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
Mostrando entradas con la etiqueta child abuse and neglect. Mostrar todas las entradas
Mostrando entradas con la etiqueta child abuse and neglect. Mostrar todas las entradas
18.2.14
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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18.6.13
Emotional, Behavioral, and Developmental Features Indicative of Neglect or Emotional Abuse in Preschool Children A Systematic Review
Aideen Mary Naughton, MB, BCh, BAO, DCH, FRCPCH; Sabine Ann Maguire, MRCPCh, FRCPI; Mala Kanthi Mann, MIInfSc, MCLIP; Rebecca Caroline Lumb, BA; Vanessa Tempest, BScEcon, MA, GDL/CPE, PgDChild; Shirley Gracias, MBChB, DCH, MRCPsych; Alison Mary Kemp, MRCP, FRCPCH
Importance Early intervention for neglect or emotional abuse in preschoolers may mitigate lifelong consequences, yet practitioners lack confidence in recognizing these children.
Objective To define the emotional, behavioral, and developmental features of neglect or emotional abuse in preschoolers.
Evidence Review A literature search of 18 databases, 6 websites, and supplementary searching performed from January 1, 1960, to February 1, 2011, identified 22 669 abstracts. Standardized critical appraisal of 164 articles was conducted by 2 independent, trained reviewers. Inclusion criteria were children aged 0 to 6 years with confirmed neglect or emotional abuse who had emotional, behavioral, and developmental features recorded or for whom the carer-child interaction was documented.
Findings Twenty-eight case-control (matched for socioeconomic, educational level, and ethnicity), 1 cross-sectional, and 13 cohort studies were included. Key features in the child included the following: aggression (11 studies) exhibited as angry, disruptive behavior, conduct problems, oppositional behavior, and low ego control; withdrawal or passivity (12 studies), including negative self-esteem, anxious or avoidant behavior, poor emotional knowledge, and difficulties in interpreting emotional expressions in others; developmental delay (17 studies), particularly delayed language, cognitive function, and overall development quotient; poor peer interaction (5 studies), showing poor social interactions, unlikely to act to relieve distress in others; and transition (6 studies) from ambivalent to avoidant insecure attachment pattern and from passive to increasingly aggressive behavior and negative self-representation. Emotional knowledge, cognitive function, and language deteriorate without intervention. Poor sensitivity, hostility, criticism, or disinterest characterize maternal-child interactions.
Conclusions and Relevance Preschool children who have been neglected or emotionally abused exhibit a range of serious emotional and behavioral difficulties and adverse mother-child interactions that indicate that these children require prompt evaluation and interventions.
Neglect is the most common form of maltreatment,1- 2 with devastating lifelong consequences. The neurobiology of the infant brain can be altered in response to early emotional neglect,3 and brain imaging technology has confirmed the structural effect of neglect on the developing brain.4 The link between infant neglect and later aggression5- 6 is highlighted by Kotch et al,7 who identified neglect in the first 2 years of life as a predictor of later aggression. Neglect means many things to many people,8 contributing to various working definitions and numerous tools to aid assessment and recognition. Social and health care professionals have a crucial role in recognizing and responding to signs of neglect, but when faced with subjective and value-based thresholds describing parental omission of good enough care, they may lack confidence in diagnosing neglect, unless there are clear physical signs (eg, faltering growth). The severe long-term consequences of emotional neglect and emotional abuse in the first 2 years of life9- 10 have been identified, alongside the difficulty in recognition at such a young age.11- 12 Underrecognition has implications for physical, mental health,13 and mortality.14 Emotional neglect and emotional abuse are variously defined within child abuse categories. In the United Kingdom and the World Health Organization definition,emotional neglect is included within the category of neglect with a separate category of emotional abuse, whereas the 2 aspects are encompassed in the broader term psychological maltreatment by the American Professional Society on the Abuse of Children (eAppendix 1), which describes patterns of damaging interactions between the parent-carer and child through acts of omission or commission, acknowledging that emotional neglect and abuse have equally damaging effects on the child. Elements of psychological maltreatment are present in most categories of abuse, but when psychological maltreatment occurs discretely, there is often delay in both recognition and intervention.15 To optimize outcomes, early recognition is paramount. This systematic review aims to identify the scientific evidence behind the emotional, behavioral, and developmental features of the child and characteristics of primary carer-child interactions associated with neglect and/or emotional abuse of preschool children.
Primary Care Interventions to Prevent Child Maltreatment: U.S. Preventive Services Task Force Recommendation Statement
Virginia A. Moyer, MD, MPH, on behalf of the U.S. Preventive Services Task Force*
Description: Update of the child abuse and neglect portion of the 2004 U.S. Preventive Services Task Force (USPSTF) recommendation statement on screening for family and intimate partner violence.
Methods: The USPSTF commissioned a systematic review on interventions to prevent child maltreatment for children at risk, focusing on new studies and evidence gaps that were unresolved at the time of the 2004 recommendation. Beneficial outcomes considered include reduced exposure to maltreatment and reduced harms to physical or mental health or mortality.
Population: This recommendation applies to children in the general U.S. population from newborn to age 18 years who do not have signs or symptoms of maltreatment.
Recommendation: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of primary care interventions to prevent child maltreatment. (I statement)
The U.S. Preventive Services Task Force (USPSTF) makes recommendations about the effectiveness of specific preventive care services for patients without related signs or symptoms.
It bases its recommendations on the evidence of both the benefits and harms of the service and an assessment of the balance. The USPSTF does not consider the costs of providing a service in this assessment.
The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize decision making to the specific patient or situation. Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms.
3.5.13
Screening women for intimate partner violence in healthcare settings
Abstract
Background
Intimate partner violence (IPV) damages individuals, their children, communities, and the wider economic and social fabric of society. Some governments and professional organisations recommend screening all women for intimate partner violence rather than asking only women with symptoms (case-finding); however, what is the evidence that screening interventions will increase identification, and referral to support agencies, or improve women's subsequent wellbeing and not cause harm?
Objectives
To assess the effectiveness of screening for intimate partner violence conducted within healthcare settings for identification, referral to support agencies and health outcomes for women.
Search methods
We searched the following databases in July 2012: CENTRAL (2012, Issue 6), MEDLINE (1948 to September Week June Week 3 2012), EMBASE (1980 to Week 28 2012), MEDLINE In–Process (3 July 2012), DARE (2012, Issue 2), CINAHL (1937 to current), PsycINFO (1806 to June Week 4 2012), Sociological Abstracts (1952 to current) and ASSIA (1987 to October 2010). In addition we searched the following trials registers: metaRegister of Controlled Trials (mRCT) (to July 2012), and International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov, Australian New Zealand Clinical Trials Registry and the International Standard Randomised Controlled Trial Number Register to August 2010. We also searched the reference lists of articles and websites of relevant organisations.
Selection criteria
Randomised or quasi-randomised trials assessing the effectiveness of IPV screening where healthcare professionals screened women face-to-face or were informed of results of screening questionnaires, compared with usual care ( which included screening for other purposes).
Data collection and analysis
Two review authors independently assessed the risk of bias in the trials and undertook data extraction. For binary outcomes, we calculated a standardised estimation of the risk ratio (RR) and for continuous data, either a mean difference (MD) or standardised mean difference (SMD). All are presented with a 95% confidence interval (CI).
Main results
We included 11 trials that recruited 13,027 women overall. Six of 10 studies were assessed as being at high risk of bias.
When data from six comparable studies were combined (n = 3564), screening increased identification of victims/survivors (RR 2.33; 95% CI 1.40 to 3.89), particularly in antenatal settings (RR 4.26; 95% CI 1.76 to 10.31).
Only three studies measured referrals to support agencies (n = 1400). There is no evidence that screening increases such referrals, as although referral numbers increased in the screened group, actual numbers were very small and crossed the line of no effect (RR 2.67; 95% CI 0.99 to 7.20).
Only two studies measured women's experience of violence after screening (one at three months, the other at six, 12 and 18 months after screening) and found no significant reduction of abuse.
Only one study measured adverse effects and data from this study suggested that screening may not cause harm. This same study showed a trend towards mental health benefit, but the results did not reach statistical significance.
There was insufficient evidence on which to judge whether screening increases take up of specialist services, and no studies included economic evaluation.
Authors' conclusions
Screening is likely to increase identification rates but rates of referral to support agencies are low and as yet we know little about the proportions of false measurement (negatives or positives). Screening does not appear to cause harm, but only one study examined this outcome. As there is an absence of evidence of long-term benefit for women, there is insufficient evidence to justify universal screening in healthcare settings. Studies comparing screening versus case finding (with or without advocacy or therapeutic interventions) for women's long-term wellbeing would better inform future policies in healthcare settings.
Plain language su
mmary
Screening women for intimate partner violence in healthcare settings
Women who have experienced physical, psychological or sexual violence from an intimate partner (for example, husband, boyfriend, ex-husband or ex-boyfriend) can suffer poor physical and mental health, poor pregnancy outcomes and premature death. Their children and families can also suffer. The effects of violence often result in women attending healthcare settings. Some people have argued that healthcare professionals should routinely ask all women attending a healthcare setting whether they have experienced violence from their partner or ex-partner. They argue that this approach (known as universal screening) might encourage women who would not otherwise do so, to disclose abuse, or to recognise their experience as ‘abuse’. In turn, this would enable the healthcare professional to provide immediate support or refer them to specialist help, or both. Some governments and health organisations recommend universal screening for intimate partner violence (IPV). Others argue that such screening should be targeted to high risk groups, such as pregnant women attending antenatal clinics (targeted screening is known as ‘selective screening’).
We carried out this review to find out two things. First, whether there was any evidence that IPV screening increases the number of women identified and the number referred on to specialist services. Second, whether screening results in health benefits to women or causes any harm.
We found 11 studies that assessed the effectiveness of IPV screening where healthcare professionals screened women face-to-face or were informed of results of screening questionnaires, compared with usual care. No study compared the benefit of universal screening versus selective screening. All the studies were conducted in high income countries. The studies looked at screening in hospitals and in community settings. Screening methods included questionnaires (paper and computer based) completed by women themselves or face-to-face screening. No study took into account differences in how much abuse women were experiencing, or whether they were able or ready to take action – something that might affect the likelihood of disclosing abuse. Further, none looked at the sustainability of screening by healthcare professionals.
Screening doubled the likelihood that abused women were identified, but did not increase the numbers referred for specialist help. Both the numbers identified and referred for support were low. Screening did not reduce the level of violence experienced by women or improve women’s health and wellbeing at any time point from three to 18 months after the screening. One study reported no evidence of harm. The remaining ten studies did not address the issue of harmful consequences. We do not know if screening increases take up of specialist services. None of the studies measured how much it costs to deliver screening.
We conclude that there is insufficient evidence to justify universal screening for intimate partner violence in healthcare settings.
24.2.13
Behavioral interventions and counseling to prevent child abuse and neglect: a systematic review to update the u.s. Preventive services task force recommendation.
Ann Intern Med. 2013 Feb 5;158(3):179-90. doi:
10.7326/0003-4819-158-3-201302050-00590.
Selph SS, Bougatsos C, Blazina I, Nelson HD.
BACKGROUND: In 2004, the U.S. Preventive Services Task Force determined that
evidence was insufficient to recommend behavioral interventions and counseling to
prevent child abuse and neglect.
PURPOSE: To review new evidence on the effectiveness of behavioral interventions
and counseling in health care settings for reducing child abuse and neglect and
related health outcomes, as well as adverse effects of interventions.
DATA SOURCES: MEDLINE and PsycINFO (January 2002 to June 2012), Cochrane Central
Register of Controlled Trials and Cochrane Database of Systematic Reviews
(through the second quarter of 2012), Scopus, and reference lists.
STUDY SELECTION: English-language trials of the effectiveness of behavioral
interventions and counseling and studies of any design about adverse effects.
DATA EXTRACTION: Investigators extracted data about study populations, designs,
and outcomes and rated study quality using established criteria.
DATA SYNTHESIS: Eleven fair-quality randomized trials of interventions and no
studies of adverse effects met inclusion criteria. A trial of risk assessment and
interventions for abuse and neglect in pediatric clinics for families with
children aged 5 years or younger indicated reduced physical assault, Child
Protective Services (CPS) reports, nonadherence to medical care, and immunization
delay among screened children. Ten trials of early childhood home visitation
reported reduced CPS reports, emergency department visits, hospitalizations, and
self-reports of abuse and improved adherence to immunizations and well-child
care, although results were inconsistent.
LIMITATION: Trials were limited by heterogeneity, low adherence, high loss to
follow-up, and lack of standardized measures.
CONCLUSION: Risk assessment and behavioral interventions in pediatric clinics
reduced abuse and neglect outcomes for young children. Early childhood home
visitation also reduced abuse and neglect, but results were inconsistent.
Additional research on interventions to prevent child abuse and neglect is
needed.
PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.
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