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

OBJECTIVE: 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 (preconsultation referral). METHODS: Children<5years-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 preconsultation referral adjusting for CAP's final assessment of abuse likelihood. RESULTS: Among the 61% (1005/1657) of cases with preconsultation referral, the CAP consultant had low concern for abuse in 38% (384/1005). Preconsultation referrals ranged from 25% to 78% of cases across 10 hospitals (P < .001). In multivariable analyses, preconsultation 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 < .05). The difference in preconsultation 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 = .023 for interaction of insurance and abuse likelihood category). There were no differences in preconsultation 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.

State Spending on Public Benefit Programs and Child Maltreatment.

BACKGROUND: To determine the association between states' total spending on benefit programs and child maltreatment outcomes. METHODS: This was an ecological study of all US states during federal fiscal years 2010-2017. The primary predictor was states' total annual spending on local, state, and federal benefit programs per person living ≤100% federal poverty limit, which was the sum of (1) cash, housing, and in-kind assistance, (2) housing infrastructure, (3) child care assistance, (4) refundable Earned Income Tax Credit, and (5) Medical Assistance Programs. The main outcomes were rates of maltreatment reporting, substantiations, foster care placements, and fatalities after adjustment for relevant confounders. Generalized estimating equations adjusted for federal spending and estimated adjusted incidence rate ratios (IRRs) and 95% confidence intervals (CIs). RESULTS: States' total spending was inversely associated with all maltreatment outcomes. For each additional $1000 states spent on benefit programs per person living in poverty, there was an associated -4.3% (adjusted IRR: 0.9573 [95% CI: 0.9486 to 0.9661]) difference in reporting, -4.0% (adjusted IRR: 0.903 [95% CI: 0.9534 to 0.9672]) difference in substantiations, -2.1% (adjusted IRR: 0.9795 [95% CI: 0.9759 to 0.9832]) difference in foster care placements, and -7.7% (adjusted IRR: 0.9229 [95% CI: 0.9128 to 0.9330]) difference in fatalities. In 2017, extrapolating $1000 of additional spending for each person living in poverty ($46.5 billion nationally, or 13.3% increase) might have resulted in 181 850 fewer reports, 28 575 fewer substantiations, 4168 fewer foster care placements, and 130 fewer fatalities. CONCLUSIONS: State spending on benefit programs was associated with reductions in child maltreatment, which might offset some benefit program costs.

Insurance Coverage for Children Impacts Reporting of Child Maltreatment by Healthcare Professionals.

OBJECTIVES: Children's insurance coverage, through increased access and use of the healthcare system, may increase the likelihood that healthcare professionals (HCPs) will detect and report child maltreatment. We sought to estimate the association between insurance coverage for children and reporting of child maltreatment by HCPs. STUDY DESIGN: We conducted a cross-sectional study of US counties from 2008 to 2015 using data from the US Census Bureau's Small Area Health Insurance Estimates, National Center for Health Statistics, and National Child Abuse and Neglect Data System. The primary predictor was counties' percent of children insured. We controlled for counties' children living at ≤200% federal poverty level, race/ethnicity demographics, and urban-rural status. The primary outcome was the rate of maltreatment reporting from HCPs. Generalized linear mixed effects models with repeated measures across years tested associations. RESULTS: We included 5517 county-year observations involving 470 876 018 child-years. Counties' percent of children insured ranged from 74.6% to 99.2% with a median of 93.7% (IQR, 91.0-95.4). For every 1 percentage point increase in counties' percent of children insured, there was an associated 2% increase in child maltreatment reporting by HCPs (adjusted incidence rate ratio, 1.02; 95% CI, 1.02-1.03). If counties' percentage of insured children had been 1 percentage point greater in 2015, a predicted 5620 (95% CI, 5620-8089) additional reports would have been generated. CONCLUSIONS: Among its other benefits for children's well-being, insurance coverage may also contribute to child protection by increasing the reporting of maltreatment among HCPs.

Assessment of factors resulting in abuse evaluations in young children with minor head trauma.

OBJECTIVE: The primary objective was to determine which of the examined factors prompted physicians to initiate a further abuse evaluation in young children with minor head injury. The recording of important historical elements in the charts of these patients was also evaluated. METHODS: Charts of 349 children less than 3 years of age with minor head injury were retrospectively reviewed. Age, race, sex, insurance status, findings on head CT, mechanism of injury, witnessing of event and delay in seeking care were analyzed for association with performance of skeletal survey and referral to Child Protective Services (CPS). RESULTS: Increased odds of CPS referral and increased odds of obtaining a skeletal survey were associated with positive findings on head CT, delay in seeking care, and unknown mechanism of injury. Despite a known association of age/ambulatory status with abuse, the age of the child was not associated with increased odds of abuse evaluation, and younger age was not associated with increased odds of documenting whether the injury was witnessed or when the injury occurred. Documentation of timing of injury was lacking in 29.2% of the charts. Witnessing of the event was undocumented in 48.7% of cases. CONCLUSION: Clinicians may not be using readily available, important information when considering the initiation of an abuse evaluation in young children. Clinicians seeing acutely injured children may need further education regarding developmental status and its effect on mechanisms of injury and the importance of detailed documentation in cases where abuse is a possible cause of injury. PRACTICE IMPLICATIONS: Historical factors associated with injuries in young children continue to be poorly documented. Increased pediatric training for emergency medicine physicians, clinical protocols for evaluation and documentation of injured children, and regular continuing medical education on child development and its implications on mechanisms of injury for clinicians practicing in acute care settings are needed changes that may bring about improvements.