Child Maltreatment is a major healthcare and public health problem in the U.S. Early and correct diagnosis of CM is essential in preventing further maltreatment that can eventually lead to morbidity and mortality. Family medicine physicians as primary health care providers play a crucial role in the evaluation and assessment of these children. However, due to inadequate training they lack confidence in evaluating and diagnosing maltreated children.
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Initiating child maltreatment evaluation and diagnosis training early during family medicine training will go a long way in improving their confidence and subsequently competence in CM evaluation, diagnosis, and management.
34 REFERENCES
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6. U.S. Department of Health and Human Services, Administration for Children and Families, Administration for Children, Youth and Families, Children’s Bureau. Child maltreatment 2013. http://www.acf.hhs.gov/sites/default/files/cb/cm2013.pdf#page=20. Updated 2015. Accessed Nov 11, 2015.
7. Child Welfare Information Gateway. Long-term consequences of child abuse and neglect. Washington, DC: U.S. Department of Health and Human Services, Children’s Bureau. https://www.childwelfare.gov/pubpdfs/long_term_consequences.pdf. Updated 2013. Accessed Nov 11, 2015.
8. Fingarson AK, Flaherty EG, Sege RD. Improving physician identification and report of child maltreatment. JCOM. 2011;18(4):185-190.
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https://www.childwelfare.gov/pubPDFs/acts.pdf#page=1&view=Introduction. Updated 2012. Accessed Nov/12, 2015.
11. Barnett D, Manly JT, Cicchetti D. Defining child maltreatment: The interface between policy and research. In: Cicchetti D, Toth SL, eds. Advances in applied developmental
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13. Korbin JE. Child maltreatment: Contemporary issues in research and policy 2. In: Korbin JE, Krungman R, eds. Handbook of child maltreatment. Springer Netherlands; 2015:64. Accessed 11/11/15. 10.1007/978-94-007-7208-3.
14. Glaser D. Emotional abuse and neglect (psychological maltreatment): A conceptual framework. Child Abuse & Neglect. 2002;26(6):702.
15. American Professional Society on the Abuse of Children. Psychosocial evaluation of suspected psychological maltreatment in children and adolescents. practice guidelines.
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16. Child Welfare Information Gateway. Risk and protective factors for child abuse and neglect. https://www.childwelfare.gov/pubPDFs/riskprotectivefactors.pdf. Updated 2004. Accessed Nov 11, 2015.
17. Leetch AN, Leipsic J, Woolridge D. Evaluation of child maltreatment in the emergency department setting. An overview of behavioral health providers. Child Adolesc
Psychiatric Clin N Am. 2015; 24(1):41-64.
18. Gothard TW, Runyan DK, Hadler JL. The diagnosis and evaluation of child maltreatment. The Journal of Emergency Medicine. 1985;3(181):194.
19. Robbins S, Cotran R. Pathologic basis of disease. In: Saunders, ed. Philadelphia: ; 1979:485-488. Accessed 11/25/15.
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21. McNeese MC, Hebeler JR. The abused child: A clinical approach to identification and management. Clin Symp. 1977;29(5):1-36.
22. White ST, Loda FA, Ingram DL, Pearson A. Sexually transmitted diseases in sexually abused children. Pediatrics. 1983;72(1):16-21.
23. Bittner S, Newberger E. Pediatric understanding of child abuse and neglect. Pediatr Rev. 1981;2(7):197-207.
24. Agency for Healthcare Research and Quality, Rockville,MD. Primary care workforce facts and stats no. 3. AHRQ Web site.
http://www.ahrq.gov/research/findings/factsheets/primary/pcwork3/index.html. Updated 2014. Accessed 1/16, 2016.
25. Rosenblatt RA, Hart LG. Physicians and rural America. West J Med. 200; 173(5):348- 351.
26. Jackson AM, Deye, KP, Halley T, et al. Curiosity and critical thinking: Identifying child abuse before it is too late. Clin Pediatr (Phila). 2015; 54(1):54-61.
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27. Thorpe EL, Zuckerbraun NS, Wolford JE, Berger RP. Missed opportunities to diagnose child physical abuse. Pediatr Emerg Care. 2014; 30(11):771-776.
28. Menoch M, Zimmerman S, Garcia-Filion P, Bulloch B. Child abuse education: An objective evaluation of resident and attending physician knowledge. Pediatr Emerg Care. 2011; 27(10):937-940.
29. Lane WG, Dubowitz H. Primary care pediatricians’ experience, comfort, and competence in the evaluation and management of child maltreatment: Do we need child abuse
37 APPENDIX 1: SYSTEMATIC REVIEW Objectives and Concepts
The main object of this paper is to elicit or demonstrate family medicine primary care physician’s confidence and competence in making a prompt diagnosis of suspected child maltreatment case and to determine the barrier to early diagnosis or accurate diagnosis of suspected child maltreatment that include neglect, physical abuse, sexual abuse and emotional abuse. I researched and reviewed journal articles related to health care, mental health, family medicine, emergency medicine and pediatrics. It was a bit challenging to obtain reasonable articles with search criteria focus on family medicine physicians hence research criteria were broadened to include emergency medicine and pediatric articles. Any form of publications including clinical trials, systematic review and research articles, etc. was included in the literature research.
Current articles mostly from the year 2009 to 2015, i.e., the last six years, was researched since searching articles more than six years old brought up a large number of articles that were not quite relevant to this project. Initially various search engines were used which include
“Google Scholar, PubMed, EBSCO Host, CINAHL and Social Work Reference Center” this was eventually narrowed down to only two search engines i.e., PubMed and EBSCO Host. Pediatrics Emergency Care Journal, was specifically reviewed for articles as well since a lot of maltreated children also present at the pediatric emergency departments.
Challenges faced during this systematic review process were unlimited. Initially, the search criteria were focused on family medicine physicians, but due to inability to obtain relevant articles the search criteria were broadened to include health care, emergency medicine, and pediatrics.
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It was also quite difficult to obtain an article that addresses all types of child maltreatment, most of the articles reviewed were on physical abuse with very few encompassing all forms of CM.
Search Criteria
Search Engine: PubMed. Search Start Date: Oct 2015.
Search Criteria and Term :( (("Delayed Diagnosis"[Majr]) OR "Diagnostic Errors"[Majr])) AND ("Child Abuse/diagnosis"[Majr].
This search term returned 36 articles, which was further filtered by reviewing articles written in English, published in the U.S. and published six years ago or less. With these criterions, the articles returned were reduced to 13.
Another search criteria and the term used on PubMed was “Evaluation and Management of Child Maltreatment” this search term produced 531 articles, this was further narrowed down to 222 articles when I used criteria such as year of publication of six years or less and only English, U.S. published journals.
Search Engine: EBSCOHost. Search Start Date: Oct 2015.
Search Criteria and Term: “child abuse” AND “diagnostic error” OR “delayed diagnosis” OR “misdiagnosis” AND “physicians”.
This search criteria and terms returned 3,913 articles; I further restricted the search criteria to articles six years old or less which returned 2,355 articles. Other criteria later added in the search was an article written in English and published in the U.S. After including all these search criteria, EBSCOHost returned 1,182 articles.
39 Search Journal: Pediatric Emergency Care Journal. Search Date: Nov 2015
Search Term: “Missed Opportunity”, “Child Physical Abuse” “Fatal Child Abuse” “Misdiagnosis of Child Abuse”.
This search strategy returned 53 articles related to missed diagnosis of child maltreatment. Articles were selected based on recent publication six years old or less, published in English in the U.S. After combing through most of the returned articles, the ones that are relevant to this project were selected, most of which appear in both PubMed and EBSCOHost search engine as well as the Pediatric Emergency Care Journal.
Article Review Summary
Jackson AM, Deye KP, Halley T, et al. Curiosity and critical thinking: Identifying child abuse before it is too late. Clinical Pediatrics. 2015;54(1):54-61.
Study Description: Review of medical records at Children’s National Medical Center in Washington, DC in a level 1 trauma center; to identify factors contributing to missed cases of child abuse at their initial presentation at the trauma center. They reviewed medical records over a 12-year period (2000-2012), and the review team includes three physicians (a child abuse pediatrician, a pediatric hospitalist, and a pediatric emergency medicine physician). The review team obtained medical records of patients diagnosed with child abuse as well as records of previous visits where they missed signs of child abuse. They also determined the cause of missed diagnosis at their initial visit.
Study Population: Children ages five weeks to 7 years old who were evaluated at Children’s Medical Center emergency department at least once before their diagnosis of child maltreatment.
40 Study Design; Retrospective Cohort Study.
Study Result: Out of a total of 18 patients reviewed almost all had an ED evaluation for their diagnosis of child maltreatment at some point. Out of these 18 children, 15 were given a different diagnosis other than child maltreatment such as fracture, contusion, overfeeding, sepsis, etc., only 3 of the 18 children had suspected diagnosis of maltreatment, but these three cases were never reported to the child protective service. Of the 18 children, a report of two fatalities was made with one of the two children who were dead on arrival at the hospital.
Some of the factors contributing to misdiagnosis in this institution include lack of history taking from verbal children occurring in 11% of the cases; inadequate physical examination in 50% of cases (improper documentation of skin findings); and unrecognized symptoms
constellation in 17% of cases. Other factors include not following maltreatment pathways or established guidelines in 33% of cases; not ordering appropriate radiologic testing were, and missing radiologic findings in 11% and 17% of cases respectively; lack of time to review medical record in 11% of cases and lack of access to previous medical record in 28% of cases. Study Limitation/Strength: One of the strengths of the study is the involvement of a well-trained CM pediatrician in reviewing records.
Limitations include a small sample size of cases reviewed; 18 cases are quite small, and this might affect the power and value of the study. The selection process improperly discussed; it is unclear if cases were randomly selected to eliminate selection bias. There were limitations in accessing medical records from previous visits due to lack of electronic medical record which the institution did not have until the year 2010. Hence, there might have been an underestimation of the total number of missed cases of abused child.
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Thorpe EL, Zuckerbraun NS, Wolford JE, Berger RP. Missed opportunities to diagnose child physical abuse. Pediatr Emerg Care. 2014;30(11):771-776.
Study Description: This study was designed to identify incidence of missed opportunity to diagnose a case of child abuse among children who presented with healing bone fracture related to abuse at various locations ( emergency department, primary care offices and subspecialty practices) of the “Children’s Hospital Pittsburgh” of the “University of Pittsburgh Medical Center” .
This study involves reviewing of medical records of all children who underwent a skeletal survey due to concern for physical child abuse over a seven yr period from April 1, 2002, to March 31st, 2009. The child protection team obtains a history and physical exam from subject’s caretakers as well as their primary care providers in addition to record review. They collected two sets of data; the first set of data includes history and physical examination for the visit at which the abuse was diagnosed, and the other data is from the previous visit before the abuse was diagnosed. They defined previous visit as any visit to the health care provider within six months of abuse diagnosis other than for well child care and all previous visits were classified as missed previous visits in which potential abuse fracture was missed or a previous unrelated visit. Study Population: Children ages range between 0.5-70.3 months who presented at the
“Children’s Hospital Pittsburgh” of the “University of Pittsburgh Medical Center” with the skeletal survey with healing fracture attributed to physical abuse. 49% of these children were female while 51% of them were male.
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Study Result: They included 1,466 subjects who had a skeletal survey performed due to concern for abuse initially. Out of these total numbers, 5 were excluded for healing skeletal survey performed more than seven days after presentation while 1,361 subjects had no healing fracture leaving only 100 subjects with a healing fracture on their skeletal survey. Out of these 100 subjects, 23 were excluded since they had non-physical abuse related fracture i.e., 77 subjects have a healing fracture on radiology assessment and diagnosis of abuse by the child protective team consensus and were eligible for chart review.
Out of 77 subjects 37 (48%) had previous visits, 16 (20%) had two or more previous visits and 27 (33%) had one missed previous visits. This study suggested that 43% of subjects
presented with signs related to trauma or for the history of trauma (20%), 10% had a nonspecific presentation, 9% were referred for evaluation, 9% had an apparent life-threatening event, 8% had a seizure while 1% had increased occipitofrontal head circumference. Based on dermatologic or skin evaluation, 74% had signs of skin trauma, 33% had skin bruises, 27% had swelling, 9% had combined swelling and bruising while 5% had epistaxis, torn frenulum, palpable chest-wall crepitus and mouth bleeding. These findings suggested that good history is taking and physical examination might prevent repeat exposure of a child to abusive injury which will subsequently prevent morbidity and mortality associated with physical abuse.
Study Limitation/Strength: There are various strengths of this study that include the use of PSS 19.0 for all data analysis, the use of kappa statistic to assess interrater reliability to determine missed or unrelated previous visit, this value was 0.94 which strongly correlates with the 95% confidence interval used and P value less than 0.05.
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The following are the limitations of this study: due to retrospective data collection, data extractor was used to assess some variables such as the reason for presentation at a previous visit that could cause bias in classifying previous visits as either missed or unrelated. There was also missing data from the previous visit with an increased likelihood of underestimating missed previous visits.
Menoch M, Zimmerman S, Garcia-Filion P, Bulloch B. Child abuse education: An objective evaluation of resident and attending physician knowledge. Pediatr Emerg Care. 2011;27(10):937-940.
Study Description: This study was carried out over a 3-month period (July-September, 2008) among pediatric residents, pediatric faculty and pediatric emergency medicine faculty in an urban, tertiary care facility to evaluate their medical knowledge of child abuse and maltreatment by survey administration by a convenient sampling of the population listed. Survey was sent out initially electronically via email, and the hard copy was later distributed among clinicians during conferences two months later. This survey consists of thirty questions developed by the hospital forensic department medical director and screened by two clinicians who are experienced in child abuse. They focused survey questions mainly on signs of physical and sexual abuse, dermatologic history, radiologic findings, abusive head trauma, risk factors for abuse,
mechanism of injury, etc. They also asked questions regarding previous education in child abuse, the question about resident’s level of training and clinician’s specialty. Hey scored answers to questions over 100% as either correct or incorrect such that a mean score of 67% will correspond to a score of 20 out of 30 questions.
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They stratified overall survey response into different categories (pediatric and medicine resident, pediatric resident, a general pediatrician and emergency medicine pediatrician) and score comparison across each stratum was done using Kruskal-Wallis test of equality of
population. The alpha level of 0.05 with 2 sided alternative hypotheses was deemed statistically significant, and they completed data analysis by Stata SE 8.0 (College Station, Tex).
Study Population: Pediatric residents, pediatric faculty and pediatric emergency medicine faculty in an urban, tertiary care facility.
Study Design: Cross-sectional study design.
Study Result: Out of 95 responders 61 (64.2) were residents, 18 (19%) were general
pediatricians, and 16 (16.8%) were pediatric emergency medicine physicians. Each question response was scored as either correct or incorrect with residents mean score of 60.4% (SD,12.9) with no difference in score based on resident’s year of training (P=0.076). Both general
pediatricians and pediatric emergency medicine physicians had a mean score of 66.7% (SD, 12.4) and 76.9% (SD, 9.1) (P=0.018) respectively. The difference in the knowledge of child abuse and neglect across physician categories was statistically significant with a P value of < 0.001). The overall mean score for this study was 63.3% (SD,13.8%) i.e., a score of 19 out of 30 questions which is less than the expected overall mean of 67% i.e., a score of 20 out of 30 indicating overall lack of clinician’s knowledge in child abuse supporting the need for child abuse education.
Study Limitation/Strength: The strength of this study is the use of Kruskal-Wallis test of equality of population to compare scores across each stratum of medical practice i.e., residents’ vs. practicing general pediatricians’ vs. pediatric emergency medicine physicians.
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Also, the difference in the knowledge of child abuse and neglect across physician categories was statistically significant with a P value of < 0.001).
The limitations of this study include lack of use of the consistent method to administer survey questions; some questions were answered via email with no 3rd party supervision hence giving responders time to look up answers to questions unlike the other group who completed hard copy survey, this might lead to response bias. This study was also carried out in a single academic institution therefore the result cannot be generalized to all settings.
Lane WG, Dubowitz H. Primary care pediatricians’ experience, comfort, and competence in the evaluation and management of child maltreatment: Do we need child abuse experts? Child Abuse Negl. 2009;33(2):76-83.
Study Description: This study was conducted among U.S. based pediatricians to assess their experience, comfort, and competence in evaluating and managing child maltreatment, rendering