Evaluation of suspected child abuse at the ED; implementation of American Academy of Pediatrics guidelines in the Netherlands.

Emergency departments (EDs) are important to detect child physical abuse. A structured approach will contribute to an adequate detection of abused children at the ED. The American Academy of Pediatrics (AAP) provided guidance in the clinical approach to the evaluation of suspected physical abuse in children. In the Netherlands, these American Academy of Pediatrics guidelines have been adopted for the clinical process of child abuse detection. Here, we describe the outcome of the clinical process in the year 2010 with 65 cases of suspected child abuse out of 3660 children presenting at an ED, and we discuss the strengths and pitfalls of this current clinical approach.

The Value of a Checklist for Child Abuse in Out-of-Hours Primary Care: To Screen or Not to Screen.

OBJECTIVES: To assess the diagnostic value of the screening instrument SPUTOVAMO-R2 (checklist, 5 questions) for child abuse at Out-of-hours Primary Care locations (OPC), by comparing the test outcome with information from Child Protection Services (CPS). Secondary, to determine whether reducing the length of the checklist compromises diagnostic value. METHODS: All children (<18 years) attending one of the participating OPCs in the region of Utrecht, the Netherlands, in a year time, were included. The checklist is an obligatory field in the electronic patient file. CPS provided data on all checklist positives and a sample of 5500 checklist negatives (dataset). The checklist outcome was compared with a report to CPS in 10 months follow up after the OPC visit. RESULTS: The checklist was filled in for 50671 children; 108 (0.2%) checklists were positive. Within the dataset, 61 children were reported to CPS, with emotional neglect as the most frequent type of abuse (32.8%). The positive predictive value (PPV) of the checklist for child abuse was 8.3 (95% CI 3.9-15.2). The negative predictive value (NPV) was 99.1 (98.8-99.3), with 52 false negatives. When the length of the checklist was reduced to two questions closely related to the medical process (SPUTOVAMO-R3), the PPV was 9.1 (3.7-17.8) and the NPV 99.1 (98.7-99.3). These two questions are on the injury in relation to the history, and the interaction between child and parents. CONCLUSIONS: The checklist SPUTOVAMO-R2 has a low detection rate of child abuse within the OPC setting, and a high false positive rate. Therefore, we recommend to use the shortened checklist only as a tool to increase the awareness of child abuse and not as a diagnostic instrument.

Value of systematic detection of physical child abuse at emergency rooms: a cross-sectional diagnostic accuracy study.

OBJECTIVES: The aim of our diagnostic accuracy study Child Abuse Inventory at Emergency Rooms (CHAIN-ER) was to establish whether a widely used checklist accurately detects or excludes physical abuse among children presenting to ERs with physical injury. DESIGN: A large multicentre study with a 6-month follow-up. SETTING: 4 ERs in The Netherlands. PARTICIPANTS: 4290 children aged 0-7 years attending the ER because of physical injury. All children were systematically tested with an easy-to-use child abuse checklist (index test). A national expert panel (reference standard) retrospectively assessed all children with positive screens and a 15% random sample of the children with negative screens 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. MAIN OUTCOME MEASURE: Physical child abuse. SECONDARY OUTCOME MEASURE: Injury due to neglect and need for help. RESULTS: 4253/4290 (99%) parents agreed to follow-up. At a prevalence of 0.07% (3/4253) for inflicted injury by expert panel decision, the positive predictive value of the checklist was 0.03 (95% CI 0.006 to 0.085), and the negative predictive value 1.0 (0.994 to 1.0). There was 100% (93 to 100) agreement about inflicted injury in children, with positive screens between the expert panel and child abuse experts. CONCLUSIONS: Rare cases of inflicted injury among preschool children presenting at ERs for injury are very likely captured by easy-to-use checklists, but at very high false-positive rates. Subsequent assessment by child abuse experts can be safely restricted to children with positive screens at very low risk of missing cases of inflicted injury. Because of the high false positive rate, we do advise careful prior consideration of cost-effectiveness and clinical and societal implications before de novo implementation.