Results of the Implementation of a New Screening Protocol for Child Abuse and Neglect At

1 Electronic supplement

3 Details on search strategy, study selection, data collection, assessment and results of our systematic review

4 on parents’ opinions of screening methods for child abuse and neglect (CAN).

6 We systematically searched the electronic databases of MEDLINE (1947 – December 2, 2014), EMBASE (1980

7 – December 2, 2014), PsychINFO (1806 – December 2, 2014), and CINAHL (1982 – December 2, 2014). The

8 main search strategy consisted of 4 components combined by ‘AND’: Child Abuse, Parents, Interview and

9 Acceptability. Synonyms (including many different synonyms for Interview, such as Assessment) for these terms

10 were combined to the corresponding component with ‘OR’. Furthermore, database specific MeSH and Thesaurus

11 terms and text words were added.

13 The lists of cited and citing references of included articles and of articles that were considered for inclusion at an

14 early stage were hand searched for additional relevant articles. We searched for both published and unpublished

15 reports. There was no language or publication restriction.

17 Full search strategy

18 MEDLINE 19 20 1 exp child abuse/ or child abuse.mp. 21 2 ((abus* or maltreatment or shaken or neglect* or batter*) adj3 (child* or infan* or adolescen* or toddler* or 22 neonat* or newborn* or baby or babies)).tw. 23 3 domestic violence/ or munchhausen.ti,ab. or non-accidental.ti,ab. or vulnerable.mp. 24 4 or/1-3 25 5 exp Professional-Family Relations/ 26 6 exp family/ or exp Parents/ or exp caregivers/ or (parent* or mother* or father* or caregiver* or family).tw. 27 7 5 or 6 28 8 ((checklist or inquir* or interview* or video* or audio* or question* or screening or assessment or 29 examination or evaluation) adj8 (perception or comfort or feeling or acceptabil* or unacceptabil*)).ti,ab. 30 9 ((being adj4 screened) or (research adj4 participation)).ti,ab. 31 10 4 and 7 and (8 or 9) 32 11 (8 or 9) and (exp domestic violence/ or vulnerable population/ or vulnerable.tw.) 33 12 10 or 11 34 35 36 EMBASE 37 38 1 exp child abuse/ or child abuse.mp. 39 2 ((abus* or maltreatment or shaken or neglect* or batter*) adj3 (child* or infan* or adolescen* or toddler* or 40 neonat* or newborn* or baby or babies)).tw. 41 3 domestic violence/ or munchhausen.ti,ab. or non-accidental.ti,ab. or vulnerable.mp. 42 4 or/1-3 43 5 exp Professional-Family Relations/ 1 2

44 6 exp family/ or exp Parents/ or exp caregivers/ or (parent* or mother* or father* or caregiver* or family).tw. 45 7 5 or 6 46 8 ((checklist or inquir* or interview* or video* or audio* or question* or screening or assessment or 47 examination or evaluation) adj8 (perception or comfort or feeling or acceptabil* or unacceptabil*)).ti,ab. 48 9 ((being adj4 screened) or (research adj4 participation)).ti,ab. 49 10 4 and 7 and (8 or 9) 50 11 (8 or 9) and (exp domestic violence/ or vulnerable population/ or vulnerable.tw.) 51 12 10 or 11 52 53 54 CINAHL 55 56 1 (MH "Special Populations") 57 2 MH (MH "Special Populations") AND TI vulnerable AND AB vulnerable 58 3 MH (MH "Special Populations") OR TI vulnerable OR AB vulnerable 59 4 (MH "Special Populations") OR TI vulnerable OR AB vulnerable 60 5 (MH "Child Abuse+") 61 6 TX child W3 abuse 62 7 TX child W3 maltreatment 63 8 S5 or S6 or S7 64 9 TX medical N5 assessment 65 10 TX medical N5 examination 66 11 TX medical N5 evaluation 67 12 (MH "Physical Examination+") 68 13 TX physical N3 examination 69 14 S9 or S10 or S11 or S12 or S13 70 15 S8 and S14 71 16 TX (munchhausen or shaken or neglect* or batter* or non-accidental injur*) W3 (child* 72 or infan* or adolescen* or toddler* or neonat* or newborn* or baby or babies) 73 17 S8 or S16 74 18 S14 and S17 75 19 (abus* or maltreatment or shaken or neglect* or batter*) N3 (child* or infan* or 76 adolescen* or toddler* or neonat* or newborn* or baby or babies) 77 20 S17 OR S19 78 21 TX parent* or mother* or father* or caregiver* or family 79 22 TI (checklist or inquir* or interview* or video* or audio* or question* or screening or 80 assessment or examination or evaluation) N8 (perception or comfort or fieling or 81 acceptabil* or unacceptabil*) 82 23 S20 AND S21 AND S22 83 24 TI (being N4 screened) or (research N4 participation) 84 25 S20 AND S21 AND S24 85 26 AB (abus* or maltreatment or shaken or neglect* or batter*) N3 (child* or infan* or 86 adolescen* or toddler* or neonat* or newborn* or baby or babies) 87 27 AB (checklist or inquir* or interview* or video* or audio* or question* or screening or 88 assessment or examination or evaluation) N8 (perception or comfort or feeling or 89 acceptabil* or unacceptabil*) 90 28 AB (being N4 screened) or (research N4 participation) 91 29 S20 AND S21 AND S27 92 30 S20 AND S21 AND S28 93 31 (MH "Domestic Violence+") 94 32 S31 and (S27 or S22 or S24 or S28) 95 33 S4 and (S27 or S22 or S24 or S28) 96 34 S23 OR S25 OR S29 OR S30 OR S32 OR S33 97 98 99 100 PsycInfo 101 102 1. exp child abuse/ or child abuse reporting/ or child neglect/ or munchhausen syndrome by proxy/ or pedophilia/ 103 or exp sexual abuse/ or child abuse.id. or pedophilia.id. or child neglect.id.

104 2. ((abus* or maltreatment or shaken or neglect* or batter*) adj3 (child* or infan* or adolescen* or toddler* or 105 neonat* or newborn* or baby or babies)).tw. 106 3. domestic violence/ or munchhausen.ti,ab. or non-accidental.ti,ab. or vulnerable.mp. 107 4. or/1-3 108 5. exp family/ or exp Parents/ or exp caregivers/ or (parent* or mother* or father* or caregiver* or family).tw. 109 6. ((checklist or inquir* or interview* or video* or audio* or question* or screening or assessment or 110 examination or evaluation) adj8 (perception or comfort or feeling or acceptabil* or unacceptabil*)).ti,ab. 111 7 ((being adj4 screened) or (research adj4 participation)).ti,ab. 112 8. 4 and 5 and (6 or 7) 113 9 (6 or 7) and (exp domestic violence/ or at risk populations/ or vulnerable.tw.) 114 10 8 or 9 115 116 117 118 Study selection:

119 Studies presenting the opinion of parents about a screening method for CAN in all children, irrespective of

120 reason for health care consult, were included. As the aim of this study was to assess parents’ opinions on

121 screening procedures for CAN, we excluded studies in which parents and children were not aware of the

122 screening (e.g. a past record check or checklist filled out by hospital staff). Studies about Intimate Partner

123 Violence (IPV) screening were only selected if the screening included at least one question specifically aimed at

124 the influence of the violence on children in the household.

125 Two reviewers (AT, EH) selected the studies independently, first based on titles, then on abstracts and keywords

126 and finally on full texts. In case of disagreement consensus was reached by discussion.

128 Data collection and assessment

129 Appraisal of the methodological quality and data extraction were performed by both reviewers (AT, EH)

130 independently. Data of included studies were extracted with a data-extraction form, and the methodological

131 quality was assessed with the Newcastle-Ottawa Scale (NOS) for cohort studies 1. Disagreements were discussed

132 until consensus was reached. Extracted data included: 1) characteristics of the study (design, year of publication,

133 type of publication, country of study conduction, funding source); 2) characteristics of the study population

134 (including age); 3) characteristics of the screening procedure (including setting); 4) characteristics of the survey

135 to measure parents opinion; 5) results of the outcome (parents’ opinion).

136 Electronic Supplement: Figure A, Prisma Flow diagram 2

4 5 1 138

139 Results

140 The electronic database search provided 1088 studies, and 275 studies were added based on citation search,

141 personal knowledge or communication with key authors. After the removal of duplicates, titles of 979 studies

142 were read, of which 83 studies were selected based on title, and subsequently 30 studies based on abstract and

143 keywords, of which full texts were read. Application of the in- and exclusion criteria led to inclusion of 7

144 studies. Figure A presents the study selection process with reasons for exclusion in a Prisma flow diagram 2.

145 The characteristics of the included studies are presented in Table A. One study was a randomized controlled trial

146 3, four were observational cross-sectional studies4-7 and two were qualitative cross-sectional studies 8;9. Three

147 studies investigated mothers’ opinions on screening tools for IPV 7-9, two studies investigated parents’ opinions

148 on screening for various psychosocial problems 3;4, one study investigated mothers’ opinion on a screening tool

149 for adverse childhood experiences 4 and one study investigated parents’ opinion on a TTI 5.

151 The quality of the seven included studies was assessed with the NOS; however, because the NOS is developed

152 for cohort studies, several items were not applicable for the studies included in this review (Table B). The quality

153 of the included studies varied, for example, only three studies used a truly representative study population 3;4;7. In

154 the included studies, the majority of parents had a positive opinion about screening, and found it acceptable

155 (Table C). In the only study about parents’ perception of children’s reaction to a complete TTI, including an

156 anogenital examination, only 2.6% of parents reported ‘some’ and only 0.7% of parents ‘a lot of’ anxiety/distress

157 in their child. The majority of parents (96.7%) reported ‘no’ or ‘a little anxiety/distress’ in their child 5.

160 161 162

5 2 6 3

164 Electronic Supplement: Table A

165 Characteristics of studies included in this review (n = 7)

First Year of Country Type of Setting Sam Sex distribution Age of Characteristics of Study aim author publicatio study ple parents parents children n size: % male/female (years) nr of pare nts/el igible pare nts Bateman 2004 UK Qualitati Health visitors questioned women 56/56 0/100 21-35 51 children (4 weeks – To explore 8 ve study, (some of which have children) (no 16 years) were exposed experiences of cross- refus to abuse/violence domestic sectional als) within the home (no violence and other information acceptability of given) a questioning tool Feigelm 2011 USA Randomi Families coming to an inner-city 191/2 7/93 (in whole Mean age 558 children (whole To evaluate an 3 zed clinic for a child health supervision 50 in sample, not 25 years sample) 0-5 years, effect of controlle visit, visiting a resident who is interv reported for (for whole median age intervention on d trial either randomized to having entio intervention group sample) intervention group: 6 1) residents, 2) received training and use a n only) months; control group: likeliness to be screening tool on addressing group 8 months screened, 3) psychosocial risk factors ; parents’ (intervention group), or not (control 238/3 satisfaction with group) 08 in child’s doctor contr ol group Fleegler 2006 USA Cross- Families visiting 2 outpatient clinics 198/2 10/90 Mean age 193 children 0-6 years, To evaluate 4 sectional for a well-child visit 60 29.3 mean age 2.1 years families 1) survey (55 burden of refus health-related ed, 7 social problems, did 2) experiences not regarding 6 4 7 5

comp screening and lete referral for the social problems, relev 3) parental ant acceptability of items screening and of the referral quest ionna ire) Gulla 5 2007 Norway Cross- As part of a larger study, children 158 Not reported Not 158 children (119 To explore how sectional aged 5-6 years old were physically (recr reported girls), mean age 5.8 non-abused survey examined, including an anogenital uited years children and examination at a pediatric outpatient by their parents department self- perceive the select anogenital ion) examination Øverlien 2013 Norway Cross- Online questionnaire, mothers were 628 0/100 Mean age 6-8 years To assess 6 sectional recruited at schools of their children (refus 34 acceptability of survey als mothers to not answer repor questions ted) regarding adverse childhood experiences of their children Richards 2002 UK Cross- Self-administered questionnaire in 1411 0/100 16 years 1198 To evaluate 1) on 7 sectional women visiting primary care (of and older prevalence of survey practices whic domestic h 730 violence, 2) with demographic childr risk factors, 3) en)/2 recording of 192 domestic (204 violence, 4) of women’s 1411 acceptability of with screening 7 6 8 7

inco mplet e quest ionna ire) Zink 9 2003 USA Qualitati Interviews with mothers staying in 32 0/100 Mean age Not reported Evaluating ve study, battered women’s shelters or volun 32 mothers/survivo cross- participating in community Intimate teers rs of Intimate sectional Partner Violence support groups Partner Violence wishes about screening 166 167

170 Electronic Supplement: Table B

171 Quality assessment of included studies with Newcastle-Ottowa Quality Assessment Scale for cohort studies 1

Study Selection Comparability Outcome (1st author, 1) Representativeness of 2) Selection 3) 4) Outcome not 1) 1) Assessment of 2) Follow-up 3) Adequacy of year of exposed cohort of non- Ascertainm present at start Comparability outcome long enough follow-up publication) exposed ent of of cohorts cohort exposure Bateman, 2004 * Not * Not applicable Not applicable c, self-report Not applicable Not applicable 8 b, somewhat applicable b, structured representative interview Feigelman, * * * Not applicable No, not on PDIS c, self-report Not applicable Not applicable 2011 3 a, truly representative a, same a, secure scale results community record Fleegler, 2006 * Not c, written Not applicable Not applicable c, self-report Not applicable Not applicable 4 b, somewhat applicable self-report representative

8 8 9 9

Gulla, 2007 5 * Not * Not applicable Not applicable c, self-report Not applicable Not applicable b, somewhat applicable a, secure representative record Øverlien, 2013 c, selected group Not c, written Not applicable Not applicable c, self-report Not applicable Not applicable 6 applicable self-report Richardson, * Not c, written Not applicable Not applicable c, self-report Not applicable Not applicable 2002 7 b, somewhat applicable self-report representative Zink, 2003 9 c, selected group Not * Not applicable Not applicable c, self-report Not applicable Not applicable applicable b, structured interview 172 173

175 Electronic Supplement: Table C

176 Summary of results on parents’ opinion of screening for CAN of studies included in this review (n = 7)

Author Screening instrument for child Instrument used to measure parents’ Opinion or acceptability of parents (year) maltreatment opinion / acceptability Bateman 8 Semi-structured interview Semi-structured interview Women felt comfortable with routine questions about interpersonal (2004) including a domestic violence violence/abuse routine questioning tool (including negative effects of domestic violence on children) Feigelman 3 Child health supervision visit with Modified Patient-Doctor Interaction Parents in intervention group reported a patient-doctor interaction of 17.4 (= (2011) a resident who has received Scale (PDIS), a 19-item yes/no significantly higher than in control group); all parents were mostly satisfied specific training; and Parent response set with scores ranging from with patient-doctor interaction Screening Questionnaire (PSQ), a 0 to 18, higher scores indicate greater 20-item yes/no screen for 6 satisfaction psycho-social risk factors, including Intimate Partner Violence and corporal punishment Fleegler 4 Self-administered computer-based A question at end of survey asking for 92% of parents would ‘welcome’ or ‘not mind at all’ a screening for health- (2006) questionnaire on 5 domains of parents’ opinion on the screening and related social problems at the pediatrician’s office during a well-child visit health-related social problems, on any subsequent referrals to local

9 10 10 11

including intimate partner agencies for each domain and in violence, housing and food general, with 4 answer options insecurity Gulla 5 Complete head to toe Questionnaire on anxiety/restlessness 66.4% of parents reported ‘no anxiety/distress of children’, 30.3% reported ‘a (2007) examination, including anogenital of child, with 5-point Likert-scale little’; 2.6% reported ‘some’, 0.7% reported ‘a lot’ and none reported ‘a examination whole lot’ Øverlien 6 13-item online screening 6 questions regarding mothers’ 97% of mothers would react positive toward being asked such screening (2013) questionnaire, including: harsh reactions to the questions, rated on a 5- questions (regardless of their answers to the screening questions) punishment, physical violence, point Likert scale psychological violence, witnessing domestic violence, sexual abuse Richardson 7 Self-administered questionnaire Items in the questionnaire asking the 80% of women would not mind being screened by their general practitioner (2002) on domestic violence, including woman’s attitude to being questioned about domestic violence and 77% would not mind being screened by the questions on partner threatening by her general practitioner or practice practice nurse (regardless of women’s answers to screening questions) and hitting/hurting children nurse on domestic violence Zink 9 (2003) Physicians’ screening questions Interview including open-ended and Most mothers were comfortable with physicians using general questions to on Intimate Partner Violence close-ended questions screen for Intimate Partner Violence in front of children, but preferred in- depth discussions in private 177 178

179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 10 12 11 13 196 197 Reference List 198 199 (1) Wells GA, Shea B, O'Connel D, Peterson J, Welch V, Losos M et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of 200 nonrandomised studies in meta-analyses. 2013. 201 Ref Type: Online Source

202 (2) Liberati A, Altman DG, Tetzlaff J et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate 203 health care interventions: explanation and elaboration. J Clin Epidemiol 2009;62:e1-34.

204 (3) Feigelman S, Dubowitz H, Lane W, Grube L, Kim J. Training pediatric residents in a primary care clinic to help address psychosocial problems 205 and prevent child maltreatment. Acad Pediatr 2011;11:474-480.

206 (4) Fleegler EW, Lieu TA, Wise PH, Muret-Wagstaff S. Families' health-related social problems and missed referral opportunities. Pediatrics 207 2007;119:e1332-e1341.

208 (5) Gulla K, Fenheim GE, Myhre AK, Lydersen S. Non-abused preschool children's perception of an anogenital examination. Child Abuse Negl 209 2007;31:885-894.

210 (6) Øverlien C, Thoresen S, Dyb G. Childhood Adverse Experience: Yes or No? Mothers' Decision-Making Process When Responding to Survey 211 Questions. Journal of Aggression, Maltreatment & Trauma 22[2], 192-210. 2013. 212

213 (7) Richardson J, Coid J, Petruckevitch A, Chung WS, Moorey S, Feder G. Identifying domestic violence: cross sectional study in primary care. 214 BMJ 2002;324:274.

215 (8) Bateman W, Whitehead K. Health visitors' domestic violence routine questioning tool: An exploration of women's experience, effectiveness and 216 acceptability. Int J of Health Promotion and Education 42[1], 14-22. 2013. 217 218 (9) Zink TM, Jacobson J. Screening for intimate partner violence when children are present: the victim's perspective. J Interpers Violence 219 2003;18:872-890. 220 221

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