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Barriers and Facilitators to Detecting Child Abuse and Neglect in General Emergency Departments

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Child abuse and neglect is common in the United States, and victims often present to emergency departments (EDs) for care. Most US children who seek care in EDs are treated in general EDs without specialized pediatric services. We aim to explore general ED providers' experiences with screening and reporting of child abuse and neglect to identify barriers and facilitators to detection of child abuse and neglect in the ED setting. We conducted 29 semistructured interviews with medical providers at 3 general EDs, exploring experiences with child abuse and neglect. Consistent with grounded theory, researchers coded transcripts and then collectively refined codes and identified themes. Data collection and analysis continued until theoretical saturation was achieved. Barriers to recognizing child abuse and neglect included providers' desire to believe the caregiver, failure to recognize that a child's presentation could be due to child abuse and neglect, challenges innate to working in an ED such as lack of ongoing contact with a family and provider biases. Barriers to reporting child abuse and neglect included factors associated with the reporting process, lack of follow-up of reported cases, and negative consequences of reporting such as testifying in court. Reported facilitators included real-time case discussion with peers or supervisors and the belief that it was better for the patient to report in the setting of suspicion. Finally, providers requested case-based education and child abuse and neglect consultation for unclear cases. Our interviews identified several approaches to improving detection of child abuse and neglect by general ED providers. These included providing education through case review, improving follow-up by Child Protective Services agencies, and increasing real-time assistance with patient care decisions. Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
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Barriers and Facilitators to Detecting Child Abuse and Neglect
in General Emergency Departments
Gunjan Tiyyagura, MD*; Marcie Gawel, RN, MSN; Jeannette R. Koziel, MSN, APRN; Andrea Asnes, MD, MSW;
Kirsten Bechtel, MD
*Corresponding Author. E-mail: gunjan.kamdar@yale.edu.
Study objective: Child abuse and neglect is common in the United States, and victims often present to emergency
departments (EDs) for care. Most US children who seek care in EDs are treated in general EDs without specialized
pediatric services. We aim to explore general ED providersexperiences with screening and reporting of child abuse and
neglect to identify barriers and facilitators to detection of child abuse and neglect in the ED setting.
Methods: We conducted 29 semistructured interviews with medical providers at 3 general EDs, exploring experiences
with child abuse and neglect. Consistent with grounded theory, researchers coded transcripts and then collectively
rened codes and identied themes. Data collection and analysis continued until theoretical saturation was achieved.
Results: Barriers to recognizing child abuse and neglect included providersdesire to believe the caregiver, failure to
recognize that a childs presentation could be due to child abuse and neglect, challenges innate to working in an ED
such as lack of ongoing contact with a family and provider biases. Barriers to reporting child abuse and neglect included
factors associated with the reporting process, lack of follow-up of reported cases, and negative consequences of
reporting such as testifying in court. Reported facilitators included real-time case discussion with peers or supervisors
and the belief that it was better for the patient to report in the setting of suspicion. Finally, providers requested case-
based education and child abuse and neglect consultation for unclear cases.
Conclusion: Our interviews identied several approaches to improving detection of child abuse and neglect by general
ED providers. These included providing education through case review, improving follow-up by Child Protective Services
agencies, and increasing real-time assistance with patient care decisions. [Ann Emerg Med. 2015;-:1-8.]
Please see page XX for the Editors Capsule Summary of this article.
0196-0644/$-see front matter
Copyright © 2015 by the American College of Emergency Physicians.
http://dx.doi.org/10.1016/j.annemergmed.2015.06.020
INTRODUCTION
Child maltreatment is common in the United States. In
2011, an estimated 1,570 children died from child abuse
and neglect, and 676,579 (9.1 per 1,000 children) were
victims of child abuse and neglect.
1
However, this estimate
likely underrepresents the true extent of child abuse and
neglect in the United States.
2-5
Federal and local laws mandate that medical providers
report cases of suspected child abuse and neglect to a Child
Protective Services agency. Despite this mandate, health
care providers often fail to recognize child abuse and neglect
and, even when they do, also fail to report it. For example,
a national study of primary care physicians in the United
States identied several reasons for these clinicians to fail to
report cases of child abuse and neglect, including familiarity
with families, perceived lack of benet to the family from
Child Protective Services involvement, and use of an
alternative management strategy such as close follow-up with
the family.
6,7
In another study, pediatric nurses identied
reporting of suspected child abuse and neglect as a priority,
but they struggled with cases that lacked objective and
clear evidence of abuse.
8
A study of Dutch emergency
department (ED) providers identied limited time, fear of
unjustied suspicions, insufcient communication skills,
and turnover of an ED staff as barriers to reporting child
abuse and neglect.
9
The acute nature of the injury or lack of access to a
primary care physician may lead child abuse and neglect
victims to the ED for care, which may be additionally
convenient because of its proximity and long hours of
operation. Thus, ED personnel are often the rst or only
medical contact and opportunity for child abuse and
neglect victims to be recognized. Rates of child abuse and
neglect in children presenting to EDs have been reported
at 0.1% to 2% in recent studies, some of which calculate
rates within a subset of children with injuries,
10-14
whereas
Volume -, no. -:-2015 Annals of Emergency Medicine 1
PEDIATRICS/ORIGINAL RESEARCH
Editors Capsule Summary
What is already known about this topic
Child abuse and neglect is underrecognized and
underreported in emergency departments (EDs), but
the reasons have not been thoroughly studied.
What question this study addressed
What are the barriers and facilitators to recognition
and reporting of child abuse and neglect in the ED?
What this study adds to our knowledge
Focused interviews of 29 ED providers in 3
Connecticut EDs revealed that barriers to recognition
include skill gaps, the desire to believe caregivers,
and personal biases. Barriers to reporting include
cumbersome processes, lack of follow-up, and concern
about erroneous reporting. Facilitators include
opportunities to discuss child abuse and neglect cases
with colleagues and experts and additional education.
How this is relevant to clinical practice
Although not directly relevant to clinical practice,
understanding the causes of underreporting of child
abuse and neglect is a requisite step in improving
recognition.
older studies involving young children presenting with
injuries report rates as high as 10%.
15,16
Additionally, there
is evidence that 20% to 30% of children who died from
child abuse and neglect had been previously evaluated by
health care providers, including ED providers, for
unrecognized abusive injuries.
17-19
The majority of children in the United States who seek care
in EDs are treated in general EDs that lack access to specialized
pediatric services.
20,21
One study that examined delays in the
identication of fractures in young children showed that
presentation to a general versus pediatric ED setting was an
independent predictor of missed diagnosis of abuse.
22
Another
study examined the variation in the diagnosis of child abuse
in severely injured infants (those with femur fractures or
traumatic brain injury) and found that 29% of these cases were
diagnosed as abuse at childrens hospitals versus 13% at
general hospitals.
23
To our knowledge, no previous study has
examined barriers to the appropriate recognition of child abuse
and neglect and reporting to Child ProtectiveServices agencies
by medical providers in general EDs in the United States,
in which a large population of children are evaluated, but
where access to pediatric emergency medicine and child
abuse and neglect expertise is minimal.
The purpose of this qualitative study was to explore
general ED providersexperiences with evaluation,
detection, and reporting of child abuse and neglect and
identify barriers and facilitators to recognizing and
reporting it. Additionally, we aimed to identify preferences
in regard to education about child abuse and neglect to
inform future interventions to improve recognition and
reporting of it in the general ED setting.
MATERIALS AND METHODS
We used a qualitative research design with one-on-one
interviews to understand general ED providersexperiences
with child abuse and neglect. We conducted 29
semistructured interviews of nurses, physicians, and
physician assistants of various levels of seniority and with
various clinical roles at 3 general EDs in Connecticut with
different models of pediatric care and in different regions of
the state. Each ED has established transfer relationships with a
tertiary care childrens hospital. ED 1 has 50,000 annual
visits, with 7,500 pediatric visits, and has 8 hours of pediatric
emergency physician availability per day; ED 2 has 36,000
annual visits, with 8,000 pediatric visits; and ED 3 has 55,000
annual visits, with 5,000 pediatric visits. Neither of the latter
2 EDs has pediatric emergency medicine availability. The
same group of physicians staff EDs 1 and 2. Any child
requiring hospitalization in ED 3 and most children requiring
hospitalization in EDs1 and 2 are transferred to a tertiary care
childrens hospital. None of the 3 general EDs has full-time,
on-site social work or child abuse expert support.
To recruit participants for interview, we used both
purposeful sampling (identifying participants who had
recently evaluated and treated patients with child abuse and
neglect, had various levels of experience and roles in the ED
setting [eg, junior and senior attending physicians, nurses
playing various roles in the clinical setting], and would be
willing to discuss their experiences with the research team)
and snowball sampling (in which existing participants
then recruited future participants from among their
colleagues).
24
In ED 1, physician and nurse leaders were
asked to identify providers with the above characteristics
and to let the providers know that they would be solicited
for an interview. A lead nurse at ED 2 provided a time
during which coverage for clinical duties was offered for
nurses to participate in our interviews. Providers at ED
3 were identied by the senior physician assistant in the
ED, also according to the above qualications.
We recruited a total of 13 physicians, 18 nurses, and
9 physician assistants. The majority was recruited through
e-mail contact; however, providers at ED 2 were approached
in person because clinical coverage was provided for their
interviews. Three physicians, 2 nurses, and 5 physician
2Annals of Emergency Medicine Volume -, no. -:-2015
Barriers to Detecting Child Abuse and Neglect Tiyyagura et al
assistants did not respond to e-mails requesting an interview,
and 1 physician did not participate because of concurrent
clinical duties.
The interview guide consisted of open-ended questions
and included prompts to encourage detailed discussion.
25
In line with grounded theory, we iteratively revised the
interview guide as new understanding was gained from
previous interviews.
26
The guide went through 3 iterations,
consisting of minor changes that were mainly used to clarify
the key questions. The Figure 1 provides the nal version
of the interview guide.
Two investigators, both with experience conducting
qualitative interviews, conducted the face-to-face
interviews. Interviews were audiotaped and transcribed
verbatim. Identifying information was removed from the
transcripts before review by the research team, which
included 2 pediatric emergency physicians, 1 pediatric
emergency medicine nurse, and 1 pediatric emergency
medicine advanced practice registered nurse. We obtained
institutional review board approval at Yale University and
from each of the participating hospitals, as well as verbal
consent of participants, before each interview.
Thematic saturation, the ongoing collection and analysis
of data until no new data emerge and concepts and
relationships between concepts are well developed, was
achieved after 18 interviews, but interviews were conducted
past the point of saturation.
24-27
The authors have inserted
explanatory remarks in brackets to clarify statements that
are quoted in the Resultssection.
Primary Data Analysis
Four researchers (G.T., M.G., J.R.K., and K.B.)
independently reviewed the transcripts and coded data with
the constant comparative method of inductive analysis; that
is, they applied initial codes or labels to summarize and
categorize portions of data and then collectively rened
codes and created themes.
28
Text segments with similar
codes were compared to ensure appropriate assignment of
the codes.
29
Code lists were iteratively revised and applied
to incoming data.
29
Finally, on completion of coding, we
clustered coded data into relevant themes. Qualitative
analysis software (HyperRESEARCH version 3.5.2;
Computer Software, Research Ware, Inc., Randolph, MA)
was used to manage and code data, facilitate data
organization and retrieval, and aid analysis.
To enhance the trustworthiness of our ndings, we used
multiple coders with varied backgrounds to analyze the
data, examined the consistency of different data sources by
interviewing different types of providers with various levels
of clinical experiences at 3 EDs, and maintained an audit
trail of our coding process.
24-27,30-32
The constant
comparative method of data collection and analysis
continued past the point of saturation, ie, when no new
concepts emerged.
26
RESULTS
Twenty-nine providers (9 emergency physicians, 16 ED
nurses, and 4 ED physician assistants) working in 3 general
EDs in Connecticut participated in the interviews. The
average length of interview was 17 minutes. There were 7
physicians and 9 nurses from ED 1, 4 of whom were also
charge nurses and 1 of whom was a nurse educator.
Participants from ED 2 were nurses who performed staff,
triage, and charge duties. Participants from ED 3 included
4 physician assistants, 2 nurses, and 2 physicians. The
median length of ED experience among the physicians and
physician assistants was 7 years, whereas the median among
the nurses was 12.5 years.
Reported barriers to recognizing child abuse and
neglect included a providers desire to believe the
caregivers story, failure to recognize that a childs clinical
presentation could be due to child abuse and neglect,
biases about caregivers, and challenges innate to working
in an ED. Quotations representing each category are
presented in Figure 2.
Providers described scenarios in which a case of abuse or
neglect may have been missed because they trusted the
Figure 1. Interview guide. CPS, Child Protective Services; CAN,
child abuse and neglect.
Tiyyagura et al Barriers to Detecting Child Abuse and Neglect
Volume -, no. -:-2015 Annals of Emergency Medicine 3
Figure 2. Themes and representative quotes.
Barriers to Detecting Child Abuse and Neglect Tiyyagura et al
4Annals of Emergency Medicine Volume -, no. -:-2015
caregiver to provide a truthful explanation about the
patients presentation. The tendency to believe a caregiver
was related to the trusting nature of a provider, the fear of
falsely judging a caregiver, and the desire to rapidly address
the patients presenting complaint, leading providers to
take for granted what the parents say as being the truth.
Providers also discussed personal failures to recognize
signs and symptoms of physical abuse related to traumatic
injuries and burns, as well as cases of possible neglect.
Many providers described increased discomfort when
dealing with cases of possible neglect versus physical abuse
and were unfamiliar with when to report such a case to
Child Protective Services. One nurse described such a case
in which he may have missed signs of neglect: When the
patient came in, her daughter had no coat, it was very cold
outside., no diaper bag, no car seat. The baby had no
blanket, just had a onesie..When probed by the
interviewer about considering calling Child Protective
Services for the patient, the nurse responded, .We just
wanted to get the baby home as soon as possible.When
probed further, the provider said he believed his role was
to address the mothers chief complaint without further
involvement in the care of an otherwise well child; at the
time, he did not believe a report to Child Protective
Services was warranted.
Personal biases based on caregiver socioeconomic status,
profession, how a caregiver was dressed, education level,
level of niceness,family structure, and where the patient
lived were thought by providers to play a role in failure to
recognize child abuse and neglect. One provider described
an interaction with a police ofcer who advocated for the
father, who was an ofcer in the military and likely
perpetrator of an infants brain injury: I know its not
abuse. Theyre really a good family, a really well-to-do
family.
Finally, challenges innate to working in the ED setting
such as missing the full story (inability to obtain all the
pertinent information in the patients medical history), lack
of continuity of care, and work-ow constraints related to
working in a busy ED were also perceived as barriers to
child abuse and neglect recognition. One physician
assistant described the challenges related to poor continuity
of care and not knowing the patients full story: Ive never
seen this child.. I dont know their family life.. I think
we probably miss more than there is because they fall
through the cracks..
Providers also described barriers to reporting child abuse
and neglect, which included factors associated with the
reporting process and perceived negative consequences of
making a Child Protective Services report. Quotations
representing each category are presented in Figure 2.
Several factors associated with the reporting process
were identied as disincentives to reporting suspected
child abuse and neglect to Child Protective Services. One
provider discussed the time-intensiveness of reporting
while working in a busy ED setting and the difculty
contacting Child Protective Services, such as frustration
with waiting on the telephone to speak to a Child
Protective Services representative. They also described
redundancy in the process of reporting and thought that
lling out a form after making an oral report was
excessive. Finally, most providers voiced concern about
poor follow-up of reported cases. One nurse discussed that
the follow-up of reported cases could serve as useful
feedback for providers: Ithinktherecouldbeabetterfull
circle with the providers that are seeing it. This really was
a great catch; this [is] not so much.to point us in the
right direction.
Providers also described the perceived negative
consequences of making a Child Protective Services report,
such as having to testify in court in relation to cases of
suspected child abuse and neglect, caregiver anger leading
to physical harm for the providers, and the potential to
falsely accuse a family of committing abuse as undesired
consequences of making a Child Protective Services report.
Facilitators to detecting child abuse and neglect included
opportunity for discussion of suspected cases with peers or
supervisors, a belief that it was better to report to Child
Protective Services if there was any suspicion of child abuse
and neglect, and an accurate understanding of the
denition of a mandated reporter and the many roles Child
Protective Services can play in a familys life. Quotations
representing each category are presented in Figure 2.
When faced with uncertainty about the diagnosis of
child abuse and neglect, many providers discussed the
case with colleagues before making the decision to report
the case to Child Protective Services. Nurses and
physicians discussed talking to members of the care team
to gather their opinions on the details of the case before
calling Child Protective Services, and some described
talking to supervisors to obtain an unbiased opinion
about the likelihood of child abuse and neglect in their
patient.
Another facilitator to detecting child abuse and neglect
included the belief that reporting to Child Protective
Services better served the patientssafetyiftherewasany
suspicion of abuse or neglect. This belief was linked to
accurately understanding the mandated reporting law and
recognizing that medical providers do not need certainty,
only suspicion, about child abuse and neglect to report to
Child Protective Services. Providers commented that
making a Child Protective Services report was not
Tiyyagura et al Barriers to Detecting Child Abuse and Neglect
Volume -, no. -:-2015 Annals of Emergency Medicine 5
malicious and could result in access to services for families
in need versus division of a family unit. This
understanding led many providers to more freely report a
case of suspected child abuse and neglect to Child
Protective Services.
Providers requested more case-based education, including
case review, immediate consultation for unclear cases of child
abuse and neglect, feedback about disposition of reported
cases, and use of a standardized and less time-intensive
reporting process to Child Protective Services. All providers
requested more education, with a preference for case-based
review, as well as sharing of pearlsand visual images related
to signs and symptoms that should alert one to consider child
abuse and neglect. Providers also requested education about
when to report child abuse and neglect, especially with gray-
area cases and those related to possible neglect (eg, ingestions,
emotional abuse, inappropriate supervision), and what to
ask and how to question children and caregivers when
considering child abuse and neglect. Providers believed that
real-time case consultation may help bridge the knowledge
gaps related to the presentation of child abuse and neglect.
One provider described a case in which she was uncertain
about the consistency of the history and physical examination
ndings and wished she could discuss the case with a child
abuse and neglect expert to obtain a second opinion on how to
proceed.
Providers universally requested feedback from Child
Protective Services about disposition of reported cases and
thought the feedback would aid providers when faced with
similar cases in the future. Finally, providers wished for a
more standardized and streamlined way to report child
abuse and neglect, including uniform education to all staff
on the steps of reporting suspected child abuse and neglect
to Child Protective Services, improving timely
communication between Child Protective Services staff and
ED staff, and decreasing the redundancy of oral and written
reporting to the service. Quotations representing each
category are presented in Figure 2.
LIMITATIONS
Because we interviewed only 29 providers in 3 EDs
within our state, our results may not be generalizable.
These interviews do not represent all general ED
experiences or models of provider stafng patterns and skill
mixes. ED providers in different states and even in different
jurisdictions and regions within states have various
relationships with pediatric centers, child abuse physicians,
and Child Protective Services agencies. However, we did
attempt to ensure the trustworthiness of our exploratory
ndings by interviewing providers from 3 general EDs
from different regions within our state, each with a
different model of care for pediatric patients. We also
interviewed a spectrum of providers with various clinical
roles in the general ED setting. Therefore, we believe that
this qualitative study does explore the factors that inuence
the recognition and reporting of child abuse and neglect in
general EDs and could serve to stimulate further study and
improvement activities. Additionally, although our data are
composed of rich narratives, they nonetheless represent
perceptions of general ED providers and not direct
objective observations of their clinical practices. Finally,
although we used one-on-one interviews to understand the
experiences of medical providers with child abuse and
neglect, a focus group may have stimulated greater
discussion among providers. We believed, however, that
one-on-one interviews would allow more candid discussion
about personal experiences with child abuse and neglect.
DISCUSSION
General ED providers face unique challenges when
addressing the issue of child abuse and neglect. In our
exploratory work, providers described a desire to believe
caregivers, personal biases based on caregiver characteristics,
inability to recognize a childs presentation could be due to
child abuse and neglect, and challenges of working in an
ED setting as possible barriers to recognizing child abuse
and neglect. The redundant and time-consuming reporting
process and the perceived negative consequences (parental
retaliation and need for testifying in future court
proceedings) of making a Child Protective Services report
were also described as barriers. Facilitators to child abuse
and neglect detection included real-time case discussion
with peers or supervisors, recognition of the importance of
reporting when there was suspicion, and the accurate
understanding of the role of mandated reporters and Child
Protective Services. Finally, providers asked for more case-
based education, feedback about reported cases, and a more
streamlined reporting process to Child Protective Services.
In a previous study that evaluated primary care
physicianschild abuse reporting experiences, physicians
who suspected abuse but did not report the injury reported
familiarity with families as a reason not to report abuse even
when recognized.
6,7
Our studysndings, in contrast,
pointed to lack of continuity of care and incomplete patient
history as reasons given by ED providers for failure to
recognize child abuse and neglect. Too little familiarity
with a patient and time constraints in an ED setting may
result in a providers minimizing or missing potentially
suspicious presentations of child abuse and neglect. Given
the inherent challenges of working in an ED setting,
additional resources, such as social work services, which can
reduce the demands of ED providers and provide more
Barriers to Detecting Child Abuse and Neglect Tiyyagura et al
6Annals of Emergency Medicine Volume -, no. -:-2015
concentrated time with families, may allow providers to
investigate concerns about possible child abuse and neglect
and mitigate some of the challenges created by insufcient
history. Additionally, institution of child abuse screening
guidelines for high-risk injuries in infants, such as fractures
or bruises, may prompt providers working in a busy setting
to consider abuse, decrease caregiver-related bias, and
initiate an evaluation for child abuse and neglect.
33
Similar to that for pediatric primary care nurses and
primary care physicians, an inability to recognize child
abuse and neglect, trust in a caregiver, and the fear of
wrongly accusing a caregiver are barriers to recognizing
child abuse and neglect in our general ED setting.
6-8
According to reports from participants in our study,
educational case-based interventions that focus on signs
and symptoms of physical abuse, various medical
presentations of neglect, and less clear cases of
maltreatment may improve recognition and reporting of
child abuse and neglect. Increased opportunities to review
and discuss cases of suspected child abuse and neglect with
knowledgeable peers within ED settings may be helpful for
ED providers to more readily recognize cases of suspected
child abuse and neglect.
Child protective teams are multidisciplinary teams of
medical and social work professionals with expertise in
child abuse and neglect that can provide more
comprehensive evaluation, documentation, and follow-up
of children suspected of having been abused or neglected.
34
However, such teams are usually found in tertiary care
childrens hospitals or in academic medical centers.
34
ED
providers in our study consulted colleagues about cases
when there was uncertainty about intentional versus
unintentional injury. This suggests that ED providers may
need additional clinical expertise and support when making
the decision to report suspected child abuse and neglect to
Child Protective Services. An important resource to develop
in an effort to improve child abuse and neglect detection
and reporting may be the identication and ongoing
support of child abuse and neglect content experts within
nonpediatric and nonacademic hospitals. The role of a
designated child abuse and neglect content expert could
include consulting about cases of possible child abuse and
neglect, providing education, including case review, serving
as liaison to local Child Protective Services ofces, and
facilitating feedback of reported cases. Dutch providers,
when discussing a facilitator to identication of child abuse
and neglect in the ED settings, similarly thought it would
be worthwhile to invest in such a child abuse and neglect
content expert (child abuse attendant) to improve quality
control, expedite treatment or referrals, and ensure proper
follow-up of patients.
9
The efcacy of such child abuse and
neglect content experts has not yet been formally evaluated.
Inadequate follow-up of reported cases may serve to
discourage providers from reporting future cases of child
abuse and neglect. Improved communication about
reported cases, the role of Child Protective Services, and the
process of reporting to Child Protective Services may
improve reporting rates and streamline the reporting
process in the ED setting.
Using qualitative methods, we have identied barriers
and facilitators of recognizing and reporting child abuse
and neglect in general EDs. Barriers include desire to
believe caregivers, personal biases, and skill gaps in
recognition of certain symptoms and signs of abuse.
Additional barriers are concerns about the perceived
cumbersome process of reporting, lack of follow-up of
reported cases, and negative consequences of erroneous
reports. We have also identied facilitators that suggest
system enhancements that could be explored to improve
child abuse and neglect recognition and reporting. These
include immediate case discussion with colleagues and
consultation with experts for unclear cases in which child
abuse and neglect is a possible diagnosis. In addition,
providers requested support in improving their recognition
of such cases. They desired case-based education and
improved communication with Child Protective Services
related to reporting and receiving disposition about
suspected cases of child abuse and neglect. Understanding
front-line providersperspectives may be a useful rst step
in creating and evaluating sustainable interventions to
improve child abuse and neglect recognition and reporting
in the ED setting.
Supervising editor: David M. Jaffe, MD
Author afliations: From the Yale University School of Medicine,
Department of Pediatrics, New Haven, CT.
Author contributions: GT and KB conceptualized and designed the
study and acquired the data. GT, MG, JRK, and KB analyzed and
interpreted the data. GT drafted the initial article. MG, JRK, AA, and
KB reviewed and revised the article. AA critically reviewed the
article. All authors approved the nal version. GT takes
responsibility for the paper as a whole.
Funding and support: By Annals policy, all authors are required to
disclose any and all commercial, nancial, and other relationships
in any way related to the subject of this article as per ICMJE conict
of interest guidelines (see www.icmje.org). The authors have stated
that no such relationships exist.
Publication dates: Received for publication November 25, 2014.
Revisions received April 30, 2015; and May 27, 2015. Accepted for
publication June 18, 2015.
Tiyyagura et al Barriers to Detecting Child Abuse and Neglect
Volume -, no. -:-2015 Annals of Emergency Medicine 7
Presented at the Eastern Society for Pediatric Research meeting,
March 2014, Philadelphia, PA; and the Pediatric Academic
Societies meeting, May 2014, Vancouver, British Columbia,
Canada.
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Barriers to Detecting Child Abuse and Neglect Tiyyagura et al
8Annals of Emergency Medicine Volume -, no. -:-2015
... Importantly, signs and symptoms of CM exposure are not always obvious, and children can be reluctant to reveal information about CM for many reasons, including fear of retribution or shame [18][19][20][21][22]. In addition, HCPs consistently express discomfort identifying CM and a desire for further training [23][24][25][26][27][28][29][30][31][32][33]; HCPs have reported specific challenges with identifying less visible forms of CM, including emotional abuse and emotional neglect, initiating conversations with children and caregivers about potential CM, and ensuring private, safe spaces for children to discuss their concerns and experiences. Similarly, guidance from the clinical literature, as well as from the National Institute of Health and Care Excellence [34] and the World Health Organization [35], indicates that once CM is identified, HCPs must respond safely to the concerns, which includes making a report to child welfare authorities (where legally indicated) and ensuring appropriate follow-up referrals. ...
... Studies exploring physician-perceived barriers to responding and reporting CM have identified a lack of education, lack of institutional policy, difficulty recognizing CM, fear of legal repercussions, negative experiences with reporting CM, and fear of additional harm to the child as obstructions to HCP responses to CM [23][24][25][26][27][28][29][30][31][32][33]. Studies involving physicians have concluded that despite knowledge of mandated reporting by HCPs, there is confusion about whose responsibility it is to report CM [38][39][40][41], with some physicians believing reporting is the responsibility of a social worker or a physician specializing in CM, which may lead to deferrals or delays in reporting [41]. ...
... In addition, several participants reflected on negative experiences with CPS, with concerns about a lack of action, unequal responses to different families that was felt to potentially be rooted in bias and discrimination, and distress in not knowing the outcome of a report. This is consistent with previous research on experiences with mandated reporting [23][24][25][26][27][28][29][30][31][32][33]39,41], and highlights the need for better understanding and communication between HCPs and CPS about their respective roles. ...
Article
Full-text available
Child maltreatment (CM) is a public health problem with devastating effects on individuals, families, and communities. Resident physicians have varied formal education in CM, and report feeling inadequately trained in identifying and responding to CM. The purpose of this study is to explore residents’ understanding of the impacts of CM, and their perceptions of their role in recognizing and responding to CM to better understand their educational needs. This study analyzed qualitative data obtained from a larger project on family violence education. Twenty-nine resident physicians enrolled in pediatric, family medicine, emergency medicine, obstetrics and gynecology, and psychiatry training programs in Alberta, Ontario, and Québec participated in semi-structured interviews to elicit their ideas, experiences, and educational needs relating to CM. Conventional (inductive) content analysis guided the development of codes and categories. Residents had thorough knowledge about the impacts of CM and their duty to recognize CM, but there was less consistency in how residents understood their role in responding to CM. Residents identified the need for more education about recognizing and responding to CM, and the need for educational content to be responsive to training, patient and family factors, and systemic issues. Despite knowledge about the impacts of CM and laws pertaining to mandated reporting, residents reported challenges with responding to concerns of CM. Findings of this study emphasize the need for better training in response to CM. Future educational interventions should consider a multidisciplinary, experiential approach.
... Within the hospitals, inadequate knowledge and awareness of child protection measures among healthcare workers prevent them from reporting and referring suspected hospitalstranded cases on time. This finding is aligned with extant literature on the reporting behavior of pediatricians encountering child abuse cases (Jones et al., 2008;Tiyyagura et al., 2015). Studies have also suggested that education and training for clinical workers should be provided to improve the report rate of suspected child protection cases (Tiyyagura et al., 2015(Tiyyagura et al., , 2019 as personnel with specific training in child protection are up to 10 times more likely to report child protection-related cases than their counterparts (Flaherty et al., 2013). ...
... This finding is aligned with extant literature on the reporting behavior of pediatricians encountering child abuse cases (Jones et al., 2008;Tiyyagura et al., 2015). Studies have also suggested that education and training for clinical workers should be provided to improve the report rate of suspected child protection cases (Tiyyagura et al., 2015(Tiyyagura et al., , 2019 as personnel with specific training in child protection are up to 10 times more likely to report child protection-related cases than their counterparts (Flaherty et al., 2013). ...
Article
Background Hospital-stranded children are defined as children who are left by parents in medical settings for over six months. These children, who legally are not classified as orphans, are excluded from existing permanent placement policies in China. Yet, little is known about this vulnerable population of children. Objective This study explores the experiences of hospital-stranded children and the causes for their plight, and examines the strengths and weaknesses of existing child protection practices in medical settings. Methods Using a multiple-case design, 20 hospital-stranded children from three children's hospitals in a first-tier Chinese city were included in this study. Sixteen hospital personnel participated in semi-structured interviews. Interview findings, case records, and field observations were analyzed using a thematic analysis approach. Current child protection practices were analyzed through a child protection system model. Results The children in this study were well cared for by the hospitals, but their rights to provision, participation, and protection were violated due to the lack of a national child protection system. Three key weaknesses of child protection practices were identified: underreporting of suspected cases, delayed action after reporting, and inadequate follow-up services. The ineffectiveness of the national child welfare system and the family-oriented cultural values in China also created barriers to the protection of hospital-stranded children. Conclusions The findings suggest an urgent need for a national child protection system. Professional child protection training for healthcare workers and collaboration among departments within and outside hospitals are also necessary to offer a systematic protective network for hospital-stranded children.
... Area 1-Practicality of machine learning-based risk models: limitations in the available data Key issue (1)-Biases in the data: Different types of biases based on care giver's profession, address, educational level, and socioeconomic status might affect the likelihood of suspicion and report of child abuse and neglect. 16 Specifically, there is an emerging body of evidence that racial biases contribute to reporting of child abuse and neglect 17,18 and addressing it in the healthcare system. 19 Because current reporting trends are skewed towards racial minorities, existing data extracted from secondary databases will likely include inherent racial biases. ...
Article
Full-text available
Child abuse and neglect are public health issues impacting communities throughout the United States. The broad adoption of electronic health records (EHR) in health care supports the development of machine learning-based models to help identify child abuse and neglect. Employing EHR data for child abuse and neglect detection raises several critical ethical considerations. This article applied a phenomenological approach to discuss and provide recommendations for key ethical issues related to machine learning-based risk models development and evaluation: (1) biases in the data; (2) clinical documentation system design issues; (3) lack of centralized evidence base for child abuse and neglect; (4) lack of "gold standard "in assessment and diagnosis of child abuse and neglect; (5) challenges in evaluation of risk prediction performance; (6) challenges in testing predictive models in practice; and (7) challenges in presentation of machine learning-based prediction to clinicians and patients. We provide recommended solutions to each of the 7 ethical challenges and identify several areas for further policy and research.
... It is necessary to understand how PEDs and CEDs differ in the management of children presenting with injuries in order to improve detection of physical abuse and prevent continuing abuse (Pierce, 2019). Abuse is missed more frequently in CEDs, where several barriers to identification of abuse, including less familiarity with children and child abuse, reduced access to pediatric specialists, and biases about caregivers have been specifically identified (Tiyyagura, Gawel, Koziel, Asnes, & Bechtel, 2015). Our child abuse guideline may have addressed these barriers, in part, by facilitating connections with a regional child protection team and standardizing the evaluation of infants with high-risk injuries. ...
Article
Background Although child physical abuse is missed more frequently in community (CEDs) vs. pediatric emergency departments (PEDs), little information exists describing how evaluations of high-risk injuries differ between these settings. Objectives To determine differences in evaluations of infants for abuse between a PED and CEDs and whether a child abuse guideline reduced these differences. Participants and setting Infants presenting to one PED (n = 162) and three CEDs (n = 159) with 3 injury categories: 1) Injuries for which the American Academy of Pediatrics recommends skeletal survey (SS) testing (infants <5-months with an oral injury or bruising, <9-months with a non-skull fracture, and < 12-months with an intracranial hemorrhage); 2) an oral injury or high-risk bruising in older infants; and 3) multiple types of high-risk injuries. Methods We assessed differences in SS testing and child protective services (CPS) reporting between the PED and CEDs before and after implementation of a child abuse guideline. Results The median (IQR) age was 4 months (2–7). Before guideline implementation, infants with injuries in categories 1 and 2 had an increased odds of SS testing in the PED vs. the CEDs (Category 1: aOR 2.83, 95% CI: 1.01–8.10; Category 2: aOR 10.1, CI: 1.2–88.0) and CPS reporting (Category 1: aOR 7.96, CI: 2.3–26.7; Category 2: aOR 12.0, CI: 1.4–103.5). After guideline implementation, there were no statistically significant differences in testing and reporting for any injury category. Conclusions Implementation of a child abuse guideline minimized differences between a PED and CEDs in the evaluation of infants with injuries concerning for abuse.
Article
Background: Physical abuse of children is reported to occur in 30-60% of homes with intimate partner violence (IPV). IPV in adult victims presenting to emergency departments (ED) represents a critical opportunity to evaluate for child safety. Objectives: The primary objective was to determine the frequency of child safety assessments (CSAs), defined as any documented inquiry about the presence of children in the household, when adults presented to EDs for IPV. The secondary aims were to assess (1) the impact of demographic factors, ED type, and social work (SW) involvement on the likelihood of CSAs, (2) the nature of children's exposure, and (3) the frequency of child protective services (CPS) reports. Methods: We performed a chart review of encounters with ICD-10-CM codes for patients aged 18-60 with IPV presenting to 3 EDs in Connecticut from 2017- 2019. Results: CSAs were completed in 179/277 encounters (78.9%) and were more likely to be completed in encounters with SW involvement than without (162/171(94.7%) vs. 17/56 (30.3%), p<.001). A total of 143 children lived in the home at the time of the incident; of the 107 children for whom the nature of exposure was known, 10 (9.3%) were physically involved and 26 (24.2%) were direct witnesses to the violence. CPS reports were made in 52.4% of the encounters in which children lived in the home. Conclusions: CSAs were omitted in one fifth of encounters for IPV. Given the high prevalence of children involved in IPV episodes, ED encounters for IPV represent an opportunity to improve the safety of children.
Article
Background Child abuse and neglect need to be addressed through a public health approach that prioritises prevention and early intervention. Nurses and midwives are core to this public health response, yet little is known about how their roles are described in Australian policy. Aim To explore how nurses’ and midwives’ roles in a public health response to child abuse and neglect are described in Australian policies about child protection, health, welfare, or development. Methods This policy review used Internet searching to identify Australian policy documents relating to child protection, health, welfare, or development published from 2009 to 2021. Data were analysed using deductive coding and content analysis. Findings Nurses’ and midwives’ contributions to a public health response to child abuse and neglect were either absent or described in scant detail within Australian policy. The information that was available represented only a portion of nursing and midwifery practices from a limited range of practice contexts. Discussion A lack of visibility and clarity of nurses’ and midwives’ roles in policy raises many challenges. This includes a lack of guidance for interdisciplinary collaboration, educational preparation of nurses and midwives, and appropriate resourcing for their interventions. Further research is urgently needed to guide future best-practice policy and practices for nurses’ and midwives’ contributions to a public health response to child abuse and neglect. Conclusion An enhanced representation of nurses’ and midwives’ roles in Australian policy is required to guide a public health approach that promotes better outcomes for all children.
Article
Objective: Child abuse is a major cause of childhood injury, morbidity, and death. There is a paucity of data on the practice of abuse interventions among this vulnerable population. The aim of our study was to identify the factors associated with interventions for child abuse on a national scale. Methods: Retrospective analysis of 2017-2018 ACS-TQIP. All children presenting with suspected/confirmed child abuse and an abuse report filed were included. Patients with missing information regarding abuse interventions were excluded. Outcomes were abuse investigations initiated among those with abuse reports, and change-of-caregiver at discharge among survivors with an investigation initiated. Multivariable regression analyses were performed. Results: 7,774 child abuse victims with an abuse report were identified. Mean age was 5±5yrs, 4,221(54%) patients were White, 2,297(30%) Black, 1,543(20%) Hispanic, and 5,298(68%) had government-insurance. Most common mechanism was blunt(63%),followed by burns(10%),and penetrating(10%). Median ISS was 5[1-12]. Most common form of abuse was physical(92%), followed by neglect(6%),sexual(3%),and psychological(0.1%). Most common perpetrator of abuse was care provider/teacher(49.5%),followed by member of immediate family(30.5%),or member of the extended/step/foster family(20.0%). 6,377(82%) abuse investigations were initiated for those with abuse reports. Of these, 1,967(33%) resulted in change-of-caregiver. Black children were more likely to have abuse investigated, and Black and Hispanic children were more likely to experience change-of-caregiver after investigations, while privately-insured children were less likely to experience both (Table 3). Conclusion: Significant racial, ethnic, and socioeconomic disparities exist in the nationwide management of child abuse. Further studies are strongly warranted to understand contributing factors and possible strategies to address them. Level of evidence: III Therapeutic/Care Management.
Article
The context of suspected maltreatment cases is likely to influence the decision of whether or not to make a formal report. Across one pilot study ( N = 368) and two experiments (Exp. 1 N = 444; Exp. 2 N =416), undergraduate students and online community participants reported their anticipated actions and beliefs when confronted with evidence of child maltreatment. Participants reviewed case dossiers built from real-world child neglect cases in which increasing levels of evidence were presented and the consequences of reporting, or not reporting, the maltreatment were made salient to the adult or child. The experiments revealed a clear difficulty in deciding whether or not to report suspected maltreatment. Highlighting the impact on either the child or the adult by describing potential consequences moved participants either closer to (child-salient) or farther from (adult-salient) a formal report. Participants were also sensitive to the amount of evidence to support a suspicion of abuse, which influenced the likelihood of a formal report. This work suggests that increasing the salience of maltreatment consequences to child victims may increase the likelihood that suspected maltreatment will be reported.
Article
Objective: The study provides considerations for generating a phenotype of child abuse and neglect in Emergency Departments (ED) using secondary data from electronic health records (EHR). Implications will be provided for racial bias reduction and the development of further decision support tools to assist in identifying child abuse and neglect. Materials and methods: We conducted a qualitative study using in-depth interviews with 20 pediatric clinicians working in a single pediatric ED to gain insights about generating an EHR-based phenotype to identify children at risk for abuse and neglect. Results: Three central themes emerged from the interviews: (1) Challenges in diagnosing child abuse and neglect, (2) Health Discipline Differences in Documentation Styles in EHR, and (3) Identification of potential racial bias through documentation. Discussion: Our findings highlight important considerations for generating a phenotype for child abuse and neglect using EHR data. First, information-related challenges include lack of proper previous visit history due to limited information exchanges and scattered documentation within EHRs. Second, there are differences in documentation styles by health disciplines, and clinicians tend to document abuse in different document types within EHRs. Finally, documentation can help identify potential racial bias in suspicion of child abuse and neglect by revealing potential discrepancies in quality of care, and in the language used to document abuse and neglect. Conclusions: Our findings highlight challenges in building an EHR-based risk phenotype for child abuse and neglect. Further research is needed to validate these findings and integrate them into creation of an EHR-based risk phenotype.
Article
Full-text available
Introduction: Social emergency medicine (EM) is an emerging field that examines the intersection of emergency care and social factors that influence health outcomes. We conducted a scoping review to explore the breadth and content of existing research pertaining to social EM to identify potential areas where future social EM research efforts should be directed. Methods: We conducted a comprehensive PubMed search using Medical Subject Heading terms and phrases pertaining to social EM topic areas (e.g., "homelessness," "housing instability") based on previously published expert consensus. For searches that yielded fewer than 100 total publications, we used the PubMed "similar publications" tool to expand the search and ensure no relevant publications were missed. Studies were independently abstracted by two investigators and classified as relevant if they were conducted in US or Canadian emergency departments (ED). We classified relevant publications by study design type (observational or interventional research, systematic review, or commentary), publication site, and year. Discrepancies in relevant publications or classification were reviewed by a third investigator. Results: Our search strategy yielded 1,571 publications, of which 590 (38%) were relevant to social EM; among relevant publications, 58 (10%) were interventional studies, 410 (69%) were observational studies, 26 (4%) were systematic reviews, and 96 (16%) were commentaries. The majority (68%) of studies were published between 2010-2020. Firearm research and lesbian, gay, bisexual, transgender, and queer (LGBTQ) health research in particular grew rapidly over the last five years. The human trafficking topic area had the highest percentage (21%) of interventional studies. A significant portion of publications -- as high as 42% in the firearm violence topic area - included observational data or interventions related to children or the pediatric ED. Areas with more search results often included many publications describing disparities known to predispose ED patients to adverse outcomes (e.g., socioeconomic or racial disparities), or the influence of social determinants on ED utilization. Conclusion: Social emergency medicine research has been growing over the past 10 years, although areas such as firearm violence and LGBTQ health have had more research activity than other topics. The field would benefit from a consensus-driven research agenda.
Article
Once it has met the paramount needs of caring for the child's injuries and arranging for his protection, the hospital should turn to the task of treating the parent, whose failure in “mothering” behavior usually reflects a deep isolation and a childhood history of similar parental abuse. With such a therapeutic rather than punitive approach, the safe return of a majority of battered children to their homes eventually becomes possible.
Conference Paper
Varying philosophical and theoretical orientations to qualitative inquiry remind us that issues of quality and credibility intersect with audience and intended research purposes. This overview examines ways of enhancing the quality and credibility of qualitative analysis by dealing with three distinct but related inquiry concerns: rigorous techniques and methods for gathering and analyzing qualitative data, including attention to validity, reliability, and triangulation; the credibility, competence, and perceived trustworthiness of the qualitative researcher; and the philosophical beliefs of evaluation users about such paradigm-based preferences as objectivity versus subjectivity, truth versus perspective, and generalizations versus extrapolations. Although this overview examines some general approaches to issues of credibility and data quality in qualitative analysis, it is important to acknowledge that particular philosophical underpinnings, specific paradigms, and special purposes for qualitative inquiry will typically include additional or substitute criteria for assuring and judging quality, validity, and credibility. Moreover, the context for these considerations has evolved. In early literature on evaluation methods the debate between qualitative and quantitative methodologists was often strident. In recent years the debate has softened. A consensus has gradually emerged that the important challenge is to match appropriately the methods to empirical questions and issues, and not to universally advocate any single methodological approach for all problems.
Article
This book presents a vision of childhood victimization, one that unifies the conventional subdivisions like child molestation, child abuse, street crime, bullying, and exposure to community violence. It shows how children are the most criminally victimized segment of the population, with over one-in-five facing multiple, serious "poly-victimizations" during a single year. Developmental Victimology, the book's term for this new integrative perspective, looks at how victimization changes across the span of childhood and offers insights about how to categorize juvenile victimizations and how to think about risk and impact developmentally. It presents new data about unexpected declines in childhood victimization during the 1990s and early 2000s and suggest some of the reasons for this drop. The book also provides a new model of society's response to child victimization - the Juvenile Victim Justice System - and a fresh way of thinking about barriers that victims and their families encounter when seeking help.
Article
Context Abusive head trauma (AHT) is a dangerous form of child abuse that can be difficult to diagnose in young children.Objectives To determine how frequently AHT was previously missed by physicians in a group of abused children with head injuries and to determine factors associated with the unrecognized diagnosis.Design Retrospective chart review of cases of head trauma presenting between January 1, 1990, and December 31, 1995.Setting Academic children's hospital.Patients One hundred seventy-three children younger than 3 years with head injuries caused by abuse.Main Outcome Measures Characteristics of head-injured children in whom diagnosis of AHT was unrecognized and the consequences of the missed diagnoses.Results Fifty-four (31.2%) of 173 abused children with head injuries had been seen by physicians after AHT and the diagnosis was not recognized. The mean time to correct diagnosis among these children was 7 days (range, 0-189 days). Abusive head trauma was more likely to be unrecognized in very young white children from intact families and in children without respiratory compromise or seizures. In 7 of the children with unrecognized AHT, misinterpretation of radiological studies contributed to the delay in diagnosis. Fifteen children (27.8%) were reinjured after the missed diagnosis. Twenty-two (40.7%) experienced medical complications related to the missed diagnosis. Four of 5 deaths in the group with unrecognized AHT might have been prevented by earlier recognition of abuse.Conclusion Although diagnosing head trauma can be difficult in the absence of a history, it is important to consider inflicted head trauma in infants and young children presenting with nonspecific clinical signs.
Article
Previous studies have found racial and socioeconomic status bias in the way clinicians screen for and detect child abuse in patients presenting to the emergency department. We hypothesized that implementing a guideline for screening would attenuate this bias. An algorithm for child abuse screening in patients younger than 1 year presenting with fractures was developed for a pediatric trauma center emergency department. Data were collected 1.5 years before and after implementation of the algorithm to investigate implementation success. Data were compared before and after the implementation of the algorithm using χ and univariate logistic regression analysis. The characteristics of patients with fractures were similar before and after the algorithm implementation. Implementation of the algorithm was related to a significant increase in algorithm required screenings: skeletal survey (p < 0.001), urinalysis (p < 0.001), and transaminase levels (p < 0.001). The racial composition of those screened did not change after the implementation of the protocol. Children with government-subsidized or no insurance were more likely to be screened for child abuse via skeletal survey before the algorithm implementation compared with those with private insurance (odds ratio, 2.7; 95% confidence interval, 1.2-6.0; p = 0.017). This relationship did not exist after the algorithm implementation (odds ratio, 1.2; 95% confidence interval, 0.56-2.46; p = 0.66). Final determination of child abuse was related to insurance status both before and after the algorithm implementation. A child abuse screening algorithm was successfully implemented in an urban trauma center. After implementation, screening was no longer associated with socioeconomic status of the patient's family, although final determination of child abuse still was. Additional research is needed to determine utility of unbiased screening on patient outcomes. Therapeutic study, level IV.