Reliability of Routinely Collected Hospital Data for Child Maltreatment Surveillance

Background  

Internationally, research on child maltreatment-related injuries has been hampered by a lack of available routinely collected health data to identify cases, examine causes, identify risk factors and explore health outcomes. Routinely collected hospital separation data coded using the International Classification of Diseases and Related Health Problems (ICD) system provide an internationally standardised data source for classifying and aggregating diseases, injuries, causes of injuries and related health conditions for statistical purposes. However, there has been limited research to examine the reliability of these data for child maltreatment surveillance purposes. This study examined the reliability of coding of child maltreatment in Queensland, Australia.     

Measuring health-related quality of life for child maltreatment: a systematic literature review

Background  

Child maltreatment causes substantial morbidity and mortality in the U.S. Morbidity associated with child maltreatment can reduce health-related quality of life. Accurately measuring the reduction in quality of life associated with child maltreatment is essential to the economic evaluation of educational programs and interventions to reduce the incidence of child maltreatment. The objective of this study was to review the literature for existing approaches and instruments for measuring quality-of-life for child maltreatment outcomes.     

Identifying perinatal risk factors for infant maltreatment: an ecological approach

Background  

Child maltreatment and its consequences are a persistent problem throughout the world. Public health workers, human services officials, and others are interested in new and efficient ways to determine which geographic areas to target for intervention programs and resources. To improve assessment efforts, selected perinatal factors were examined, both individually and in various combinations, to determine if they are associated with increased risk of infant maltreatment. State of Georgia birth records and abuse and neglect data were analyzed using an area-based, ecological approach with the census tract as a surrogate for the community. Cartographic visualization suggested some correlation exists between risk factors and child maltreatment, so bivariate and multivariate regression were performed. The presence of spatial autocorrelation precluded the use of traditional ordinary least squares regression, therefore a spatial regression model coupled with maximum likelihood estimation was employed.     

Quality of life in maltreated children and adult survivors of child maltreatment: a systematic review

Purpose

To review data on health-related quality of life (HRQoL) in individuals with childhood trauma, including psychological maltreatment, physical maltreatment, sexual abuse, and neglect.

Methods

The literature search was conducted with pre-defined keywords using the following electronic bibliographic databases: EMBASE, PubMed, MEDLINE, CINAHL, PsyINFO, PSYNDEX, and Cochrane Database of Systematic Reviews. Further databases were searched for relevant dissertations. Study selection and data extraction were completed by two independent reviewers.

Results

The literature search yielded 1568 entries. Nineteen articles met all inclusion criteria and were retained for further analysis. Findings quite consistently showed significant negative associations between child maltreatment and both self- and proxy-rated HRQoL. Effect sizes range from small to large. Number of types of maltreatment and HRQoL were found to be negatively related.

Conclusion

Data on HRQoL for maltreated children are still rare. Studies often investigate adult survivors of child maltreatment. Considering HRQoL in children and adolescents who suffered maltreatment would allow the planning of effective interventions and the evaluation of treatments to improve HRQoL of these children.

     

Fatal child maltreatment associated with multiple births in Japan: nationwide data between July 2003 and March 2011

Objectives

The purpose of the present study is to clarify the impact of multiple births in fatal child maltreatment (child death due to maltreatment).

Methods

The national annual reports on fatal child maltreatment, which contain all cases from July 2003 to March 2011, published by the Ministry of Health, Labor and Welfare of Japan, were used as the initial sources of information. Parent–child murder–suicide cases were excluded from the analyses. Multiple births, teenage pregnancy and low-birthweight were regarded as the exposed groups. The relative risks (RRs) and their 95 % confidence intervals (CIs) were estimated using the data from the above reports and vital statistics. These analyses were performed both including and excluding missing values.

Results

Among 437 fatal child maltreatment cases, 14 multiple births from 13 families were identified. The RRs of multiple births per individual were 1.8 (95 % CI 1.0–3.0) when including missing values and 2.7 (95 % CI 1.5–4.8) when excluding missing values. The RRs of multiple births per family were 3.6 (95 % CI 2.1–6.2) when including missing values and 4.9 (95 % CI 2.7–9.0) when excluding missing values. The RR tended to be much lower than the RR of teenage pregnancy (RR 12.9 or 22.2), but slightly higher than the RR of low-birthweight (RR 1.4 or 2.9).

Conclusions

Families with multiple births had elevated risk for fatal child maltreatment both per individual and per family unit. Health providers should be aware that multiple pregnancies/births may place significant stress on families and should provide appropriate support and intervention.     

Child maltreatment prevention: a systematic review of reviews

Objective

To synthesize recent evidence from systematic and comprehensive reviews on the effectiveness of universal and selective child maltreatment prevention interventions, evaluate the methodological quality of the reviews and outcome evaluation studies they are based on, and map the geographical distribution of the evidence.

Methods

A systematic review of reviews was conducted. The quality of the systematic reviews was evaluated with a tool for the assessment of multiple systematic reviews (AMSTAR), and the quality of the outcome evaluations was assessed using indicators of internal validity and of the construct validity of outcome measures.

Findings

The review focused on seven main types of interventions: home visiting, parent education, child sex abuse prevention, abusive head trauma prevention, multi-component interventions, media-based interventions, and support and mutual aid groups. Four of the seven – home-visiting, parent education, abusive head trauma prevention and multi-component interventions – show promise in preventing actual child maltreatment. Three of them – home visiting, parent education and child sexual abuse prevention – appear effective in reducing risk factors for child maltreatment, although these conclusions are tentative due to the methodological shortcomings of the reviews and outcome evaluation studies they draw on. An analysis of the geographical distribution of the evidence shows that outcome evaluations of child maltreatment prevention interventions are exceedingly rare in low- and middle-income countries and make up only 0.6% of the total evidence base.

Conclusion

Evidence for the effectiveness of four of the seven main types of interventions for preventing child maltreatment is promising, although it is weakened by methodological problems and paucity of outcome evaluations from low- and middle-income countries.     

The burden of child maltreatment in China: a systematic review

Objective

To estimate the health and economic burdens of child maltreatment in China.

Methods

We did a systematic review for studies on child maltreatment in China using PubMed, Embase, PsycInfo, CINAHL-EBSCO, ERIC and the Chinese National Knowledge Infrastructure databases. We did meta-analyses of studies that met inclusion criteria to estimate the prevalence of child neglect and child physical, emotional and sexual abuse. We used data from the 2010 global burden of disease estimates to calculate disability-adjusted life-years (DALYs) lost as a result of child maltreatment.

Findings

From 68 studies we estimated that 26.6% of children under 18 years of age have suffered physical abuse, 19.6% emotional abuse, 8.7% sexual abuse and 26.0% neglect. We estimate that emotional abuse in childhood accounts for 26.3% of the DALYs lost because of mental disorders and 18.0% of those lost because of self-harm. Physical abuse in childhood accounts for 12.2% of DALYs lost because of depression, 17.0% of those lost to anxiety, 20.7% of those lost to problem drinking, 18.8% of those lost to illicit drug use and 18.3% of those lost to self-harm. The consequences of physical abuse of children costs China an estimated 0.84% of its gross domestic product – i.e. 50 billion United States dollars – in 2010. The corresponding losses attributable to emotional and sexual abuse in childhood were 0.47% and 0.39% of the gross domestic product, respectively.

Conclusion

In China, child maltreatment is common and associated with large economic losses because many maltreated children suffer substantial psychological distress and might adopt behaviours that increase their risk of chronic disease.     

Risk factors for maltreatment-related infant hospitalizations in New York City, 1995–2004

Background

Child maltreatment is a major public health problem, but population-based surveillance and research is hindered by limitations of official child welfare data. The present study used a promising complementary data source, hospital discharge data, to investigate risk factors for infant injuries suggestive of maltreatment.

Public health surveillance of fatal child maltreatment: analysis of 3 state programs

Objectives. We sought to describe approaches to surveillance of fatal child maltreatment and to identify options for improving case ascertainment.Methods. Three states—California, Michigan, and Rhode Island—used multiple data sources for surveillance. Potential cases were identified, operational definitions were applied, and the number of maltreatment deaths was determined.Results. These programs identified 258 maltreatment deaths in California, 192 in Michigan, and 60 in Rhode Island. Corresponding maltreatment fatality rates ranged from 2.5 per 100000 population in Michigan to 8.8 in Rhode Island. Most deaths were identified by child death review teams in Rhode Island (98%), Uniform Crime Reports in California (56%), and child welfare agency data in Michigan (44%). Compared with the total number of cases identified, child welfare agency (the official source for maltreatment reports) and death certificate data underascertain child maltreatment deaths by 55% to 76% and 80% to 90%, respectively. In all 3 states, more than 90% of cases ascertained could be identified by combining 2 data sources.Conclusions. No single data source was adequate for thorough surveillance of fatal child maltreatment, but combining just 2 sources substantially increased case ascertainment. The child death review team process may be the most promising surveillance approach.Child maltreatment causes a significant number of fatalities in the United States, and accurately determining the number of maltreatment-related deaths each year remains a challenge. With data from child protective services agencies, the National Child Abuse and Neglect Data System estimated there were nearly 1500 child abuse–related or neglect-related deaths in 2004 (2.0 per 100 000 children).1 However, child protective services data are known to underestimate maltreatment deaths for a variety of reasons including difficulties identifying, investigating, and reporting deaths to child protective services; lack of standard definitions of child maltreatment; and differing legal standards for substantiation of maltreatment.2^,3In the United States, a death certificate is the official record of death. Death certificates include a determination of the cause and manner of death and are often used to summarize the mortality burden of injuries and diseases. It is, however, well documented that these vital records underestimate the magnitude of fatal child maltreatment.3^–6 In fact, 50% to 60% of all child maltreatment deaths are not identified as such by death certificates,3^,5^,6 with 1 report estimating that 85% of deaths related to child maltreatment are recorded on the death certificate as attributable to other causes.7The combination of data from multiple sources to obtain more accurate identification of individuals with the condition under surveillance (i.e., case ascertainment) has enhanced public health surveillance of injuries and violence8^–11 and has shown promise as a method for obtaining more accurate estimates of mortality related to child maltreatment.3^,6 In September 2001, the Centers for Disease Control and Prevention (CDC) funded programs in 3 states—California, Michigan, and Rhode Island—to develop and evaluate public health surveillance of fatal child maltreatment through the use of multiple data sources for case ascertainment. We describe the approaches taken in these programs and summarize the epidemiology of fatal child maltreatment. Because underascertainment of fatal child maltreatment by both child protective services and death certificate data are well documented, we focused on the relative utility of additional data sources available for surveillance and explored various options for improving case ascertainment. Four of the authors took part in the state programs (T. M. C. and V. J. P. in Michigan, S. J. W. in California, and W. V-O. in Rhode Island). By summarizing options for surveillance based on their experiences, we hope to provide useful information to other states interested in establishing surveillance for fatal child maltreatment.     

Health-related quality of life in the aftermath of child maltreatment: follow-up study of a hospital sample

Objective

In the aftermath of child maltreatment or neglect, the health-related quality of life (HRQoL) in children is likely to be affected. However, research on quality of life in maltreated children is lacking. The aim of this study is to compare the HRQoL in a follow-up sample of children referred to an interdisciplinary hospital child protection team (CPT) to match controls and to explore correlates of HRQoL.

Method

Of the 319 in- and outpatient children referred to the CPT at the University Children’s Hospital Zurich between 2005 and 2006, an eligible sample of 180 children was contacted for a follow-up. HRQoL was assessed for 42 former patients using the self- and proxy-rated KIDSCREEN-27 for children above the age of 6 years and the TAPQOL parent report for children younger than 6 years. HRQoL-scores in the maltreatment group were compared with HRQoL in 39 matched controls.

Results

Self-reported HRQoL in maltreated children above the age of 6 years was significantly impaired compared to matched controls. The caregiver-rated HRQoL of maltreated children, however, was not affected. Low socioeconomic status and number of life events were associated with impaired self-reported HRQoL. Analyzed together with these factors, maltreatment lost its predictive power on HRQoL.

Conclusion

Maltreated children and adolescents suffer from impaired HRQoL even after the maltreatment has been disclosed and targeted by interventions. The impact of socioeconomic environment reinforces the importance of a multidisciplinary and systemic approach to maltreatment as applied by the CPT. Although the nature of discordance between child and caregiver report is not known, researchers and clinicians are strongly encouraged to assess the victim’s self-reported HRQoL independently of their proxies’ view.     

Agreement on Child Maltreatment Decisions: A Nonrandomized Study on the Effects of Structured Decision-Making

Background

Practitioners investigating cases of suspected child maltreatment often disagree whether a child is subject to or at risk of abuse or neglect in the family and, if so, what to do about such abuse or neglect. Structured decision-making is considered to be a solution to the problem of subjective judgments and decisions.

Objective

This study investigates the effects of ORBA, a method for structured decision-making in Advice and Reporting Centres for Child Abuse and Neglect (ARCCAN), on interrater agreement of judgments and decisions.

Methods

Two groups of ARCCAN practitioners, one trained in using ORBA and one untrained, used a questionnaire to make judgments and decisions on the same case vignettes. Interrater agreement on the judgments was obtained by calculating the percentage of agreement, intra class correlation, and the Kappa coefficient.

Results

Both ORBA trained and untrained practitioners showed little agreement on judgments and decisions, except for the judgment on child maltreatment substantiation, for which trained practitioners showed fair agreement. Agreement among trained and untrained practitioners only differed for some judgments and decisions, and differences were not always in the same direction.

Conclusions

This result indicates no convincing evidence that structured decision-making leads to better agreement on decisions concerning child abuse and neglect. Recommendations for improvements in uniform decision-making and further research are given.     

Predictors of health-related quality of life in maltreated children and adolescents

Purpose

Research on the consequences of child maltreatment has primarily focused on behavior and mental health; the children’s overall well-being has not received the same attention. A number of studies have investigated health-related quality of life (HRQoL) among victims of child maltreatment, but there is still a lack of knowledge about predictors of HRQoL in maltreated children and adolescents. This study seeks to bridge the gap by drawing data from the German multi-site study Child Abuse and Neglect Case-Management (CANMANAGE).

Methods

Parents or caregivers of 350 children and adolescents completed a proxy version of the Kidscreen-10-Index, a multidimensional instrument measuring child HRQoL. An additional 249 children age 8 years and older completed a self-report version. Multiple regression analyses were performed to identify potential predictors for both self- and proxy-rated HRQoL.

Results

Comparisons with the reference group revealed a significantly lower mean proxy-rated HRQoL, the self-rated HRQoL of the study sample was not significantly impaired. Predictors of impaired self-reported HRQoL were older age, self-reported posttraumatic stress symptoms (PTSS), and self-reported emotional and behavioral symptoms. Predictors of impaired proxy-reported HRQoL again were older age, self-reported PTSS, and emotional and behavioral symptoms in the child/adolescent, as reported by the caregiver, as well as low socioeconomic status. Multivariate analysis explained 20% and 38% of the variability in self-reported and proxy-rated HRQoL, respectively.

Conclusions

It is important to treat PTSS and emotional and behavioral symptoms in maltreated children, as these two phenomena are strong cross-sectional predictors of a child’s HRQoL. Trauma-focused cognitive behavioral therapies are one possible option to address the needs of such children.

     

Child maltreatment investigations and substantiations in child protection services: Factors distinguishing children with intellectual disabilities

BackgroundChildren with intellectual disabilities (ID) are more vulnerable to maltreatment than children without ID. Few studies focused on understanding the experiences of maltreatment of children with ID, limiting our capacity to adequately care for them.ObjectiveThis study examined the types of maltreatment with which ID is associated among child protection investigations, and identified the individual, environmental, and service-related factors distinguishing children with ID from those without, among children with substantiated maltreatment.MethodsSecondary data from an incidence study on investigated child maltreatment including 2053 children aged 6–17 years old were analyzed through univariate and multivariate logistic regressions. ID was present for 5.7% (n = 117) of the children.ResultsID was associated with increased odds of being investigated for neglect and decreased odds of being investigated or substantiated for psychological maltreatment. The factors that most distinguished children with ID from other children were physical disabilities (8.45, p < 0.001) and autism spectrum disorder (11.33, p < 0.001) in the child and having at least one parent with ID (16.21, p < 0.001). Two other environmental factors, including having been reported by a professional (2.13, p = 0.047), distinguished children with ID from the other children.ConclusionsChildren with ID who experienced maltreatment present with greater adversity than children without ID. Professionals play a preponderant role in reporting situations of maltreatment for children with ID and need additional training to properly respond to maltreatment of children with ID.     

Multiple types of child maltreatment and adolescent mental health in Viet Nam

Objective

To examine the prevalence of multiple types of maltreatment (MTM), potentially confounding factors and associations with depression, anxiety and self-esteem among adolescents in Viet Nam.

Methods

In 2006 we conducted a cross-sectional survey of 2591 students (aged 12–18 years; 52.1% female) from randomly-selected classes in eight secondary schools in urban (Hanoi) and rural (Hai Duong) areas of northern Viet Nam (response rate, 94.7%). Sequential multiple regression analyses were performed to estimate the relative influence of individual, family and social characteristics and of eight types of maltreatment, including physical, emotional and sexual abuse and physical or emotional neglect, on adolescent mental health.

Findings

Females reported more neglect and emotional abuse, whereas males reported more physical abuse, but no statistically significant difference was found between genders in the prevalence of sexual abuse. Adolescents were classified as having nil (32.6%), one (25.9%), two (20.7%), three (14.5%) or all four (6.3%) maltreatment types. Linear bivariate associations between MTM and depression, anxiety and low self-esteem were observed. After controlling for demographic and family factors, MTM showed significant independent effects. The proportions of the variance explained by the models ranged from 21% to 28%.

Conclusion

The combined influence of adverse individual and family background factors and of child maltreatment upon mental health in adolescents in Viet Nam is consistent with research in non-Asian countries. Emotional abuse was strongly associated with each health indicator. In Asian communities where child abuse is often construed as severe physical violence, it is important to emphasize the equally pernicious effects of emotional maltreatment.     

Child sexual abuse in southern Brazil and associated factors: a population-based study

Background  

The prevalence of child sexual abuse (CSA) in the population has been poorly described in developing countries. Population data on child sexual abuse in Brazil is very limited. This paper aims to estimate lifetime prevalence of child sexual abuse and associated factors in a representative sample of the population aged 14 and over in a city of southern Brazil.     

Does substantiated childhood maltreatment lead to poor quality of life in young adulthood? Evidence from an Australian birth cohort study

Purpose

To examine the independent effect of single and multiple forms of substantiated childhood maltreatment (CM) on quality of life (QoL), controlling for selected potential confounders and/or covariates, and concurrent depressive symptoms.

Methods

We used data from a prospective pre-birth cohort of 8556 mothers recruited consecutively during their first antenatal clinic visit at the Mater Hospital from 1981 to 1983 in Brisbane, Australia. The data were linked to substantiated cases of CM reported to the child protection government agency up to the age of 14 years. The sample consisted of 3730 (49.7% female) young adults for whom there were complete data on QoL at the 21-year follow-up. The mean age of participants was 20.6 years. Logistic regression models were used to assess the association between CM and QoL measured at the 21-year follow-up.

Results

There were statistically significant associations between exposure to substantiated CM and poorer QoL. This also applied to the subcategories of childhood physical abuse, childhood emotional abuse (CEA), and neglect. These associations were generally stable after adjusting for confounders/covariates and concurrent depressive symptoms, except physical abuse. CEA with or without neglect significantly and particularly predicted worse subsequent QoL.

Conclusions

Exposure to any substantiated maltreatment substantially contributed to worse QoL in young adulthood, with a particular association with CEA and neglect. Prior experiences of CM may have a substantial association with subsequent poorer QoL.

     

Preventable injury deaths: a population-based proxy of child maltreatment risk in California

Objective

This study used group variations in child injury fatality rates to assess racial bias in the population of children identified as victims of maltreatment.

Methods

Injury fatality and maltreatment data from California were compiled for the years 1998–2007. Death and maltreatment risk ratios (RRs) and 95% confidence intervals (CIs) were computed by race and age. Rates of excess child injury mortality by race were derived from three different baseline rates of death. Substantiations per excess injury death were calculated.

Results

Compared with white children, black children faced a risk of substantiated maltreatment that was more than twice as great (black RR: 2.39, 95% CI 2.37, 2.42) and were fatally injured at nearly twice the rate (black RR: 1.89, 95% CI 1.68, 2.12). Per excess death, however, black children had rates of substantiated maltreatment allegations that were equivalent to or lower than the rates for white children.

Conclusions

These data support claims that, at least in California, black-white racial disparities observed in maltreatment rates reflect real group differences in risk. These data provide no evidence of systematic racial bias in the child protective services'' substantiation process.In the United States, data collected by child protective services (CPS) consistently indicate that black children are abused and neglected at roughly twice the rate of white children.^1–3 Yet, these data reflect only maltreatment victims known to CPS, with other sources suggesting the count of abused and neglected children may be far higher.^4,5 Unknown is whether the group of maltreated children identified by CPS is racially representative of the broader population of maltreated children.In an effort to overcome the limitations of CPS data, the National Incidence Study of Child Abuse and Neglect (NIS) has been conducted on four separate occasions between 1980 and 2006.^4,6–8 The NIS attempts to estimate the actual number and characteristics of maltreated children based on cases reported to CPS, as well as knowledge of abused and neglected children ascertained from other professionals. Despite large black-white disparities observed in CPS-reported rates of maltreatment, the first three waves of the NIS failed to identify any statistically significant racial differences in the community incidence of abuse and neglect.^6–8 As such, it was widely concluded that there must be a racially biased identification of black children by CPS.^9–11 For the first time, however, the most recent wave of the NIS found that black children were maltreated at significantly higher rates than white children, reporting “strong and pervasive race differences in the incidence of maltreatment.”⁴The purpose of this study was to examine racial disparities in child maltreatment using a new, population-based and public health-oriented approach. Given the incomplete nature of CPS data,^5,12,13 the contradictory claims and sampling controversies that surround the NIS,^14–16 and research arising from other sources suggesting possible reporting and CPS substantiation bias of black children,^17–19 it seemed an opportune time to consider other data that might inform an understanding of racial disparities. In this ecological study, data from two public surveillance systems were used to assess possible bias in one source (data collected by CPS) by using the more complete and objective information available in the other (vital statistics death data). Rates of excess injury mortality were based on different assumptions as to the fraction of injury deaths that were preventable. The ratios of substantiations per excess death were compared across races. It was hypothesized that racial variability in rates of excess injury death would be observed—arising from disproportionate burdens of poverty, substance use, and other risk factors—but that absent widespread bias on the part of CPS, there would be a fairly consistent count of substantiations for each excess death.     

Impact of interpersonal adversity in childhood on adult mental health: how much is mediated by social support and socio-economic status in Japan?

Objectives

To examine the extent to which social support and socio-economic status (SES) in adulthood mediate the impact of interpersonal adversity in childhood on adult mental health using large-scale population data in Japan.

Study design

Cross-sectional survey.

Methods

Data were derived from the Japanese Study of Stratification, Health, Income and Neighbourhood, which was conducted from October 2010 to February 2011 in four municipalities in and around the Tokyo metropolitan area. Survey participants were community residents aged 25–50 years who were selected at random from voter registration lists. The total sample size was 3292. The self-reported experience of parental maltreatment (physical abuse and/or neglect) and bullying in school and their impacts on adult mental health (in terms of K6 = 5+, K6 = 13+ and suicide ideation) were examined using multivariate logistic models.

Results

Interpersonal adversity in childhood has a negative impact on adult mental health even after controlling for childhood SES. For example, the odds ratio for K6 = 5+, responding to parental maltreatment, was 2.64 (95% confidence interval 2.04–3.41). Perceived social support and adult SES mediated the impact of interpersonal adversity in childhood, but a substantial proportion of the impact was unexplained by their mediating effects; social support and adult SES only mediated 11–24% and 6–12%, respectively. It was also found that social support and adult SES (except educational attainment) did not moderate the negative impact of interpersonal adversity in childhood.

Conclusions

This analysis highlighted that the impact of interpersonal adversity in childhood is relatively independent of social support and SES in adulthood. This result has clear policy implications; more focus should be placed on policies that aim to reduce incidents of childhood maltreatment and bullying per se, both of which have a long-lasting direct impact on mental health.