Improving the clinical assessment of acute presentations of child maltreatment using a quality and child rights framework Dr Paul Hotton Vulnerable Child Fellow at Liverpool Hospital South Western Sydney Local Health District Dual Trainee in Community Child Health and General Paediatrics Dr Shanti Raman Community Paediatrician: Child Protection South Western Sydney Local Health District
Child Maltreatment (CM) Major public health & social-welfare problem CM associated with: Child health/developmental problems Adult mortality and morbidity (cf ACE) Strong evidence-base for medical examination in the assessment of CM. Little known about the health & social outcomes for children following assessment for acute CM.
Why Clinical Assessments for CM are Important Children at risk of abuse/neglect: utilize health services +++ Frontline health services (Emergency Dept. & Paediatrics) Not ideal venues for acute CM assessments Screening tools for ED poor evidence base Good evidence for comprehensive clinical assessment Clinical guidelines exist for acute CM assessment Identifies health & supports for vulnerable children
South Western Sydney Local Health District (SWSLHD) Area of 6,243 square km Population 919,787 rapidly growing Culturally & Linguistically diverse Many sub-populations with social risk: Small & disadvantaged Aboriginal population Newly arriving migrants/refugees
Acute CM Assessments in SWS Unique service Population & Community responsive Community Paediatrics Sexual Assault (SA) Services Not a tertiary Paediatric Hospital Service Joint Work Collaboration Committed to Child & Family focussed assessment / management Hospital Social Work General Paediatrics
Previous Study Addressing Clinical Assessments for CM CM in 2 5 % of Paediatric ED presentations Gaps & good local practice Identified minimum standards for clinical assessment
Minimum Standards
Aims of the Study 1. Describe acute presentations of CM in SWS, to one unique hospital service, during 2013-2014 2. Identify health & social outcomes for children following medical assessment Support or Refute Allegations of CM Identify support and intervention needs 3. Determine if the cases fulfil established minimal standards for clinical assessment of CM. 4. Identify if acute assessments supports a child rights framework
Methods Gathered data from Acute Child Protection Database (Community Paediatrics & SA) For all referrals for acute assessment <16 yrs, between 1st January 2013-31st December 2014. Performed simple descriptive analysis on clinical data. To identify Health / Social Outcomes To identify if MS attained and children s rights upheld
What Minimum Standards?
Findings Types of CM 204 cases referred 187 assessed 17 were phone consultations (4 SA & 13 PA) TYPE OF CM NUMBER PERCENTAGE Physical Assault (PA) 18 9 % PA + Other CM (excluding SA) 17 8 % Sexual Assault (SA) 74 36 % SA + other CM including PA 70 34 % Neglect 2 1 % Review of Sibling of Index case 6 3 %
Demographics Age & Gender AGE GENDER 8.1 3 1 Type Mean Age Range SA 9 1 16 yrs. NON SA 4.7 3wk 13yr TYPE FEMALE MALE SA 85% 15% NON SA 36% 64%
Demographics Ethnicity 35 30 25 20 15 10 5 0 TOTAL % SA % NON SA % Area Indigenous Born Overseas Middle East Europe Asian SWS 1.7 % 32.7% 15% 8% 12% NSW 2.5 % 34.2% - 8% - Census Date 2011
Who Referred? 9% 8% 2% Joint Investigation Response Team (JIRT) Police Emergency 10% Community Services (CS) 12% 59% Paediatricians Other
Who Assessed? 2% 3% 7% 16% Community Paediatrics (CP) Joint Assessment (CP/SA) Sexual Assault (SA) 26% Phone consultation SA 46% General Paediatricians + Comm Paeds advice Phone consultation CP
Types of Examination Done SA : n 148 NON SA : n 39 Forensic Medical Refused Forensic Medical 6% 47% 46% 47% 54%
Outcome of SA Assessments OUTCOME Number (n = 148) No SA issues 29 20 No SA, other CM concerns 10 7 SA - no injury, CM concerns 21 14 SA - no injury 43 29 SA injury documented 10 7 SA - confirmed 26 17 Refused Medical assessment 9 6 %
Outcome of Non SA Assessments OUTCOME Number (n = 39) No Injury 3 8 Accident 8 20 Unclear 4 10 Inflicted injury 21 54 Other CM 3 8 %
Outcomes Social & Family 51 % home with no Child Protection agency involvement 17 % home with Child Protection agency involvement 28 % were placed into Out of Home Care (OOHC) Some already removed before assessment 46% of Non SA were placed into OOCH Large proportion had JIRT (Forensic) Investigation Majority unknown outcome 15 % of case Person of Interest charged
More Than Just a CM Assessment 58 % of CM assessments lead to other health concerns: Chronic Medical Conditions Developmental Delays Dental Cavities Hearing and Vision concerns Behavioural issues School Difficulties Mental Health concerns Joint assessments: Better identification of health concerns
Minimum Standards Achieved? MINIMAL STANDARDS (MS) Results % Trained Doctors 187 / 187 100 Social Worker present 179 / 187 95 Protocol used 186 /187 99.5 Report generated 170 / 187 91 Report Counter signed 170 / 170 100 Report in the Medical Records 170 / 170 100 Medical follow up assessment 82 / 187 44 Psychosocial follow up 80 / 187 43
Is the Child in Mind? Timing : Mean length 1.6 days (longest 22 SA; 27 - PA) After hours 72% 28% 96 % of Out of Hours: SA OUT of HOURS IN HOURS Child accompanied by: 54% 10% 32% 4% No Carer Support person Long Term Carer Relative
Discussion Types of CM 70% Acute referral SA related 42% had >2 or more CM issues 17% of cases referred had no CM concerns Largely due to overcalling SA cases Neglect 1% of cases Other pathways for referrals and assessments Hard to determine Mounting evidence that Neglect can be most damaging
Discussion Girls higher risk of CM 75% compare to 25% Majority are SA Reflects published data Ethnicity breakdown Incompletely documented for SA only Aboriginal over representation Siblings 3% of siblings reviewed as a result of CM in another sibling SWS has alternative pathways/clinics
Discussion Health concerns identified in many Reflects growing international evidence Identification improved with joint / collaborative assessment Social Outcomes Unsure if acute assessments make a difference Minimum Standards Overwhelmingly achieved but Only 44 % had medical follow up Child Rights 28 % occurred out of hours Forensic need 32 % occurred with no carer/support person
Conclusion First study of its kind describing acute CM presentations Minimum standards for CM assessment fulfilled in most Improvements needed in follow up after acute assessment Better identification of neglect essential Difficult to determine how child rights promoting this service is
REFERENCES Arora N, Kaltner M, Williams J. Health needs of regional Australian Children in Out of Home Care. Journal of Paediatrics and Child Health. (2014); 50, 782 786. Chang, David C., Vinita Knight, Susan Ziegfeld, Adil Haider, Dawn Warfield, and Charles Paidas. The Tip of the Iceberg for Child Abuse: The Critical Roles of the Pediatric Trauma Service and Its Registry. Journal of Trauma 57 (2004): 1189 98. Cuijpers, Pim, Filip Smit, Froukje Unger, Yvonne Stikkelbroek, Margreet ten Have, and Ron de Graaf. The Disease Burden of Childhood Adversities in Adults: A Population-Based Study. Child Abuse & Neglect 35 (2011): 937 45. Fang, Xiangming, et al. The Economic Burden of Child Maltreatment in the United States and Implications for Prevention. Child Abuse & Neglect 36 (2012): 156 65. Gilbert, Ruth, et all. Burden and Consequences of Child Maltreatment in High-Income Countries. The Lancet 373 (2009): 68 81. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of(ace) study. Am J Prev Med 1998;14(4):245 58. Gilbert R et al. Child Maltreatment 2; Recognising and Responding to Child Maltreatment. The Lancet. (2009); 373, 167-180 King, Wendalyn K., Eric L. Kiesel, and Harold K. Simon. Child Abuse Fatalities: Are We Missing Opportunities for Intervention? Pediatric Emergency Care 22 (2006): 211 14. Raman S, Hodes D. Cultural Issues in Child Maltreatment. Journal of Paediatrics and Child Health. (2012). 48; 30-37. Raman S, Maiese M, Hurley K, Greenfield D. Addressing the Clinical Burden of Child Physical Abuse and Neglect in a Large Metropolitan Region: Improving the Evidence-Base Social Sciences 3 (2014): 771 784 Saunder J, Blyth F, Kelly A. Child Abuse: A Family Issues Are we adequately assessing siblings of index child abuse cases? Archives of Disease in Childhood. (2014); 99, 77-78 Ziegler, David S., John Sammut, and Anne C. Piper. Assessment and Follow-up of Suspected Child Abuse in Preschool Children with Fractures Seen in a General Hospital Emergency Department. Journal of Paediatrics and Child Health 41 (2005): 251 55
Acknowledgement Cath Dunn Acting Manager of Sexual Assault Services, South Western Sydney Local Health District Rosemary Isaac Director of Sexual Assault Services, South Western Sydney Local Health District Chris Holstein Administrator of Sexual Assault Services, South Western Sydney Local Health District