Detection of Child Abuse in Emergency Departments: a Multi-Centre Study
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Original article Arch Dis Child: first published as 10.1136/adc.2010.202358 on 30 January 2011. Downloaded from Detection of child abuse in emergency departments: a multi-centre study Eveline C F M Louwers, 1,2 I d a J K o r f a g e , 1 M a r j o J A f f o u r t i t ,2 Dop J H Scheewe,3 Marjolijn H van de Merwe,4 Francoise A F S R Vooijs-Moulaert,5 C l a i r e M C W o l t e r i n g , 6 Mieke H T M Jongejan,7 M a d e l o n R u i g e , 8 H e n r i ë t t e A M o l l ,2 Harry J De Koning1 1 Department of Public Health, A B S T R A C T Erasmus MC, University O b j e c t i v e This study examines the detection rates of What is already known on this topic Medical Centre Rotterdam, Rotterdam, The Netherlands suspected child abuse in the emergency departments of 2 Department of Pediatrics, seven Dutch hospitals complying and not complying with ▶ Although child abuse victims have higher Erasmus MC-Sophia Children’s screening guidelines for child abuse. emergency department use than the general Hospital, Rotterdam, The D e s i g n Data on demographics, diagnosis and sus- paediatric population, child abuse unfortu- Netherlands pected child abuse were collected for all children aged 3 Department of Pediatrics, nately often remains unrecognised in the emer- ≤18 years who visited the emergency departments over IJsselland Hospital, gency department. Capelle aan den IJssel, The a 6-month period. The completion of a checklist of warn- ▶ Preventing recurrent abuse or recognising Netherlands ing signs of child abuse in at least 10% of the emergency 4 abuse at an early stage is essential to limit its Advies en Meldpunt department visits was considered to be compliance with Kindermishandeling long-term effects. Zuid-Holland, Gouda, The screening guidelines. Netherlands R e s u l t s A total of 24 472 visits were analysed, 54% of 5 Department of Pediatrics, which took place in an emergency department comply- Rivas Zorggroep Beatrix ing with screening guidelines. Child abuse was sus- What this study add s Hospital, Gorinchem, The pected in 52 children (0.2%). In 40 (77%) of these 52 Netherlands 6 Department of Pediatrics, cases, a checklist of warning signs had been completed ▶ Reinier de Graaf Gasthuis, compared with a completion rate of 19% in the total Staff suspected child abuse in only 0.2% of Delft, The Netherlands sample. In hospitals complying with screening guide- all children visiting seven Dutch emergency 7 Department of Pediatrics, lines for child abuse, the detection rate was higher departments over 6 months. St Franciscus Gasthuis, (0.3%) than in those not complying (0.1%, p<0.001). ▶ The detection rate of suspected child abuse Rotterdam, The Netherlands was higher in emergency departments com- 8 Department of Pediatrics, C o n c l u s i o n During a 6-month period, emergency HagaZiekenhuis Juliana department staff suspected child abuse in 0.2% of all plying than not complying with screening Children’s Hospital, The Hague, children visiting the emergency department of seven guidelines. The Netherlands ▶ Hospitals should increase compliance with Dutch hospitals. The numbers of suspected abuse cases http://adc.bmj.com/ screening guidelines and implement policies to Correspondence to detected were low, but an increase is likely if uniform Eveline C F M Louwers, screening guidelines are widely implemented. improve emergency department detection of Department of Public Health, child abuse. Erasmus MC, University Medical Centre Rotterdam, Room-Ae 106, PO Box 2040, I N T R O D U C T I O N 3000 CA Rotterdam, The emergency departments could increase detection Child abuse i s a serious public health problem Netherlands; e.louwers@ rates, leading to a decrease in the short- and long- on September 26, 2021 by guest. Protected copyright. e r a s m u s m c . n l with high morbidity and mortality; worldwide, term effects of child abuse. 2 10 Therefore, the aim 155 000 deaths occur annually in children as a of the current study is to assess the detection rates 1 Accepted 18 December 2010 result of abuse or neglect. Preventing recurrent of child abuse in emergency departments in hos- Published Online First abuse or recognising early abuse is diffi cult but 30 January 2011 pitals complying and not complying with uniform essential if long-term effects are to be limited. screening guidelines and examine the characteris- Although victims of child abuse have higher tics of cases of suspected abuse. emergency department use than the general pae- diatric population, child abuse unfortunately often remains unrecognised in the emergency M E T H O D S department. 2 – 6 The province of South-Holland in the Netherlands Woodman et al 4 found consistent evidence that has a population of 3.5 million people which is physical abuse affects 1 in 11 children in the UK served by 22 hospitals. So that the cohort would each year and estimated that about 1% of all inju- be representative, data were collected from emer- ry-induced child visits to emergency departments gency departments in seven hospitals (a university are due to physical abuse. In the Netherlands, an children’s hospital, three teaching hospitals and estimated 107 200–160 000 children are victims of three rural hospitals) which together have approx- child abuse annually; however, hospital staff were imately 200 000 emergency department visitors responsible for only 6% of the 16 156 reports on annually. child welfare in 2008. 7 – 9 This paper is freely available online under the BMJ Journals The overall impression is of suboptimal detec- Detection of child abuse unlocked scheme, see http:// tion of child abuse in hospitals. Implementing a All children aged 0–18 years who visited the emer- adc.bmj.com/info/unlocked.dtl uniform screening protocol for child abuse in gency departments with a new complaint over a 422 Arch Dis Child 2011;96:422–425. doi:10.1136/adc.2010.202358 05_archdischild202358.indd 422 3/26/2011 10:28:49 AM Original article Arch Dis Child: first published as 10.1136/adc.2010.202358 on 30 January 2011. Downloaded from 6-month period were included. W e checked all data on cases screening checklist for child abuse. Based on all this informa- of suspected abuse, and considered it to be a case of suspected tion, we assessed whether or not emergency department staff child abuse if emergency department staff noted their suspi- suspected child abuse. cions in the medical record. Children who were specifi cally referred to the hospital with a suspicion of child abuse were Statistical analysis not included in the number of cases detected in the emergency The χ 2 test was used to compare baseline categorical variables department. T he defi nition used for child abuse was any form between hospitals complying and not complying with screen- of threatening or violent physical, mental or sexual interac- ing policy, between cases screened and not screened for child tion with a minor which is perpetrated actively or passively by abuse, and between children with and without suspected parents or other persons on whom the minor is dependent and abuse. The Wilcoxon rank test was used for the continuous causes or will probably cause physical or mental injury and variable age. Analyses were performed using the statisti- 11 serious harm to the minor. cal package SPSS 15.0. Statistical signifi cance was defi ned as All hospitals had a checklist of warning signs of child abuse p<0.05. available in the emergency department. These checklists were either used for all children visiting the emergency department, R E S U L T S or, in one hospital, only for children with trauma, and were Emergency department visitors mostly completed by emergency department nurses. If one of the warning signs on the checklist was ticked, the emer- During the 6-month study period, 24 472 children aged ≤18 gency department nurse informed the treating specialist that years visited one of the seven emergency departments with the suspicion of child abuse was increased. The frequency of a new complaint. Of these, 56% (13 754) were male, and checklist use varied greatly. Compliance with screening guide- more than 40% (10 546) were 4 years of age or younger. The lines for child abuse in the emergency department was consid- majority (52%) visited the emergency department without ered to be use of the checklist in at least 10% of all emergency being referred, and most (60%) had a surgical problem (eg, a department visits by children. The numbers of suspected fracture). abuse cases detected in the emergency department were com- Of all children, 54% visited an emergency department pared between hospitals complying and not complying with which complied with screening guidelines. The patients in the screening guidelines. these hospitals were older, less often self-referred, and more This study was approved by the Medical Ethical Committee often treated by a paediatrician than those who visited hospi- of the Erasmus MC, University Medical Centre Rotterdam. tals not complying with screening guidelines ( table 1 ). Data collection and processing S c r e e n i n g Data were collected over 6 months in each hospital. In fi ve Overall, the checklist was completed for 36% of emergency of the seven hospitals this period covered August 2007 to department visitors (ranging from 16% to 56%) in hospitals January 2008.