Child abuse, neglect, and exploitation of young people

Standardising assessment and response

When clinicians respond to physical findings consistently, such as by performing a standard work-up for pre-ambulatory children with unexplained fractures, physical abuse is more likely to be identified, and this has been shown to reduce re-injury rates significantly.7 As emphasised by Schwartz et al,4 by acting in accordance with local protocols and guidelines, clinicians can allay caregivers’ concerns about the appropriateness of further investigation while also de-escalating a stressful scenario, and explain: “This is what I always do.”

Assessors’ bias when deciding who to investigate further is also likely to be diminished when healthcare providers act consistently. They will be less likely to fail to evaluate an injured child appropriately because their caregivers presented themselves well, and similarly less likely to generate inappropriate concern because a caregiver who did not have transportation was delayed in seeking care. A large, multi-site US retrospective cohort study of infants with traumatic brain injury demonstrated that if white infants had been evaluated at the same rate as black infants, an additional 14% of white infants would have been evaluated with a skeletal survey that may have revealed occult fractures.8 While it is difficult to conclude whether this disproportionality led to missed cases of child abuse in white children or over-evaluation in black children, both undesirable outcomes have been replicated in older studies.910

Systematically screening children for child abuse may increase detection, as demonstrated in an interventional cohort study of all people aged less than 18 years attending emergency departments of seven Dutch hospitals over 23 months. Of 104 028 attendees, 243 (0.2%) were cases of suspected child abuse. After implementing a nurse-initiated child abuse screening checklist, the screening rate increased from 20% to 67%, and detection rate of abuse was significantly higher among screened versus non-screened patients (0.5% v 0.1%).11 Screening tools, however, may be ineffective if a clinician does not remember to screen or fails to recognise an injury to be high-risk for abuse in the first place.

Further standardisation of best practice could be facilitated by the use of electronic medical record-based tools such as clinical decision support systems.1213 Although these tools are not widely implemented in clinical care currently, validation studies suggest that they have the potential to help identify injuries concerning for child abuse and provide patient-specific recommendations about assessment and reporting to child welfare (social) services.1415 For example, when a clinician evaluates a febrile infant and documents in the free text of a note that the child has a bruise, a natural language processing algorithm can interpret the narrative data and alert the clinician about signs of abuse.16 Integration of such automated, evidence based alerts triggered by clinician-initiated screening tools (active screening) or diagnoses, investigations, or natural language processing of electronic notes (passive screening) has improved recognition of child abuse and has standardised clinician behaviour.1517

Our understanding of the impact of both protocol-based practice and clinical decision support systems on improving detection of abuse and diminishing racial, ethnic, and socioeconomic disparities in evaluating and reporting to child welfare (social) services is incomplete and should remain a research priority.18

Accessing experts

Both linked articles stress the importance of discussing initial concerns with a child abuse or safeguarding specialist early during the assessment process. Further specialist assistance, such as a radiologist when considering a fracture or a haematologist when assessing the cause of bruising, may be required to distinguish between an abusive injury or one that is explained by a non-abusive medical problem. Child abuse specialists, including named nurses and doctors for safeguarding, can provide expertise in guiding evaluation or deciding when to report to child welfare (social) services.19 Leveraging telemedicine or telementoring, peer mentoring designed to improve capacity to manage medical problems in areas where subspecialty care is sparse, may improve access to child abuse specialists in sites and areas where paediatric expertise is underrepresented.20

Improving documentation

Careful and objective documentation by the generalist, including using supplemental photographic documentation, avoids possible overinterpretation of findings, removes suggestions of mechanism or intent, and optimises language for any legal proceedings—a point reiterated by both linked articles. In addition to promoting successful recognition of potentially abusive injuries, objective and non-judgmental documentation is also important when caregivers request access to medical records or when medical documentation is released to patients without charge or delay, as is the case with the federally mandated rule, Open Notes, in the United States.21

Recognising child maltreatment is a critical task for all frontline providers who assess children. Careful and consistent application of evidence, collaboration, and sensitivity in documentation are more likely to lead to correct identification of children who require protection, while not over-evaluating and burdening the caregivers of those who do not.