Costs of childhood physical abuse: comparing inflicted and unintentional traumatic brain injuries

Developmental Outcomes Following Abusive Head Trauma in Infancy: A Systematic Review

OBJECTIVE

A systematic review of the literature was conducted to identify measures used to evaluate developmental outcomes after abusive head trauma (AHT), as well as describe outcomes among those with AHT, and explore factors and interventions influencing such outcomes.

DESIGN

This systematic review adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. The protocol is in PROSPERO, registration number CRD42020179592. On April 17, 2020, OVID Medline, Embase, OVID PsycINFO, Web of Science, CINAHL, Cochrane Library, and Google Scholar were searched (since inception). Inclusion criteria included original, peer-reviewed study data; AHT exposure; infants younger than 24 months at time of AHT; and evaluation of developmental outcomes. Reviewers independently evaluated studies for inclusion and assessed risk of bias using the Effective Public Health Practice Project quality assessment tool for quantitative studies. A descriptive synthesis approach was utilized as variability of study designs, follow-up periods, and outcome assessment tools precluded a meta-analytic approach.

RESULTS

Fifty-nine studies were included; 115 assessment tools were used to evaluate developmental outcomes; and 42 studies examined factors influencing outcomes. Two studies evaluated interventions. Five percent of studies ( n = 3) were rated low risk of bias.

CONCLUSIONS

Notable variation was observed in terms of case ascertainment criteria. Developmental outcomes after AHT have been assessed in a manner that limits understanding of how AHT impacts development, as well as the efficacy of interventions intended to improve outcomes. Researchers and clinicians are encouraged to adopt consistent diagnostic and assessment approaches.

Traumatic head injury due to child maltreatment: epidemiology, cost analysis, and impact of prevention

BACKGROUND

Traumatic head injury due to child maltreatment (THI-CM), also known as abusive head trauma (AHT), is a significant public health problem due to the wide array of consequences affecting multiple domains of a child's health and development. Several studies have evaluated its cost on healthcare systems, families, and societies. Many jurisdictions have implemented caregiver education programs to prevent THI-CM.

OBJECTIVES

This paper aims to provide a brief overview of the epidemiology and cost analysis of THI-CM and discuss its prevention and the intergenerational transmission of child maltreatment.

METHODS

Although not systematic, a literature search of original articles published from 2000 to 2022 in English and French was undertaken using the following databases: PubMed, EMBASE (Ovid), and PsycINFO (OVID). The search combined terms related to traumatic head injury and child maltreatment, with terms related to its cost and prevention. Studies of children aged 0-5 years old were included. The authors completed a screen of the titles and abstracts to determine relevance with respect to this article.

RESULTS

Globally, although THI-CM accounts for a small proportion of cases of child maltreatment, there is a high incidence of death and neurological sequelae compared to other causes of head trauma.The incidence of THI-CM is likely underestimated due to the lack of standardized definitions, differences in reporting, and challenges in identifying less severe cases. Cost analysis studies reveal the significant short- and long-term costs associated with THI-CM. Caregiver education programs have been studied and implemented in many centers and have shown varying but promising results.

CONCLUSION

A multi-pronged approach to prevention efforts should be considered to support families and help to prevent THI-CM and maltreatment throughout childhood.

Acquired Brain Injury in the Context of Family Violence: A Systematic Scoping Review of Incidence, Prevalence, and Contributing Factors

Brain injury is often a precursor to, or result of, family violence. Yet there is little research identifying the connection of these two phenomena. The health cost (personal or societal) of brain injury within the family violence context is difficult to ascertain. Family violence can lead to lifelong psychological or physical scars and even death. A systematic review was conducted over three databases using Medical Subject Heading terms to investigate incidence, prevalence, and contributing factors of brain injury within a family violence context. Inclusion criteria were primary studies, any person who experienced traumatic brain injury in a familial context. Seven hundred and seven studies of varied designs were initially identified with 43 meeting inclusion criteria. Data were extracted and a deductive narrative synthesis was performed. The accuracy and generalizability of incidence and prevalence statistics was hindered by underreporting of family violence and the specificity of some of the population groups (e.g., female inmates). The factors contributing to brain injury within the family violence context had multifactorial causation and varied greatly across the populations studied. Five social determinants of health were identified: biological, behavioral, structural, social, and environmental. These factors included age and gender of parent/baby, crying as an antecedent of family violence, previous exposure to abuse as a child, hostile living environments, previous trauma, financial pressures, employment status, housing availability, and exposure to natural disasters. Future investigation into the nexus between brain injury and family violence is required; however, this is complicated due to global inconsistency of definitions, assessment tools, and research methods used.

Social determinants of health, personalized medicine, and child maltreatment

This review begins with a brief summary of the importance of child maltreatment as a major public health problem, given its prevalence and the substantial human and economic costs involved. The focus then shifts to consideration of personalized medicine and child maltreatment, including genetic and genomics factors, as well as the role of social determinants of health. Research on epigenetics related to child abuse and neglect is presented, followed by that pertaining to a few specific social factors, such as poverty, parental depression and substance use, and domestic (or intimate partner) violence. The review ends with a discussion of interventions to help address social determinants of health with brief descriptions of several model programs, and thoughts concerning the role of personalized medicine in addressing child maltreatment in the foreseeable future. IMPACT: This paper synthesizes knowledge on social determinants of health and advances in genetics and genomics related to the prevention of child maltreatment. It provides examples of model approaches to addressing the prevention of child maltreatment in primary care practices.

Costs for physical and mental health hospitalizations in the first 13 years of life among children engaged with Child Protection Services

BACKGROUND

Longitudinal data on health costs associated with physical and mental conditions are not available for children reported to child protection services.

OBJECTIVE

To estimate the costs of hospitalization for physical and mental health conditions by child protection status, including out-of-home-care (OOHC) placement, from birth until 13-years, and to assess the excess costs associated with child protection contact over this period.

PARTICIPANTS AND SETTING

Australian population cohort of 79,285 children in a multi-agency linkage study.

METHODS

Costs of hospitalization were estimated from birth (if available) using Round 17, National Hospital Cost Data Collection (2012-13; deflated to 2015-16 AUD). Records of the state child protection authority determined contact status. Data were reported separately for children in OOHC. Hospital separations were classified as mental disorder-related if the primary diagnosis was recorded in ICD-10 Chapter V (F00-F99).

RESULTS

Hospital separations were more common in children with child protection contact. Physical health care costs per child decreased with age for all children, but were significantly higher for children with contact. Mental health costs per child were always significantly higher for children with contact, with marked increases at 3 ≤ 4 years and 8 ≤ 9 years. Point estimates of annual costs per child were always highest for children with an OOHC placement. The net present value of the excess costs was $3,224 per child until 13- years, discounted at 5 %.

CONCLUSIONS

Children in contact with child protection services show higher rates and costs for physical and mental health hospitalizations in each of their first 13 years of life.

Abusive Injuries Are Worse Than Vehicular Injuries: Should We Refocus Prevention?

OBJECTIVES

The objective of this study was to compare the injury severity and outcome of motor vehicle and nonaccidental traumatic injuries and examine trends in mortality rates over time.

METHODS

We reviewed data from 2005 to 2013 from a level 1 pediatric trauma center including demographics, injury severity, and outcomes. Primary outcomes of interest were mortality rates and hospital length of stay.

RESULTS

Injury severity scores were significantly worse for nonaccidental traumas (NATs) (P < 0.001) compared with motor vehicle collisions and motor pedestrian collisions. Nonaccidental traumas were also found to have significantly longer length of stay and higher fatality rates (P < 0.001). Significant differences were also found for the types of injuries sustained for head, extremity, trunk, and other injuries (P < 0.001), and for internal injuries (P < 0.01. Admission rates also dropped for both motor vehicle collisions and motor pedestrian collisions across the 9-year period (P < 0.001) but remained stable for NATs.

CONCLUSION

In this study population, more severe injuries, higher mortality rates, and longer hospital stays were observed in pediatric NAT compared with those sustained through vehicular means. Furthermore, we observed statistically significant declines in motor vehicle-related injuries compared with NAT.

The impact of an educational intervention on knowledge about infant crying and abusive head trauma

BACKGROUND

Infants follow a predictable trajectory of increased early crying. Frustration with crying is reported to be a trigger for abusive head trauma (AHT).

OBJECTIVE

To evaluate the impact of postpartum delivery of the educational program, the Period of PURPLE Crying (PURPLE), in a group of first-time mothers. The primary objective was to determine whether there was a change in knowledge about infant crying and shaking after exposure to PURPLE. Factors associated with change in knowledge were also examined.

METHOD

A total of 93 participants were recruited over a four-month period at a tertiary care hospital in Nova Scotia. Pre- and postintervention data were collected.

RESULTS

Knowledge about infant crying increased significantly after program delivery (P=0.001). Low baseline crying knowledge was a significant predictor of increased knowledge about infant crying (P≤0.01). There was an insignificant decrease in shaking knowledge (P=0.5), which may have been the consequence of high baseline knowledge.

CONCLUSION

An educational program for new parents appears to be warranted, especially with respect to improving knowledge about infant crying. This may have a positive benefit in AHT prevention. Additional studies are required to evaluate the impact of the program on other caregivers and on rates of AHT.

Long-term outcome of abusive head trauma

Abusive head trauma is a severe inflicted traumatic brain injury, occurring under the age of 2 years, defined by an acute brain injury (mostly subdural or subarachnoidal haemorrhage), where no history or no compatible history with the clinical presentation is given. The mortality rate is estimated at 20-25% and outcome is extremely poor. High rates of impairments are reported in a number of domains, such as delayed psychomotor development; motor deficits (spastic hemiplegia or quadriplegia in 15-64%); epilepsy, often intractable (11-32%); microcephaly with corticosubcortical atrophy (61-100%); visual impairment (18-48%); language disorders (37-64%), and cognitive, behavioral and sleep disorders, including intellectual deficits, agitation, aggression, tantrums, attention deficits, memory, inhibition or initiation deficits (23-59%). Those combined deficits have obvious consequences on academic achievement, with high rates of special education in the long term. Factors associated with worse outcome include demographic factors (lower parental socioeconomic status), initial severe presentation (e.g., presence of a coma, seizures, extent of retinal hemorrhages, presence of an associated cranial fracture, extent of brain lesions, cerebral oedema and atrophy). Given the high risk of severe outcome, long-term comprehensive follow-up should be systematically performed to monitor development, detect any problem and implement timely adequate rehabilitation interventions, special education and/or support when necessary. Interventions should focus on children as well as families, providing help in dealing with the child's impairment and support with psychosocial issues. Unfortunately, follow-up of children with abusive head trauma has repeatedly been reported to be challenging, with very high attrition rates.

Advocacy opportunities for pediatricians caring for maltreated children

Pediatricians are advocates for children. It is one of the central elements of the job description. In the course of their work, pediatricians have many opportunities to advocate for abused and neglected children. The most effective form of advocacy that most pediatricians will engage in with regard to child abuse and neglect is by being highly skilled doctors who provide excellent clinical care to children and families, knowing how to recognize child abuse and what to do when they encounter it, and being familiar with the resources of their communities.

Paediatric patients with abusive head trauma treated in US Emergency Departments, 2006-2009

OBJECTIVE

To study characteristics and outcomes of paediatric patients with abusive head trauma (AHT) treated in emergency departments.

METHODS

Nationwide Emergency Department Sample (NEDS) data were analysed. The CDC recommended AHT definition was used to classify children ≤ 4 years with head trauma into AHT and non-AHT groups. Outcomes were compared between patients with AHT and patients with non-AHT. Logistic models were fitted to identify risk factors.

RESULTS

An estimated 10 773 paediatric patients with AHT were treated in EDs in 2006-2009. The average annual rate was 12.83 per 100 000 for children ≤ 4 years. Children < 1 year of age accounted for most AHT cases (60.6%) and males had a significantly higher AHT rate than females. Medicaid was the primary payer for 66.1% of AHT injuries and 40.3% of non-AHT injuries. The case mortality rate was 53.9 (95% CI = 41.0-66.7) per 1000 patients with AHT compared with 1.6 (95% CI = 1.4-1.9) per 1000 patients with non-AHT.

CONCLUSIONS

Child caregivers should be educated about the serious consequences of AHT and proper techniques for caring for infants. Unbiased and accurate documentation of AHT by physicians and medical coders is crucial for monitoring AHT injuries.

Analysis of national empirical data on the characteristics and trends of injury among Taiwan's victims of hospitalized child abuse between 1997 and 2009

OBJECTIVE

To investigate the characteristics and trends of injury among hospitalized child abuse children younger than 18 years between 1997 and 2009.

METHODS

We selected hospitalized child abuse cases from the Taiwan's National Health Insurance (NHI) Database in accordance with ICD-9-CM 995.5x or E967.x.

RESULTS

There were 1,212 victims of hospitalized child abuse during the research period, including 735 boys and 477 girls. The victims were most frequently inflicted by the father or stepfather, and the most common injury was intracranial damage; besides, the victims most commonly sought treatment in medical centers. Infants younger than 1 year accounted for the highest percentage of hospitalized victims. Although there were no apparent trends in the overall hospitalization rate of the child abuse victims over the 13-year period, the rate of abuse among girls increased gradually over the years.

CONCLUSIONS

The medical staff in hospitals should provide appropriate treatment to the victims and contact relevant organizations to intervene; moreover, government agencies should formulate effective control measures to develop a safe growth environment for children.

Primary prevention of pediatric abusive head trauma: a cost audit and cost-utility analysis

OBJECTIVES

To obtain comprehensive, reliable data on the direct cost of pediatric abusive head trauma in New Zealand, and to use this data to evaluate the possible cost-benefit of a national primary prevention program.

METHODS

A 5 year cohort of infants with abusive head trauma admitted to hospital in Auckland, New Zealand was reviewed. We determined the direct costs of hospital care (from hospital and Ministry of Health financial records), community rehabilitation (from the Accident Compensation Corporation), special education (from the Ministry of Education), investigation and child protection (from the Police and Child Protective Services), criminal trials (from the Police, prosecution and defence), punishment of offenders (from the Department of Corrections) and life-time care for moderate or severe disability (from the Accident Compensation Corporation). Analysis of the possible cost-utility of a national primary prevention program was undertaken, using the costs established in our cohort, recent New Zealand national data on the incidence of pediatric abusive head trauma, international data on quality of life after head trauma, and published international literature on prevention programs.

RESULTS

There were 52 cases of abusive head trauma in the sample. Hospital costs totaled $NZ2,433,340, child protection $NZ1,560,123, police investigation $NZ1,842,237, criminal trials $NZ3,214,020, punishment of offenders $NZ4,411,852 and community rehabilitation $NZ2,895,848. Projected education costs for disabled survivors were $NZ2,452,148, and the cost of projected lifetime care was $NZ33,624,297. Total costs were $NZ52,433,864, averaging $NZ1,008,344 per child. Cost-utility analysis resulted in a strongly positive economic argument for primary prevention, with expected case scenarios showing lowered net costs with improved health outcomes.

CONCLUSIONS

Pediatric abusive head trauma is very expensive, and on a conservative estimate the costs of acute hospitalization represent no more than 4% of lifetime direct costs. If shaken baby prevention programs are effective, there is likely to be a strong economic argument for their implementation. This study also provides robust data for future cost-benefit analysis in the field of abusive head trauma prevention.

Medical costs attributable to child maltreatment a systematic review of short- and long-term effects

CONTEXT

Child maltreatment is a serious and prevalent public health problem, which has been shown to be associated with numerous short- and long-term effects on mental and physical health. Few estimates of the medical costs of these effects have been published to date. To determine the range and quality of currently available estimates and identify the gaps and needs for future research, this article reviews research on medical costs of child maltreatment.

EVIDENCE ACQUISITION

Peer-reviewed literature on child maltreatment and medical costs was identified by searching major databases. Twelve articles on the medical costs of child maltreatment were identified.

EVIDENCE SYNTHESIS

Eight studies describe short-term costs among children; four describe adult, long-term costs. Most studies used convenience samples, captured a partial share of the total costs, and did not follow best practices for econometric analysis of medical costs.

CONCLUSIONS

Child maltreatment is associated with substantial medical costs in childhood and adulthood, but estimates vary widely because of differences in research designs, types of cost data, and study quality. Econometric estimates of the annual medical costs in adulthood range from zero to about $800. Per-episode estimates of child costs, based on mean comparisons, range from $0 to >$24,000.

Child Abuse and Neglect

It is important for surgeons to be able to accurately assess and diagnose child abuse. While they are generally not the only medical professionals involved in the care of children with suspected abuse, they are highly regarded by hospital and social service staff, and their input regarding the cause of injury is unlikely to be ignored. Appropriate diagnosis of abusive injury can prevent future morbidity and mortality in these vulnerable patients, and can also reduce the trauma to families from false accusations of abuse. A sensitive and open-ended history, thorough physical examination, appropriate diagnostic workup with consideration of child abuse as an underlying cause, appropriate documentation of findings, and determination of safety for discharge can greatly improve an abused child's current and future health and safety.

Abusive head trauma during a time of increased unemployment: a multicenter analysis

OBJECTIVE

To evaluate the rate of abusive head trauma (AHT) in 3 regions of the United States before and during an economic recession and assess whether there is a relationship between the rate of AHT and county-level unemployment rates.

METHODS

Clinical data were collected for AHT cases diagnosed in children younger than 5 years from January 1, 2004 until June 30, 2009, by hospital-based child protection teams within 3 geographic regions. The recession was defined as December 1, 2007 through June 30, 2009. Quarterly unemployment rates were collected for every county in which an AHT case occurred.

RESULTS

During the 5½-year study period, a total of 422 children were diagnosed with AHT in a 74-county region. The overall rate of AHT increased from 8.9 in 100,000 (95% confidence interval [CI]: 7.8-10.0) before the recession to 14.7 in 100,000 (95% CI: 12.5-16.9) during the recession (P < .001). There was no difference in the clinical characteristics of subjects in the prerecession versus recession period. There was no relationship between the rate of AHT and county-level unemployment rates.

CONCLUSIONS

The rate of AHT increased significantly in 3 distinct geographic regions during the 19 months of an economic recession compared with the 47 months before the recession. This finding is consistent with our understanding of the effect of stress on violence. Given the high morbidity and mortality rates for children with AHT, these results are concerning and suggest that prevention efforts might need to be increased significantly during times of economic hardship.

Missed and missing cases of abusive injuries: the magnitude and the measurement of the problem

OBJECTIVE

The authors' objective is to describe the disparity between the case-fatality rates for inflicted versus unintentional injuries of children, and to emphasize its utility as a way of estimating the effectiveness of the ascertainment of inflicted injuries of children.

METHOD

Determination, comparison, and explanation of the case-fatality-rate disparity in four injury databases were derived from hospitalized injury cases.

RESULTS

The CFR disparity is 6-14-fold in the 4 injury databases. The CFR disparity varies strongly and inversely with the observed incidence of inflicted injuries in the databases.

CONCLUSIONS

A large disparity between the case fatality rates (CFRs) of inflicted and unintentional injuries exists in a number of injury databases. Inflicted injuries have much higher CFRs than unintentional injuries. The disparity can be accounted for by "missed" (incorrectly diagnosed) and "missing" (unseen) cases.

PRACTICE IMPLICATIONS

Present diagnostic criteria for physically abusive (inflicted) injuries are forensically-driven and too conservative for public health purposes. New public-health-oriented case definitions for "inflicted injury" are needed. Programs to reduce injury recidivism in young children should be a part of overall injury prevention.

Clinical report—the pediatrician’s role in child maltreatment prevention

It is the pediatrician’s role to promote the child’s well-being and to help parents raise healthy, well-adjusted children. Pediatricians, therefore, can play an important role in the prevention of child maltreatment. Previous clinical reports and policy statements from the American Academy of Pediatrics have focused on improving the identification and management of child maltreatment. This clinical report outlines how the pediatrician can help to strengthen families and promote safe, stable, nurturing relationships with the aim of preventing maltreatment. After describing some of the triggers and factors that place children at risk for maltreatment, the report describes how pediatricians can identify family strengths, recognize risk factors, provide helpful guidance, and refer families to programs and other resources with the goal of strengthening families, preventing child maltreatment, and enhancing child development.

The utility and challenges of using ICD codes in child maltreatment research: A review of existing literature

OBJECTIVE

The objectives of this article are to explore the extent to which the International Statistical Classification of Diseases and Related Health Problems (ICD) has been used in child abuse research, to describe how the ICD system has been applied, and to assess factors affecting the reliability of ICD coded data in child abuse research.

METHODS

PubMed, CINAHL, PsychInfo and Google Scholar were searched for peer reviewed articles written since 1989 that used ICD as the classification system to identify cases and research child abuse using health databases. Snowballing strategies were also employed by searching the bibliographies of retrieved references to identify relevant associated articles. The papers identified through the search were independently screened by two authors for inclusion, resulting in 47 studies selected for the review. Due to heterogeneity of studies meta-analysis was not performed.

RESULTS

This paper highlights both utility and limitations of ICD coded data. ICD codes have been widely used to conduct research into child maltreatment in health data systems. The codes appear to be used primarily to determine child maltreatment patterns within identified diagnoses or to identify child maltreatment cases for research.

CONCLUSIONS

A significant impediment to the use of ICD codes in child maltreatment research is the under ascertainment of child maltreatment by using coded data alone. This is most clearly identified and, to some degree, quantified, in research where data linkage is used.

PRACTICE IMPLICATIONS

The importance of improved child maltreatment identification will assist in identifying risk factors and creating programs that can prevent and treat child maltreatment and assist in meeting reporting obligations under the CRC.

Child maltreatment law and policy as a foundation for child advocacy

Advocacy for children is a fundamental pediatric concern and activity. Notwithstanding achievements for children to date, pediatrics can do more in the twenty-first century to advocate for children and promote research on ways in which advocacy for children can be improved. Evidence-based advocacy should take many directions including legislation, system change in local and state agencies such as social services and health departments, financial assistance including Medicaid, evidence provided to courts at trial and on appeal through "friend of the court" participation, family guidance, public education, and the promotion of pediatric law and bioethics.

Abusive head trauma

Child physical abuse that results in injury to the head or brain has been described using many terms, including battered child syndrome, whiplash injuries, shaken infant or shaken impact syndrome, and nonmechanistic terms such as abusive head trauma or nonaccidental trauma. These injuries sustained by child abuse victims are discussed in detail in this article, including information about diagnosis, management and outcomes. The use of forensics, the use imaging studies, and associated injuries are also detailed.

Association of injury visits in children and child maltreatment reports

Injuries are a leading cause of childhood morbidity and are also common manifestations of child maltreatment, especially among young children. In an effort to determine whether injury-related Emergency Department (ED) visits among children aged 0 to 4 years were associated with child maltreatment reports, we identified all children with at least one injury-related ED visit in Missouri during 2000. Data on these injured children were linked to Missouri Child Protective Services (CPS) child abuse and neglect reports for 2000 and 2001. There were 50,068 children with at least one injury-related ED visit. Using children with one injury-related ED visit as the reference category, we calculated the relative risk of having a CPS report (or a substantiated report) for children with two, three, and four or more ED visits before a CPS report (or substantiated report). Compared to children with one visit, children with two visits were more likely to have a CPS report (relative risk [RR] 1.9; 95% confidence interval [CI] 1.8-2.0) and a substantiated report (RR 2.5; 95% CI 2.1-2.9). For children with four or more visits, the relative risk of a report and substantiated report was 3.8 (95% CI 3.0-4.7) and 4.7 (95% CI 2.4-9.2), respectively. Children with two or more injury-related ED visits in 1 year are more likely to be reported for child maltreatment and to have a substantiated report.

Assessing the cost-effectiveness of Family Connections

OBJECTIVE

To assess the cost-effectiveness of two alternate forms of Family Connections (FC), a child neglect prevention program, in relation to changes in risk and protective factors and improvements in child safety and behavioral outcomes.

METHODS

In the original FC study, a sample of 154 families (473 children) in a poor, urban neighborhood, who met risk criteria for child neglect, were randomly assigned to receive either a 3- or 9-month intervention. CPS reports and self-report and observational data on risk and protective factors, safety, and behavioral outcomes were collected prior to, at the end of, and 6-months post intervention. The current study compared the costs of delivering the 3- or 9-month intervention in relation to reported improvements in risk and protective factors, safety, and behavioral outcomes for each group.

RESULTS

The 3-month intervention was more cost effective than the 9-month intervention in relation to positive changes in risk and protective factors and child safety. However, cost-effectiveness analysis indicated that the 9-month intervention was more cost effective (CE ratio=$276) than the 3-month intervention (CE ratio=$337) in relation to improved unit changes in the child's behavior between baseline and 6 months after service closure.

CONCLUSIONS

This study successfully explored the cost-effectiveness of the FC intervention in relation to its intended outcomes. More extensive cost analyses are currently being conducted in the replication of this program in multiple jurisdictions across the United States.

PRACTICE IMPLICATIONS

Practitioners in community-based programs must make difficult decisions about the optimal length of time to serve children and families. Prevention programs may be more competitive for funding when they have demonstrated cost-effectiveness. Study results indicated that a 3-month intervention was more cost effective than a 9-month intervention in enhancing protective factors and reducing the risk of child neglect; 9-month intervention was more cost effective than 3-month intervention in reducing problematic child behavior. Further research is needed before practitioners should consider these findings in relation to their own decisions about the timing of service closures.

The relation between child death and child maltreatment

The death of a child is a sentinel event in a community, and a defining marker of a society's policies of safety and health. Child death as a result of abuse and neglect is a tragic outcome that occurs in all nations of the world. The true incidence of fatal child abuse and neglect is unknown. The most accurate incidence data of such deaths have been obtained from countries where multi-agency death review teams analyse the causes of child fatalities, as is done in the United States and Australia.

Perpetrator accounts in infant abusive head trauma brought about by a shaking event

OBJECTIVE

To analyze perpetrator and medical evidence collected during investigations of infant abusive head trauma (IAHT), with a view to (a) identifying cases where injuries were induced by shaking in the absence of any impact and (b) documenting the response of infant victims to a violent shaking event.

METHOD

A retrospective study was undertaken of IAHT cases investigated by the Queensland Police Service over a 10-year period. Cases of head trauma involving subdural and/or subarachnoid hematoma and retinal hemorrhages, in the absence of any evidence of impact, were defined as shaking-induced. Perpetrator statements were then examined for further evidence to support the shaking hypothesis and for descriptions of the victim's immediate response to a shaking event.

RESULTS

From a total of 52 serious IAHT cases, 13 (25%) were found to have no medical or observer evidence of impact. In 5 of those 13 cases, there was a statement by the perpetrator to the effect that the victim was subjected to a shaking event. In several cases both with and without evidence of associated impact, perpetrator accounts described an immediate neurological response on the part of the victim.

CONCLUSION

The study confirms that IAHT resulting in death or serious neurological impairment can be induced by shaking alone. In cases where the infant's medical condition was adequately described, the symptoms of head injury presented immediately.

Early case conferences shorten length of stay in children admitted to hospital with suspected child abuse

OBJECTIVE

To compare the outcomes of two models for the management of children admitted to hospital with suspected child abuse: routine early case conferencing versus standard evaluation.

METHODS

Between March 2001 and February 2002 professionals from the Royal Children's Hospital, Melbourne, Victoria Police and Child Protection services collaborated on a randomized controlled study involving children admitted to hospital with suspected child abuse. The intervention group (n = 13) received a case conference within 24 h of the child's admission to hospital. The control group (n = 12) were managed according to standard procedures whereby each organization conducted their own evaluation (and a case conference might or might not have been held). Patients were followed for 3 months with data collected from all three professional groups.

RESULTS

The process of evaluation, the eventual diagnosis of child abuse and the confidence with which professionals made this diagnosis was not significantly different between the groups. Case conferences were judged to be useful regardless of their timing. Mean length of stay in the intervention group was significantly less than in controls (42.4 h vs 99.7 h, P = 0.01).

CONCLUSION

Early case conferences appear to shorten the period of time children spend in hospital when child abuse is suspected. This has significant implications for reducing costs for all organizations involved in the evaluation of suspected child abuse.

The costs of interpersonal violence--an international review

This article reviews evidence of the economic impact of interpersonal violence internationally. In the United States, estimates of the costs of interpersonal violence reach 3.3% of GDP. The public sector-and thus society in general-bears the majority of these costs. Interpersonal violence is defined to include violence between family members and intimate partners, and violence between acquaintances and strangers that is not intended to further the aims of any formally defined group or cause. Although these types of violence disproportionately affect poorer countries, there is a scarcity of studies of their economic impact in these countries. International comparisons are complicated by the calculation of economic losses based on foregone wages and income, thus undervaluing economic losses in poorer countries.

Abusive head trauma in young children: characteristics and medical charges in a hospitalized population

OBJECTIVE

To describe the presenting characteristics, hospital course, and hospital charges associated with hospital admissions for head trauma in young children at a regional pediatric trauma center, and to examine whether these factors differ among abused and non-abused subjects.

METHOD

Comparative case series study involving a retrospective medical record review of children less than 3 years of age admitted to Children's Hospital of Pittsburgh from January 1, 1995 to December 31, 1999. Subjects (n=377) were identified on the basis of ICD-9-CM codes for head injury. Subjects were classified as abused or non-abused based on standard criteria using information about the type of injuries, the history provided by the caretaker, and physical and radiographic findings.

RESULTS

Eighty nine (23.6%) subjects were classified as abused and 288 (76.4%) were classified as non-abused. Abused subjects were more likely then non-abused subjects to be <1 year of age (vs. >1 year of age) (OR: 9.8; 95% CI: 5.0, 19.2), covered by Medicaid (vs. commercial insurance) (OR: 2.8; 95% CI: 1.7, 4.8), and admitted to the ICU (OR: 3.5; 95% CI: 2.1, 5.8; p<.001). The caretakers of abused subjects were more likely to give a history of no trauma or minor trauma compared to the caretakers of non-abused subjects (97% vs. 54%, p<.001). Length of stay was significantly greater for abused subjects versus non-abused subjects (mean: 9.25 days vs. 3.03 days, p<.001). Hospital charges (1999 dollars) were significantly higher for abused (mean+/-SD: 40,082 dollars +/- 58,004 dollars) versus non-abused (mean +/- SD: 15,671 dollars +/- 41,777 dollars) subjects.

CONCLUSIONS

These results highlight the differences in the demographics, presenting characteristics and economic impact of abusive head injuries compared to non-abusive head injuries.