Hospital-based Child Protection Teams Research Articles

Factors Impacting Maltreatment Evaluation and Reports to Child Protective Services in Pediatric Substance Exposures.

The objective of this study was to assess demographic, clinical, and psychosocial factors associated with pediatric substance exposures, describe the medical evaluation, and identify factors associated with social work (SW) and hospital-based child protection team (CPT) safety assessments and reports to child protective services (CPS). We retrospectively reviewed charts of electronic medical records for children ages 0 to 72 months presenting for accidental ingestion evaluated May 1, 2015 to May 1, 2021 at a level 1 pediatric trauma center. Cases of environmental exposures, iatrogenic medication errors, dosing errors, and allergies/adverse reactions were excluded. Data were analyzed using descriptive statistics; χ 2 and multivariable logistic regression analysis assessed factors associated with two primary outcomes of interest, SW/CPT assessment and CPS report. Among 773 total cases of substance exposures during the studied time frame, 27% were referred to SW/CPT for further safety assessments and 15.4% were reported to CPS. Being admitted to the hospital, prescription medication or recreational/illegal/illicit substance exposures, and increasing psychosocial risk factors were found to be significantly associated with referrals. Age, race, and insurance status were not found to be associated. Toxicology screening was performed in only 24.7% of cases. Of those eligible for further imaging per hospital protocol, skeletal surveys were obtained in 5.5% of cases and head imaging was obtained in 9% of cases. There is significant variability in pediatric substance exposure assessment practices. Disparities based on demographic characteristics are uncommon. Perceived severity of condition, exposures involving recreational/illegal/illicit substances, and greater prevalence of family psychosocial adversities are associated with higher rates of SW/CPT assessment and CPS reports.

The structure, function, task, and effectiveness of hospital-based child protection teams in Taiwan

BackgroundChild protection teams (CPTs) are established in many countries with an intent to safeguard children at risk for maltreatment. However, the tasks and effectiveness of CPTs in Taiwan and many countries remain unclear. ObjectiveA two-step, descriptive correlational study aimed to explore the implementation status and needs concerning the structure, functions, tasks, and effectiveness of hospital-based CPTs using a self-developed evaluation tool in Taiwan. Participants and settingFive experts and 10 CPT members were evaluated the psychometric properties of the evaluation tool. The main study participants comprised 153 CPT members in Taiwan in 2020. MethodsContent validity, factor analysis, test-retest reliability, and internal consistency were used to evaluate the psychometric properties of the instrument. Descriptive and correlational statistics were to describe the implementation status and needs of the structure, functions, tasks, and effectiveness of hospital-based CPTs and their relationships. ResultsThe psychometric properties of the tool were acceptable and satisfactory. The mean scores for each dimension of CPT implementation status were 2.77–2.93 (potential range 0–4) with the lowest for collaboration (mean = 1.97) and incentive (mean = 1.93). The average need scores for each dimension ranged 7.96–8.12 (potential range 0–10), indicating high needs for each dimension, particularly in support, cohesion, and incentive. The implementation status was significantly, weakly correlated with the needs. ConclusionsThere is a need to further strengthen the structure and function of the CPTs and to improve its implementation in Taiwan. It is important to improve inter-agency collaboration and to establish an incentive mechanism for hospital CPTs. Working closely with community agencies is also needed to provide a good quality of care to the maltreated child and the family.

Hospital-Based Case Management Model for Child Protection Teams in Taiwan: An Action Research Approach.

Hospital-based child protection teams play an important role in the multidisciplinary assessment, treatment, care, and rehabilitation of abused children and their families. However, the process by which these teams are built and promoted has not been explored adequately in the literature. This study was developed to examine the process used to promote child protection team case management and to evaluate the related results. An action research model was adopted in this study. The participants and the investigator were members of a child protection team at a medical center in southern Taiwan. Qualitative and quantitative assessments were used to identify problems related to organizational structure, intervention procedures, and evaluation effectiveness. Thereafter, the study program was implemented, and the results were evaluated. Content analysis of the qualitative data, including transcribed interviews with external benchmark members and members of the hospital's team and text entries from the investigator's reflective journal, was conducted. Quantitative data, including monitoring indicators for team case management, were analyzed using descriptive statistics. Three important concepts emerged related to changes in the promotion of case management by hospital child protection teams. These included formulation of a team operation model through visits to benchmark hospitals, establishment of the case management and monitoring mechanism based on team consensus, and expansion of collaboration with external agencies through the establishment of a child and adolescent protection medical regional integration center. The results of the promotion process were affected by factors that included member willingness, teamwork, hospital support, and national policy. Use of the hospital child protection team case management model developed in this study was shown to facilitate the provision of consultation services, integrate the opinions and resources of experts from various fields, and allow the timely provision of acute care, follow-up family environment support, and social resources required by children and their family members. These measures help prevent the reoccurrence of child abuse and enable children to grow up healthily and free from violence.

A regional multidisciplinary network enhances child abuse case management

We previously reported an inadequate response to intracranial hemorrhage (ICH) cases under 24 months of age in Yokohama from 2011 to 2013. Hence, it is very important to evaluate how the establishment of a regional multidisciplinary network for child abuse affects the response to ICH cases in medical institutions. We conducted a questionnaire survey of ICH cases under 24 months of age from 2014 to 2016 using a regional multidisciplinary network for child abuse established in Yokohama in September 2013. We investigated the patients' characteristics, examinations to identify inflicted injury, and reports made to the hospital-based child protection team (CPT) or regional child protective service (CPS), and compared the results of a previous study and the current study, which corresponds to before and after the establishment of the regional network, respectively. The total number of ICH cases was 50 in 3 years. The number of cases surveyed for covert fracture and fundus hemorrhage increased significantly after the establishment of the regional network (P = 0.0001 and P = 0.0182, respectively). The number of cases reported as suspected child abuse was 41 (82%) to the hospital-based CPTs and 27 (54%) to the regional CPSs. There were significant differences between before and after the establishment of the regional network regarding CPT (P = 0.0062) and CPS (P = 0.0215) reports. A regional multidisciplinary network can enhance response and cooperation to address child abuse. It deepens our understanding of such care and improves awareness by hospital personnel of child abuse.

Hospital-based child protection teams that care for parents who abuse or neglect their children recognize the need for multidisciplinary collaborative practice involving perinatal care and mental health professionals: a questionnaire survey conducted in Japan.

BackgroundChild abuse and/or neglect is a serious issue, and in many cases, parents are the perpetrators. Hospital-based child protection teams (CPTs) play pivotal roles in the management of not only abused and/or neglected children but also of their parents; this is generally conducted through multidisciplinary practice. The aim of this study is to survey hospital-based CPT members to determine the professions they perceive to be most applicable to participation in CPTs.Participants and methodsThe participants were members of CPTs affiliated with hospitals that had pediatric emergency departments and which were located in Chiba Prefecture; specifically, 114 CPT members from 23 hospitals responded to this survey. The two main questionnaire items concerned are as follows: 1) each respondent’s evaluation of conducting assessments, providing support, and implementing multidisciplinary collaborative practice in the treatment of abusive and negligent parents, and 2) each CPT member’s opinion on the professions that are most important for CPT activities. An exploratory factor analysis (EFA) was performed to explore the factor structure of the data, and a correlation analysis was performed using the result obtained.ResultsThe EFA returned two factors: multidisciplinary collaborative practice (α = 0.84) and assessment and support (α = 0.89). A correlational analysis showed that multidisciplinary collaborative practice had a positive correlation for obstetricians (r = 0.315, p = 0.001), neonatologists (r = 0.261, p = 0.007), midwives (r = 0.248, p = 0.011), and psychiatrists (r = 0.194, p = 0.048); however, assessment and support was only significantly correlated with midwives (r = 0.208, p = 0.039).ConclusionThis study showed that hospital-based CPT members highly evaluate multidisciplinary collaborative practice for the management of abusive and/or negligent parents, and they believe that, in addition to pediatric physicians and nurses, perinatal care and mental health professionals are the most important participants in advanced CPT activities.

Inadequate sociomedical evaluation of possible abusive head trauma in Yokohama.

There have been no previous studies on the adequacy of combined evaluation of possible abusive head trauma cases by frontline medical personnel, hospital-based child protection teams, and child protective services in local districts of Japan. We conducted a questionnaire survey of hospitalized patients under 24 months old with a diagnosis of intracranial hemorrhage (ICH) from January 2011 to December 2013. Eleven large-scale general hospitals in Yokohama, Japan were surveyed, which provide centralized inpatient care to moderately-severely ill children. A total of 51 ICH patients were listed from eight hospitals. Median patient age was 7 months, and 84% were younger than 12 months. The most common diagnosis on computed tomography was subdural hematoma (n = 26; 51%). Of a total of 51 cases, 31 (61%) occurred inside the home; the injury scene was unknown in six cases (12%). We reviewed these 37 cases from the viewpoint of evaluation with concern for suspected child abuse. Three out of 37 patients (8%) were not examined for inflicted skin lesions, and skeletal surveys and funduscopy were not conducted in 14 (38%) and 15 (41%), respectively. Thirteen out of 37 cases (35%) were not reported to hospital-based child protection teams and 22 (59%) were not reported to regional child protective services. The sociomedical evaluation of possible child abuse appears to be systematically inadequate in Yokohama.

A Qualitative Study on Intervening Work Experiences of Hospital-Based Child Protection Team on Child Abuse Death Cases

A Qualitative Study on Intervening Work Experiences of Hospital-Based Child Protection Team on Child Abuse Death Cases

Assessing the accuracy of the International Classification of Diseases codes to identify abusive head trauma: a feasibility study

ObjectiveTo assess the accuracy of an International Classification of Diseases (ICD) code-based operational case definition for abusive head trauma (AHT).MethodsSubjects were children <5 years of age evaluated for AHT by...

Predicting the decisions of hospital based child protection teams to report to child protective services, police and community welfare services

This study examines judgments made by hospital-based child protection teams (CPTs) when determining if there is reasonable suspicion that a child has been maltreated, and whether to report the case to a community welfare agency, to child protective services (CPS) and/or to the police. A prospective multi-center study of all 968 consecutive cases referred to CPTs during 2010–2011 in six medical centers in Israel. Centers were purposefully selected to represent the heterogeneity of medical centers in Israel in terms of size, geographical location and population characteristics. A structured questionnaire was designed to capture relevant information and judgments on each child referred to the team. Bivariate associations and multivariate multinomial logistic regressions were conducted to predict whether the decisions would be (a) to close the case, (b) to refer the case to community welfare services, or (c) to report it to CPS and/or the police. Bivariate and multivariate analyses identified a large number of case characteristics associated with higher probability of reporting to CPS/police or of referral to community welfare services. Case characteristics associated with the decisions include socio-demographic (e.g., ethnicity and financial status), parental functioning (e.g., mental health), previous contacts with authorities and hospital, current referral characteristics (e.g., parental referral vs. child referral), physical findings, and suspicious behaviors of child and parent. Most of the findings suggest that decisions of CPTs are based on indices that have strong support in the professional literature. Existing heterogeneity between cases, practitioners and medical centers had an impact on the overall predictability of the decision to report. Attending to collaboration between hospitals and community agencies is suggested to support learning and quality improvement.

Sentinel Injuries in Infants Evaluated for Child Physical Abuse

Relatively minor abusive injuries can precede severe physical abuse in infants. Our objective was to determine how often abused infants have a previous history of "sentinel" injuries, compared with infants who were not abused. Case-control, retrospective study of 401, <12-month-old infants evaluated for abuse in a hospital-based setting and found to have definite, intermediate concern for, or no abuse after evaluation by the hospital-based Child Protection Team. A sentinel injury was defined as a previous injury reported in the medical history that was suspicious for abuse because the infant could not cruise, or the explanation was implausible. Of the 200 definitely abused infants, 27.5% had a previous sentinel injury compared with 8% of the 100 infants with intermediate concern for abuse (odds ratio: 4.4, 95% confidence interval: 2.0-9.6; P < .001). None of the 101 nonabused infants (controls) had a previous sentinel injury (P < .001). The type of sentinel injury in the definitely abused cohort was bruising (80%), intraoral injury (11%), and other injury (7%). Sentinel injuries occurred in early infancy: 66% at <3 months of age and 95% at or before the age of 7 months. Medical providers were reportedly aware of the sentinel injury in 41.9% of cases. Previous sentinel injuries are common in infants with severe physical abuse and rare in infants evaluated for abuse and found to not be abused. Detection of sentinel injuries with appropriate interventions could prevent many cases of abuse.

The experience of paediatric residents participating in a child protection rotation: A qualitative study

Practitioners working in the field of child maltreatment are at risk for vicarious traumatization. For Canadian paediatric residents, exposure to child abuse during training is limited. To explore how paediatric residents experience a mandatory rotation within a hospital-based child protection team (CPT) from an emotional and professional development standpoint. Eight paediatric residents were interviewed following their CPT rotation and transcripts were analyzed using a phenomenological approach. Exemplar quotes were then highlighted. FOUR MAJOR THEMES WERE IDENTIFIED: baseline experiences; individual resident factors; intrinsic CPT rotation factors; and overall rotation assessment. The themes and their subthemes were used to inform a conceptual model of residents' experiences. The knowledge provided through residents' accounts can be applied to strengthen future educational opportunities in the field of child maltreatment and offer insight to help guide the development of support systems and debriefing processes that are important in this challenging field.

Abusive Head Trauma During a Time of Increased Unemployment: A Multicenter Analysis

To evaluate the rate of abusive head trauma (AHT) in 3 regions of the United States before and during an economic recession and assess whether there is a relationship between the rate of AHT and county-level unemployment rates. Clinical data were collected for AHT cases diagnosed in children younger than 5 years from January 1, 2004 until June 30, 2009, by hospital-based child protection teams within 3 geographic regions. The recession was defined as December 1, 2007 through June 30, 2009. Quarterly unemployment rates were collected for every county in which an AHT case occurred. During the 5½-year study period, a total of 422 children were diagnosed with AHT in a 74-county region. The overall rate of AHT increased from 8.9 in 100,000 (95% confidence interval [CI]: 7.8-10.0) before the recession to 14.7 in 100,000 (95% CI: 12.5-16.9) during the recession (P < .001). There was no difference in the clinical characteristics of subjects in the prerecession versus recession period. There was no relationship between the rate of AHT and county-level unemployment rates. The rate of AHT increased significantly in 3 distinct geographic regions during the 19 months of an economic recession compared with the 47 months before the recession. This finding is consistent with our understanding of the effect of stress on violence. Given the high morbidity and mortality rates for children with AHT, these results are concerning and suggest that prevention efforts might need to be increased significantly during times of economic hardship.

The Decision of Hospital-Based Child Protection Teams to Report to Community Child Protective Services

The study describes the decision making of a hospital-based child protection team (CPT) considering whether to report a case to the community child protective services (CPS).

Factors That Influence the Effectiveness of Child Protection Teams

More than $55 million is spent on hospital-based child protection teams (CPTs) annually, but there is no consensus on what makes CPTs effective. The objective of this study was to create expert consensus on tasks that CPTs should perform and factors that contribute to effectiveness. A modified Delphi approach was used to create expert consensus among professionals with experience working on or with hospital-based CPTs. Three initial rounds of surveys were conducted; a first round of open-ended questions generated topics related to CPT tasks and factors related to team effectiveness. A Likert scale (range: 1-7) determined rank. In the fourth round, participants ranked the top 5 variables associated with effectiveness. Twenty-six (90%) of 29 participants completed the first 3 rounds, and 20 (67%) completed the final ranking. Experts believed that CPTs should provide communication of findings to appropriate agencies (mean Likert score: 7.0), court testimony (7.0), medical consultations (6.9), multidisciplinary case review (6.6), and forensic interviews (6.0). CPT success should be determined by professionals who use CPT services (6.6) and CPT members (6.5). Variables that were ranked most often as critical to effectiveness included interdisciplinary collaboration (95% of participants), provision of resources (80%), and team collegiality (75%). Variables that were ranked as most detrimental included inadequate staffing (85%) and lack of collegiality (80%). A multidisciplinary team working in a collegial atmosphere seems to be the major key to CPT effectiveness. In addition to providing services, CPTs should focus on improving collegiality and interdisciplinary collaboration and should seek performance feedback from referring professionals and CPT members.

A multidisciplinary approach for the treatment of child abuse in Korea

Results : Of the 76 children, 6 were infants, 10 were 1-3 years old, were 3-10 years old, and 19 were over 10 years old. Seven children (9.2%) were neglected and 27 (35.5%) and 44 (57.9%) were sexually and physically abused, respectively. In more than half of the cases, the perpetrators were the father or mother of the children. Most children (41 cases, 53.9%) were abused at their homes. The mean follow-up duration from the time of abuse infliction was 54.3±49.2 months, and the current mean age of the children was 8.3±6.4 years. Moderate and severe developmental delay and physical disability were observed in 6 (25.0%) and 3 (12.5%) cases, respectively. In 13 children (54.2%), the Global Assessment of Functioning Scale (GAF) score was less than 60, which indicates mild mental disability. Conclusion : A hospital-based child protection team may witness the different proportion of abuse types and patterns by conducting a nation-wide survey of child abuse cases. (Korean J Pediatr 2009;52:1207-1215)

Update on child maltreatment

Recent literature regarding assessment, management and prevention of child maltreatment will be considered. Unexplained infant and child death will also be reviewed. Controversies in the evaluation of unexpected infant death and inflicted traumatic brain injury are ongoing. Evidence continues to accumulate describing the serious long-term sequelae of child maltreatment. Studies have examined the earliest beginnings of these adverse outcomes commencing in childhood. Despite sustained efforts to develop a variety of training and intervention programs, the deployment of these efforts has been hampered by the lack of evidence that they make any difference in improving recognition of child abuse or in preventing recurrent maltreatment. There is a great need in the child abuse field for more formal, rigorous assessment of all manner of intervention programs. Efforts to improve the recognition of and management of child abuse need to be sustained. As our understanding of child maltreatment continues to grow, evidence-based interventions will likely improve outcomes for abused children and their families. General pediatricians are often the first to notice signs and symptoms of possible child maltreatment; collaboration with hospital-based Child Protection Teams is critical when considering the possibility of abuse or neglect.

Decision making by the child protection team of a medical center.

The article Decision Making by the Child Protection Team of a Medical Center by Benbenishty and Chen in this issue (pp. 285-293) describes an interesting study from Israel examining the decision-making process of hospital-based child protection teams (CPT). These teams are mandated by the Israeli Ministry of Health. The authors noted that social workers, nurses, and physicians are regular members of these teams. The authors looked at information cues (constructed from a literature review) that professionals used in making the decision whether to intervene in a situation of suspected child abuse or neglect. Three experienced social workers rated the charts of 139 children referred, presumably by hospital personnel, to the CPT; 98 children were subsequently referred to a child protection officer (CPO), and 41 were not. The study determined that family characteristics such as inadequate parental explanation of the child's injury, immigrant status, and poverty had high probability of resulting in a referral to the CPO. The authors noted that they did not intend to study whether these decisions were accurate. However, in the introduction to the article, they commented that unnecessary referrals cause pain and may cause more harm than good. We agree and note that allocating resources to studying decision making without considering whether the outcomes were bad or good for families and children is of limited use. Although it is interesting to study the decision-making processes of a team of professionals in a hospital over a period of time and find that decision making has been consistent, it is more important to find out whether families and children benefited flora the process. Consistency of decision making does not necessarily result in good outcomes or even fair process. For example, racism and classism can be consistently practiced. This study's findings confirmed that in this hospital, with this CPT, new immigrant families who did not own homes or have steady incomes were referred to the child protection system more often than others. The question that this finding raises is whether the decisions were correct or if they reflected consistent, but problematic practices on the part of the CPT. The authors did not examine whether language was a factor in the finding related to new immigrants. Research in the United States has found that non-English speaking people may look more confused and evasive if they are not communicating in their own language. This is especially so for sensitive topics (Malgady & Zayas, 2001). The authors offered several interpretations of their findings related to nontraditional, poor, and immigrant families. …

Cost Analysis of the Child Protection Team

The suggestion is often made that hospital-based child protection teams are expensive, should be funded from outside sources, and somehow are not really the responsibility of a pediatric service. On the contrary, we feel that hospital-based child protection teams are properly funded along with all other medical care through the usual sources. In order to place the cost of a typical workup of an abused child in perspective, we have compared it to the cost of the evaluation and initial treatment of children with diabetes mellitus and leukemia.