Hospital Child Protection Team Research Articles

Emergency Department Triage Chief Complaints Among Children Evaluated for Physical Abuse Concerns.

The aims of this study were to describe chief complaints provided at emergency department triage for young children ultimately given a diagnosed with injuries concerning for physical abuse and compare chief complaints by hospital child protection team assessment (abuse most likely, accident most likely, undetermined) among children younger than 2 years who were the subject of a report to child protective services. This is a retrospective review of children evaluated by the child protection team at an urban children's hospital over a 5-year period. Children younger than 2 years who were the subject of a report to child protective services for suspected physical abuse were included. Chief complaints noted in emergency department triage notes were categorized as follows: 1, medical sign or symptom; 2, accidental trauma incident; 3, identified injury; 4, concern for abuse; or 5, multiple unrelated complaints. Child protection team assessments were categorized as follows: 1, abuse most likely; 2, accident most likely; or 3, undetermined. We used descriptive statistics and tests of association (χ2, Fisher exact, Kruskal-Wallis). Median age of the 422 children included was 4.9 months. Child protection team assessment was abuse most likely in 44%, accident most likely in 23%, and undetermined in 34%. Chief complaints in the overall sample were 39% medical, 29% trauma incident, 16% injury, 10% abuse concern, and 6% multiple unrelated. When the abuse most likely and accident most likely groups were compared, medical chief complaints were more common in the former (47% vs 19%, P < 0.001), whereas trauma incident chief complaints were more common in the latter (19% vs 64%, P < 0.001). Most common medical complaints in the abuse most likely group were altered mental status, abnormal limb use, swelling, pain, apnea, and vomiting. Many children found to have injuries concerning for abuse (47%) present without mention of trauma, injury, or abuse concern as part of the chief complaint. Our findings suggest important topics to include in training physicians about recognition of abuse.

Diagnosis codes dramatically underestimate the burden of abuse

BackgroundInternational Classification of Diseases (ICD) billing codes are not well-suited to estimate physical abuse prevalence among hospitalized patients and may be even less accurate in emergency departments (EDs). The Centers for Disease Control and Prevention (CDC) has recently published a child abuse and neglect syndromic surveillance definition to more accurately examine national abuse trends among ED visits. ObjectiveTo retrospectively apply the CDC syndromic definition to a population of physically abused children and determine its sensitivity for abuse in an ED and at hospital discharge.Participants and Setting.All physically abused children <5 years seen in the ED and evaluated by the child protection team from 2016 to 2020 at a large Midwestern children's hospital. MethodsRetrospective cross-sectional study utilizing the hospital's child protection team administrative database, the Pediatric Health Information System and the electronic health record to identify the study sample, chief complaint, and abuse-specific codes assigned in the ED and at hospital discharge. Abuse-specific codes were defined as all ICD-10-CM and Systematized Nomenclature of Medicine – Clinical Terms (SNOMED CT) codes included in the CDC syndromic definition, which was applied to the sample and its sensitivity determined. ResultsAmong the 550 abused patients identified, most were male (58.4 %), white (65.1 %), <2 years old (80.4 %), and had public insurance (81.6 %). When applying the CDC syndromic definition, only 11.6 % were identified as abused in the ED and 65.3 % were identified at hospital discharge. ConclusionsThe CDC syndrome surveillance definition lacks sensitivity in identifying abuse in the ED or at hospital discharge.

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.

Children at the Intersection of Pediatric Palliative Care and Child Maltreatment: A Vulnerable and Understudied Population

ContextConcerns for child maltreatment can complicate the provision of pediatric palliative care (PPC). Little is known about the vulnerable population of children with life-threatening conditions involved with PPC and state Child Protective Services (CPS) or hospital Child Protection Teams (CPTs). More information is needed to inform and optimize collaborative care. ObjectivesDefine and describe the population of children with PPC involvement for whom there was concern for maltreatment. MethodsSingle-center retrospective chart review of children with PPC involvement for whom there was concern for maltreatment, defined as involvement of CPS/CPT between 2005 and 2017. Medical and demographic variables were abstracted and analyzed. Analyses include descriptive tabulation and measurements of association between PPC and CPS/CPT variables. ResultsAmong 1804 children followed by PPC, 189 (10.4%) had documented CPS/CPT involvement. Among those, 113 (60%) had CPT involvement, 88 (47%) had concerns of medical neglect, and 100 (53%) had simultaneous CPS/CPT and PPC involvement. Goals of PPC consultation varied by clinical characteristics and concerns for medical neglect. Frequency of CPT involvement and physical abuse concerns also varied by child clinical characteristics. ConclusionPPC practitioners regularly encounter children with CPS/CPT involvement. PPC practitioners should be aware of the risk of maltreatment in their patients. Although rare in the general pediatric population, medical neglect is a relatively frequent maltreatment concern in children cared for by PPC. PPC practitioners have an opportunity to aid in proper evaluation of medical neglect in children they care for. Closer PPC collaboration with CPS/CPT may further optimize care.

Child Protection Team Consultation for Injuries Potentially Due to Child Abuse in Community Emergency Departments.

Emergency care for children is provided predominantly in community emergency departments (CEDs), where abusive injuries frequently go unrecognized. Increasing access to regional child abuse experts may improve detection of abuse in CEDs. In three CEDs, we intervened to increase involvement of a regional hospital child protection team (CPT) for injuries associated with abuse in children<12 months old. We aimed to increase CPT consultations about these infants from the 3% baseline to an average of 50% over 12months. We interviewed CED providers to identify barriers and facilitators to recognizing and reporting abuse. Providers described difficulties differentiating abusive from nonabusive injuries and felt that a second opinion would help. Using a plan-do-study-act approach, beginning in April 2018, we tested, refined, and implemented interventions to increase the frequency of CPT consultation, including leadership and champion engagement, provider training, clinical pathway implementation, and an audit and feedback process. Data were collected for 15 months before and 17 months after initiation of interventions. We used a statistical process control chart to track CPT consultations about children<1 year old with high-risk injuries, use of skeletal surveys (SSs), and reports to child protective services (CPS). Evidence of special cause was identified beginningin June 2018, with a shift of 8 points to one side of the center line. For the subsequent 8-month period, the CPT was consulted for a mean of 47.5% of children with high-risk injuries; this was sustained for an additional 7months. The average percentage of infants with high-risk injuries who received a SS increased from 6.7% to 18.9% and who were reported to CPS increased from 10.7% to 32.6%. Targeted interventions in CEDs increased the frequency of CPT consultation, SS use, and reports to CPS for infants with high-risk injuries. Such interventions may improve recognition of physical abuse.

Utility of screening urinalysis to detect abdominal injuries in suspected victims of child physical abuse

BackgroundUrinalysis, liver enzymes (LE) and lipase are used to screen for abdominal injuries in children with suspected physical abuse (SPA). However, data on the utility of urinalysis is limited. ObjectivesDescribe the prevalence of hematuria in evaluations for SPA. Determine test characteristics of hematuria, LE and lipase to identify kidney and other abdominal injuries among children with SPA. Participants and settingChildren < 7 years receiving a urinalysis during evaluation for SPA by a hospital child protection team. MethodsDemographic, clinical, and laboratory data including presence of hematuria (blood on urine dipstick), elevated LE (> 80 U/L) and elevated lipase (> 100 U/L) were abstracted retrospectively. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for the overall study population and for patients without abdominal symptoms. ResultsTen percent of patients had hematuria (N = 237). Prevalence of abdominal and kidney injuries was 7 % and 1 % respectively. Of 3 patients with kidney injury, 2 had hematuria and all had elevated LE. Sensitivity (67 %) and NPV (99 %) of hematuria to detect kidney injuries were lower than LE and the same as lipase. Specificity (91 %) and PPV (8%) of hematuria to detect kidney injury were greater than LE and similar to lipase. Sensitivity of hematuria to detect any abdominal injury (50 %) was lower than LE (81 %). Sensitivity of hematuria to detect occult abdominal injury was 0 %. ConclusionsHematuria alone did not lead to detection of kidney injury. Test characteristics of hematuria were largely similar or inferior to LE and lipase.

National survey of hospital child protection teams in Japan

This study aimed to investigate the penetration rate of child protection teams (CPTs) in medical institutions and associations between CPT functions and hospital services. We collected data in October of 2015 from 377 hospitals in Japan offering pediatric organ transplantation. The questionnaire included questions regarding the existence of a CPT, the number of child maltreatment cases discussed and reported per year, CPT functions including 21 items about staffing, manuals, meeting, prevention, education, and collaboration, and the services provided by the hospital. Of the 377 institutions, 122 (32.4%) answered the survey. There were significant associations between CPT functions and the number of pediatric beds (r = .27), number of pediatricians (r = .27), number of outpatients (r = .39), number of emergency outpatients (r = .28), and emergency medical care (p = .009). In a multiple regression analysis, CPT functions were significantly associated with the number of CPT members, pediatric outpatient numbers, and pediatric emergency outpatient numbers. Japan has no CPT guidelines that outline what CPTs should offer in terms of structure, staffing, functions, and systems. Hospitals with many pediatric and emergency outpatients are expected to play major roles in providing services such as specialty care, intensive care, and education. They are also expected to play a role in detecting and managing child maltreatment, and have, by their own initiative, improved their capacities to achieve these goals.

Abusive head trauma and accidental head injury: a 20-year comparative study of referrals to a hospital child protection team

AimTo describe children referred for suspected abusive head trauma (AHT) to a hospital child protection team in Auckland, New Zealand.MethodsComparative review of demographics, histories, injuries, investigations and diagnostic outcomes for...

Child protection decisions to substantiate hospital child protection teams’ reports of suspected maltreatment

The present study focuses on the way child protection officers (CPOs) in Israel assess suspected abuse and neglect (SCAN) reports made by hospital child protection teams (CPTs), to determine whether the alleged maltreatment is substantiated. The study was conducted in six medical centers and included 358 reports investigated by CPOs for SCAN. A structured questionnaire was completed by hospital CPTs to capture all relevant information on each child referred to the CPTs. Structured phone interviews were conducted with each of the CPOs who received a CPT report. Bivariate associations and multivariate logistic regressions were conducted to estimate the substantiation rate of cases reported by CPTs and the types of maltreatment substantiated, as well as to identify case characteristics of the child and the family that were associated with the CPOs’ substantiation decision. CPO follow-up investigations revealed a substantiation rate of 53.5%. The maltreatment type most commonly substantiated was neglect. The case characteristics associated with substantiation included socio-demographic background, parents’ health and functioning, previous contact with social services, characteristics of the hospital referral, medical findings and an assessment of the parents’ behaviors. The findings of the study highlighted the importance of cooperation between the health and welfare services and the policy makers. This cooperation is essential for identifying early signs of maltreatment. Enhanced cooperation and effective information transfer between various professionals would help prevent or at least reduce the recurrence of maltreatment and would ensure that the children and their families are treated appropriately.

Increased Serum Creatine Phosphokinase in a Child With Bruising Due to Physical Abuse

Bruising is a frequent and often sentinel injury in children who are victims of physical abuse. Children who are evaluated in an emergency department for bruising, which may be due to abuse, present a challenge to physicians; the injuries themselves are medically minor and their severity can only be described qualitatively with photographs. Nonetheless, bruising in an infant or bruising in unusual locations in young children can indicate violence and risk. These children also present a challenge to the Child Protective Services system because the injuries generally resolve quickly without medical treatment and do not result in long-term sequelae. Creatine phosphokinase (CPK) is released from injured muscle and results in increased serum CPK concentrations. We report on a case of isolated bruising due to child physical abuse in which serum CPK concentrations were markedly increased, demonstrating clinically unsuspected rhabdomyolysis. The increased serum CPK concentrations provided important quantitative information about the seriousness of the bruising. A subsequent chart review of children evaluated by our hospital's child protection team for isolated bruising during a 6-year period demonstrated that there were other children with bruising due to abuse who also had increased serum CPK concentrations. This information suggests that increased serum CPK in children with bruising due to abuse may be more common than previously thought and that this information may have the potential to be used to provide quantitative, objective information about the seriousness of the bruising. We recommend that physicians consider measuring serum CPK in children with bruising due to physical abuse.

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

In the aftermath of child maltreatment or neglect, the health-related quality of life (HRQoL) in children is likely to be affected. However, research on quality of life in maltreated children is lacking. The aim of this study is to compare the HRQoL in a follow-up sample of children referred to an interdisciplinary hospital child protection team (CPT) to match controls and to explore correlates of HRQoL. Of the 319 in- and outpatient children referred to the CPT at the University Children's Hospital Zurich between 2005 and 2006, an eligible sample of 180 children was contacted for a follow-up. HRQoL was assessed for 42 former patients using the self- and proxy-rated KIDSCREEN-27 for children above the age of 6 years and the TAPQOL parent report for children younger than 6 years. HRQoL-scores in the maltreatment group were compared with HRQoL in 39 matched controls. Self-reported HRQoL in maltreated children above the age of 6 years was significantly impaired compared to matched controls. The caregiver-rated HRQoL of maltreated children, however, was not affected. Low socioeconomic status and number of life events were associated with impaired self-reported HRQoL. Analyzed together with these factors, maltreatment lost its predictive power on HRQoL. Maltreated children and adolescents suffer from impaired HRQoL even after the maltreatment has been disclosed and targeted by interventions. The impact of socioeconomic environment reinforces the importance of a multidisciplinary and systemic approach to maltreatment as applied by the CPT. Although the nature of discordance between child and caregiver report is not known, researchers and clinicians are strongly encouraged to assess the victim's self-reported HRQoL independently of their proxies' view.

Retinal Hemorrhages in Low-Risk Children Evaluated for Physical Abuse

To describe the prevalence of retinal hemorrhage (RH) in children without intracranial injury who are being evaluated for abusive head trauma and to validate previously derived criteria for identifying patients within this population who are at low risk of having RH on dilated eye examination. Medical record review. Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center from January 1, 2006, to April 30, 2010. One hundred ninety-four infants and children evaluated for physical abuse by the hospital Child Protection Team who did not have intracranial injury and who underwent a dilated eye examination to evaluate for RH. Number of children with RH who met a set of low-risk criteria: no intracranial hemorrhage with or without a simple, nonoccipital skull fracture, normal mental status, and no bruising on the head or face. Of the 194 patients without intracranial injury who underwent dilated eye examination, 141 children (72.7%) met low-risk criteria. None of these 141 patients had RH. Of the 53 participants who did not meet low-risk criteria, 2 children (3.8%) had RH. In children evaluated for physical abuse who fulfill a set of low-risk criteria, the dilated eye examination should not be a necessary component of the abuse evaluation. Use of these criteria can significantly decrease the number of children who need to undergo a dilated eye examination as part of an evaluation for abusive head trauma.

Methodological challenges in following up patients of a hospital child protection team: is there a recruitment bias?

BackgroundThe aims of this study are to describe the methodological challenges in recruiting a follow-up sample of children referred to an interdisciplinary hospital child protection team (CPT) and to compare participating versus non-participating groups on several demographic variables and maltreatment characteristics.MethodsOf the 319 in- and outpatients referred to the CPT at University Children's Hospital Zurich from 2005–2006 a sample of 180 children was drawn to contact for a follow-up. The children and their parents were asked to participate in a face-to-face interview at the hospital; in 42 cases the children and parents consented to do so. Alternatively, the parents could take part in a telephone interview (n = 39). Non-participation resulted because no contact or adequate communication in German, French, or English could be established (n = 49) or because the parents or children refused to participate (n = 50).ResultsParticipants and non-participants did not differ significantly in mean child age at follow-up, gender, family status, place of residence, certainty and type of maltreatment, and type of perpetrator. However, the child's nationality had a significant impact: Percentages of foreign nationals were higher in the fully participating group (45%; n = 19) and the non-contactable group (53%; n = 26) and significantly lower in the refusal (26%; n = 10) and the telephone interview group (18%; n = 9). Although a high percentage of families had moved in the few years since the CPT intervention (32%; n = 57), the percentage of moves was not significantly higher in non-participants compared to participants.ConclusionsFurther research is needed to support these results in different national backgrounds and to test for biases in variables not included – especially socioeconomic status. This includes gathering more detailed information on non-participants, while respecting ethical boundaries. Overall, the fact that only child's nationality was unevenly distributed between participants and non-participants is encouraging.

The contribution of a hospital child protection team in determining suspected child abuse and neglect: Analysis of referrals of children aged 0–9

Background Hospital professionals have a unique opportunity to identify victims of child abuse and neglect (CAN). The hospital multi-disciplinary Child Protection Team (CPT) offers a means for optimizing procedures, maximizing caution and enhancing decision-making. Objective The current study describes cases of children aged 0–9 years referred to the CPT, to identify the contribution of the CPT to the assessment process in determining reasonable suspicion of child abuse or neglect. Methods The files of all 990 cases of children aged 0–9 referred to the CPT from 1991 thru 2006 were abstracted. Results Nearly equal rates of boys and girls were referred to the CPT, and the average age was 2.4 years (SD 2.6), with over two-thirds aged 0–2. Half of the cases arrived at the hospital due to accident or trauma, and nearly one-third due to illness. Eighty-five neonates were referred due to parental risk factors identified at birth. The most common reasons prompting referral to the CPT were medical indication and parent behavior, with parents most often the suspected source of danger. Over half of the cases (566) were reported to authorities. Nearly half of those reported were cases of suspected physical neglect, 21.5% were suspected of physical abuse, and 7.6% of sexual abuse. There were significant differences in the patterns of reporting and types of suspicion both for the various age groups (p < 0.001) and the genders (p < 0.001), as well as by age-gender groups (shown in the first figure). Conclusions The current findings illuminate the various factors and steps involved in the hospital CPT's assessment of preliminary suspicions of CAN raised by front-line clinicians. It is recommended that standardized criteria be developed based on current state-of-knowledge.

Distinguishing neglect from abuse and accident: analysis of the case files of a hospital child protection team in Israel

The study compares the characteristics of children assessed as neglected, physically abused, or accident victims by a hospital child protection team (CPT) and identifies the information on which the CPT based its assessments. The comparison is based on content analysis of records of 414 children examined by the CPT in a major hospital in Israel between 1991 and 2006, of whom 130 (31.4%) were neglected, 54 (13.0%) were physically abused, and 230 (55.6%) were accident victims. Findings of three hierarchical logistic regressions show that the children classified as neglected had the most early development problems, but were the least likely to have received psychological treatment, and that that their families were the most likely to be receiving state financial support and to have had prior contact with the social services. They also show that the CPT had received the least information indicative of maltreatment about these children from the community and that their medical and physical examinations aroused the least suspicion. Finally, they show that the impressions the hospital staff and CPT had of the parents during the hospital visit had greater power to distinguish between the groups than the children's characteristics or the parents' socio-demographic background. The findings attest to the ability of the CPT to differentiate between neglect victims and physical abuse or accident victims. With this, they also point to ambiguities in the classification process that should be addressed by further research and training and to the need for detailed and thorough documentation of the information and observations on which the CPT's assessments are based.

Methodological considerations in defining child maltreatment

Braillon, Bewley and Dubois [1] rightly stress the impor-tance of the deleterious effects of secondhand smoke onchildren’s physical health.Uniform definitions of child maltreatment and neglectare lacking. However, definitions describing physicalmaltreatment as the intentional use of physical force againsta child that results in or has the potential to result inphysical injury are broadly accepted by child protectionresearchers and practitioners [2, 3]. The behaviour groupedwithin this definition—like hitting, kicking, punching orbeating—possibly shares comparable causes and conse-quences. This assumption is endorsed by the substantialresearch on risk factors of physical maltreatment [4].Although we would restrain from defining secondhandsmoke as physical maltreatment, regularly exposing a childto secondhand smoke can be defined as a failure to providethe basic need of a healthy environment. This failure oftencoincides with other neglectful behaviour like takingchildren out till late at night, deficits in nutrition or con-sumption of alcohol during pregnancy. Such patterns areregularly referred to hospital child protection teams or otherchild protection agencies. Research on the epidemiology ofchild maltreatment identifies neglect as the most commonform of maltreatment with enormous costs for public health[3, 5, 6].

Characteristics associated with maltreatment types in children referred to a hospital protection team

The aim of this paper is to describe characteristics associated with maltreatment types in children referred to the child protection team at the University Children's Hospital Zürich. Since 2003, the child protection team has registered data on each case in a standardized form. To examine differences in gender, age, nationality, and socioeconomic status by type of maltreatment, regression analyses were conducted for the 1,484 cases that were referred from 2003 to 2006. The most common types of referred maltreatment were sexual (38%) and physical maltreatment (31%) with mean ages of 8.4 and 7 years, respectively. Compared to physical maltreatment, where gender distribution was equal, there was a higher risk for girls to become victims of sexual maltreatment. Younger children were at higher risk for neglect (mean age 5 years). Low socioeconomic status increased the risk for physical as compared to sexual maltreatment. However, whether the child was of Swiss or of foreign nationality was not associated with an increased risk for any type of maltreatment when controlling for socioeconomic status. As this study is one of a few to analyze characteristics in child maltreatment referred to a hospital child protection team, further research is needed. To improve international comparability, thorough documentation of the cases is encouraged.

A window of opportunity: Referral of adolescents to the hospital Child Protection Team

The arrival of an adolescent at the hospital provides a window of opportunity to help those exposed to abuse or neglect, by looking beyond the presenting symptom. The Child Protection Team (CPT) assesses cases of suspected abuse or neglect (SCAN) referred by hospital staff. As adolescents pose a particular array of presentations, this study assessed their socio-demographic features and characteristics of hospitalization in order to improve procedures for identifying SCAN. The study group included all 674 referrals of 10-17-year-olds to the CPT from 1991-2007. Their files were abstracted and demographics compared to similarly-aged Emergency Department (ED) admissions. Different patterns were found by gender and age group. The youngest group (10-13 years) included a higher rate of boys than girls (47.9% vs. 27.6%), and among the oldest (16-17 years) the rate of girls was higher (31.9% vs 15.8%). Comparison with all ED admissions indicated a lower rate of younger girls and a higher rate of 14-15-year-old girls in the study group. The study group also had a higher rate of immigrants (12.8% vs. 4.7%). The most frequent reason for arrival at the hospital was suicidal behavior (30.9%). Older age was related to fewer arrivals for trauma/burn and more suicidal behavior. In 83.1% of the referrals, reports were made to welfare authorities and/or police. The suspicion in 64.2% of the referrals was emotional abuse or physical/emotional neglect; in 18.8%, physical and/or sexual abuse was suspected. The older groups had lower rates of physical and/or sexual abuse and higher rates of emotional abuse or physical/emotional neglect. This study highlights the importance of age-by-gender analysis and understanding of the differential susceptibility of early, middle and late adolescence to SCAN.

Roundtable Sessions of a Children's Hospital Child Protection Team

Roundtable Sessions of a Children's Hospital Child Protection Team

Roundtable Sessions of a Children's Hospital Child Protection Team

Roundtable Sessions of a Children's Hospital Child Protection Team