hospitals (currently) across Canada. To date, CHIRPP is an understudied source of child maltreatment (CM) surveillance data. This study: (1) describes CM cases identified in the CHIRPP database between1997/98 to 2010/11; (2) assesses the level of CM case capture over the 14-year period and; (3) uses content analysis to identify additional information captured in text fields.

Methods

We reviewed cases of children under 16 whose injuries were reported as resulting from CM from 1997/98 to 2010/11. A time trend analysis of cases to assess capture was conducted and content analysis was applied to develop a codebook to assess information from text fields in CHIRPP. The frequency of types of CM and other variables identified from text fields were calculated. Finally, the frequency of types of CM were presented by age and gender.

Results

A total of 2200 CM cases were identified. There was a significant decrease in the capture of CM cases between 1999 and 2005. Physical abuse was the most prevalent type (57%), followed by sexual assault (31%), unspecified maltreatment (7%), injury as the result of exposure to family violence (3%) and neglect (2%). Text fields provided additional information including perpetrator characteristics, the use of drugs and/or alcohol during the injury event, information regarding the involvement of non-health care professionals, whether maltreatment occurred during a visitation period with a parent and, whether the child was removed from their home.

Conclusions

The findings from this initial study indicate that CHIRPP could be a complimentary source of CM data. As an injury surveillance system, physical abuse and sexual assault were better captured than other types of CM. Text field data provided unique information on a number of additional details surrounding the injury event, including risk factors.

Previous Emergency Medical Services Use by Victims of Child Homicide

INTRODUCTION

The medical diagnoses and frequency of emergency department visits made by children who are later given a diagnosis of maltreatment do not differ much from those of nonabused children. However, the type of medical complaints and frequency of emergency medical services (EMS) use by child homicide victims before their death are not known. We compared EMS use between child homicide victims and children who died from natural causes before their death.

METHODS

This was a retrospective case-control study of children 0 to 5 years old who died in Houston, Texas, from 2005 to 2010. Cases were child homicide victims. Controls were children who died from natural causes. We reviewed death data and EMS and child protective services (CPS) encounter information before the victim's death. The association between death type (natural vs homicide) and EMS use was assessed using Poisson regression with EMS count adjusted for exposure time.

RESULTS

There were 89 child homicides and 183 natural deaths. Age at death was significantly higher for homicides than natural deaths (1.1 vs 0.2 y, P < 0.001). Homicide victims used EMS services (39% vs 14%, P < 0.001) and had previous CPS investigations (55% vs 7%, P < 0.001) significantly more often than children who died from natural causes. Poisson regression, after adjustment for age, revealed that the homicide group had more EMS calls than the natural death group (β = 0.55; 95% confidence interval, 0.04-1.07; P = 0.03). However, the EMS use frequency and working assessments were not helpful in identifying maltreatment victims.

CONCLUSIONS

Child homicide victims use EMS more often and have a higher number of CPS investigations before their death than children who die from natural causes. However, the frequency and nature of EMS medical complaints are not helpful in identifying maltreatment.

Screening for child abuse using a checklist and physical examinations in the emergency department led to the detection of more cases

AIM

We studied the accuracy of a screening checklist (SPUTOVAMO), complete physical examination (top-to-toe inspection, TTI) and their combination in detecting child abuse in the emergency department (ED).

METHODS

Consecutive patients admitted to the ED of the Academic Medical Center in Amsterdam between January 2011 and 1 July 2013 were included. An Expert Panel assigned a consensus diagnosis to positive cases. For all other and missed cases, the Child Abuse Counselling and Reporting Centre diagnosis was used.

RESULTS

We included 17 229 admissions of 12 198 patients. In 46%, SPUTOVAMO was performed, in 33% TTI; 421 children (4.3%) tested positive on either or both, with 68 positive consensus diagnoses. In eight children not reported to the Expert Panel, the Child Abuse Counselling and Reporting Center diagnosis was positive. Ten of 3519 (0.3%) children testing negative on both were child abuse cases; 0.88% of the study group had a final child abuse diagnosis. The estimated PPV was 0.46 for SPUTOVAMO, 0.44 for TTI and 0.43 for the combination.

CONCLUSION

Combining screening tests significantly increased the number of test positives and led to more child abuse cases detected. Combined screening for child abuse in all children less than 18 years old presenting to an ED is recommended.

Development of screening tool for child abuse in the korean emergency department: Using modified Delphi study

Mandatory reporting rate of suspected child abuse by health care provider is relatively low in South Korea. The purpose of the study was to develop a screening tool for child abuse and evaluate the feasibility of using this screening tool in emergency department (ED) of South Korea. Injured children younger than 14 years old in the ED were enrolled as subjects to use this screening tool. Candidate items for screening tool were decided after reviewing relevant previous studies by researchers. Using the modified Delphi method, it was judged that the consensus for items of screening tool was achieved in 2 rounds, and the final item of the screening tool was decided through the discussion in the final round. The registry including the developed screening tool was applied to 6 EDs over 10 weeks. Variables of the registry were retrospectively analyzed. A child abuse screening tool called Finding Instrument for Non-accidental Deeds (FIND) was developed. It included 8 questions. One item (suspected signs in physical examination) had 100% agreement; 3 items (inconsistency with development, inconsistent history by caregivers, and incompatible injury mechanism) had 86.7% agreement; and 4 items (delayed visit, inappropriate relationship, poor hygiene, and head or long bone injury in young infants) had 80% agreement. During the period of registry enrollment, the rate of screening with FIND was 72.9% (n = 2815). 36 (1.3%) cases had 1 or more "positive" responses among 8 items. Two (0.07%) cases were reported to the Child Protection Agency. An ED based screening tool for child abuse consisting of 8 questions for injured children younger than 14 years old was developed. The use of screening tools in Korean ED is expected to increase the reporting rate of child abuse. However, further study is necessary to investigate the accuracy of this screening tool using a national child abuse registry.

Implementation of routine electronic health record-based child abuse screening in General Emergency Departments

BACKGROUND

Routine child abuse screening is an approach to early identification of abuse. Previous studies evaluated paper-based screens; the widespread use of electronic health records suggests that screening is more likely to succeed if integrated into the electronic record.

OBJECTIVE

To implement an electronic health record-based child abuse screen in a diverse hospital system and to evaluate the screening rate, rate of positive screens, and number of reports to Child Protective Services and assess whether hospital and patient characteristics are associated with these rates.

PARTICIPANTS AND SETTING

Children <13 years of age evaluated at one of 13 Emergency Departments within University of Pittsburgh Medical Center Health System.

METHODS

A previously validated child abuse screen was slightly modified and integrated into Cerner. Multivariable logistic regression models were used to estimate the odds of the outcomes of interest, controlling for key covariates.

RESULTS

Of 17,163 eligible children: 68% received the screen of which 1.9% were positive. The rate of reports to Child Protective Services was higher among children who were screened (p < 0.0001). Younger children were more likely to be screened, have a positive screen, and have a report filed. There was no difference in the odds of being screened according to hospital teaching status, size or urban vs rural location.

CONCLUSIONS

A child abuse screening tool can be integrated into the electronic health record in a large health-care network. The increased number of reports among children who were screened suggests that screening facilitates detection of suspected maltreatment.

Risk of rehospitalisation and death for vulnerable New Zealand children

OBJECTIVES

There is considerable need to improve the effectiveness of healthcare to reduce morbidity and mortality. Child hospitalisations are influenced by determinants of health, including the home environment. Our aims were: (1) To investigate whether children hospitalised with potentially avoidable conditions thought to be associated with the home have an increased risk of rehospitalisation and death, (2) To investigate whether children hospitalised with particular subgroups of potentially avoidable conditions have an increased risk of rehospitalisation and death, (3) To assess the usefulness of these subgroups for identifying at-risk children.

DESIGN

We used four existing groups of potentially avoidable conditions developed based on expert opinion: 1. the potentially avoidable hospitalisations (PAH) group, associated with social/environmental conditions, 2. the potentially avoidable hospitalisations attributable (at least in part) to the home environment (PAHHE) group, 3. the crowding group, and 4. the Ministry of Health (MoH) group. We analysed national New Zealand hospital discharge data (2000-2014). Rehospitalisation and death were described using Kaplan-Meier curves. Group effectiveness for identifying at-risk children was assessed using Cox proportional hazard models with children hospitalised for non-PAH conditions as comparison.

RESULTS

In total, 1425085 hospital admissions occurred, for 683115 unique children. Rehospitalisation was relatively common (71.0%). Death was rare (0.6%). All groups performed moderately well identifying at-risk children. Children with PAH have increased risk of rehospitalisation (adjusted HR (aHR):2.30-3.60) and death (aHR:3.07-10.44). PAH group had highest sensitivity (75.1%). The MoH group has the highest positive predictive value (rehospitalisation: 86.2%, death: 2.5%).

CONCLUSIONS

Children in the MoH group are very likely to benefit from housing interventions. Rehospitalisation and early mortality are useful assessment measures. Rehospitalisation exerts a considerable burden, and child deaths are catastrophic.

Screening Children for Abuse and Neglect: A Review of the Literature

Child abuse and neglect occur in epidemic numbers in the United States and around the world, resulting in major physical and mental health consequences for abused children in the present and future. A vast amount of information is available on the signs and symptoms and short- and long-term consequences of abuse. A limited number of instruments have been empirically developed to screen for child abuse, with most focused on physical abuse in the context of the emergency department, which have been found to be minimally effective and lacking rigor. This literature review focuses on physical, sexual, and psychological abuse and neglect, occurring in one or multiple forms (polyabuse). A systematic, in-depth analysis of the literature was conducted. This literature review provides information for identifying children who have been abused and neglected but exposes the need for a comprehensive screening instrument or protocol that will capture all forms of child abuse and neglect. Screening needs to be succinct, user-friendly, and amenable for use with children at every point of care in the healthcare system.

Paediatric femur fractures at the emergency department: accidental or not?

Only a small proportion of all paediatric fractures is caused by child abuse or neglect, especially in highly prevalent long bone fractures. It can be difficult to differentiate abusive fractures from non-abusive fractures. This article focuses on femoral fractures in young children. Based on three cases, this article presents a forensic evidence-based approach to differentiate between accidental and non-accidental causes of femoral fractures. We describe three cases of young children who were presented to the emergency department because of a suspected femur fracture. Although in all cases, the fracture had a similar location and appearance, the clinical history and developmental stage of the child led to three different conclusions. In the first two cases, an accidental mechanism was a plausible conclusion, although in the second case, neglect of parental supervision was the cause for concern. In the third case, a non-accidental injury was diagnosed and appropriate legal prosecution followed. Any doctor treating children should always be aware of the possibility of child abuse and neglect in children with injuries, especially in young and non-mobile children presenting with an unknown trauma mechanism. If a suspicion of child abuse or neglect arises, a thorough diagnostic work-up should be performed, including a full skeletal survey according to the guidelines of the Royal College of Radiologists and the Royal College of Paediatrics and Child Health. In order to make a good assessment, the radiologist reviewing the skeletal survey needs access to all relevant clinical and social information.

Parents' Opinion About a Routine Head-to-Toe Examination of Children as a Screening Instrument for Child Abuse and Neglect in Children Visiting the Emergency Department

INTRODUCTION

To improve detection of child abuse and neglect (CAN), many emergency departments use screening methods. Apart from diagnostic accuracy, possible harms of screening methods are important to consider, especially because most children are not abused and do not benefit from screening. We performed a systematic literature review to assess parents' opinions about CAN screening, in which we could only include 7 studies, all reporting that the large majority of participating parents favor screening. Recently, a complete physical examination (called "top-toe" inspection [TTI], a fully undressed inspection of the child) was implemented as a CAN screening method at the emergency department of a teaching hospital in The Netherlands. This study describes parents' opinions about the TTI.

METHODS

We used a questionnaire to assess parents' opinions about the TTI of their children when visiting the emergency department. During the study period, 1000 questionnaires were distributed by mail.

RESULTS

In total, 372 questionnaires were returned (37%). A TTI was performed for 194 children (52%). The overall attitude of parents whose children underwent a TTI was positive; 77.3% of the respondents found the TTI acceptable, and 1.5% (N = 3) found it unacceptable. Seventy percent of the respondents agreed with the theorem that all children who visit the emergency department should have a TTI performed, and 7.3% (N = 14) disagreed.

DISCUSSION

Contrary to what is commonly believed, both in our systematic literature review and in our questionnaire study, the majority of participating parents agree with screening for CAN in general and with the TTI specifically. Sharing the results of this study with ED personnel and policy makers could take away prejudices about perceived disagreement of parents, thereby improving implementation of and adherence to CAN screening.

Results of the implementation of a new screening protocol for child maltreatment at the Emergency Department of the Academic Medical Center in Amsterdam

OBJECTIVE

This study examines the results of the implementation of a new screening protocol for child maltreatment (CM) at the Emergency Department (ED) of the Academic Medical Center in Amsterdam, The Netherlands. This protocol consists of adding a so called 'top-toe' inspection (TTI), an inspection of the fully undressed child, to the screening checklist for child maltreatment, the SPUTOVAMO.

DESIGN

We collected data from all patients 0-18 years old directly after introduction (February 2010) and 9 months later. Outcome measures were: completion of the screening and reasons for non-adherence. Data were collected on age, gender, reason for visiting the ED (defined by International Classification of Disease, ICD), presence of a chronic illness, type of professional performing the TTI and admission during week or weekend days.

RESULTS

In February 560 and in November 529 paediatric patients were admitted. In February the complete screening protocol was performed in 42% of all children, in November in 17%. A correlation between completion of the SPUTOVAMO and having a TTI performed was found. Older age and presence of a chronic illness influenced the chance of having both SPUTOVAMO and TTI performed negatively. The completion rate of SPUTOVAMO was influenced by ICD code. Completion of TTI was influenced by type of investigator. The best performing professional was the ED physician followed by the paediatrician followed by the ED nurse. The reasons for not performing a TTI were not documented. Refusal of the TTI by a patient or parent was reported three times.

CONCLUSION

Implementation of this new screening protocol for CM was only mildly successful and declined in time. A negative correlation between older child age and having a chronic illness and completion of the screening was found. A practical recommendation resulting from this study could be that, if CM screening protocols prove to be effective in detecting CM, regular training sessions have to be held. Filling out the checklist is something that could be performed by ED nurses. Performing a TTI is perhaps easier for the ED physicians to make part of their daily routine.

Support and monitoring of families after child abuse detection based on parental characteristics at the Emergency Department

BACKGROUND

The 'Hague Protocol' enables professionals at the adult Emergency Department (ED) to detect child abuse based on three parental characteristics: (i) suicide attempt or self-harm, (ii) domestic violence or (iii) substance abuse, and to refer them to the Reporting Centre for Child Abuse and Neglect (RCCAN). This study investigates what had happened to the families three months after this referral.

METHOD

ED referrals based on parental characteristics (N = 100) in which child abuse was confirmed after investigation by the RCCAN were analysed. Information was collected regarding type of child abuse, reason for reporting, duration of problems prior to the ED referral, previous involvement of support services or other agencies, re-occurrence of the problems and outcome of the RCCAN monitoring according to professionals and the families.

RESULTS

Of the 100 referred cases, 68 families were already known to the RCCAN, the police or family support services, prior to the ED referral. Of the 99 cases where information was available, existing support was continued or intensified in 31, a Child Protection Services (CPS) report had to be made in 24, new support was organized for 27 cases and in 17 cases support was not necessary, because the domestic problems were already resolved. Even though the RCCAN is mandated to monitor all referred families after three months, 31 cases which were referred internally were not followed up.

CONCLUSION

Before referral by the ED two thirds of these families were already known to organizations. Monitoring may help provide a better, more sustained service and prevent and resolve domestic problems. A national database could help to link data and to streamline care for victims and families. We recommend a Randomized Controlled Trial to test the effectiveness of this Protocol in combination with the outcomes of the provided family support.

Improving practice in safeguarding at the interface between hospital services and children’s social care: a mixed-methods case study

Background

Hospital settings have an important impact on children harmed by parents and carers. Concern arises from the capacity of these settings to respond effectively to individual needs despite increased NHS policy awareness and actions on safeguarding. Patient safety initiatives have rarely modelled in detail the social and cultural dynamics of child health settings and children’s safeguarding. This study is focused on supporting and evaluating clinician-led service design in an acute trust. A suite of initiatives and artefacts has been designed, based on sociotechnical principles, on the premise that only a thorough understanding of human, social and organisational challenges will afford effective solutions.

Objectives

The study addresses the following primary question: ‘Can a safeguarding culture be designed within the hospital environment that will provide the conditions for the detection of children at risk of abuse and support protective actions before discharge, including collaboration with external agencies?’ Objectives include the development of a sociologically rich understanding of why diagnostic failures and communication breakdowns occur; the design of a suite of integrated interventions for promoting a positive safety culture, following a user-centred approach; and the evaluation of the effectiveness of this package, including its generalisability across sites.

Design

The study took place in two sites: the primary site where the initiatives were developed and a further site with the original intention of transferring developments. The investigation follows a broaddesign scienceapproach. The evaluation of a design intervention relies on a rigorous understanding of the realities of everyday practice, and the study thus draws on mixed methods to examine the impact of service redesign on cultures and practices.

Findings

The data suggest that safeguarding children can become mainstream patient safety business. Board support is vital. In our primary site, there has been a steady integration of learning from serious case reviews and other child protection-related processes with ‘patient safety’-related incidents, with growing recognition that similar systemic issues impact on both domains. Making use of a familiar vocabulary to redescribesafeguardingas asafetyissue, and thus as something fundamental to the functions of an acute hospital, has been part of the success. The data suggest that persistence, resilience and vigilance from the safeguarding leadership and executive teams are crucial. Current policy includes the development of the Child Protection Information Sharing project, which is intended to improve information flow between the NHS, particularly hospitals and children’s social care. The findings from this study suggest the importance of good design, piloting, incrementalism and a thorough empirical engagement with everyday practices during implementation of this and any future information systems based reform.

Conclusions

Safeguarding takes place in a complex system and even minor changes within any part of that system can impact on the rest in unpredictable ways. It is important that managers adopt a ‘design attitude’ and seek to mitigate unintended consequences through careful experimentation. The findings suggest the need for the design of systems to enhance communication and not simply to ‘share information’. Technological solutions impact on everyday decision-making and can have unintended consequences. Attention to forces of change and stasis in health settings, the factors affecting technology transfer and the impact of the configuration of local authority services are suggested as a key priorities for future research.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Evaluation of child maltreatment in the emergency department setting: an overview for behavioral health providers

Emergency providers are confronted with medical, social, and legal dilemmas with each case of possible child maltreatment. Keeping a high clinical suspicion is key to diagnosing latent abuse. Child abuse, especially sexual abuse, is best handled by a multidisciplinary team including emergency providers, nurses, social workers, and law enforcement trained in caring for victims and handling forensic evidence. The role of the emergency provider in such cases is to identify abuse, facilitate a thorough investigation, treat medical needs, protect the patient, provide an unbiased medical consultation to law enforcement, and provide an ethical testimony if called to court.

Detecting child abuse based on parental characteristics: does the Hague Protocol cause parents to avoid the emergency department?

OBJECTIVES

The Hague Protocol is used by professionals at the adult Emergency Departments (ED) in The Netherlands to detect child abuse based on three parental characteristics: (1) domestic violence, (2) substance abuse or (3) suicide attempt or self-harm. After detection, a referral is made to the Reporting Center for Child Abuse and Neglect (RCCAN). This study investigates whether implementing this Protocol will lead parents to avoid medical care.

METHOD

We compared the number of patients (for whom the Protocol applied) who attended the ED prior to implementation with those attending after implementation. We conducted telephone interviews (n = 14) with parents whose children were referred to the RCCAN to investigate their experience with the procedure.

RESULTS

We found no decline in the number of patients, included in the Protocol, visiting the ED during the 4 year implementation period (2008-2011). Most parents (n = 10 of the 14 interviewed) were positive and stated that they would, if necessary, re-attend the ED with the same complaints in the future.

CONCLUSION

ED nurses and doctors referring children based on parental characteristics do not have to fear losing these families as patients.

Insufficient evidence for the use of a physical examination to detect maltreatment in children without prior suspicion: a systematic review

BACKGROUND

Although it is often performed in clinical practice, the diagnostic value of a screening physical examination to detect maltreatment in children without prior suspicion has not been reviewed. This article aims to evaluate the diagnostic value of a complete physical examination as a screening instrument to detect maltreatment in children without prior suspicion.

METHODS

We systematically searched the databases of MEDLINE, EMBASE, PsychINFO, CINAHL, and ERIC, using a sensitive search strategy. Studies that i) presented medical findings of a complete physical examination for screening purposes in children 0-18 years, ii) specifically recorded the presence or absence of signs of child maltreatment, and iii) recorded child maltreatment confirmed by a reference standard, were included. Two reviewers independently performed study selection, data extraction, and quality appraisal using the QUADAS-2 tool.

RESULTS

The search yielded 4,499 titles, of which three studies met the eligibility criteria. The prevalence of confirmed signs of maltreatment during screening physical examination varied between 0.8% and 13.5%. The designs of the studies were inadequate to assess the diagnostic accuracy of a screening physical examination for child maltreatment.

CONCLUSIONS

Because of the lack of informative studies, we could not draw conclusions about the diagnostic value of a screening physical examination in children without prior suspicion of child maltreatment.

Is early detection of abused children possible?: a systematic review of the diagnostic accuracy of the identification of abused children

Background

Early detection of abused children could help decrease mortality and morbidity related to this major public health problem. Several authors have proposed tools to screen for child maltreatment. The aim of this systematic review was to examine the evidence on accuracy of tools proposed to identify abused children before their death and assess if any were adapted to screening.

Methods

We searched in PUBMED, PsycINFO, SCOPUS, FRANCIS and PASCAL for studies estimating diagnostic accuracy of tools identifying neglect, or physical, psychological or sexual abuse of children, published in English or French from 1961 to April 2012. We extracted selected information about study design, patient populations, assessment methods, and the accuracy parameters. Study quality was assessed using QUADAS criteria.

Results

A total of 2 280 articles were identified. Thirteen studies were selected, of which seven dealt with physical abuse, four with sexual abuse, one with emotional abuse, and one with any abuse and physical neglect. Study quality was low, even when not considering the lack of gold standard for detection of abused children. In 11 studies, instruments identified abused children only when they had clinical symptoms. Sensitivity of tests varied between 0.26 (95% confidence interval [0.17-0.36]) and 0.97 [0.84-1], and specificity between 0.51 [0.39-0.63] and 1 [0.95-1]. The sensitivity was greater than 90% only for three tests: the absence of scalp swelling to identify children victims of inflicted head injury; a decision tool to identify physically-abused children among those hospitalized in a Pediatric Intensive Care Unit; and a parental interview integrating twelve child symptoms to identify sexually-abused children. When the sensitivity was high, the specificity was always smaller than 90%.

Conclusions

In 2012, there is low-quality evidence on the accuracy of instruments for identifying abused children. Identified tools were not adapted to screening because of low sensitivity and late identification of abused children when they have already serious consequences of maltreatment. Development of valid screening instruments is a pre-requisite before considering screening programs.

A new protocol for screening adults presenting with their own medical problems at the Emergency Department to identify children at high risk for maltreatment

Identifying child abuse and neglect solely on the grounds of child characteristics leaves many children undetected. We developed a new approach (Hague protocol) based on characteristics of parents who attend the Emergency Department (ED) because they have the following problems: (1) intimate partner violence, (2) substance abuse, or (3) suicide attempt or other serious psychiatric problems. The goal of this protocol is to enable the Reporting Center for Child Abuse and Neglect (RCCAN) to rapidly assess family problems and offer voluntary community based support to these parents. The aim of this study is to assess whether this protocol for screening adults presenting for care in the Emergency Department can identify children at high risk for maltreatment. A before and after study was conducted at 9 EDs in 3 regions in the Netherlands (one intervention region and 2 control regions). During the period January 2006 to November 2007, prior to the introduction of the Hague protocol, from a total of 385,626 patients attending the ED in the intervention region 4 parents (1 per 100,000) were referred to the RCCAN. In the period after introduction of the protocol (December 2007 to December 2011), the number rose to 565 parents from a total of 885,301 patients attending the ED (64 per 100,000). In the control region, where the protocol was not implemented, these figures were 2 per 163,628 (1 per 100,000) and 10 per 371,616 (3 per 100,000) respectively (OR=28.0 (95 CI 4.6-170.7)). At assessment, child abuse was confirmed in 91% of referred cases. The protocol has a high positive predictive value of 91% and can substantially increase the detection rate of child abuse in an ED setting. Parental characteristics are strong predictors of child abuse. Implementing guidelines to detect child abuse based on parental characteristics of parents attending the adult section of the ED can increase the detection rate of child abuse and neglect allowing appropriate aid to be initiated for these families.

Educational paper: Detection of child abuse and neglect at the emergency room

The emergency room (ER) represents the main system entry for crises-based health care visits. It is estimated that 2% to 10% of children visiting the ER are victims of child abuse and neglect (CAN). Therefore, ER personnel may be the first hospital contact and opportunity for CAN victims to be recognised. Early diagnosis of CAN is important, as without early identification and intervention, about one in three children will suffer subsequent abuse. This educational paper provides the reader with an up-to-date and in-depth overview of the current screening methods for CAN at the ER.

CONCLUSION

We believe that a combined approach, using a checklist with risk factors for CAN, a structured clinical assessment and inspection of the undressed patient (called 'top-toe' inspection) and a system of standard referral of all children from parents who attend the ER because of alcohol or drugs intoxication, severe psychiatric disorders or with injuries due to intimate partner violence, is the most promising procedure for the early diagnosis of CAN in the ER setting.