Child Abuse: The Value of Systematic Screening at Emergency Rooms

Abstract

There is no conclusive evidence that diagnostic tools detect physical child abuse among children coming to emergency rooms (ERs), but his evidence is urgently needed because both false-positive and false-negative diagnoses have serious adverse effects. This thesis describes several aspects of the procedure of child abuse detection at ERs. In chapter 2 we describe the results of a randomised controlled trial that evaluated the effectiveness of an electronic learning programme called ‘The Next Page’on the performance of nurses in the recognition of child abuse in a simulated case in the ER. The study consisted of two groups: the intervention and the control group. In both groups performance in simulated cases was measured as the primary outcome and self-efficacy as the secondary outcome. Nurses in the intervention group performed significantly better during the simulation than the untrained nurses and reported (non significant) higher self-efficacy. Both groups had a significant increase of the self-efficacy score. To draw a better picture of the current approach of child abuse detection at an ER, we describe the clinical process of child abuse detection at an academic ER in the year 2010 in chapter 3. Out of 3660 children that attended the ER, in 65 cases (1.8%) there was a suspicion of child abuse. Eventually, two cases (3.1%) were reported to Social Services. The cornerstone of this thesis is the CHAIN-ER study (Child Abuse Inventory at Emergency Rooms) which aimed at assessing the diagnostic accuracy of the nationally implemented SPUOVAMO-R checklist for physical abuse as primary outcome, and for neglect and need for help from social services as secondary outcome. SPUTOVAMO-R is the revised version of SPUTOVAMO. Chapter 4 describes the rationale and design of CHAIN-ER. Chapter 5 shows the results of CHAIN-ER. In this large multicentre study with a 6-months follow-up we included 4290 children aged 0-7 years attending the ER because of physical injury. All children were systematically tested with the index test. A national expert panel (reference standard) retrospectively assessed all checklist positive cases and a 15% random sample of the checklist negative cases for physical abuse, using additional information, namely, an injury history taken by a paediatrician, information provided by the general practitioner, youth doctor and social services by structured questionnaires, and 6-month follow-up information. The panel found three children to be intentionally injured (0·1%). All three cases were captured by SPUTOVAMO-R but at very high false positive rates. Subsequent assessment by child abuse experts can be safely restricted to checklist positives without missing any cases of inflicted injury. SPUTOVAMO-R also has a very high positive predictive value for the outcome "injury caused by neglect" but again against very high false positive rates. In addition, the inter-rater agreement for injury caused by neglect was very poor, indicating that it is not able to unequivocally diagnose injury due to neglect. Therefore, prediction of this outcome measure with SPUTOVAMO-R seems unfeasible in young children. SPUTOVAMO-R is not an accurate detection instrument for the outcome need for help from social services either.