Detection of child abuse in emergency departments: a multi-centre study

Attitudes and responses of Victorian paediatric intensive care doctors to the detection and reporting of child maltreatment

AIM

To determine the attitudes and responses of Victorian paediatric intensive care doctors to the detection and reporting of child maltreatment.

METHODS

A prospective study conducted in a 30-bed paediatric intensive care unit of a university teaching hospital using data collected from a questionnaire completed by paediatric intensive care consultants and registrars. The questionnaire covered the following domains - doctors' knowledge of Victorian mandatory reporting legislation, doctors' history of reporting and doctors' current role in the detection and reporting of child maltreatment.

RESULTS

The questionnaire was completed by 37 doctors. All but one doctor considered their role in the detection and reporting of all six forms of maltreatment (physical abuse, sexual abuse, emotional abuse, neglect, exposure to domestic violence and grooming to facilitate later sexual activity with a child) very important or somewhat important. Thirty-two percent of doctors did not feel adequately trained to detect child maltreatment while 51% did not feel adequately trained to report maltreatment. If a doctor wanted to make a report to Child Protection about the physical or sexual abuse of a child, only one would likely make Child Protection their first point of contact.

CONCLUSIONS

Paediatric intensive care doctors show a strong intent to detect and report child maltreatment across a broad range of maltreatment types. Doctors are likely to contact one or more members of a child's care team and/or one or more relevant hospital/community services before making a report to Child Protection about the physical or sexual abuse of a child. Opportunities exist for the further education of doctors in regards to the detection and reporting of child maltreatment.

Screening for Child Abuse in the Emergency Department of Academic Hospital Paramaribo in Suriname

Background. Child abuse in Suriname has a prevalence between 58.2% and 68.8%. This prospective observational study evaluates the implementation of screening for child abuse at the Emergency Department (ED) of the Academic Hospital Paramaribo (AZP). Methods. Children (0-16 years) presenting with injury from 01-02-2018 until 31-08-2018 were eligible. Case-record-forms were completed. Multidisciplinary meetings were used to evaluate positive screened and admitted patients. Diagnostic accuracy was calculated and results were compared to retrospective data from 2016. Results. 3253 Children attended the ED. In 1190 (36.6%) children, the screening was completed. The screening was positive in 148 (12%); in 71 (6%) cases child abuse was confirmed. The sensitivity and specificity were 0.88 and 0.92 respectively, PPV 0.43, NPV 0.99. There was a significant increase of detected child abuse cases; 4.4% in 2016 versus 6% in 2018 (P = .04). Conclusion. Implementation of screening at the ED in the AZP increased detection of child abuse. To improve screening's accuracy, more education for healthcare professionals is pivotal.

A Systematic Review on Evaluating Responsiveness of Parent- or Caregiver-Reported Child Maltreatment Measures for Interventions

Aims: Child maltreatment (CM) is a global public health and social problem, resulting in serious long-term health and socioeconomic consequences. As parents are the most common perpetrators of CM, parenting interventions are appropriate strategies to prevent CM. However, research on parenting interventions on CM has been hampered by lack of consensus on what measures are most responsive to detect a reduction in parental maltreating behaviours after parenting intervention. This systematic review aimed to evaluate the responsiveness of all current parent- or caregiver-reported CM measures. Methods: A systematic search was conducted in CINAHL, Embase, ERIC, PsycINFO, PubMed and Sociological Abstracts. The quality of studies and responsiveness of the measures were evaluated using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines for systematic reviews of patient-reported outcome measures. Only measures developed and published in English were included. Studies reporting data on responsiveness of the included measures were selected. Results: Sixty-nine articles reported on responsiveness of 15 identified measures. The study quality was overall adequate. The responsiveness of the measures was overall insufficient or not reported; high-quality evidence on responsiveness was limited. Conclusions: Only the Physical Abuse subscale of the ISPCAN Child Abuse Screening Tool for use in Trials (ICAST-Trial) can be recommended as most responsive for use in parenting interventions, with high-quality evidence supporting sufficient responsiveness. All other overall scales or subscales of the 15 included measures were identified as promising based on current data on responsiveness. Additional psychometric evidence is required before they can be recommended.

Recognizing Nonaccidental Trauma in a Pediatric Tertiary Hospital: A Quality Improvement Imperative

Abusive injuries can go unrecognized or improperly managed by medical providers. This study sought to standardize the nonaccidental trauma (NAT) workup and improve NAT evaluation completion for children <7 months with concerning injuries in the pediatric emergency department (PED) and inpatient settings at an urban, tertiary care children's hospital.

Methods

The quality improvement (QI) team created hospital guidelines for suspected NAT, including age-based recommendations (care bundle). The team embedded an order for NAT evaluation into the electronic health record (EHR). The QI team provided education on child abuse identification and evaluation across the hospital. Hospital providers received written guides focused on enhancing communication with families. Outcome measures included monthly NAT bundle use and cases between incomplete bundles in children with suspicious injuries. Chart review of incomplete bundles helped accurately identify patients who needed NAT bundles and improved accurate NAT bundle completion for appropriate patients.

Results

Appropriate NAT bundle completion increased from 31% during the baseline period in January 2019 to 100% in April 2020 and remained at 100% for the remainder of the study period, ending June 2021. The number of patients between missed bundles was 11 from August 2019 until March 2020, when it increased to 583. There were no missed bundles from March 2020 through June 2021.

Conclusions

Standardizing NAT evaluation and creating a NAT care bundle to facilitate the appropriate evaluation preceded an increase in appropriate bundle completion in patients <7 months old with possible NAT in the PED and inpatient units.

Sofa and bed-related pediatric trauma injuries treated in United States emergency departments

INTRODUCTION

Children under the age of 5 years suffer from the highest rates of fall-related injuries. Caretakers often leave young children on sofas and beds, however, falling and rolling off these fixtures can lead to serious injury. We investigated the epidemiologic characteristics and trends of bed and sofa-related injuries among children aged <5 years treated in US emergency departments (EDs).

METHODS

We conducted a retrospective analysis of data from the National Electronic Injury Surveillance System from 2007 through 2021 using sample weights to estimate national numbers and rates of bed and sofa-related injuries. Descriptive statistics and regression analyses were employed.

RESULTS

An estimated 3,414,007 children aged <5 years were treated for bed and sofa-related injuries in emergency departments (EDs) in the United States from 2007 through 2021, averaging 115.2 injuries per 10,000 persons annually. Closed head injuries (30%) and lacerations (24%) comprised the majority of injuries. The primary location of injury was the head (71%) and upper extremity (17%). Children <1 year of age accounted for most injuries, with a 67% increase in incidence within the age group between 2007 and 2021 (p < 0.001). Falling, jumping, and rolling off beds and sofas were the primary mechanisms of injury. The proportion of jumping injuries increased with age. Approximately 4% of all injuries required hospitalization. Children <1 year of age were 1.58 times more likely to be hospitalized after injury than all other age groups (p < 0.001).

CONCLUSION

Beds and sofas can be associated with injury among young children, especially infants. The annual rate of bed and sofa-related injuries among infants <1 year old is increasing, which underscores the need for increased prevention efforts, including parental education and improved safety design, to decrease these injuries.

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.

The characteristics of children referred to a child protection team in Japan and factors associated with decision-making: A retrospective study using a medical database

BACKGROUND

Despite the potential efficacy of hospital-based multidisciplinary child protection team (CPTs), research analyzing Japanese CPT databases is scarce.

OBJECTIVE

We aimed to describe the characteristics of children and families reported to a CPT in Japan and investigate factors associated with the substantiation of maltreatment.

PARTICIPANTS AND SETTING

This retrospective, cross-sectional study took place in a national children's hospital in Japan and included 350 children who were reported to CPTs between April 2014 and March 2018.

METHODS

Univariable and multivariable logistic regression analyses were conducted using the CPT database and medical records.

RESULTS

Among 350 cases, 33.4 % were substantiated. Children of <6 years of age comprised 73.4 % of the cases. The majority (67.7 %) received an injury-related diagnosis and physical maltreatment was suspected in 68.3 % of cases. In the univariable analysis, older age, a primary diagnosis other than injury, reporting department, psychological maltreatment, witnessing intimate partner violence, maltreatment by relatives other than biological father or mother, developmental disability, emotional/behavioral difficulty or psychological disorder, maternal/paternal psychological difficulty, and maternal history of maltreatment were significantly associated with substantiation. When adjusted for demographic, child and familial factors, a diagnosis other than injury (AOR 2.02, 95 % CI = 1. 11-3.65) and parental psychological difficulties (AOR 2.49, 95 % CI = 1.37-4.55) were independently associated with substantiation.

CONCLUSION

Most cases reported to our CPT were young children with an injury-related diagnosis. Substantiation was associated with a diagnosis other than injury and parental psychological difficulties. Further prospective and comprehensive studies are needed to establish universal guidelines for databases of hospital-based CPTs.

The Typology and Topography of Child Abuse and Neglect: The Experience of a Tertiary Children's Centre

Effective child protection systems and processes require reliable and accurate data. The aim of this study was to determine what data could be extracted from hospital records in a single site that reflected a child’s journey from admission with suspected abuse to the decisions regarding substantiation made by the multidisciplinary child protection team. A retrospective study of the case records of 452 children referred to a major UK children’s tertiary centre for suspected child maltreatment was undertaken. Child maltreatment was substantiated in 65% of referred cases, with the majority of referrals coming from children living in the most deprived neighbourhoods in the country. Domestic violence and abuse and the child’s previous involvement with statutory bodies were associated with case substantiation. Physical abuse predominated, with soft tissue injuries, including dog bites and burns, most frequent. Burns were related almost exclusively to supervisory neglect. There were also cases of medical neglect. Emotional abuse was associated with exposure to domestic violence and abuse and to self-harm. The strengths and limitations for single-centre data systems were explored, concluding with a recommendation to establish an agreed national and international minimum data set to protect children from maltreatment.

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.

Nurses' intention to report child abuse in Saudi Arabia: A cross-sectional study

BACKGROUND

Child abuse is a prevalent problem with short and long-term consequences. While most countries have enacted child abuse reporting laws, the Saudi healthcare system has not paid sufficient attention to nurses' role in the reporting of child abuse.

OBJECTIVE

This study aimed to 1) identify the factors associated with nurses' intention to report child abuse by testing a hypothetical model; 2) examine the patterns underlying their intention to report child abuse; and 3) investigate the differences in reporting based on clinical practice areas.

PARTICIPANTS AND SETTING

A convenience sample of 248 nurses recruited from emergency and pediatric inpatient units and primary healthcare centers in Riyadh, Saudi Arabia was used.

METHODS

In this cross-sectional study, data were collected using the Child Abuse Report Intention Scale and another self-report measure in February 2019.

RESULTS

Most nurses had not reported even one case of child abuse during their clinical practice. Knowledge about child abuse (β = .210, P = 0.000), subjective norms (β = .218, P = 0.001), and organizational support in guideline implementation (β = .138 P = 0.038) were significantly associated with the intention to report child abuse. Nurses reported a stronger intention to report child sexual abuse than other types of abuse. Clinical practice areas were significantly associated with nurses' intention to report child abuse.

CONCLUSIONS

Nurses' professional preparation for child abuse reporting is inadequate. The findings underscore the importance of enhancing their knowledge about child abuse and reporting laws, promoting social support, and creating an empowering clinical environment.

The true cost of child abuse at a level 1 pediatric trauma center

BACKGROUND

Child physical abuse (CPA) is a significant cause of morbidity and mortality. Children who sustain CPA consume significant healthcare resources. We hypothesized that the costs to care for children who sustain for children with CPA-type injuries are greater than the costs to care for children who sustain accidental injuries.

METHODS

All confirmed CPA patients between the ages of 0 and 19 years old, who were admitted to a level 1 pediatric trauma center between January 2010 and September 2018, were retrospectively reviewed. We compared outcomes, including mortality, length of stay (LOS), diagnostic work-up, and overall cost using propensity matching between CPA and accidentally injured trauma patients. Patients were matched based on injury severity score (ISS).

RESULTS

The CPA cohort (n = 595) was younger (1.31 +/- 1.96 years, p < 0.0001) than the accidental trauma patients (8.6 +/-5.54 years). The majority of the CPA patients had Medicaid coverage (75.1%), when compared to accidental trauma patients (37.5%; p < 0.0001). CPA patients had longer ICU LOS (2.43 days; p < 0.0001), increased ventilation days (2.57 days; p < 0.0001), and longer hospital LOS (6.56 days; p = 0.0004). The overall mortality rate for CPA patients was higher than accidental trauma patients (9.9% vs. 1.2%; p < 0.0001). The median hospital cost was significantly higher for those with CPA ($18,000) than accidental trauma ($10,100; p < 0.0001).

CONCLUSION

The costs to care for children who sustain CPA-type injuries are significantly greater than the costs to care for children who sustain accidental trauma. Better screening tools, more provider education and broader community outreach efforts are needed to reduce the societal and economic costs associated with child physical abuse.

STUDY TYPE

Treatment.

LEVEL OF EVIDENCE

Level III.

What We Can Learn From Failure: An EHR-Based Child Protection Alert System

This study aimed to evaluate the efficacy of a newly implemented Child Protection Alert System (CPAS) that utilizes triggering diagnoses to identify children who have been confirmed/strongly suspected as maltreated. We retrospectively reviewed electronic health records (EHRs) of 666 patients evaluated by our institution's child protection team between 2009 and 2014. We examined each EHR for the presence of a pop-up alert, a persistent text-based visual alert, and diagnoses denoting child maltreatment. Diagnostic accuracy of the CPAS for child maltreatment identification was assessed. Of 323 patients for whom child maltreatment was confirmed/strongly suspected, 21.7% (70/323) had a qualifying longitudinal diagnosis listed. The pop-up alert fired in 14% of cases (45/323) with a sensitivity and specificity of 13.9% (95% CI [10.4%, 18.2%]) and 100% (95% CI [98.9%, 100.0%]), respectively. The text-based visual alert displayed in 44 of 45 cases. The CPAS is a novel simple way to support clinical decision-making to identify and protect children at risk of (re)abuse. This study highlights multiple barriers that must be overcome to effectively design and implement a CPAS to protect at-risk children.

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.

Every child, every time: hospital-wide child abuse screening increases awareness and state reporting

PURPOSE

A review of our child abuse evaluation system demonstrated a lack of standardization leading to low reporting levels. The purpose of this quality improvement initiative was to develop a standard child abuse screening tool; an education program increasing awareness to child abuse; and to measure the impact of the screening tool in reporting.

METHODS

A screening tool was developed and implemented for all trauma patients < 15 years of age; staff was educated; and a child protection team (CPT) was established. Within 9 months, screening was extended to all patients admitted to the children's hospital. Screening compliance, number of child abuse reporting forms (CY-47) filed, and consultations to the CPT were monitored.

RESULTS

Initially, there was an average screening compliance of 56%. After making the program hospital-wide, the compliance rate increased to an average of 96%; and the average number of CPT consults increased from 2 to 10 per month. Over this study period, the average number of CY-47s filed increased from 6.1 to 7.3 per month.

CONCLUSIONS

Hospital-wide use of an objective screening tool, frequent re-education, and the support of an experienced child protection team led to improved child abuse screening compliance and more consistent suspected-abuse reporting rates.

Child abuse and the pediatric surgeon: A position statement from the Trauma Committee, the Board of Governors and the Membership of the American Pediatric Surgical Association

BACKGROUND

The pediatric surgeon is in a unique position to assess, stabilize, and manage a victim of child physical abuse (formerly nonaccidental trauma [NAT]) in the setting of a formal trauma system.

METHODS

The American Pediatric Surgical Association (APSA) endorses the concept of child physical abuse as a traumatic disease that justifies the resource utilization of a trauma system to appropriately evaluate and manage this patient population including evaluation by pediatric surgeons.

RESULTS

APSA recommends the implementation of a standardized tool to screen for child physical abuse at all state designated trauma or ACS verified trauma and children's surgery hospitals. APSA encourages the admission of a suspected child abuse patient to a surgical trauma service because of the potential for polytrauma and increased severity of injury and to provide reliable coordination of services. Nevertheless, APSA recognizes the need for pediatric surgeons to participate in a multidisciplinary team including child abuse pediatricians, social work, and Child Protective Services (CPS) to coordinate the screening, evaluation, and management of patients with suspected child physical abuse. Finally, APSA recognizes that if a pediatric surgeon suspects abuse, a report to CPS for further investigation is mandated by law.

CONCLUSION

APSA supports data accrual on abuse screening and diagnosis into a trauma registry, the NTDB and the Pediatric ACS TQIP® for benchmarking purposes and quality improvement.

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.

Child abuse and neglect in the Jaffna district of Sri Lanka - a study on knowledge attitude practices and behavior of health care professionals

Background

Victims and perpetrators of child abuse do not typically self-report to child protection services, therefore responsibility of detection and reporting falls on the others. Knowledge on child protection is essential for the first contact person and such information is sparse in research literature originally coming from Sri Lanka. Anecdotally, several cases of child abuse have been missed out at the first contact level. Therefore we undertook this survey to assess the knowledge, attitudes towards child protection and the experiences of medical officers, nursing officers and social workers on child protection.

Method

This was a descriptive analytical study carried out in hospitals and the community during March–October 2016. An anonymous content validated self-administered questionnaire was used as the study instrument. Knowledge, Attitude, Practices and Behaviour were assessed via multiple choice questions and responses according to Likert score. Three anonymised case records were given as case vignettes to be studied by the participants and their responses were also recorded on the questionnaire.

Results

Among the 246 responders 156 (63.4%) were doctors. All groups of professionals identified the forms of child abuse correctly and the social indicators of child abuse was correctly identified in 152 (61.7%). Majority failed to identify the features of the perpetrator. Majority of the professionals showed a favourable response in attitude when dealing with child maltreatment. 153 (62%) had suspected child abuse in their career and 64% of them had reported it to the authority. Fifty two (21%) had attended a training workshop on child abuse and 65.8% of the responders were not satisfied with their knowledge. 229(93%) of them indicated that they wanted some form of education on child maltreatment. The Knowledge, Attitude and Behaviour towards child abuse were significantly good on people with experience in the field of Paediatrics and Judicial Medical work, when compared to those who did not have the experience in these two fields. (p value< 0.01).

Conclusion

Although the knowledge among health professionals regarding child abuse and care was satisfactory, further areas need reinforcement. The attitude was more positive, the behavior and practices on child maltreatment needed reinforcement via workshops and continuing medical education.

Prevalence of nonaccidental trauma among children at American College of Surgeons-verified pediatric trauma centers

BACKGROUND

Child abuse remains a national epidemic that has detrimental effects if unnoticed in the clinical setting. Extreme cases of child abuse, or nonaccidental trauma (NAT), have large financial burdens associated with them due to treatment costs and long-term effects of abuse. Clinicians who have additional training and experience with pediatric trauma are better equipped to detect signs of NAT and have more experience reporting it. This additional training and experience can be measured by using the American College of Surgeons (ACS) Pediatric Trauma verification. It is hypothesized that ACS-verified pediatric trauma centers (vPTCs) have an increased prevalence of NAT because of this additional experience and training relative to non-ACS vPTCs.

METHODS

The National Trauma Data Bank, for the years 2007 to 2014, was utilized to compare the prevalence of NAT between ACS vPTCs relative to non-ACS vPTCs to produce both crude and Injury Severity Score adjusted prevalence ratio estimates.

RESULTS

The majority of NAT cases across all hospitals were male (58.3%). The mean age of the NAT cases was 2.3 years with a mean Injury Severity Score (ISS) of 11.1. The most common payment method was Medicaid (64.4%). The prevalence of NAT was 1.82 (1.74-1.90) times higher among ACS vPTCs and 1.81 (1.73-1.90) after adjusting for ISS.

CONCLUSIONS

The greater prevalence of NAT at vPTCs likely represents a more accurate measure of NAT among pediatric trauma patients, likely due to more experience and training of clinicians.

LEVEL OF EVIDENCE

Prognostic/Epidemiological, Level II.

Pancreatic Laceration in a Pediatric Patient: An Unexpected Diagnosis

Pediatric pancreatic injuries are rare. We present an atypical case that occurred in a 4-year-old male. The child presented with a twenty-four-hour history of vomiting that had progressed to right lower quadrant abdominal pain on examination in the emergency department. The initial differential was gastroenteritis versus appendicitis. An abnormality on the ultrasonography and an elevated lipase level eventually led to an MRI showing a complete transection through the posterior margin of the pancreas. The patient was admitted to pediatric surgery and underwent a successful distal pancreatectomy with preservation of the spleen. On further inquiry specific to trauma, the child disclosed that his older brother had punched him in his abdomen the night before. The child's parents were separated due to intimate partner violence, and this older sibling recently had been very stressed. The sibling was referred for mental health evaluation and counseling, and the case reported to the county children and youth investigative services system. A low threshold for considering trauma and child abuse in the pediatric population is recommended when significant intra-abdominal injury is diagnosed.

Analysis of contextual variables in the evaluation of child abuse in the pediatric emergency setting

OBJECTIVE

This article comprises a sample of abuse modalities observed in a pediatric emergency room of a public hospital in the Lisbon metropolitan area and a multifactorial characterization of physical and sexual violence. The objectives are: (1) to discuss the importance of social and family variables in the configuration of both types of violence; (2) to show how physical and sexual violence have subtypes and internal diversity.

METHODS

A statistical analysis was carried out in a database (1063 records of child abuse between 2004 and 2013). A form was applied to cases with suspected abuse, containing data on the child, family, abuse episode, abuser, medical history, and clinical observation. A factorial analysis of multiple correspondence was performed to identify patterns of association between social variables and physical and sexual violence, as well as their internal diversity.

RESULTS

The prevalence of abuse in this pediatric emergency room was 0.6%. Physical violence predominated (69.4%), followed by sexual violence (39.3%). Exploratory profiles of these types of violence were constructed. Regarding physical violence, the gender of the abuser was the first differentiating dimension; the victim's gender and age range were the second one. In the case of sexual violence, the age of the abuser and co-residence with him/her comprised the first dimension; the victim's age and gender comprised the second dimension.

CONCLUSION

Patterns of association between victims, family contexts, and abusers were identified. It is necessary to alert clinicians about the importance of social variables in the multiple facets of child abuse.

Do abused young children feel less pain?

The objective of this study was to investigate whether acute pain in abused children was under recognized by doctors and nurses compared to children evaluated for accidental injuries. We hypothesize that an abused child's reaction to physical pain could be an additional symptom of this challenging diagnosis. For the observational prospective case control study in an emergency department, children were eligible when: younger than six years old, the reported trauma occurred within the previous seven days, the trauma comprised a bone injury or burn, and the child was able to express his or her pain. The case group comprised children for whom the medical team reported their abuse suspicions and supporting information to a court, and whose cases of abuse were subsequently confirmed. The control group consisted of children with a plausible cause for their injury and no obvious signs of abuse. The children were matched according to their age and type of trauma. The pain was assessed by doctors and nurses before analgesic administration using a certified pain scale. Among the 78 included children, pain was significantly less recognized in the abused children vs. the controls (relative risk=0.63; 95% CI: 0.402-0.986; p=0.04). We observed a discrepancy between the nurses' and doctors' scores for the pain assessments (Kappa coefficient=0.59, 95% CI: 0.40-0.77). Our results demonstrate that pain expression in abused children is under recognized by medical staff. They also suggest that abused children may have reduced pain expression after a traumatic event. Paying particular attention to the pain of abused children may also optimize the analgesic treatment.

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.

Detection of the awareness rate of abuse in pediatric patients admitted to emergency medicine department with injury

Objective

It was aimed to investigate whether neglected and abused pediatric patients are properly recognized and reported by emergency physicians in the emergency department (ED).

Methods

This prospective study was conducted on patients between 0 and 6 years of age presenting with trauma to ED. Patients were examined again by an emergency medicine specialist independent from the physician who did the first intervention during clinical follow-up phase after notification of patients presenting with trauma to emergency physician. Asked radiological examinations and clinical follow-up were performed. The suspected abuse evaluation form, consisting 12 items, which was formed by considering the forms used in previous studies was used to examine the awareness of physicians in cases of abuse suspicion.

Results

A total of 126 patients were included in our study. 54% of cases (n = 68) were male and mean age was determined to be 31.3 ± 18.9 months. It was found that no judicial records were written to 35.7% (n = 45) of our patients and that 11.1% (n = 5) of these patients were hospitalized. In 51.1% (n = 23) of patients without judicial records, multiple suspected abuse findings were identified. According to evaluation of first physician, it was found that 75.9% (n = 41) of discharged patients had no judicial records and was not considered as neglect and abuse.

Conclusion

We conclude that detection rates of abuse can be increased by developing child abuse screening forms and ensuring the continuity of the necessary training programs.

Emergency Department Utilization in Children <36 Months Is Not an Independent Risk Factor for Maltreatment

BACKGROUND AND OBJECTIVES

Early childhood high-frequency use (HFU) of the emergency department (ED) has been endorsed as a marker for increased risk of child maltreatment. In a prior analysis of pediatric ED (PED) visits by 16,664 children, 0-36 months old, we defined early childhood HFU (the 90th percentile) as five or more visits. The purpose of this study was to follow HFU patients to determine if they had a higher likelihood of reported maltreatment.

METHODS

This is a single-center, cross-sectional, observational study of the association between PED use in early life and subsequent intervention by child protective services (CPS). CPS data were obtained from a Department of Social Services database for subjects meeting criteria for PED HFU as well as sex, race, and ethnicity-matched controls. Multivariable analyses were performed to assess if HFU was independently associated with child maltreatment.

RESULTS

While CPS involvement was more highly represented in the group with PED HFU, so were many confounding variables such as African American race, history of hospital admissions, and social work consultations in the PED for any reason. HFU, by itself, is not a risk factor for a major intervention by CPS.

CONCLUSIONS

In efforts to identify children at risk for maltreatment, objective assessments such as PED utilization are potential markers to utilize to aid in recognition. Unfortunately, there are many risk factors for increased PED utilization that act as confounders for this marker. Future work is necessary to identify children at risk for maltreatment in the ED.

Comparing corporal punishment and children's exposure to violence between caregivers: Towards better diagnosis and prevention of intrafamilial physical abuse of children

Any intervention involving child victims of intrafamilial abuse must take the alleged underlying motives for the abuse into account. The aim of this study is to further our understanding of intrafamilial physical abuse of children, by comparing its various aspects while considering the alleged underlying motives. A preliminary sample of 1656 cases of alleged physical abuse in the northern region of Portugal was analysed, with two main motives being identified: corporal punishment (CP) (G1 = 927) and exposure to violence between caregivers (EVC) (G2 = 308). Statistically significant differences were found between the two motives (p < 0.05) for the following variables: (1) age of the alleged victims, (2) sex of the alleged abuser, (3) risk factors affecting the alleged abuser, (4) abuser/victim relationship, (5) injury-producing mechanism, (6) time between last abuse and forensic medical examination and (7) location of injuries. Evidence-based knowledge of these differences may help in accurate diagnosis by doctors (particularly forensic physicians) and prevention of this type of violence through support strategies (including tertiary prevention strategies).

Uncovering the burden of intentional injuries among children and adolescents in the emergency department

Introduction

In low- and middle-income countries, injuries are a leading cause of mortality in children. Much work has been done in the context of unintentional injuries but there is limited knowledge about intentional injuries among children. The objective of this paper was to understand the characteristics of children with intentional injuries presenting to emergency departments in Pakistan.

Methods

The data was from the Pakistan National Emergency Departments Surveillance (Pak-NEDS), conducted from November 2010 to March 2011 in seven major emergency departments of Pakistan. Data on 30,937 children under 18 years of age was collected. This paper reports frequency of intentional injuries and compares patient demographics, nature of injury, and discharge outcome for two categories of intentional injuries: assault and self-inflicted injuries.

Results

Intentional injuries presenting to the emergency departments (EDs) accounted for 8.2% (2551/30,937) amongst all other causes for under 18 years. The boy to girl ratio was 1:0.35. Intentional injuries included assault (n = 1679, 65.8%) and self-inflicted injuries (n = 872, 34.2%). Soft tissue injuries were most commonly seen in assault injuries in boys and girls but fractures were more common in self-inflicted injuries in both genders.

Conclusion

Intentional injury is one of the reasons for seeking emergency treatment amongst children and a contributor to morbidity in EDs of Pakistan. Moreover, such injuries may be underestimated due to lack of reporting and investigative resources. Early identification may be the first step leading to prevention.

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.

Hospital based emergency department visits attributed to child physical abuse in United States: predictors of in-hospital mortality

OBJECTIVES

To describe nationally representative outcomes of physical abuse injuries in children necessitating Emergency Department (ED) visits in United States. The impact of various injuries on mortality is examined. We hypothesize that physical abuse resulting in intracranial injuries are associated with worse outcome.

MATERIALS AND METHODS

We performed a retrospective analysis of the Nationwide Emergency Department Sample (NEDS), the largest all payer hospital based ED database, for the years 2008-2010. All ED visits and subsequent hospitalizations with a diagnosis of "Child physical abuse" (Battered baby or child syndrome) due to various injuries were identified using ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification) codes. In addition, we also examined the prevalence of sexual abuse in this cohort. A multivariable logistic regression model was used to examine the association between mortality and types of injuries after adjusting for a multitude of patient and hospital level factors.

RESULTS

Of the 16897 ED visits that were attributed to child physical abuse, 5182 (30.7%) required hospitalization. Hospitalized children were younger than those released treated and released from the ED (1.9 years vs. 6.4 years). Male or female partner of the child's parent/guardian accounted for >45% of perpetrators. Common injuries in hospitalized children include- any fractures (63.5%), intracranial injuries (32.3%) and crushing/internal injuries (9.1%). Death occurred in 246 patients (13 in ED and 233 following hospitalization). Amongst the 16897 ED visits, 1.3% also had sexual abuse. Multivariable analyses revealed each 1 year increase in age was associated with a lower odds of mortality (OR = 0.88, 95% CI = 0.81-0.96, p < 0.0001). Females (OR = 2.39, 1.07-5.34, p = 0.03), those with intracranial injuries (OR = 65.24, 27.57-154.41, p<0.0001), or crushing/internal injury (OR = 4.98, 2.24-11.07, p<0.0001) had higher odds of mortality compared to their male counterparts.

CONCLUSIONS

In this large cohort of physically abused children, younger age, females and intracranial or crushing/internal injuries were independent predictors of mortality. Identification of high risk cohorts in the ED may enable strengthening of existing screening programs and optimization of outcomes.

Child maltreatment in India

Child maltreatment is a global problem but is more difficult to assess and manage in developing countries such as India where one-fifth of the world's total child population resides. Certain forms of maltreatment such as feticide, infanticide, abandonment, child labour, street-begging, corporal punishment and battered babies are particularly prevalent in India. Most physicians still need to be sensitized in order to suspect child abuse on the basis of unexplained trauma, multiple fractures, parental conflict and other corroborative evidence. This article summarizes the various aspects of this major problem in resource-poor settings in the hope that it will assist in the planning of services addressing child physical and sexual abuse and neglect in India and in other developing countries. A culture of non-violence towards children needs to be built into communities in order to provide an environment conducive to the overall development of the child. Rehabilitation of abused children and their families requires a multi-disciplinary service including paediatricians, child psychologists and social workers, and the training of police forces in how to tackle the problem.

A systematic review of abusive visceral injuries in childhood--their range and recognition

OBJECTIVES

To define what abusive visceral injuries occur, including their clinical features and the value of screening tests for abdominal injury among abused children.

METHODS

We searched 12 databases, with snowballing techniques, for the period 1950-2011, with all identified studies undergoing two independent reviews by trained reviewers, drawn from pediatrics, radiology, pediatric surgery and pathology. Of 5802 studies identified, 188 were reviewed. We included studies of children aged 0-18, with confirmed abusive etiology, whose injury was defined by computed tomography, contrast studies or at surgery/post mortem. We excluded injuries due to sexual abuse, or those exclusively addressing management or outcome.

RESULTS

Of 88 included studies (64 addressing abdominal injuries), only five were comparative. Every organ in the body has been injured, intra-thoracic injuries were commoner in those aged less than five years. Children with abusive abdominal injuries were younger (2.5-3.7 years vs. 7.6-10.3 years) than accidentally injured children. Duodenal injuries were commonly recorded in abused children, particularly involving the third or fourth part, and were not reported in accidentally injured children less than four years old. Liver and pancreatic injuries were frequently recorded, with potential pancreatic pseudocyst formation. Abdominal bruising was absent in up to 80% of those with abdominal injuries, and co-existent injuries included fractures, burns and head injury. Post mortem studies revealed that a number of the children had sustained previous, unrecognized, abdominal injuries. The mortality from abusive abdominal injuries was significantly higher than accidental injuries (53% vs. 21%). Only three studies addressed screening for abdominal injury among abused children, and were unsuitable for meta-analysis due to lack of standardized investigations, in particular those with 'negative' screening tests were not consistently investigated.

CONCLUSIONS

Visceral injuries may affect any organ of the body, predominantly abdominal viscera. A non-motor vehicle related duodenal trauma in a child aged<five years warrants consideration of abuse as an etiology. In the absence of clear evidence for a screening strategy, clinical vigilance is warranted in any young child with suspected abuse for the presence of abdominal injury, where the absence of abdominal bruising or specific symptoms does not preclude significant injury.

New hospital-based policy for children whose parents present at the ER due to domestic violence, substance abuse and/or a suicide attempt

Child maltreatment is a major social problem with many adverse consequences, and a substantial number of maltreated children are not identified by health care professionals. In 2010, in order to improve the identification of maltreated children in hospitals, a new hospital-based policy was developed in Amsterdam, The Netherlands. This policy was adapted from another policy that was developed in The Hague, the Netherlands, in 2007. In the new Amsterdam policy, all adults presenting at the emergency department due to domestic violence, substance abuse, and/or a suicide attempt are asked whether they have any children in their care. If this is the case, parents are urged to visit the outpatient pediatric department together with all of their children. During this visit, problems are evaluated and voluntary referrals can be arranged to different care organizations. If parents refuse to cooperate, their children are reported to the Dutch Child Abuse Counseling and Reporting Centre. The two aims of this study are to describe (1) characteristics of the identified families and (2) the referrals made to different voluntary and involuntary care organizations during the first 2 years after implementation of the policy. Data were collected from medical records. One hundred and six children from 60 households were included, of which 68 children because their mother was a victim of domestic violence. Referrals to care organizations were arranged for 99 children, of which 67 on a voluntary basis. The Amsterdam policy seems successful in arranging voluntary support for the majority of identified children.

Characteristics and trends of hospitalized pediatric abuse head trauma in Wuhan, China: 2002–2011

This study investigated characteristics and trends of hospitalized abuse-related traumatic brain injuries (TBI) treated at a large pediatric medical center in Wuhan, China during the past 10 years. De-identified hospital discharge data for patients 0–4 years old hospitalized at the Wuhan Medical Care Center for Women and Children were analyzed, and ICD-10 codes were used to identify cases of TBI. Medical notes provided by doctors in the medical record were used to identify TBI cases in which suspected child abuse was the cause. From 2002 to 2011, 3,061 pediatric TBI patients were hospitalized and 4.6% (140) of these cases were suspected child abuse-related. The majority of suspected child abuse cases involved children younger than 1 year of age (68.6%) and usually affected males (63.6%). Children with non-Abusive Head Trauma (AHT) were more likely to have full recovery outcome (68.4%, 95% CI: 66.6%–70.0%) than children with suspected AHT (44.3%, 95% CI: 36.1%–52.5%). The proportion of all childhood TBI attributable to abuse did not appear to have increased in the 10-year period at this medical center. This is the first comprehensive study highlighting the important role of suspected child abuse in causing TBIs among Chinese children. Child abuse as a major cause of TBIs among infants in China should be studied further, and there should be greater awareness of this important social and medical problem in China.

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.

Effects of systematic screening and detection of child abuse in emergency departments

OBJECTIVE

Although systematic screening for child abuse of children presenting at emergency departments might increase the detection rate, studies to support this are scarce. This study investigates whether introducing screening, and training of emergency department nurses, increases the detection rate of child abuse.

METHODS

In an intervention cohort study, children aged 0 to 18 years visiting the emergency departments of 7 hospitals between February 2008 and December 2009 were enrolled. We developed a screening checklist for child abuse (the "Escape Form") and training sessions for nurses; these were implemented by using an interrupted time-series design. Cases of suspected child abuse were determined by an expert panel using predefined criteria. The effect of the interventions on the screening rate for child abuse was calculated by interrupted time-series analyses and by the odds ratios for detection of child abuse in screened children.

RESULTS

A total of 104028 children aged 18 years or younger were included. The screening rate increased from 20% in February 2008 to 67% in December 2009. Significant trend changes were observed after training the nurses and after the legal requirement of screening by the Dutch Health Care Inspectorate in 2009. The detection rate in children screened for child abuse was 5 times higher than that in children not screened (0.5% vs 0.1%, P < .001).

CONCLUSIONS

These results indicate that systematic screening for child abuse in emergency departments is effective in increasing the detection of suspected child abuse. Both a legal requirement and staff training are recommended to significantly increase the extent of screening.

Child abuse pediatrics: prevention, evaluation, and treatment

PURPOSE OF REVIEW

This review is designed to update the general pediatrician with information about current child maltreatment literature. The authors have selected salient articles, which inform daily practice of any professional involved in the care of children who may be at risk of child abuse.

RECENT FINDINGS

The field of child abuse pediatrics continues to engender controversy in both medical journals and courtrooms. As scrutiny about the basis for the diagnosis increases, clinicians and researchers work to build a solid base of scientific evidence with thorough and well-designed studies. This is most evident with regards to abusive head trauma, wherein both lay and scientific press challenge the possibility that infants can be severely injured or killed by shaking, blunt force trauma, or both.

SUMMARY

Child abuse pediatrics is a well-established and credible medical field. Although child physical and sexual abuse are age-old problems, public acknowledgement and intervention models are relatively new, and medical literature continues to reflect an increasing and deeper understanding of the impact of abuse throughout the world.

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

We explored trends in six developed countries in three types of indicators of child maltreatment for children younger than 11 years, since the inception of modern child protection systems in the 1970s. Despite several policy initiatives for child protection, we recorded no consistent evidence for a decrease in all types of indicators of child maltreatment. We noted falling rates of violent death in a few age and country groups, but these decreases coincided with reductions in admissions to hospital for maltreatment-related injury only in Sweden and Manitoba (Canada). One or more child protection agency indicators increased in five of six countries, particularly in infants, possibly as a result of early intervention policies. Comparisons of mean rates between countries showed five-fold to ten-fold differences in rates of agency indicators, but less than two-fold variation in violent deaths or maltreatment-related injury, apart from high rates of violent child death in the USA. These analyses draw attention to the need for robust research to establish whether the high and rising rates of agency contacts and out-of-home care in some settings are effectively reducing child maltreatment.

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.