Data resource profile: the Edinburgh Child Protection Dataset - a new linked administrative data source of children referred to Child Protection paediatric services in Edinburgh, Scotland.

Introduction: Child maltreatment affects a substantial number of children. However current evidence relies on either longitudinal studies, which are complex and resource-intensive, or linked data studies based on social services data, which is arguably the tip of the iceberg in terms of children who are maltreated. Reliable, linked, population-level data on children referred to services due to suspected abuse or neglect will increase our ability to examine risk factors for, and outcomes following, abuse and neglect. Objective: The objective of this project was to create a linkable population level dataset, The Edinburgh Child Protection Dataset (ECPD), comprising all children referred to the Edinburgh Child Protection Paediatric healthcare team due to a concern about their welfare between 1995 and 2015. Methods: The paper presents the process for creating the dataset. The analyses provide examples of available data from the main referrals dataset between 1995 and 2011 (where data quality was highest). Results: 19,969 referrals were captured, relating to 11,653 children. Of the 19,969 referrals, a higher proportion were girls (54%), although boys were referred for physical abuse more often than girls (41% versus 30%). Younger children were more likely to be referred for physical abuse (35% of 0-4 year olds vs. 27% 15+): older children were more likely to be referred for sexual abuse (48% of 15+ years vs. 18% of 0-4 years). Most referrals came from social workers (46%) or police (31%). Conclusions: The ECPD offers a unique insight into the characteristics of referrals to child protection paediatric services over a key period in the history of child protection in Scotland. It is hoped that by making these data available to researchers, and able to be easily linked with both mother and child current and future health records, evidence will be created to better support maltreated children and monitor changes over time.

Maltreatment or violence-related injury in children and adolescents admitted to the NHS: comparison of trends in England and Scotland between 2005 and 2011.

OBJECTIVE: Legislation to safeguard children from maltreatment by carers or violence by others was advanced in England and Scotland around 2004-2005 and resulted in different policies and services. We examined whether subsequent trends in injury admissions to hospital related to maltreatment or violence varied between the two countries. SETTING AND PARTICIPANTS: We analysed rates of all unplanned injury admission to National Health Service (NHS) hospitals in England and Scotland between 2005 and 2011 for children and adolescents aged less than 19 years. OUTCOMES: We compared incidence trends for maltreatment or violence-related (MVR) injury and adjusted rate differences between 2005 and 2011 using Poisson or negative binomial regression models to adjust for seasonal effects and secular trends in non-MVR injury. Infants, children 1-10 years and adolescents 11-18 years were analysed separately. RESULTS: In 2005, MVR rates were similar in England and Scotland for infants and 1-10-year-olds, but almost twice as high in Scotland for 11-18-year-olds. MVR rates for infants increased by similar amounts in both countries, in line with rising non-MVR rates in England but contrary to declines in Scotland. Among 1-10-year-olds, MVR rates increased in England and declined in Scotland, in line with increasing non-MVR rates in England and declining rates in Scotland. Among 11-18-year-olds, MVR rates declined more steeply in Scotland than in England along with declines in non-MVR trends. CONCLUSIONS: Diverging trends in England and Scotland may reflect true changes in the occurrence of MVR injury or differences in the way services recognise and respond to these children, record such injuries or a combination of these factors. Further linkage of data from surveys and services for child maltreatment and violence could help distinguish the impact of policies.

Child protection medical assessments: why do we do them?

INTRODUCTION: Child protection guidelines highlight the importance of medical assessments for children suspected of having been abused. AIM: To identify how medical assessments might contribute to a diagnosis of child abuse and to the immediate outcome for the child. METHOD: Review of all notes pertaining to medical assessments between January 2002 and March 2006. RESULTS: There were 4549 child protection referrals during this period, of which 848 (19%) proceeded to a medical examination. 742 (88%) case notes were reviewed. Of the medical examinations, 383 (52%) were for alleged physical abuse, 267 (36%) for sexual abuse and 20 (3%) for neglect. 258 (67%) of the physical abuse cases were considered to have diagnostic or supportive findings as compared to 61 (23%) of the sexual abuse cases (chi2=146.31, p<0.001). In diagnostic or supportive examinations or where other potentially abusive concerns were identified, 366 (73%) proceeded to further multi-agency investigation and 190 (41%) to case conference. 131 (69%) of these resulted in the registration of the child on the child protection register. Other health concerns were identified in 121 (31%) of physical and 168 (63%) of sexual abuse cases. CONCLUSION: In this case series, 465 (63%) out of 742 examinations showed signs diagnostic or supportive of alleged abuse or highlighted other abusive concerns. This endorses the view that medical examination is an important component in the assessment of child abuse as it provides information to support or refute an allegation and helps to identify the health and welfare needs of vulnerable children.

Non-accidental injury in children--an update.

The abuse of children is a universal problem. It affects children from all social classes, racial and religious groups. Child abuse involves acts of commission or omission which directly or indirectly result in harm to the child and prevent a normal development into healthy adulthood. Those responsible may be members of a family, a community or an institution. The prevalence of child abuse and neglect is difficult to measure since events tend to be unreported because they happen behind closed doors. The majority of children who have been physically abused present with soft tissue injuries, thermal injuries and fractures. This article is focused on the physical abuse of children with particular emphasis on fractures.

Incidence and demography of non-accidental head injury in southeast Scotland from a national database.

BACKGROUND: This study utilized an existing national database of cases of non-accidental head injury (NAHI; also called inflicted traumatic brain injury [inflicted TBI] and shaken baby syndrome [SBS]) in Scotland to report the incidence, confidence intervals, and demography of such cases in Southeast Scotland. METHODS: This prospective population-based study was conducted from January 1998 to September 2006. Data from the Lothian region of Scotland, where there is known full ascertainment of infant head injuries, including NAHI, have been used to calculate the incidence rate for this region of Scotland, with government statistics providing the normal annual infant population as the denominator. A new Scottish Index of Multiple Deprivation (SIMD), which assesses a very focused area (data zone population size=750) and provides novel information about social demography for education, housing, employment, health, crime, income, and geographic accessibility to services, was applied to the identified cases of NAHI during this study period. RESULTS: The mean incidence of NAHI in southeast Scotland for 8.75 years was 33.8/100,000 infants per year. The cases of NAHI were mostly located in the lowest 1 (or 2) quintiles for all SIMD domains (education, housing, employment, health, crime, income), although they had good accessibility to medical and other community services. CONCLUSIONS: The incidence rates from this prospective study for NAHI are considerably higher than other published UK surveys and are not considered to reflect a cluster effect. The perpetrators in this study fit a strongly skewed profile aggregating to the lowest socioeconomic groups in the community.

Epidemiology of oronasal hemorrhage in the first 2 years of life: implications for child protection.

BACKGROUND: Epistaxis in childhood is common but unusual in the first years of life. Oronasal blood has been proposed as a marker of child abuse. METHODS: We performed a retrospective review of all hospital notes of children in the Lothian region of Scotland who were <2 years of age and in whom facial blood had been recorded over a 10-year period. RESULTS: There were 77,173 accident and emergency department attendances with 58,059 admissions during the 10-year study period in children <2 years of age; 16 cases of nose bleed and 3 cases of hemoptysis were recorded. All cases of hemoptysis were associated with significant bouts of coughing and respiratory infections. Epistaxis in 8 cases was associated with visible trauma and in 4 cases with thrombocytopenia (secondary to malignancy in 3). In 2 cases, an associated apparent life-threatening event was described, and in 2 cases there was a coincident upper respiratory tract infection. Review of previous and subsequent history suggested 7 cases of "accidental" injury that might have been caused by abuse. These cases are described here. All children who presented with this problem to the accident and emergency department had been admitted for observation or management. CONCLUSIONS: Epistaxis is rare in the accident and emergency department and hospital in the first 2 years of life and is often associated with injury or serious illness. The investigation of all cases should involve a pediatrician with expertise in child protection.

The epidemiology of fractures in children.

A retrospective study of all paediatric fractures presenting to hospital in Edinburgh, Scotland in 2000 was undertaken. It showed that the incidence of fractures was 20.2/1000/year and that 61% of children's fractures occurred in males. Analysis of paediatric fractures shows that there are six basic fracture distribution curves with six fractures showing a bimodal distribution but most having a unimodal distribution affecting younger or older children. The incidence of fractures increases with age with falls from below bed height (<1m) being the commonest cause of fracture. The majority of fractures in children involve the upper limb. Lower limb fractures are mainly caused by twisting injuries and road traffic accidents. The incidence of fractures in cyclists and pedestrians remains relatively high whereas the incidence in vehicle occupants is low suggesting that road safety programs have been successful. Similar programs should be instituted for young cyclists. The importance of accident prevention programmes in the home is also highlighted.

A retrospective case series of skeletal surveys in children with suspected non-accidental injury.

INTRODUCTION: The skeletal survey is widely used as the principal radiological investigation in suspected physical abuse of infants and young children. However, the evidence on which current guidelines are based is limited, especially for siblings of index cases. We conducted a retrospective study to describe the characteristics of children who underwent skeletal surveys for suspected non-accidental injury (NAI) in the Edinburgh area; to evaluate the diagnostic efficacy of skeletal surveys; and to identify any predictive factors that might guide clinical practice. METHODS: All skeletal surveys performed at the Royal Hospital for Sick Children in Edinburgh for suspected non-accidental injury between 1/1/99 and 31/12/03 were reviewed. RESULTS: Seventy-seven children underwent skeletal surveys for suspected NAI. Data were available for 76 (70 index cases and 6 siblings). Of the index cases, 17 (24%) skeletal surveys were positive, with a mean of 2.5 fractures per child (range 0-9). The age of positive cases ranged from 2 weeks to 36 months with the majority (14, 82%) being under 12 months of age. Nine (53%) were boys. In index children with positive results, indications for skeletal survey were head injury (skull fracture in 2, 12%; intracranial injury in 4,24%); skeletal fracture (excluding skull fracture) in 6 (35%) and bruising in 4 (24%). chi(2) analysis revealed no significant differences in age, sex or primary reason for skeletal survey between those with a negative and positive skeletal survey. Six skeletal surveys were performed on siblings of children with known or suspected NAI. The siblings' ages ranged from 1 to 36 months although 3 (50%) were under 12 months of age. One (17%) of the siblings' surveys (a twin) was positive. CONCLUSION: The age of a child (<12 months) and type of presenting injury (overt fracture or head injury) are factors which can help the clinician to decide whether or not to obtain a skeletal survey. There remains a lack of evidence for the effectiveness of skeletal survey in the siblings of index children. Guidelines for the process of repeating uncertain skeletal surveys are needed.

Early intervention service for non-abusing parents of victims of child sexual abuse: Pilot study.

BACKGROUND: Childhood sexual abuse is a non-specific risk factor for psychopathological disorders in childhood and later life. The response of non-abusing parents to disclosure of abuse may influence the child's outcome. Aims To assess the level of psychopathological symptoms in parents and children following disclosure of sexual abuse and the changes following a parental treatment intervention. METHOD: Parents completed standardised rating scales about their own and their child's symptoms. These were repeated following the intervention. RESULTS: Thirty-nine parents of 31 children completed scales at the baseline assessment; 18 repeated these following interventions. Initially, parents reported high rates of psychopathological symptoms in themselves and their children, which were reduced following the intervention. CONCLUSIONS: This study confirms the high rates of psychopathological symptoms found in parents of children following disclosure of sexual abuse. Children clinically identified for intervention had higher measured levels of psychopathological symptoms. Targeted treatment interventions are needed.

Older children and adolescents surviving with vertically acquired HIV infection.

This article describes the characteristics of children infected vertically with HIV surviving 10 years or more who were enrolled in the prospective European Collaborative Study. Thirty-four of 187 infected children were identified with a median age of 11.4 years (range, 10.1-15.9 years). Factors examined included clinical status, immunologic and virologic characteristics, type of antiretroviral therapy, and psychosocial characteristics. By 10 years of age, 6 (18%) children had progressed to Class A as determined by the system of the U.S. Centers for Disease Control and Prevention (CDC), 17 (52%) to class B, 7 (21%) to class C, and 3 (9%) had remained asymptomatic. At 73% (904 of 1234) of scheduled clinic visits, these children had no symptoms of HIV disease. Most children were in CDC immune categories 1 (18, 56%) or 2 (11, 34%) at their last visit. Three quarters (24 patients) were on combination therapy with three or more drugs, although 3 children had never received any antiretroviral therapy. Nineteen (56%) children were living with at least 1 parent and the mothers of 13 (38%) children had died. Most (77%) children had been told about their HIV infection. Children infected vertically with HIV who have survived their first 10 years are mainly free of serious symptoms. As they enter adolescence, additional services are needed including support with disclosure to others, therapy, and sexual health.