Predictors of Making a Referral to Child Protective Services Prior to Expert Consultation.

2023

05/2023

1876-2867

OBJECTIVES: Suspicion for child abuse is influenced by implicit biases. Evaluation by a Child Abuse Pediatrician (CAP) may reduce avoidable child protective services (CPS) referrals. Our objective was to investigate the association of patient demographic, social and clinical characteristics with CPS referral before consultation by a CAP (pre-consultation referral).

METHODS: Children <5 years-old undergoing in-person CAP consultation for suspected physical abuse from February 2021 through April 2022 were identified in CAPNET, a multicenter child abuse research network. Marginal standardization implemented with logistic regression analysis examined hospital-level variation and identified demographic, social, and clinical factors associated with pre-consultation referral adjusting for CAP's final assessment of abuse likelihood.

RESULTS: Among the 61% (1005/1657) of cases with pre-consultation referral, the CAP consultant had low concern for abuse in 38% (384/1005). Pre-consultation referrals ranged from 25% to 77% of cases across 10 hospitals (P<0.001). In multivariable analyses, pre-consultation referral was associated with public insurance, caregiver history of CPS involvement, history of intimate partner violence, higher CAP level of concern for abuse, hospital transfer, and near-fatality (all P<0.05). The difference in pre-consultation referral prevalence for children with public versus private insurance was significant for children with low CAP concern for abuse (52% vs 38%) but not those with higher concern for abuse (73% vs 73%), (P=0.023 for interaction of insurance and abuse likelihood category). There were no differences in pre-consultation referral based on race or ethnicity.

CONCLUSIONS: Biases based on socioeconomic status and social factors may impact decisions to refer to CPS before CAP consultation.

10.1016/j.acap.2023.05.002

Acad Pediatr

37178908

The CAPNET multi-center data set for child physical abuse: Rationale, methods and scope.

2022

105653

06/2022

1873-7757

BACKGROUND: The pediatric subspecialty of Child Abuse Pediatrics (CAP) was certified by the American Board of Medical Subspecialties in 2006. Relative to its impact on pediatric health, CAP-focused research has been relatively under-funded. Multi-center networks related to CAP-focused research have made important advances, but have been limited in scope and duration. CAPNET is multi-center network whose mission is to support CAP-focused research.

OBJECTIVE: To describe the rationale, development, and scope of the CAPNET research network infrastructure, the CAPNET data registry and associated data resources.

METHODS: Based on existing priorities for CAP-focused research, we used consensus building and iterative testing to establish inclusion criteria, common data elements, data quality assurance, and data sharing processes for children with concerns of physical abuse.

RESULTS: We describe the rationale, methods and intended scope for the development of the CAPNET research network and data registry. CAPNET is currently abstracting data for children <10 years (120 months) old who undergo sub-specialty evaluation for physical abuse at 10 US pediatric centers (approximately 4000 evaluations/year total) using an online data capture form. Data domains include: demographics; visit timing and providers, medical/social history, presentation, examination findings, laboratory and radiographic testing, diagnoses, outcomes, and data for contact children. We describe the methods and criteria for collecting and validating data which are broadly available to CAP investigators.

CONCLUSIONS: CAPNET represents a new data resource for the CAP research community and will increase the quantity and quality of CAP-focused research.

10.1016/j.chiabu.2022.105653

Child Abuse Negl

35779985

Child Abuse Pediatrics Research Network: The CAPNET Core Data Project.

2022

07/2022

1876-2867

OBJECTIVE: Examine the epidemiology of subspecialty physical abuse evaluations within CAPNET, a multicenter child abuse pediatrics research network.

METHODS: We conducted a cross-sectional study of children <10 years old who underwent an evaluation (in-person or remote) by a child abuse pediatrician (CAP) due to concerns for physical abuse at ten CAPNET hospital systems from February 2021 through December 2021.

RESULTS: Among 3667 patients with 3721 encounters, 69.4% were < 3 years old; 44.3% < 1 year old, 59.1% male; 27.1% Black; 57.8% White, 17.0% Hispanic; and 71.0 % had public insurance. The highest level of care was outpatient/emergency department in 60.7%, inpatient unit in 28.0% and intensive care in 11.4%. CAPS performed 79.1% in-person consultations and 20.9% remote consultations. Overall, the most frequent injuries were bruises (35.2%), fractures (29.0%), and traumatic brain injuries (TBI) (16.2%). Abdominal (1.2%) and spine injuries (1.6%) were uncommon. TBI was diagnosed in 30.6% of infants but only 8.4% of 1-year old children. In 68.2% of cases a report to child protective services (CPS) was made prior to CAP consultation; in 12.4% a report was made after CAP consultation. CAPs reported no concern for abuse in 43.0% of cases and mild / intermediate concern in 22.3%. Only 14.2% were categorized as definite abuse.

CONCLUSION: Most children in CAPNET were <3 years old with bruises, fractures, or intracranial injuries. CPS reports were frequently made prior to CAP consultation. CAPs had a low level of concern for abuse in majority of cases.

10.1016/j.acap.2022.07.001

Acad Pediatr

35840086

Emergency Department Child Abuse Evaluations During COVID-19: A Multicenter Study.

2022

08/2022

1098-4275

BACKGROUND AND OBJECTIVE: The reported impacts of the COVID-19 pandemic on child maltreatment in the United States have been mixed. Encounter trends for child physical abuse within pediatric emergency departments may provide insights. Thus, this study sought to determine the change in the rate of emergency department encounters related to child physical abuse.

METHODS: A retrospective study within the Pediatric Emergency Care Applied Research Network Registry. Encounters related to child physical abuse were identified by 3 methods: child physical abuse diagnoses among all ages, age-restricted high-risk injury, or age-restricted skeletal survey completion. The primary outcomes were encounter rates per day and clinical severity before (January 2018-March 2020) and during the COVID-19 pandemic (April 2020-March 2021). Multivariable Poisson regression models were fit to estimate rate ratios with marginal estimation methods.

RESULTS: Encounter rates decreased significantly during the pandemic for 2 of 3 identification methods. In fully adjusted models, encounter rates were reduced by 19% in the diagnosis-code cohort (adjusted rate ratio: 0.81 [99% confidence interval: 0.75-0.88], P <.001), with the greatest reduction among preschool and school-aged children. Encounter rates decreased 10% in the injury cohort (adjusted rate ratio: 0.90 [confidence interval: 0.82-0.98], P = .002). For all 3 methods, rates for lower-severity encounters were significantly reduced whereas higher-severity encounters were not.

CONCLUSIONS: Encounter rates for child physical abuse were reduced or unchanged. Reductions were greatest for lower-severity encounters and preschool and school-aged children. This pattern calls for critical assessment to clarify whether pandemic changes led to true reductions versus decreased recognition of child physical abuse.

10.1542/peds.2022-056284

Pediatrics

35707943

A standardized definition of near-fatal child maltreatment: Results of a multidisciplinary Delphi process.

2020

104893

2020 Dec 26

1873-7757

<p><strong>BACKGROUND: </strong>The 2016 Presidential Commission to Eliminate Child Abuse and Neglect Fatalities identified systematic review of all cases of near-fatal child maltreatment as a necessary step towards prevention of child maltreatment fatalities. A critical barrier to adoption of this recommendation is the lack of a standard definition of "near-fatality" in the context of suspected child maltreatment.</p>

<p><strong>OBJECTIVE: </strong>To develop a consensus definition of near-fatal child maltreatment to be used in practice, policy, and research.</p>

<p><strong>PARTICIPANTS AND SETTING: </strong>A multidisciplinary expert panel of 23 individuals from across the U.S. including child abuse pediatricians, pediatric intensivists, pediatric emergency medicine physicians, child welfare administrators, child welfare researchers, and child injury/fatality researchers.</p>

<p><strong>METHODS: </strong>A modified Delphi process reflecting an iterative process of 3 rounds of surveys of expert opinion, statistical summary of survey response, and feedback of summary statistics. Consensus was defined as 75 % of panelists ranking an element as required (≥80 on a scale of 0-100) to meet a definition of near-fatality (75th% threshold).</p>

<p><strong>RESULTS: </strong>Experts defined near-fatal child maltreatment as life-threatening cardiopulmonary dysfunction directly attributable to suspected abuse or neglect as evidenced by (a) respiratory insufficiency/failure requiring intubation and mechanical ventilation, (b) respiratory insufficiency/failure requiring medications to reverse effects of toxic ingestion, or (c) cardiac arrhythmia with/without cardiopulmonary resuscitation (CPR).</p>

<p><strong>CONCLUSIONS: </strong>A consensus definition of near-fatal child maltreatment should be introduced in child protective services processes and in child fatality/near-fatality reviews to improve our ability to identify, review, and respond to trends in near-fatal child maltreatment at local, regional, and national levels.</p>

10.1016/j.chiabu.2020.104893

Child Abuse Negl

33373847

More data, more questions: No simple answer about which children should undergo screening neuroimaging for clinically occult abusive head trauma.

2020

104561

2020 Jun 13

1873-7757

<p>Abusive head trauma (AHT) is the leading cause of fatal child physical abuse. Victims may initially present with clinically occult AHT without overt signs of head trauma or with only subtle, nonspecific symptoms, which can make timely recognition of AHT challenging. Research has shown missed opportunities for early detection of AHT in the medical setting are common and can lead to repeated injury. Neuroimaging is needed to diagnose clinically occult AHT but is not without risk. Researchers have worked to understand the yield of neuroimaging in detection of clinically occult AHT and to identify risk factors, yet findings have varied widely across studies. Identifying which children undergoing physical abuse evaluations are at highest risk of clinically occult AHT is key to development of evidence-based imaging decision support tools for clinicians. Here we discuss the recent literature, identify potential reasons for variation across studies, and offer opportunities for future research.</p>

10.1016/j.chiabu.2020.104561

Child Abuse Negl

32544698

Occult head injuries in infants evaluated for physical abuse.

2020

104431

2020 Mar 03

1873-7757

<p><strong>BACKGROUND: </strong>Abusive head injuries in infants may be occult but clinically or forensically important. Data conflict regarding yield of neuroimaging in detecting occult head injuries in infants evaluated for physical abuse, with prior studies identifying yields of 4.3-37.3 %.</p>

<p><strong>OBJECTIVES: </strong>(1) To quantify yield of computed tomography or magnetic resonance imaging in identification of occult head injuries in infants with concerns for physical abuse and (2) to evaluate risk factors for occult head injuries.</p>

<p><strong>PARTICIPANTS AND SETTING: </strong>We conducted a retrospective, stratified, random systematic sample of 529 infants &lt;12 months evaluated for physical abuse at 4 urban children's hospitals in the United States from 2008-2012. Infants with signs or symptoms suggesting head injury or skull fracture on plain radiography (N = 359), and infants without neuroimaging (N = 1) were excluded.</p>

<p><strong>METHODS: </strong>Sampling weights were applied to calculate proportions of infants with occult head injuries. We evaluated for associations between hypothesized risk factors (age &lt;6 months, rib or extremity fracture, facial bruising) and occult head injury using chi-square tests.</p>

<p><strong>RESULTS: </strong>Of 169 neurologically normal infants evaluated for abuse, occult head injury was identified in 6.5 % (95 % CI: 2.6, 15.8). Infants &lt;6 months were at higher risk (9.7 %; 95 % CI: 3.6, 23.3) than infants 6-12 months (1.0 %; 95 % CI: 1.3, 20.2). Rib fracture, extremity fracture and facial bruising were not associated with occult head injury.</p>

<p><strong>CONCLUSIONS: </strong>Occult head injuries were less frequent than previously reported in some studies, but were identified in 1 in 10 infants &lt;6 months. Clinicians should have a low threshold to obtain neuroimaging in young infants with concern for abuse.</p>

10.1016/j.chiabu.2020.104431

Child Abuse Negl

32143091

Use and Utility of Skeletal Surveys to Evaluate for Occult Fractures in Young Injured Children.

2018

2018 Aug 16

1876-2867

<p><strong>OBJECTIVES: </strong>To describe the percentage and characteristics of children &lt;24 months old with non-motor vehicle crash (non-MVC)-related injuries who 1) undergo a skeletal survey and 2) have occult fractures.</p>

<p><strong>METHODS: </strong>We performed a retrospective chart review of a stratified, systematic random sample of 1769 children &lt;24 months old with non-MVC-related bruises, burns, fractures, abdominal injuries, and head injuries at 4 children's hospitals from 2008-2012. Sampling weights were assigned to each child to allow for representative hospital-level population estimates. Logistic regression models tested for associations between patient characteristics with outcomes of skeletal survey completion and occult fracture identification.</p>

<p><strong>RESULTS: </strong>Skeletal surveys were performed in 46.3% of 0-5 month olds, 21.1% of 6-11 month olds, 8.0% of 12-17 month olds and 6.2% of 18-24 month olds. Skeletal surveys were most performed in children with traumatic brain injuries (64.7%) and rib fractures (100%) and least in burns (2.1%) and minor head injuries (4.4%). In adjusted analyses, increased age, private insurance and reported history of accidental trauma were associated with decreased skeletal survey use (all p≤0.001). The prevalence of occult fractures on skeletal survey ranged from 24.6% in infants 0-5 month olds to 3.6% in 18-24 month olds, and varied within age categories based on the presenting injury (p&lt;0.001).</p>

<p><strong>CONCLUSIONS: </strong>The high rate of occult fractures in infants 0-5 months old underscores the importance of increasing the use of skeletal surveys in this population. Further research is needed to identify the injury characteristics of older infants and toddlers most at risk for occult fractures.</p>

10.1016/j.acap.2018.08.007

Acad Pediatr

30121318

Cervical Spine Imaging and Injuries in Young Children With Non-Motor Vehicle Crash-Associated Traumatic Brain Injury.

2018

2018 Feb 15

1535-1815

<p><strong>OBJECTIVES: </strong>The aim of this study was to evaluate cervical magnetic resonance imaging (MRI) and computed tomography (CT) practices and cervical spine injuries among young children with non-motor vehicle crash (MVC)-associated traumatic brain injury (TBI).</p>

<p><strong>METHODS: </strong>We performed a retrospective study of a stratified, systematic random sample of 328 children younger than 2 years with non-MVC-associated TBI at 4 urban children's hospitals from 2008 to 2012. We defined TBI etiology as accidental, indeterminate, or abuse. We reported the proportion, by etiology, who underwent cervical MRI or CT, and had cervical abnormalities identified.</p>

<p><strong>RESULTS: </strong>Of children with non-MVC-associated TBI, 39.4% had abusive head trauma (AHT), 52.2% had accidental TBI, and in 8.4% the etiology was indeterminate. Advanced cervical imaging (CT and/or MRI) was obtained in 19.1% of all children with TBI, with 9.3% undergoing MRI and 11.7% undergoing CT. Cervical MRI or CT was performed in 30.9% of children with AHT, in 11.7% of accidental TBI, and in 10.7% of indeterminate-cause TBI. Among children imaged by MRI or CT, abnormal cervical findings were found in 22.1%, including 31.3% of children with AHT, 7.1% of children with accidental TBI, and 0% of children with indeterminate-cause TBI. Children with more severe head injuries who underwent cervical imaging were more likely to have cervical injuries.</p>

<p><strong>CONCLUSIONS: </strong>Abusive head trauma victims appear to be at increased risk of cervical injuries. Prospective studies are needed to define the risk of cervical injury in children with TBI concerning for AHT and to inform development of imaging guidelines.</p>

10.1097/PEC.0000000000001455

Pediatr Emerg Care

29461428

Research priorities for a multi-center child abuse pediatrics network - CAPNET.

2017

152-157

2017 Mar

1873-7757

<p>Although child maltreatment medical research has benefited from several multi-center studies, the new specialty of child abuse pediatrics has not had a sustainable network capable of pursuing multiple, prospective, clinically-oriented studies. The Child Abuse Pediatrics Network (CAPNET) is a new multi-center research network dedicated to child maltreatment medical research. In order to establish a relevant, practical research agenda, we conducted a modified Delphi process to determine the topic areas with highest priority for such a network. Research questions were solicited from members of the Ray E. Helfer Society and study authors and were sorted into topic areas. These topic areas were rated for priority using iterative rounds of ratings and in-person meetings. The topics rated with the highest priority were missed diagnosis and selected/indicated prevention. This agenda can be used to target future multi-center child maltreatment medical research.</p>

10.1016/j.chiabu.2017.01.015

Child Abuse Negl

28161656