To report or not to report: examination of the initial primary care management of suspicious childhood injuries

ObjectiveThis study examined the validity of primary health care providers’ (PHCPs) assessment of suspicion that an injury was caused by child abuse and their decision to report suspected child abuse to child protective services (CPS).MethodsBy using a subsample of injuries drawn from the 15,003 childhood injuries evaluated in the Child Abuse Recognition and Evaluation Study, PHCPs completed telephone interviews concerning a stratified sample (no suspicion of abuse; suspicious but not reported; and suspicious of abuse and reported) of 111 injury visits. Two techniques were used to validate the PHCPs’ initial decision: expert review and provider retrospective self-assessment. Five child abuse experts reviewed clinical vignettes created by using data prospectively collected by PHCPs about the patient encounter. The PHCPs’ opinions 6 weeks and 6 months after the injury-related visits were elicited and analyzed.ResultsPHCPs and experts agreed about the suspicion of abuse in 81% of the cases of physical injury. PHCPs did not report 21% of injuries that experts would have reported. Compared with expert reviewers, PHCPs had a 68% sensitivity and 96% specificity in reporting child abuse. A PHCP’s decision to report suspected child abuse to CPS did not reduce the frequency of primary care follow-up in the 6 months after the index visit. PCHPs received information from their state CPS in 70% of the reported cases.ConclusionsChild abuse experts and PHCPs are in general agreement concerning the assessment of suspected child physical abuse, although experts would have reported suspected abuse to CPS more frequently than the PHCPs. Future training should focus on clear guidance for better recognition of injuries that are suspicious for child abuse and state laws that mandate reporting.     

The Use of Experts to Evaluate a Child Abuse Guideline in Community Emergency Departments

ObjectiveGuidelines and pathways exist to help frontline providers evaluate injured children for suspected child abuse. Little, however, is known about whether the decision-making resulting from these interventions is correct. Therefore, in the absence of an available gold-standard test, we used experts’ judgments to examine the appropriateness of these clinical decisions. We evaluated community emergency department (ED) providers’ adherence to a guideline recommending a child protection team (CPT) consultation for infants with injuries associated with abuse. We then compared providers’ decision-making to experts’ recommendations before and after guideline implementation.MethodsTwo experts conducted a blinded, retrospective review of injured infants from 3 community EDs (N = 175). Experts rated the likelihood that an injury was abusive, indeterminate, or accidental, and made recommendations that were compared with skeletal survey (SS) testing and child protective services (CPS) reporting by providers before and after guideline implementation.ResultsPostguideline implementation, there was a significant increase in CPT consultations in indeterminate cases (14.3% vs 72.2%, P < .001) and in SS testing when experts recommended SS (20.6% vs 56.8%, P = .002). In contrast, a higher percentage of cases for whom the experts did not recommend reporting were reported to CPS (1.8% vs 14.6%, P = .02).ConclusionsProviders consulted the CPT most often for indeterminate cases. SS testing was in line with expert recommendations, but CPS reporting diverged from expert recommendations. Interventions linking community ED providers with a CPT may improve the evaluation of infants with injuries concerning for abuse.     

Child Abuse Pediatrics Research Network: The CAPNET Core Data Project

ObjectiveExamine the epidemiology of subspecialty physical abuse evaluations within CAPNET, a multicenter child abuse pediatrics research network.MethodsWe conducted a cross-sectional study of children <10 years old who underwent an evaluation (in-person or remote) by a child abuse pediatrician (CAP) due to concerns for physical abuse at ten CAPNET hospital systems from February 2021 through December 2021.ResultsAmong 3667 patients with 3721 encounters, 69.4% were <3 years old; 44.3% <1 year old, 59.1% male; 27.1% Black; 57.8% White, 17.0% Hispanic; and 71.0 % had public insurance. The highest level of care was outpatient/emergency department in 60.7%, inpatient unit in 28.0% and intensive care in 11.4%. CAPs performed 79.1% in-person consultations and 20.9% remote consultations. Overall, the most frequent injuries were bruises (35.2%), fractures (29.0%), and traumatic brain injuries (TBI) (16.2%). Abdominal (1.2%) and spine injuries (1.6%) were uncommon. TBI was diagnosed in 30.6% of infants but only 8.4% of 1-year old children. In 68.2% of cases a report to child protective services (CPS) was made prior to CAP consultation; in 12.4% a report was made after CAP consultation. CAPs reported no concern for abuse in 43.0% of cases and mild/intermediate concern in 22.3%. Only 14.2% were categorized as definite abuse.ConclusionMost children in CAPNET were <3 years old with bruises, fractures, or intracranial injuries. CPS reports were frequently made prior to CAP consultation. CAPs had a low level of concern for abuse in majority of cases.     

Barriers to physician identification and reporting of child abuse

Physicians systematically underidentify and underreport cases of child abuse. These medical errors may result in continued abuse, leading to potentially severe consequences. We have reviewed a number of studies that attempt to explain the reasons for these errors. The findings of these various studies suggest several priorities for improving the identification and reporting of child maltreatment: Improve continuing education about child maltreatment. Continuing education should focus not only on the identification of maltreatment but also on management and outcomes. This education should include an explanation of the role of CPS investigator and the physician's role in an investigation. The education should provide physicians with a better understanding of the overall outcome for children reported to CPS to help physicians gain perspective on the small number of maltreated children they may care for in their practice. This education should emphasize that the majority of maltreated children will benefit from CPS involvement. New York is the only state that mandates all physicians, as well as certain other professionals, take a 2-hour course called Identification and Reporting of Child Abuse and Maltreatment prior to licensing. Cited studies in this article suggest that such a mandate might be expected to improve identification and reporting, thereby encouraging other states to adopt similar regulations. Give physicians the opportunity to debrief with a trained professional after detecting and reporting child abuse. The concept of child abuse and the gravity of the decision to report can be troubling to the reporter. The debriefing could include discussions of uncomfortable feelings physicians may experience related to their own countertransference reactions. Provide resources to assist physicians in making the difficult determination of suspected maltreatment. The role of accessible telephone consultation should be evaluated, along with formalized collaborations with local Emergency Departments with pediatric expertise. Improve the relationship between CPS and medical providers. For example, CPS workers should systematically inform the reporting physician about the progress of their investigation and the outcome for the child and family. Several past reports have made specific suggestions to improve the working relationship. Warner and Hanson recommended that positive outcomes be programmed into the reporting process. They suggested that CPS have special phone lines staffed by well-trained employees for mandated reporters to call. Finkelhor and Zellman proposed a more radical change to improve the working relationship between CPS and mandated reporters. They suggested that certain professionals, with demonstrated expertise in the recognition and treatment of child abuse and registered as such, should have "flexible reporting options." Options include the ability to defer reporting, if there are no immediate threats to a child, or to make a report in confidence and defer the investigation until necessary. Finkelhor and Zellman emphasized that this model would improve physician-reporting compliance and enhance the role of CPS while reducing the work burden for CPS. Improve interaction with the legal system. Child abuse pediatric experts who have courtroom experience could provide education and support to physicians who have little preexisting experience with the legal system. Reimbursement for time spent supporting legal proceedings should be equitable and may reduce physician concerns about lost patient revenue. Retrospective studies and vignette analyses provide much information about some of the barriers to child maltreatment reporting and describe many of the reasons why physicians do not identify and report all child maltreatment. Future prospective examinations of physician decision-making may further explain the physician's decision-making process and the barriers he or she faces when identifying and reporting child abuse.     

Prise en charge et prévention de la maltraitance au Québec: programme de pédiatrie sociojuridique de l''hôpital Sainte-Justine à Montréal

In Quebec, the Child's Protection law protects the child from birth until 18 years of age when child abuse or neglect is suspected. Since 1990, the program of the Child Protection Clinic of Sainte-Justine Hospital (Montreal) offers a special unit for evaluation and prevention of child abuse and neglect, constituted by a multidisciplinary team including five pediatricians. About 500 children are referred each year in external consultations or from hospital units. In addition, the pediatricians participate in the “programme Santé-Enfance-Jeunesse”, a prevention program in the Montreal area. They also act as expert witnesses in court. Thus Quebec's pediatricians fully participate in a child's protection with their activities in different levels of diagnosis, management and prevention of child abuse and neglect     

Perceived social risk in medical decision-making for physical child abuse: a mixed-methods study

Background

The medical literature reports differential decision-making for children with suspected physical abuse based on race and socioeconomic status. Differential evaluation may be related to differences of risk indicators in these populations or differences in physicians’ perceptions of abuse risk. Our objective was to understand the contribution of the child’s social ecology to child abuse pediatricians’ perception of abuse risk and to test whether risk perception influences diagnostic decision-making.

Methods

Thirty-two child abuse pediatrician participants prospectively contributed 746 consultations from for children referred for physical abuse evaluation (2009–2013). Participants entered consultations to a web-based interface. Participants noted their perception of child race, family SES, abuse diagnosis. Participants rated their perception of social risk for abuse and diagnostic certainty on a 1–100 scale. Consultations (n?=?730) meeting inclusion criteria were qualitatively analyzed for social risk indicators, social and non-social cues. Using a linear mixed-effects model, we examined the associations of social risk indicators with participant social risk perception. We reversed social risk indicators in 102 cases whilst leaving all injury mechanism and medical information unchanged. Participants reviewed these reversed cases and recorded their social risk perception, diagnosis and diagnostic certainty.

Results

After adjustment for physician characteristics and social risk indicators, social risk perception was highest in the poorest non-minority families (24.9 points, 95%CI: 19.2, 30.6) and minority families (17.9 points, 95%CI, 12.8, 23.0). Diagnostic certainty and perceived social risk were associated: certainty increased as social risk perception increased (Spearman correlation 0.21, p?<?0.001) in probable abuse cases; certainty decreased as risk perception increased (Spearman correlation (?)0.19, p?=?0.003) in probable not abuse cases. Diagnostic decisions changed in 40% of cases when social risk indicators were reversed.

Conclusions

CAP risk perception that poverty is associated with higher abuse risk may explain documented race and class disparities in the medical evaluation and diagnosis of suspected child physical abuse. Social risk perception may act by influencing CAP certainty in their diagnosis.

     

Pediatrician characteristics associated with child abuse identification and reporting: results from a national survey of pediatricians

Pediatrician experience with child protective services (CPS) and factors associated with identifying and reporting suspected child physical abuse were examined by a survey of members of the American Academy of Pediatrics (AAP). Respondents provided information about their demographics and experience, attitudes and practices with child abuse. They indicated their diagnosis and management of a child in a purposely ambiguous clinical vignette. Pediatricians who had received recent child abuse education were more confident in their ability to identify and manage child abuse. High confidence in ability to manage child abuse and positive attitude about domestic violence screening and value of anticipatory guidance predicted that pediatricians would have high suspicion that the child in the vignette was abused and that they would report the child to CPS. Future efforts to improve medical intervention in child abuse should focus on physician attitudes and experience, as well as cognitive factors.     

Factors affecting pediatricians' reporting of suspected child maltreatment.

OBJECTIVE: To identify factors associated with pediatricians' decision not to report suspected child maltreatment. DESIGN: A survey was distributed to a random sample of pediatricians in a single state. Participants were asked if they had ever suspected child abuse or neglect but did not report. In addition, all were asked to list all the considerations that pediatricians incorporate into their decisions not to report. RESULTS: One hundred ninety-five pediatricians completed the survey (56% of those eligible). Twenty-eight percent of respondents stated that they had considered reporting an incident of suspected child maltreatment but had chosen not to. Providers who had chosen not to report were more likely to be men (P = .006), to have been in practice longer (P = .001), to have reported more cases (P = .001), to have been deposed (P = .001) or to have testified (P = .01) in child maltreatment cases, and to have been threatened with lawsuit (P = .02) than were pediatricians who had never declined to report. Multivariate logistic regression demonstrated that male gender (odds ratio [OR] 2.18; 95% confidence interval [CI] 1.05-4.49), years in practice (OR 1.23; 95% CI 1.05-1.44), and experience reporting (OR 1.28; 95% CI 1.02-1.60) were all independently associated with decisions not to report. Respondents who had declined to report were more likely to cite lack of knowledge about reporting laws and process (P = .05) and poor experiences with child service agencies (P = .03) as reasons for not reporting than were their counterparts who had never declined to report suspected maltreatment. CONCLUSIONS: Many barriers exist to reporting suspected maltreatment. Specific educational interventions may be helpful in eliminating barriers to reporting.     

Current pediatric roles in child abuse and neglect.

Many pediatricians are being called on to undertake expanded roles in the field of child abuse and neglect, whether as a practicing pediatrician, a hospital-based child abuse consultant, or as a child protection team pediatrician. The practicing pediatrician must consider the diagnosis of child abuse and neglect, confirm the diagnosis, report all suspected cases to child protective services, hospitalize any abused child who needs protection, and provide preventive services. The hospital-based child abuse consultant should provide consultation to primary physicians, report seriously injured cases for the primary physician or surgeon, provide expert medical testimony on difficult to prove cases, teach house staff and medical students about child abuse and neglect, and improve treatment services for abused children who are hospitalized. The child protection team pediatrician will usually become involved in the broader problem of improving team decision making and the interagency system that deals with child abuse and neglect.     

Evolución de los ingresos por maltrato infantil durante 15 años

AimTo measure the incidence of admissions for maltreatment between 1995 and 2009 and to determine their main clinical and epidemiological characteristics.MethodsRetrospective review of children diagnosed with maltreatment over 15years in a third level hospital.ResultsA total of 97 cases (median incidence 0.5 cases per 1000 children admitted per year) were found. There was an increasing rate of physical maltreatment, while those of sexual abuse declined. 51 (53.6%) female; median age 3.3 years (p25-75: 7.6 months-10.0 years). Just under half (43.3%) or 42 patients, had a primary complaint unrelated to abuse. The most common injuries were haematomas (43; 44.3%). In 91 (93.8%) cases the perpetrator was found to be a member of the child's own family (77; 74.9%, one of the parents or both).ConclusionsThe increase in admissions for physical maltreatment stresses the need to insist in a prevention policy. The decrease in admissions for sexual abuse was probably attributable to changes in the care circuit rather than a real decrease. In almost half of the cases the suspicion of maltreatment arose upon physical examination or after complementary tests, making it advisable that maltreatment is included in the differential diagnosis in multiple consultations. The majority of maltreatment occurred in the context of the victim's family.     

We Have All Been Working in Our Own Little Silos Forever: Exploring a Cross-Sector Response to Child Maltreatment

ObjectiveA child protective services (CPS) investigation for maltreatment signals risk for childhood toxic stress and poor health outcomes. Despite this, communication between child welfare and health care professionals is rare. We present a qualitative exploration of experiences with, barriers to, and hopes for cross-sector collaboration for children with suspected maltreatment.MethodsWe conducted focus groups with child welfare and health care professionals participating in a cross-sector learning collaborative to improve care for children at high risk for toxic stress. Participants were asked to describe 2 phenomena: identifying and responding to childhood adversities in their professional settings and cross-sector collaboration in cases of suspected maltreatment. Analysis included an iterative process of reading, coding and comparing themes across groups.ResultsHealth care professionals shared positive experiences in screening for social risks in clinic, while child welfare professionals expressed mixed attitudes toward social risk screening during CPS investigations. Consistent with prior research, health care professionals reported limited communication with CPS caseworkers about patients but suggested that relationships with child welfare professionals might reduce these barriers. Child welfare professionals described the poor quality of information provided in referrals from medical settings. Caseworkers also recognized that improved communication could support better understanding of maltreatment concerns and sharing of outcomes of CPS investigation.ConclusionsOur project extends previously published research by describing potential benefits of child welfare and child health care collaboration in cases of suspected maltreatment. Lack of effective cross-sector communication and concerns about confidentiality present significant barriers to uptake of these collaborative practices.     

An approach to child maltreatment documentation and participation in the court system

When asked to provide an assessment of a patient for whom there are concerns of suspected maltreatment, the clinician may have uncertainty about how to best proceed for a number of reasons including the actual or potential involvement of a child welfare authority. Existing literature helps to define the role of the medical expert in child abuse assessments, but there is little published guidance targeted to the general practitioner. The present article offers practical advice about the approach to: documentation of a child abuse assessment; providing testimony and behaviour in the court system for the nonexpert; and, finally, guidance for individuals giving expert or opinion evidence for medicolegal purposes. In all cases, if the clinician has specific concerns or unanswered questions about their role and responsibilities, they can contact their professional medicolegal association for support.     

Health care providers' experience reporting child abuse in the primary care setting. Pediatric Practice Research Group

OBJECTIVES: To describe (1) primary care providers' experiences identifying and reporting suspected child abuse to child protective services (CPS) and (2) variables affecting providers' reporting behavior. DESIGN AND METHODS: Health care providers (76 physicians, 8 nurse practitioners, and 1 physician assistant) in a regional practice-based network completed written surveys that collected information about the demographic characteristics of each provider and practice; the provider's career experience with child abuse; and the provider's previous year's experience identifying and reporting suspected child abuse, including experience with CPS. RESULTS: All providers (N = 85) in 17 participating practices completed the survey. In the preceding 1 year, 48 respondents (56%) indicated that they had treated a child they suspected was abused, for an estimated total of 152 abused children. Seven (8%) of 85 providers did not report a total of 7 children with suspected abuse (5% of all suspected cases). A majority of providers (63%; n = 29) believed that children who were reported had not benefited from CPS intervention, and 21 (49%) indicated that their experience with CPS made them less willing to report future cases of suspected abuse. Providers who had some formal education in child abuse after residency were 10 times more likely to report all abuse than were providers who had none. CONCLUSIONS: Primary care providers report most, but not all, cases of suspected child abuse that they identify. Past negative experience with CPS and perceived lack of benefit to the child were common reasons given by providers for not reporting. Education increases the probability that providers will report suspected abuse.     

Child physical abuse with and without other forms of maltreatment: dysfunctionality versus dysnormality

The fact that most etiological studies of physical abuse have not taken into account co-occurrence of different forms of maltreatment calls into question the validity of our knowledge on the subject. The aim of this study, therefore, is to compare the etiological patterns of cases of physical abuse reported to Quebec child protective services (CPS) according to whether the abuse occurs alone or co-occurs with other forms of maltreatment. The data are taken from the Quebec Incidence Study (QIS), which examined 4,929 reports investigated by Quebec CPS in the fall of 1998. The cases included 514 children who were physically abused: 269 of them were not subjected to any other type of maltreatment and 245 were also victims of one or two other forms of maltreatment. The survey form provided information on more than 30 characteristics of the children reported, their families, and their parental figures. Bivariate and direct logistic regression analyses revealed that the profile of physical abuse cases varies depending on whether the physical abuse occurs alone (what we are calling dysnormality) or in combination with one or two other forms of maltreatment (dysfunctionality). Those results will help deepen our etiological knowledge of physical abuse and may serve to inspire different types of intervention for the two groups of children.     

A Novel Scale to Communicate Perceived Likelihood of Child Sexual Abuse

Background and ObjectiveChild abuse pediatricians (CAPs) are often asked to determine the likelihood that a particular child has been sexually abused. These determinations affect medical and legal interventions, and are important for multisite research. No widely accepted scale is available to communicate perceived sexual abuse likelihood. In this study, we measure intra- and inter-rater reliability of a 5-point scale to communicate child sexual abuse likelihood.MethodsWe developed a 5-point scale of perceived likelihood of child sexual abuse with example cases and medical-legal language for each risk category. We then surveyed CAPs who regularly perform sexual abuse evaluations using the abstracted facts of 15 actual cases with concern for sexual abuse. A subset of participants rated the same vignettes again, 1 month later.ResultsOf 512 invited participants, 240 (46.7%) responded, with 145 (28.3%) indicating that they regularly perform sexual abuse evaluations, 116 initially completing all 15 vignettes, and 36 completing repeat ratings at least 1 month later. The scale showed consistent stepwise increase in mean perceived likelihood of abuse and intention to report for each increase in scale rating. Inter-rater agreement was substantial (Fleiss’ weighted kappa 0.64) and test-retest reliability among 36 participants was almost perfect (Cohen's kappa = 0.81).ConclusionsWe introduce a scale of perceived sexual abuse likelihood that appears to reflect CAPs’ perceptions and intention to report. This scale may be a reasonable metric for use in multicenter studies. CAPs demonstrated substantial inter- and intrarater reliability when evaluating sexual abuse likelihood in case vignettes. While this scale may improve communication of sexual abuse likelihood among experts, its examples should not be used as a legal standard or a clinical criterion for sexual abuse diagnosis.     

Beyond Munchausen syndrome by proxy: identification and treatment of child abuse in a medical setting

The condition widely known as Munchausen syndrome by proxy comprises both physical abuse and medical neglect and is also a form of psychological maltreatment. Although it is a relatively rare form of child abuse, pediatricians need to have a high index of suspicion when faced with seemingly inexplicable findings or treatment failures. The fabrication of a pediatric illness is a form of child abuse and not merely a mental health disorder, and there is a possibility of an extremely poor prognosis if the child is left in the home. In this statement, factors are identified that may help the physician recognize this insidious type of child abuse that occurs in a medical setting, and recommendations are provided for physicians regarding when to report a case to their state's child protective service agency.     

Validating Use of ICD-10 Diagnosis Codes in Identifying Physical Abuse Among Young Children

ObjectiveEvaluate the positive predictive value of International Classification of Disease, 10th Revision, Clinical Modification (ICD-10-CM) codes in identifying young children diagnosed with physical abuse.MethodsWe extracted 230 charts of children <24 months of age who had any emergency department, inpatient, or ambulatory care encounters between Oct 1, 2015 and Sept 30, 2020 coded using ICD-10-CM codes suggestive of physical abuse. Electronic health records were reviewed to determine if physical abuse was considered during the medical encounter and assess the level of diagnostic certainty for physical abuse. Positive predictive value of each ICD-10-CM code was assessed.ResultsOf 230 charts with ICD-10 codes concerning for physical abuse, 209 (91%) had documentation that a diagnosis of physical abuse was considered during an encounter. The majority of cases, 138 (60%), were rated as definitely or likely abuse, 36 cases (16%) were indeterminate, and 35 (15%) were likely or definitely accidental injury. Other forms of suspected maltreatment were discussed in 16 (7%) charts and 5 (2%) had no documented concerns for child maltreatment. The positive predictive values of the specific ICD-10 codes for encounters rated as definitely or likely abuse varied considerably, ranging from 0.89 (0.80–0.99) for T74.12 “Adult and child abuse, neglect, and other maltreatment, confirmed” to 0.24 (95% CI: 0.06–0.42) for Z04.72 “Encounter for examination and observation following alleged child physical abuse.”ConclusionsICD-10-CM codes identify young children who experience physical abuse, but certain codes have a higher positive predictive value than others.     

The psychological maltreatment of children--technical report

Psychological maltreatment is a common consequence of physical and sexual abuse but also may occur as a distinct entity. Until recently, there has been controversy regarding the definition and consequences of psychological maltreatment. Sufficient research and consensus now exist about the incidence, definition, risk factors, and consequences of psychological maltreatment to bring this form of child maltreatment to the attention of pediatricians. This technical report provides practicing pediatricians with definitions and risk factors for psychological maltreatment and details how pediatricians can prevent, recognize, and report psychological maltreatment. Contemporary references and resources are provided for pediatricians and parents     

Educational paper

It is the pediatrician’s role to promote the child’s well-being and to help parents raise healthy, well-adjusted children. Today’s pediatricians are confronted with a patient population in which there is a high prevalence of child abuse in its different presentations (physical, sexual, and psychological abuse and/or neglect). The immediate and long-term consequences of child abuse often are lifelong and even life-threatening in its most dramatic presentation. Unfortunately, detection of child abuse remains a difficult challenge for many physicians but also for the “well-trained” pediatrician, leaving many abused children unreported. This paper addresses the important role pediatricians can play in the detection, diagnosis, and prevention of child maltreatment.