How Should Clinicians and Health Care Organizations Promote Equity in Child Abuse and Neglect Suspicion, Evaluation, and Reporting?

Victims of child abuse and neglect come from every racial, ethnic, and socioeconomic background, yet clinical evaluation, reporting to child protective services, and responses to reports inequitably harm Black children and malign families of color. Racial bias and inequity in suspicion, reporting, and substantiation of abuse and neglect and in services offered and delivered, foster care placement, and criminal prosecution are widely documented. In response, clinicians and health care organizations should promote equity by educating clinicians about racial bias, standardizing evaluation using clinical decision support tools, and working with policy makers to support prevention services. If we decide that it is ethically justifiable for clinicians to err on the side of overreporting, we must ensure fair distribution of associated benefits and harms among all children and families.

Cost effectiveness of SEEK: A primary care-based child maltreatment prevention model.

BACKGROUND: Funding for prevention interventions is often quite limited. Cost-related assessments are important to best allocate prevention funds. OBJECTIVES: To determine the (1) overall cost for implementing the Safe Environment for Every Kid (SEEK) model, (2) cost of implementation per child, and (3) cost per case of maltreatment averted. DESIGN: Cost-effective analysis of a randomized controlled trial. PARTICIPANTS AND SETTING: 102 pediatric providers at 18 pediatric primary care practices. 924 families with children < 6 years receiving care by those providers. METHODS: Practices and their providers were randomized to either SEEK training and implementation or usual care. Families in SEEK and control practices were recruited for evaluation. Rates of psychological and physical abuse were calculated by parent self-report 12 months following recruitment. Model costs were calculated including salaries for team members, provider time for training and booster sessions, and development and distribution of materials. RESULTS: Implementing SEEK in all 18 practices would have cost approximately $265,892 over 2.5 years; $3.59 per child per year; or $305.58 ($229.18-$381.97) to prevent one incident. Based on a very conservative cost estimate of $2779 per maltreatment incident, SEEK would save an estimated $2,151,878 in health care costs for 29,610 children. CONCLUSIONS: The SEEK model is cost saving. Cost per case of psychological and physical abuse averted were significantly lower than the short-term costs of medical and mental health care for maltreated children. SEEK model expansion has the potential to significantly decrease medical, mental health, and other related costs associated with maltreatment.

Social determinants of health, personalized medicine, and child maltreatment.

This review begins with a brief summary of the importance of child maltreatment as a major public health problem, given its prevalence and the substantial human and economic costs involved. The focus then shifts to consideration of personalized medicine and child maltreatment, including genetic and genomics factors, as well as the role of social determinants of health. Research on epigenetics related to child abuse and neglect is presented, followed by that pertaining to a few specific social factors, such as poverty, parental depression and substance use, and domestic (or intimate partner) violence. The review ends with a discussion of interventions to help address social determinants of health with brief descriptions of several model programs, and thoughts concerning the role of personalized medicine in addressing child maltreatment in the foreseeable future. IMPACT: This paper synthesizes knowledge on social determinants of health and advances in genetics and genomics related to the prevention of child maltreatment. It provides examples of model approaches to addressing the prevention of child maltreatment in primary care practices.

Psychosocial Factors Associated with Healthy and Unhealthy Interpregnancy Intervals.

Purpose: To examine the influence of psychosocial factors, including anxiety, depression, social support, maternal substance abuse, and intimate partner violence (IPV) on interpregnancy intervals (IPIs). Methods: B'more for Healthy Babies-Upton/Druid Heights is part of a citywide initiative to improve the health of at-risk pregnant women and their children. Participants with at least one prior birth completed baseline, postpartum, and 3-month follow-up surveys with questions about pregnancy, medical, and psychosocial history. Associations between IPI and the independent variables were assessed using chi-square analysis and analysis of variance. Multivariable multinomial logistic regression models examined significant associations while controlling for other independent variables and potential confounders. Results: Participants with current IPV were more likely to have a short IPI (odds ratio [OR]=13.1; 95% confidence interval [CI]=1.07-158.9; p=0.04) than healthy IPI. Women with family social support were more likely to have a healthy IPI (OR=5.88, 95% CI=1.02-31.25, p=0.05) than those without family social support. Maternal anxiety and depression did not significantly influence IPI. Conclusion: IPV increased the likelihood of having an unhealthy IPI among this population and family social support increased the likelihood of having a healthy IPI. Additional efforts to address IPV and enhance family social support may lead to improved pregnancy outcomes.

Communities, Social Justice, and Academic Health Centers.

In November 2015, the Association of American Medical Colleges (AAMC) held its annual meeting in Baltimore, Maryland. In response both to health and health care inequities faced by residents of Baltimore and to the imminent trial of the police officers charged with Freddie Gray's death, AAMC leaders thought it crucial to address issues of health inequity, social injustice, and the role an academic health center (AHC) can play in improving the health of the community it serves. In collaboration with community-engaged researchers from Johns Hopkins University and University of Maryland, Baltimore, AAMC staff interviewed Baltimore residents, soliciting their perspectives on how medical education, clinical care, and research can and should respond to social injustice and the social determinants of health. The authors used the resulting videoed interviews to frame a conversation during the annual meeting aimed at developing concrete actions that an individual, an institution, or the AAMC can take to address social injustice and health inequities in the Baltimore community and beyond. The robust conversation and the action steps identified by participants led to the development of a toolkit to build the capacity of AHCs and their communities to engage in similar, action-oriented programming. The success of the conversation inspired future meeting sessions that purposefully incorporate community voices and expertise. This Perspective presents results of this action planning and places the proposed set of activities within the current health care context to demonstrate how community expertise and wisdom can inform and advance efforts to improve the health of all.

The effects of health care-based violence intervention programs on injury recidivism and costs: A systematic review.

BACKGROUND: Youth violence affects thousands annually, with homicide being the third leading cause of death for those aged 10 to 24 years. This systematic review aims to evaluate the published evidence for the effects of health care-based violence intervention programs (VIPs), which focus on reducing recurrent presentations for injury due to youth violence ("recidivism"). METHODS: Health literature databases were searched. Studies were retained if peer reviewed and if programs were health care based, focused on intentional injury, addressed secondary or tertiary prevention (i.e., preventing recidivism and reducing complications), included participants aged 14 to 25 years, had greater than 1-month follow-up, and evaluated outcomes. Studies of child and sexual abuse and workplace, intimate partner, and self-inflicted violence were excluded. Extracted data subject to qualitative analysis included enrollment and retention, duration of follow-up, services provided, statistical analysis, and primary and intermediate outcomes. RESULTS: Of the 2,144 citations identified, 22 studies were included in the final sample. Twelve studies were randomized controlled trials representing eight VIPs. Injury recidivism was assessed in six (75%) of eight programs with a significant reduction in one (17%) of six programs. Of the randomized controlled trials showing no difference in recidivism, all were either underpowered or did not include a power analysis. Two observational studies also showed significant reduction in recidivism. Significant intermediate outcomes included increased service use, attitude change, and decreases in violence-related behavior. Reductions in injury recidivism led to reductions in health care and criminal justice system costs. CONCLUSIONS: Three studies showing reduced injury recidivism and several studies showing positive intermediate outcomes identify VIPs as a promising practice. Many studies were limited by poor methodological quality, including high losses to follow-up. LEVEL OF EVIDENCE: Systematic review, level III.

Examination of the Comorbidity of Mental Illness and Somatic Conditions in Hospitalized Children in the United States Using the Kids' Inpatient Database, 2009.

OBJECTIVE: To examine the associations between mental and physical illness in hospitalized children. METHODS: The data for this analysis came from the 2009 Kids' Inpatient Database (KID). Any child with an International Classification of Diseases, Ninth Revision code indicative of depressive, anxiety, or bipolar disorders or a diagnosis of sickle cell disease, diabetes mellitus type 1 or 2, asthma, or attention-deficit/hyperactivity disorder (ADHD) were included. Using SAS software, we performed χ(2) tests and multivariable logistic regression to determine degrees of association. RESULTS: Children discharged with sickle cell disease, asthma, diabetes mellitus type 1, diabetes mellitus type 2, and ADHD were 0.94, 2.76, 3.50, 6.37, and 38.39 times more likely to have a comorbid anxiety, depression, or bipolar disorder diagnosis than other hospitalized children, respectively. CONCLUSIONS: Children with several chronic physical illnesses (asthma, diabetes mellitus type 1, diabetes mellitus type 2) and mental illnesses (ADHD) have higher odds of being discharged from the hospital with a comorbid mood or anxiety disorder compared with other children discharged from the hospital. It is therefore important to screen children hospitalized with chronic medical conditions for comorbid mental illness to ensure optimal clinical care, to improve overall health and long-term outcomes for these children.

Transforming the healthcare response to intimate partner violence and taking best practices to scale.

BACKGROUND: Intimate partner violence (IPV) is prevalent among adolescent and adult women, with significant physical, sexual, and mental health consequences. In 2011, the Institute of Medicine's Clinical Preventive Services for Women consensus report recommended universal screening for violence as a component of women's preventive services; this policy has been adopted by the Health Resources and Services Administration (HRSA). These policy developments require that effective clinic-based interventions be identified, easily implemented, and taken to scale. METHODS: To foster dialogue about implementing effective interventions, we convened a symposium entitled "Responding to Violence Against Women: Emerging Evidence, Implementation Science, and Innovative Interventions," on May 21, 2012. Drawing on multidisciplinary expertise, the agenda integrated data on the prevalence and health impact of IPV violence, with an overview of the implementation science framework, and a panel of innovative IPV screening interventions. Recommendations were generated for developing, testing, and implementing clinic-based interventions to reduce violence and mitigate its health impact. RESULTS: The strength of evidence supporting specific IPV screening interventions has improved, but the optimal implementation and dissemination strategies are not clear. Implementation science, which seeks to close the evidence to program gap, is a useful framework for improving screening and intervention uptake and ensuring the translation of research findings into routine practice. CONCLUSIONS: Findings have substantial relevance to the broader research, clinical, and practitioner community. Our conference proceedings fill a timely gap in knowledge by informing practitioners as they strive to implement universal IPV screening and guiding researchers as they evaluate the success of implementing IPV interventions to improve women's health and well-being.

The SEEK model of pediatric primary care: can child maltreatment be prevented in a low-risk population?

OBJECTIVE: To examine the effectiveness of the Safe Environment for Every Kid (SEEK) model of enhanced pediatric primary care to help reduce child maltreatment in a relatively low-risk population. METHODS: A total of 18 pediatric practices were assigned to intervention or control groups, and 1119 mothers of children ages 0 to 5 years were recruited to help evaluate SEEK by completing assessments initially and after 6 and 12 months. Children's medical records and Child Protective Services data were reviewed. The SEEK model included training health professionals to address targeted risk factors (eg, maternal depression), the Parent Screening Questionnaire, parent handouts, and a social worker. Maltreatment was assessed 3 ways: 1) maternal self-report, 2) children's medical records, and 3) Child Protective Services reports. RESULTS: In the initial and 12-month assessments, SEEK mothers reported less Psychological Aggression than controls (initial effect size = -0.16, 95% confidence interval [95% CI] -0.27, -0.05, P = .006; 12-month effect size = -0.12, 95% CI -0.24, -0.002, P = .047). Similarly, SEEK mothers reported fewer Minor Physical Assaults than controls (initial effect size = -0.16, 95% CI -0.29, -0.03, P = .019; 12-month effect size = -0.14, 95% CI -0.28, -0.005, P = .043). There were trends in the same positive direction at 6 months, albeit not statistically significant. There were few instances of maltreatment documented in the medical records and few Child Protective Services reports. CONCLUSIONS: The SEEK model was associated with reduced maternal Psychological Aggression and Minor Physical Assaults. Although such experiences may not be reported to protective services, ample evidence indicates their potential harm. SEEK offers a promising and practical enhancement of pediatric primary care.

The safe environment for every kid model: impact on pediatric primary care professionals.

OBJECTIVE: To examine whether the Safe Environment for Every Kid (SEEK) model of enhanced primary care would improve the attitudes, knowledge, comfort, competence, and behavior of child health care professionals (HPs) regarding addressing major risk factors for child maltreatment (CM). METHODS: In a cluster randomized controlled trial, 18 private practices were assigned to intervention (SEEK) or control groups. SEEK HPs received training on CM risk factors (eg, maternal depression). The SEEK model included the parent screening questionnaire and the participation of a social worker. SEEK's impact was evaluated in 3 ways: (1) the health professional questionnaire (HPQ), which assessed HPs' attitudes and practice regarding the targeted problems; (2) observations of HPs conducting checkups; and (3) review of children's medical records. RESULTS: The 102 HPs averaged 45 years of age; 68% were female, and 74% were in suburban practices. Comparing baseline scores with 6-, 18-, and 36-month follow-up data, the HPQ revealed significant (P < .05) improvement in the SEEK group compared with controls on addressing depression (6 months), substance abuse (18 months), intimate partner violence (6 and 18 months), and stress (6, 18, and 36 months), and in their comfort level and perceived competence (both at 6, 18, and 36 months). SEEK HPs screened for targeted problems more often than did controls based on observations 24 months after the initial training and the medical records (P < .001). CONCLUSIONS: The SEEK model led to significant and sustained improvement in several areas. This is a crucial first step in helping HPs address major psychosocial problems that confront many families. SEEK offers a modest yet promising enhancement of primary care.

Primary care pediatricians' experience, comfort and competence in the evaluation and management of child maltreatment: do we need child abuse experts?

OBJECTIVE: We assessed the self-reported experience, comfort and competence of primary care pediatricians in evaluating and managing child maltreatment (CM), in rendering opinions regarding the likelihood of CM, and in providing court testimony. We examined pediatricians' need for expert consultation when evaluating possible maltreatment. METHODS: A questionnaire was mailed to 520 randomly selected AAP members. Pediatricians were asked how frequently they evaluated and reported children for suspected maltreatment, and whether child abuse pediatricians were available to and used by them. Pediatricians were asked to rate their knowledge, comfort and competence in the management of CM. Demographic information was also gathered. Pediatricians' experience with CM, their comfort, self-reported competence, and need for expert assistance is described. Logistic regression was used to assess factors that predicted pediatricians' sense of competence while controlling for covariates found to be significant in bivariate analyses. RESULTS: One hundred forty-seven questionnaires were eligible for analysis. The majority of respondents had little experience evaluating and reporting suspected CM, and was interested in having expert consultation. While pediatricians often felt competent in conducting medical exams for suspected maltreatment, they felt less competent in rendering a definitive opinion, and did not generally feel competent to testify in court. Sense of competence was particularly low for sexual abuse. Increased practice experience and more courses in CM led to increased sense of competence in some areas. CONCLUSIONS: Pediatricians acknowledged many limitations to providing care to maltreated children, and expressed interest in subspecialist input. PRACTICE IMPLICATIONS: These findings add additional support to the American Board of Pediatrics' decision to create a Child Abuse Pediatrics subspecialty. The findings also indicate a need to ensure funding for fellowship training programs in this field.

Screening for parental substance abuse in pediatric primary care.

OBJECTIVE: Parental alcohol and drug abuse may have significant deleterious effects on children. Although screening in the pediatric office is recommended, few screening measures have been evaluated for use in this setting. We sought to validate a 2-question screening tool for parental substance abuse. METHODS: A total of 216 caregivers bringing children to a primary care clinic completed a brief screening for psychosocial problems that contained 2 substance abuse questions. To assess reliability and validity of the questionnaire, recruited caregivers returned within 2 months to complete a computerized study protocol that contained the brief screening questions and the substance abuse sections of the Composite International Diagnostic Inventory (CIDI). RESULTS: Sixteen percent of caregivers acknowledged a problem with drugs or alcohol on the CIDI. A "yes" response to either screening question had a sensitivity of 29%, specificity of 95%, positive predictive value of 17%, and negative predictive value of 98% for drug abuse. Values were 13%, 96%, 33%, and 87%, respectively for predicting alcohol abuse. CONCLUSIONS: Brief screening in pediatric primary care can identify many, but not all, parents who may need intervention for problems with drugs and/or alcohol. Children should benefit from such screening if it enables parents to acknowledge and receive treatment for substance abuse. Further research is needed to assess whether sensitivity of screening can be improved without sacrificing brevity.

Update on child abuse prevention.

PURPOSE OF REVIEW: Child abuse remains a significant problem in the United States with 2.9 million reports and 825 000 indicated cases in 2005. This report will highlight recent efforts toward child abuse prevention, focusing on home visiting programs, abusive head trauma primary prevention, parent training programs, sexual abuse prevention, and the effectiveness of laws banning corporal punishment. RECENT FINDINGS: Most home visitation programs have demonstrated a lack of effectiveness in recent randomized trials. One exception is the Nurse Family Partnership, which remains the most effective and longest enduring intervention for high-risk families. Child sexual abuse prevention programs and parent training programs need further evaluation with more rigorous methodology and outcome measures. Providing universal parent education about coping with crying infants appears to be effective in lowering the incidence of abusive head trauma. Although advocated for, further study will determine the effectiveness of laws banning corporal punishment or mandating abusive head trauma education to parents of newborns. SUMMARY: Pediatricians play an important role in the prevention of child maltreatment. Their knowledge of the effectiveness of different programs can help guide parents toward appropriate services.

What factors affect the identification and reporting of child abuse-related fractures?

Child abuse is a serious problem in the United States. Because orthopaedic surgeons are responsible for identifying and reporting suspicious fractures to child protective services, we asked two primary questions: (1) How skilled are orthopaedists in distinguishing abuse-related from noninflicted fractures and making appropriate child protective services reports?; and (2) Are decisions influenced by orthopaedist training or by the race or socioeconomic status of injured children? We developed and mailed a questionnaire containing 10 case vignettes to 974 US orthopaedists. Respondents assessed the likelihood of abuse and need to report to child protective services. Two versions of the questionnaire differed by the race and socioeconomic status of vignette families. Average respondent scores were 79% for correct diagnoses and 73% for correct reporting decisions. Pediatric orthopaedists had higher adjusted scores for identifying abuse-related versus noninflicted injuries (82% versus 73%) and for appropriately reporting to child protective services (76% versus 66%) compared with general orthopaedists. Both groups had difficulty distinguishing abuse-related from noninflicted long-bone fractures in infants and toddlers. We found no differences in appropriate identification or reporting of fractures by race but did find differences by social class. Additional training in identifying abuse-related long-bone fractures appears necessary. Orthopaedists should consider the potential for bias when assessing children with fractures for possible abuse.

Disparities in the circumstances of asthma deaths in Maryland.

The reasons for significant disparities in asthma mortality are unclear. Maryland vital statistics and medical examiner data were used to examine timing, location, and circumstances of asthma deaths. We found that unexplained deaths increased substantially over the past 10 years and that young, male, and black asthmatics were more likely to die before hospital admission. Factors contributing to disparities included better availability of anti-inflammatory medications among whites versus blacks, and a higher incidence of positive toxicology screens among males versus females. Disparities in asthma mortality might be reduced through efforts to optimize asthma treatment and reduce illicit drug use.

Racial differences in the evaluation of pediatric fractures for physical abuse.

CONTEXT: Child maltreatment is a significant problem within US society, and minority children have higher rates of substantiated maltreatment than do white children. However, it is unclear whether minority children are abused more frequently than whites or whether their cases are more likely to be reported. OBJECTIVES: To determine whether there are racial differences in the evaluation and Child Protective Services (CPS) reporting of young children hospitalized for fractures. DESIGN, SETTING, AND PATIENTS: Retrospective chart review conducted at an urban US academic children's hospital among 388 children younger than 3 years hospitalized for treatment of an acute primary skull or long-bone fracture between 1994 and 2000. Children with perpetrator-admitted child abuse, metabolic bone disease, birth trauma, or injury caused by vehicular crash were excluded. MAIN OUTCOME MEASURES: Ordering of skeletal surveys and filing reports of suspected abuse. RESULTS: Reports of suspected abuse were filed for 22.5% of white and 52.9% of minority children (P<.001). Abusive injuries, as determined by expert review, were more common among minority children than among white children (27.6% vs 12.5%; P<.001). Minority children aged at least 12 months to 3 years (toddlers) were significantly more likely to have a skeletal survey performed compared with their white counterparts, even after controlling for insurance status, independent expert determination of likelihood of abuse, and appropriateness of performing a skeletal survey (adjusted odds ratio [OR], 8.75; 95% confidence interval [CI], 3.48-22.03; P<.001). This group of children was also more likely to be reported to CPS compared with white toddlers, even after controlling for insurance status and likelihood of abuse (adjusted OR, 4.32; 95% CI, 1.63-11.43; P =.003). By likelihood of abuse, differential ordering of skeletal surveys and reporting of suspected abuse were most pronounced for children at least 12 months old with accidental injuries; however, differences were also noted among toddlers with indeterminate injuries but not among infants or toddlers with abusive injuries. Minority children at least 12 months old with accidental injuries were more than 3 times more likely than their white counterparts to be reported for suspected abuse (for children with Medicaid or no insurance, relative risk [RR], 3.08; 95% CI, 1.37-4.80; for children with private insurance, RR, 3.74; 95% CI, 1.46-6.01). CONCLUSION: While minority children had higher rates of abusive fractures in our sample, they were also more likely to be evaluated and reported for suspected abuse, even after controlling for the likelihood of abusive injury. This suggests that racial differences do exist in the evaluation and reporting of pediatric fractures for child abuse, particularly in toddlers with accidental injuries.

Child sexual abuse evaluations: adherence to recommendations.

Sixty-eight parents of children with alleged child sexual abuse (CSA) were surveyed 4 months after visiting an interdisciplinary CSA evaluation clinic in order to examine the extent to which recommendations were recalled and implemented. Of those parents for whom specific recommendations were provided, 9% recalled recommendations for medical follow-up, 79% recalled recommendations for child therapy, and 43% recalled recommendations for parental therapy. Families were more likely to receive and adhere to recommendations when there were behavioral problems and a strong indication of CSA. To improve communication with families, the reasons for recommendations must be clearly conveyed, and possible barriers to implementation should be anticipated and addressed. In addition, recommendations need to be realistic, and professionals need to facilitate the implementation of their treatment plan.