Proposed system to detect child abuse could deter parents from seeking treatment, pressure group says
BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e8705 (Published 28 December 2012) Cite this as: BMJ 2012;345:e8705All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
“The proposed linkage of data on abused children is based on a belief that some abusive parents manipulate health systems to make it harder for services to recognize patterns of injury. If this is true - and it seems plausible - then those same parents will be motivated to manipulate the new system for similar reasons.”[1]
The first point to establish is - has the child been subject to physical abuse?
The believers of the so-called “triad” –subdural haemorrhage, retinal haemorrhage and encephalopathy - proclaim there is no better proof of physical abuse.
However there is good evidence that hypoinsulinism, an autoimmune response to antigenic stimulation which is demonstrated by hyperglyaemia, is a feature of “tissue scurvy”[2-6].
Tissue Scurvy would explain all the bruises. haemorrhages and fractures seen in these allegedly “abused children” since it affects the functions of the liver, inhibits carboxylation of some coagulation factors and osteocalcin and thus causes the “triad”.
Tissue Scurvy will be a new concept to most of your readers but it debunks the myth of the Shaken Baby Syndrome and should prevent false accusations of child abuse.
A fuller report is soon to be published.
Michael Innis.FRCPA; FRCPath
References:
1. Cris Jones- Nigel Hawkes. 345:doi:10.1136/bmj.e8705
2.Clemetson CAB. Vaccinations, Inoculations and Ascorbic Acid. Jour Ortho Mol Med 1999;14:137 –142
3. Kalokerinos A Every Second Child Thomas Nelson (Australia) Limited 1974
4. Cunningham JJ. The Glucose/Insulin System and Vitamin C:Implications in Insulin-dependent Diabetes Mellitus. J Am Coll Nutr; 1998:vol 17 p105-108
5.Cunningham JJ, Ellis SL, McVeigh KL, Levine RE, ,Jorge Calies Escandon Reduced mononuclear leucocyte ascorbic acid content in adults with insulin-dependent diabetes mellitus consuming adequate dietary vitamin C Metabolism 1981;vol 40;148-149.
6.Innis MD. Vitamin K Deficiency Disease. Jour of Orthomol Med 2008;vol 23; 15-20
Competing interests: I have given Expert Testimony for the Defence in the USA, UK and Australia and I have been paid for my services
The proposed linkage of data on abused children is based on a belief that some abusive parents manipulate health systems to make it harder for services to recognise patterns of injury. If this is true - and it seems plausible - then those same parents will be motivated to manipulate the new system for similar reasons.
One unintended, but entirely foreseeable, consequence is that some of those children, some of the time, will be denied health care that they would otherwise have received. For those who become non-attenders there will be no benefit from data linkage because the data will not be collected, but significant harm may result from missed treatment.
Traditionally healthcare has been provided confidentially in order to encourage such patients to present for treatment. As medical information is increasingly used for the prevention and detection of crime a point will be reached where the harm caused by deterring people from treatment will outweigh the benefit of reducing harm
Competing interests: No competing interests
The Child Protection Information System (CPIS) represents progress in providing healthcare professionals with information about support for children by social care services – something welcomed by health professionals.1 As we understand it, CPIS focuses on children presenting to A&E departments who are currently on a child protection plan or in out-of-home care. We are concerned that CPIS represents a response to high profile cases as it runs counter to the best available research evidence.
Maltreatment infrequently results in injury or medical problems; this was the case in only 12% of all children with substantiated maltreatment in Canada in 2008,2 and not all such children present to A&E. Our systematic review estimated that up to 1% of A&E attendances for injury are related to abuse or neglect.3 Maltreated children are more likely to be identified via medical presentations (not necessarily related to maltreatment) or through their parents.1 4
As CPIS focuses only on children with child protection plans or subject to out-of-home care it will inevitably miss most maltreated children. Although 4-10% of children experience maltreatment annually, few of these are referred to children’s social care services, and even fewer are placed on a child protection plan (0.5% of all children) or in out-of-home care (0.2% of all children; data from DfE website 2011-12). CPIS will capture data on recurrent A&E attendances. However, as our systematic review found no evidence that maltreated children have substantially more attendances at A&E than non-maltreated children,5 it is unclear how such data should be interpreted and by whom.
Another potential disadvantage of CPIS is false reassurance of the negative. Not currently the subject of a plan or in out-of-home care adds little useful information with regard to risk status but could be interpreted as reassuring and lead to cases being missed. Our review concluded that information on child protection plans would not be useful as a screening test in A&E.3
Given the lack of evidence to support the focus of CPIS and its potential for harm, rigorous evaluation is essential. Research using anonymous linkage of routinely captured children’s social care data with healthcare data from A&E, hospital admissions and primary care would allow evaluation of the likely detection and false positive rates and would help to predict how and with whom information on social care contacts could most effectively be shared. Until such evidence is available, much could be achieved by ensuring that children attending A&E (or their parents) who give rise to concerns are followed up in the community, and at the very least, are registered with a GP. As the first point of healthcare contact with children and families, GPs are well placed to recognise and respond to the most prevalent forms of maltreatment – chronic neglect and emotional abuse – and to respond to risk factors, such as drug or alcohol misuse, in the parents.1 The government should be asking where information on social care services would most likely lead to effective interventions for vulnerable children and their families. We suggest focusing on family doctors.1
Reference List
1. Woodman J, Allister J, Rafi I, de Lusignan S, Belsey J, Petersen I, et al. Simple approaches to improve recording of concerns about child maltreatment in primary care records: developing a quality improvement intervention. Br J Gen Pract 2012;62(600):e478-e86(9).
2. Ruiz-Casares M, Trocme N, Fallon B. Supervisory neglect and risk of harm. Evidence from the Canadian Child Welfare System. Child Abuse Negl 2012;36(6):471-80.
3. Woodman J, Pitt M, Wentz R, Taylor B, Hodes D, Gilbert RE. Performance of screening tests for child physical abuse in accident and emergency departments. Health Technol Assess 2008;12(33):iii, xi-xiii 1-95.
4. Kugler B, Woodman J, Carroll J, Fertleman C, Gilbert R. Child protection guidance needs to address parent behaviour. CHILD: Care, Health and Development 2012;doi:10.1111/cch.12007.
5. Woodman J, Lecky F, Hodes D, Pitt M, Taylor B, Gilbert R. Screening injured children for physical abuse or neglect in emergency departments: a systematic review. Child Care Health Dev 2010;36(2):153-64.
Competing interests: No competing interests
Re: Proposed system to detect child abuse could deter parents from seeking treatment, pressure group says
There is much resonance around the Maksim Kuzmin case today. Being acquainted with the topic child abuse [1], I would like to comment that mechanisms of detection, reporting, prevention and handling of child abuse are much better developed in the USA than in the former SU. In Russia, many people (neighbors, teachers, family friends etc.) see child abuse but do not report. Some of them think that it is normal, others mistrust authorities.
1. Jargin SV. Letter from Russia: child abuse and alcohol misuse in a victim. Alcohol and Alcoholism 2011;46(6):734-6.
Competing interests: No competing interests