Effects of Systematic Screening and Detection of Child Abuse in Emergency Departments

Department of Public Health, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands.
PEDIATRICS (Impact Factor: 5.47). 08/2012; 130(3):457-64. DOI: 10.1542/peds.2011-3527
Source: PubMed


Although systematic screening for child abuse of children presenting at emergency departments might increase the detection rate, studies to support this are scarce. This study investigates whether introducing screening, and training of emergency department nurses, increases the detection rate of child abuse.
In an intervention cohort study, children aged 0 to 18 years visiting the emergency departments of 7 hospitals between February 2008 and December 2009 were enrolled. We developed a screening checklist for child abuse (the "Escape Form") and training sessions for nurses; these were implemented by using an interrupted time-series design. Cases of suspected child abuse were determined by an expert panel using predefined criteria. The effect of the interventions on the screening rate for child abuse was calculated by interrupted time-series analyses and by the odds ratios for detection of child abuse in screened children.
A total of 104028 children aged 18 years or younger were included. The screening rate increased from 20% in February 2008 to 67% in December 2009. Significant trend changes were observed after training the nurses and after the legal requirement of screening by the Dutch Health Care Inspectorate in 2009. The detection rate in children screened for child abuse was 5 times higher than that in children not screened (0.5% vs 0.1%, P < .001).
These results indicate that systematic screening for child abuse in emergency departments is effective in increasing the detection of suspected child abuse. Both a legal requirement and staff training are recommended to significantly increase the extent of screening.

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Available from: Eveline C F M Louwers,
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    • "A patient was also excluded from the list if both inclusion and exclusion criteria were indicated. For the analyses, we considered patients as potential cases if at least two or more professionals classified them as such (see Louwers et al., 2012, for details). Because the aim was to measure the accuracy of screening, we excluded children who were known to have been abused at the moment they visited the emergency department (e.g., the carers/patients reported it themselves; they were brought in by the police). "
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    ABSTRACT: Although screening for child abuse at emergency departments (EDs) increases the detection rate of potential child abuse, an accurate instrument is lacking. This study was designed to measure the accuracy of a screening instrument for detection of potential child abuse used in EDs. In a prospective cohort study at three Dutch EDs, a 6-item screening instrument for child abuse, Escape, was completed for each child visiting the ED. The data from the completed Escape instrument was used to calculate sensitivity, specificity, and the positive/negative predictive value per item. The clinical notes and conclusions of the screen instruments of all potentially abused children reported to the hospitals' Child Abuse Teams were collected and reviewed by an expert panel. A logistic regression model was used to evaluate the predictors of potential abuse. Completed Escape instruments were available for 18,275 ED visits. Forty-four of the 420 children with a positive screening result, and 11 of the 17,855 children with a negative result were identified as potentially abused. Sensitivity of the Escape instrument was 0.80 and specificity was 0.98. Univariate logistic regression showed that potentially abused children were significantly more likely to have had an aberrant answer to at least one of the items, OR=189.8, 95% CI [97.3, 370.4]. Most of the children at high risk for child abuse were detected through screening. The Escape instrument is a useful tool for ED staff to support the identification of those at high risk for child abuse.
    Child abuse & neglect 12/2013; 38(7). DOI:10.1016/j.chiabu.2013.11.005 · 2.34 Impact Factor
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    • "Several authors have already considered screening in emergency departments [11-13]. A large study in the United Kingdom evaluated the accuracy of potential makers: child age, type of injuries, incidence of repeat attendance, and the accuracy of clinical screening assessments for detecting physical abuse in injured children attending Accident and Emergency departments [13]. "
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    ABSTRACT: Early detection of abused children could help decrease mortality and morbidity related to this major public health problem. Several authors have proposed tools to screen for child maltreatment. The aim of this systematic review was to examine the evidence on accuracy of tools proposed to identify abused children before their death and assess if any were adapted to screening. We searched in PUBMED, PsycINFO, SCOPUS, FRANCIS and PASCAL for studies estimating diagnostic accuracy of tools identifying neglect, or physical, psychological or sexual abuse of children, published in English or French from 1961 to April 2012. We extracted selected information about study design, patient populations, assessment methods, and the accuracy parameters. Study quality was assessed using QUADAS criteria. A total of 2 280 articles were identified. Thirteen studies were selected, of which seven dealt with physical abuse, four with sexual abuse, one with emotional abuse, and one with any abuse and physical neglect. Study quality was low, even when not considering the lack of gold standard for detection of abused children. In 11 studies, instruments identified abused children only when they had clinical symptoms. Sensitivity of tests varied between 0.26 (95% confidence interval [0.17-0.36]) and 0.97 [0.84-1], and specificity between 0.51 [0.39-0.63] and 1 [0.95-1]. The sensitivity was greater than 90% only for three tests: the absence of scalp swelling to identify children victims of inflicted head injury; a decision tool to identify physically-abused children among those hospitalized in a Pediatric Intensive Care Unit; and a parental interview integrating twelve child symptoms to identify sexually-abused children. When the sensitivity was high, the specificity was always smaller than 90%. In 2012, there is low-quality evidence on the accuracy of instruments for identifying abused children. Identified tools were not adapted to screening because of low sensitivity and late identification of abused children when they have already serious consequences of maltreatment. Development of valid screening instruments is a pre-requisite before considering screening programs.
    BMC Pediatrics 12/2013; 13(1):202. DOI:10.1186/1471-2431-13-202 · 1.93 Impact Factor
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    • "Using a screening checklist, along with staff training and physician follow-up, systematic screening increased the abuse detection rate 5-fold in a sample of over 100,000 cases (aged 18 or younger), from 7 hospitals, over a 22 month period. Louwers et al. (2012) study checklist approach contained 6 questions, where any positive response was seen to reflect maltreatment risk and the need for more in-depth assessment. These were: (1) Is the history consistent? "
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    ABSTRACT: A human rights perspective places the care for children in the obligation sphere. The duty to protect from violence is an outcome of having a declaration confirming inalienable human rights. Nationally, rights may be reflected in constitutions, charters, and criminal codes. Trans-nationally, the United Nation's (UN) Convention on the Rights of the Child (CRC) prioritizes a child's basic human rights, given their dependent status. UN CRC signatory countries commit to implementing minimal standards of care for minors. Laws requiring professionals to report child maltreatment to authorities is one practical strategy to implement minimal child protection and service standards. Mandatory reporting laws officially affirms the wrong of maltreatment, and the right of children. Mandatory reporting can be conceptualized as part of a resilience process, where the law sets the stage for child safety and well-being planning. Although widely enacted law, sizeable research gaps exist in terms of statistics on mandatory reporting compliance in key settings; obstacles and processes in mandatory reporting; the provision of evidence-based training to support the duty to report; and the training-reporting-child outcomes relationship, this latter area being virtually non-existent. The fact that mandatory reporting is not presently evidence-based cannot be separated from this lack of research activity in mandatory reporting. Reporting is an intervention that requires substantial inter-professional investment in research to guide best practices, with methodological expectations of any clinical intervention. Child abuse reporting is consistent with a clinician's other duties to report (i.e., suicidality, homicidality), practice-based skills (e.g., delivering "bad" news, giving assessment feedback), and the pervasive professional principle of "best interests" of the child. Resilience requires the presence of resources and, mandated reporting, is one such resource to the maltreated child. Practice strategies identified in the literature are discussed.
    Child abuse & neglect 01/2013; 37(2-3). DOI:10.1016/j.chiabu.2012.11.005 · 2.34 Impact Factor
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