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Value of systematic detection of physical child abuse at emergency rooms: a cross-sectional diagnostic accuracy study
Judith S Sittig1, Cuno S P M Uiterwaal2, Karel G M Moons2
1Department of Paediatrics, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, The Netherlands Mental Health Care 'GGZ Centraal', Hilversum, The Netherlands.
Insights
Child abuse checklists accurately identify physical abuse in emergency rooms, but have high false-positive rates. Further expert assessment can safely focus on children with positive screens, minimizing missed cases.
Area of Science:
- Pediatric Emergency Medicine
- Child Abuse Detection
- Diagnostic Accuracy Studies
Background:
- Child abuse is a significant concern in emergency departments.
- Accurate identification of physical abuse in children presenting with injuries is crucial.
- Existing screening tools require validation for diagnostic accuracy.
Purpose of the Study:
- To evaluate the diagnostic accuracy of a widely used checklist for detecting physical child abuse.
- To determine the effectiveness of the Child Abuse Inventory at Emergency Rooms (CHAIN-ER) checklist in identifying or excluding physical abuse.
- To assess the utility of the checklist in a pediatric emergency room setting.
Main Methods:
- A large, multicenter diagnostic accuracy study involving 4290 children aged 0-7 years presenting to 4 emergency rooms in the Netherlands.
- Children with physical injuries were screened using an easy-to-use child abuse checklist (index test).
- A national expert panel (reference standard) retrospectively assessed cases with positive screens and a random sample of negative screens for physical abuse, incorporating injury history, collateral information, and 6-month follow-up.
Main Results:
- The study reported a prevalence of inflicted injury of 0.07% (3/4253).
- The checklist demonstrated a high negative predictive value (1.0 [0.994 to 1.0]), indicating it rarely missed cases of abuse.
- However, the positive predictive value was low (0.03 [95% CI 0.006 to 0.085]), signifying a high rate of false positives.
Conclusions:
- Easy-to-use checklists can effectively capture rare instances of inflicted injury in children presenting to emergency rooms, but with a high false-positive rate.
- Subsequent expert assessment can be safely limited to children with positive checklist screens, with a very low risk of missing abuse cases.
- Careful consideration of cost-effectiveness and clinical/societal implications is advised before implementing these checklists widely due to the high false-positive rate.
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.
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