The Evaluation of Suspected Child Physical Abuse

The Evaluation of Suspected Child Physical Abuse
Cindy W. Christian, MD, FAAP, COMMITTEE ON CHILD ABUSE AND NEGLECT

PEDIATRICS Volume 135, number 5, May 2015

The American Academy of Pediatrics (AAP) has updated its child physical abuse guideline to include new information on the lasting effects of abuse and on how pediatricians can protect children. The guideline highlights risk factors for abuse and abusive injuries that are frequently overlooked.
Child physical abuse is an important cause of pediatric morbidity and abstract mortality and is associated with major physical and mental health problems that can extend into adulthood. Pediatricians are in a unique position to identify and prevent child abuse, and this clinical report provides guidance to the practitioner regarding indicators and evaluation of suspected physical abuse of children. The role of the physician may include identifying abused children with suspicious injuries who present for care, reporting suspected abuse to the child protection agency for investigation, supporting families who are affected by child abuse, coordinating with other professionals and community agencies to provide immediate and long-term treatment to victimized children, providing court testimony when necessary, providing preventive care and anticipatory guidance in the office, and advocating for policies and programs that support families and protect vulnerable children

School-based education programmes for the prevention of child sexual abuse.

Walsh K, Zwi K, Woolfenden S, Shlonsky A.

Cochrane Database Syst Rev. 2015 Apr 16;4:CD004380. [Epub ahead of print]

BACKGROUND: Child sexual abuse is a significant global problem in both magnitude

and sequelae. The most widely used primary prevention strategy has been the

provision of school-based education programmes. Although programmes have been

taught in schools since the 1980s, their effectiveness requires ongoing scrutiny.

OBJECTIVES: To systematically assess evidence of the effectiveness of

school-based education programmes for the prevention of child sexual abuse.

Specifically, to assess whether: programmes are effective in improving students'

protective behaviours and knowledge about sexual abuse prevention; behaviours and

skills are retained over time; and participation results in disclosures of sexual

abuse, produces harms, or both.

SEARCH METHODS: In September 2014, we searched CENTRAL, Ovid MEDLINE, EMBASE

 and 11 other databases. We also searched two trials registers and screened the

reference lists of previous reviews for additional trials.

SELECTION CRITERIA: We selected randomised controlled trials (RCTs),

cluster-RCTs, and quasi-RCTs of school-based education interventions for the

prevention of child sexual abuse compared with another intervention or no

intervention.

DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the

eligibility of trials for inclusion, extracted data, and assessed risk of bias.

We summarised data for six outcomes: protective behaviours; knowledge of sexual

abuse or sexual abuse prevention concepts; retention of protective behaviours

over time; retention of knowledge over time; harm; and disclosures of sexual

abuse.

MAIN RESULTS: This is an update of a Cochrane Review that included 15 trials (up

to August 2006). We identified 10 additional trials for the period to September

2014. We excluded one trial from the original review. Therefore, this update

includes a total of 24 trials (5802 participants). We conducted several

meta-analyses. More than half of the trials in each meta-analysis contained unit

of analysis errors.1. Meta-analysis of two trials (n = 102) evaluating protective

behaviours favoured intervention (odds ratio (OR) 5.71, 95% confidence interval

(CI) 1.98 to 16.51), with borderline low to moderate heterogeneity (Chi² = 1.37,

df = 1, P value = 0.24, I² = 27%, Tau² = 0.16). The results did not change when

we made adjustments using intraclass correlation coefficients (ICCs) to correct

errors made in studies where data were analysed without accounting for the

clustering of students in classes or schools.2. Meta-analysis of 18 trials (n =

4657) evaluating questionnaire-based knowledge favoured intervention

(standardised mean difference (SMD) 0.61, 95% CI 0.45 to 0.78), but there was

substantial heterogeneity (Chi² = 104.76, df = 17, P value < 0.00001, I² = 84%,

Tau² = 0.10). The results did not change when adjusted for clustering (ICC: 0.1

SMD 0.66, 95% CI 0.51 to 0.81; ICC: 0.2 SMD 0.63, 95% CI 0.50 to 0.77).3.

Meta-analysis of 11 trials (n =1688) evaluating vignette-based knowledge favoured

intervention (SMD 0.45, 95% CI 0.24 to 0.65), but there was substantial

heterogeneity (Chi² = 34.25, df = 10, P value < 0.0002, I² = 71%, Tau² = 0.08).

The results did not change when adjusted for clustering (ICC: 0.1 SMD 0.53, 95%

CI 0.32 to 0.74; ICC: 0.2 SMD 0.60, 95% CI 0.31 to 0.89).4. We included four

trials in the meta-analysis for retention of knowledge over time. The effect of

intervention seemed to persist beyond the immediate assessment (SMD 0.78, 95% CI

0.38 to 1.17; I² = 84%, Tau² = 0.13, P value = 0.0003; n = 956) to six months

(SMD 0.69, 95% CI 0.51 to 0.87; I² = 25%; Tau² = 0.01, P value = 0.26; n = 929).

The results did not change when adjustments were made using ICCs.5. We included

three studies in the meta-analysis for adverse effects (harm) manifesting as

child anxiety or fear. The results showed no increase or decrease in anxiety or

fear in intervention participants (SMD -0.08, 95% CI -0.22 to 0.07; n = 795) and

there was no heterogeneity (I² = 0%, P value = 0.79; n=795). The results did not

change when adjustments were made using ICCs.6. We included three studies (n =

1788) in the meta-analysis for disclosure of previous or current sexual abuse.

The results favoured intervention (OR 3.56, 95% CI 1.13 to 11.24), with no

heterogeneity (I² = 0%, P value = 0.84). However, adjusting for the effect of

clustering had the effect of widening the confidence intervals around the OR

(ICC: 0.1 OR 3.04, 95% CI 0.75 to 12.33; ICC: 0.2 OR 2.95, 95% CI 0.69 to

12.61).Insufficient information was provided in the included studies to conduct

planned subgroup analyses and there were insufficient studies to conduct

meaningful analyses.The quality of evidence for all outcomes included in the

meta-analyses was moderate owing to unclear risk of selection bias across most

studies, high or unclear risk of detection bias across over half of included

studies, and high or unclear risk of attrition bias across most studies. The

results should be interpreted cautiously.

AUTHORS' CONCLUSIONS: The studies included in this review show evidence of

improvements in protective behaviours and knowledge among children exposed to

school-based programmes, regardless of the type of programme. The results might

have differed had the true ICCs or cluster-adjusted results been available. There

is evidence that children's knowledge does not deteriorate over time, although

this requires further research with longer-term follow-up. Programme

participation does not generate increased or decreased child anxiety or fear,

however there is a need for ongoing monitoring of both positive and negative

short- and long-term effects. The results show that programme participation may

increase the odds of disclosure, however there is a need for more programme

evaluations to routinely collect such data. Further investigation of the

moderators of programme effects is required along with longitudinal or data

linkage studies that can assess actual prevention of child sexual abuse.

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004380.pub3/full

European report on preventing child maltreatment 2013

Child maltreatment is a leading cause of health inequality, with the socioeconomically disadvantaged more at risk, perpetuating social injustice. Though it is a priority in most countries of the WHO European Region, few devote adequate resources and attention to its prevention.

This report outlines the high burden of child maltreatment, its causes and consequences and the cost−effectiveness of prevention programmes. It makes compelling arguments for increased investment in prevention and, by offering policy-makers a preventive approach based on strong evidence and shared experience, it will help them respond to increased demands from the public to tackle child maltreatment.

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Insufficient evidence for the use of a physical examination to detect maltreatment in children without prior suspicion: a systematic review.

Eva MM Hoytema van Konijnenburg^13*†, Arianne H Teeuw^1†, Tessa Sieswerda-Hoogendoorn¹, Arnold G E Leenders² and Johanna H van der Lee¹

Systematic Reviews 2013, 2:109  doi:10.1186/2046-4053-2-109

Background

Although it is often performed in clinical practice, the diagnostic value of a screening physical examination to detect maltreatment in children without prior suspicion has not been reviewed. This article aims to evaluate the diagnostic value of a complete physical examination as a screening instrument to detect maltreatment in children without prior suspicion.

Methods

We systematically searched the databases of MEDLINE, EMBASE, PsychINFO, CINAHL, and ERIC, using a sensitive search strategy. Studies that i) presented medical findings of a complete physical examination for screening purposes in children 0–18 years, ii) specifically recorded the presence or absence of signs of child maltreatment, and iii) recorded child maltreatment confirmed by a reference standard, were included. Two reviewers independently performed study selection, data extraction, and quality appraisal using the QUADAS-2 tool.

Results

The search yielded 4,499 titles, of which three studies met the eligibility criteria. The prevalence of confirmed signs of maltreatment during screening physical examination varied between 0.8% and 13.5%. The designs of the studies were inadequate to assess the diagnostic accuracy of a screening physical examination for child maltreatment.

Conclusions

Because of the lack of informative studies, we could not draw conclusions about the diagnostic value of a screening physical examination in children without prior suspicion of child maltreatment.

Screening for child abuse at emergency departments: a systematic review

Screening for child abuse at emergency departments: a systematic review
Louwers E, Affourtit M, Moll H, Koning H, Korfage I.Arch Dis Child 2010;95:214-218.
Introduction Child abuse is a serious problem worldwide and can be difficult to detect. Although children who experience the consequences of abuse will probably be treated at an emergency department, detection rates of child abuse at emergency departments remain low. Objective To identify effective interventions applied at emergency departments that significantly increase the detection rate of confirmed cases of child abuse. Design This review was carried out according to the Cochrane Handbook. Two reviewers individually searched PubMed, the Cochrane Library, EMBASE, Web of Science and CINAHL for papers that met the inclusion criteria. Results Fifteen papers describing interventions were selected and reviewed; four of these were finally included and assessed for quality. In these studies the intervention consisted of a checklist of indicators of risk for child abuse. After implementation, the rate of detected cases of suspected child abuse increased by 180% (weighted mean in three studies). The number of confirmed cases of child abuse, reported in two out of four studies, showed no significant increase. Conclusions Interventions at emergency departments to increase the detection rate of cases of confirmed child abuse are scarce in the literature. Past study numbers and methodology have been inadequate to show conclusive evidence on effectiveness.

Pediatric Primary Care to Help Prevent Child Maltreatment: The Safe Environment for Every Kid (SEEK) Model

Howard Dubowitz, MD, MS, Susan Feigelman, MD, Wendy Lane, MD and Jeongeun Kim, PhD.
CONTEXT. Effective strategies for preventing child maltreatment are needed. Few primary care–based programs have been developed, and most have not been well evaluated.
OBJECTIVE. Our goal was to evaluate the efficacy of the Safe Environment for Every Kid model of pediatric primary care in reducing the occurrence of child maltreatment.
METHODS. A randomized trial was conducted from June 2002 to November 2005 in a university-based resident continuity clinic in Baltimore, Maryland. The study population consisted of English-speaking parents of children (0–5 years) brought in for child health supervision. Of the 1118 participants approached, 729 agreed to participate, and 558 of them completed the study protocol. Resident continuity clinics were cluster randomized by day of the week to the model (intervention) or standard care (control) groups. Model care consisted of (1) residents who received special training, (2) the Parent Screening Questionnaire, and (3) a social worker. Risk factors for child maltreatment were identified and addressed by the resident physician and/or social worker. Standard care involved routine pediatric primary care. A subset of the clinic population was sampled for the evaluation. Child maltreatment was measured in 3 ways: (1) child protective services reports using state agency data; (2) medical chart documentation of possible abuse or neglect; and (3) parental report of harsh punishment via the Parent-Child Conflict Tactics scale.
RESULTS. Model care resulted in significantly lower rates of child maltreatment in all the outcome measures: fewer child protective services reports, fewer instances of possible medical neglect documented as treatment nonadherence, fewer children with delayed immunizations, and less harsh punishment reported by parents. One-tailed testing was conducted in accordance with the study hypothesis.
CONCLUSIONS. The Safe Environment for Every Kid (SEEK) model of pediatric primary care seems promising as a practical strategy for helping prevent child maltreatment. Replication and additional evaluation of the model are recommended.