National survey of hospital child protection teams in Japan

This study aimed to investigate the penetration rate of child protection teams (CPTs) in medical institutions and associations between CPT functions and hospital services. We collected data in October of 2015 from 377 hospitals in Japan offering pediatric organ transplantation. The questionnaire included questions regarding the existence of a CPT, the number of child maltreatment cases discussed and reported per year, CPT functions including 21 items about staffing, manuals, meeting, prevention, education, and collaboration, and the services provided by the hospital. Of the 377 institutions, 122 (32.4%) answered the survey. There were significant associations between CPT functions and the number of pediatric beds (r = .27), number of pediatricians (r = .27), number of outpatients (r = .39), number of emergency outpatients (r = .28), and emergency medical care (p = .009). In a multiple regression analysis, CPT functions were significantly associated with the number of CPT members, pediatric outpatient numbers, and pediatric emergency outpatient numbers. Japan has no CPT guidelines that outline what CPTs should offer in terms of structure, staffing, functions, and systems. Hospitals with many pediatric and emergency outpatients are expected to play major roles in providing services such as specialty care, intensive care, and education. They are also expected to play a role in detecting and managing child maltreatment, and have, by their own initiative, improved their capacities to achieve these goals.     

Diagnostic agreement when comparing still and video imaging for the medical evaluation of child sexual abuse

Still photo imaging is often used in medical evaluations of child sexual abuse (CSA) but video imaging may be superior. We aimed to compare still images to videos with respect to diagnostic agreement regarding hymenal deep notches and transections in post-pubertal females. Additionally, we evaluated the role of experience and expertise on agreement. We hypothesized that videos would result in improved diagnostic agreement of multiple evaluators as compared to still photos. This was a prospective quasi-experimental study using imaging modality as the quasi-independent variable. The dependent variable was diagnostic agreement of participants regarding presence/absence of findings indicating penetrative trauma on non-acute post-pubertal genital exams. Participants were medical personnel who regularly perform CSA exams. Diagnostic agreement was evaluated utilizing a retrospective selection of videos and still photos obtained directly from the videos. Videos and still photos were embedded into an on-line survey as sixteen cases. One-hundred sixteen participants completed the study. Participant diagnosis was more likely to agree with study center diagnosis when using video (p < 0.01). Use of video resulted in statistically significant changes in diagnosis in four of eight cases. In two cases, the diagnosis of the majority of participants changed from no hymenal transection to transection present. No difference in agreement was found based on experience or expertise. Use of video vs. still images resulted in increased agreement with original examiner and changes in diagnostic impressions in review of CSA exams. Further study is warranted, as video imaging may have significant impacts on diagnosis.     

Institutional child abuse in Greece: some preliminary findings

A long-term study on child abuse and neglect in Greece is being carried out at the Institute of Child Health, Athens. A multidisciplinary team is investigating the nature of the problem in Greece, is trying a system of therapeutic intervention to families, is evaluating the adequacy of child protection as it is used in child abuse and neglect, and is examining the efficacy of the law. During a one year period, 5 children cared for in institutions were referred to the program. All were boys. All were children with minor or major handicaps. Two of died from the abusive incident. A study of the circumstances of the injury, and of the conditions in Greek institutions, supports the idea that institutional and family child abuse share many common characteristics. Special mention is made of the Greek circumstances pertaining to child protection and the law.     

Relationship between child abuse exposure and reported contact with child protection organizations: Results from the Canadian Community Health Survey

Much of what is known about child abuse in Canada has come from reported cases of child abuse and at-risk samples, which likely represent the most severe cases of child abuse in the country. The objective of the current study is to examine the prevalence of a broad range of child abuse experiences (physical abuse, sexual abuse, and exposure to IPV) and investigate how such experiences and sociodemographic variables are related to contact with child protection organizations in Canada using a representative general population sample. Data were drawn from the 2012 Canadian Community Health Survey: Mental Health collected from the 10 provinces using a multistage stratified cluster design (n = 23,395; household response rate = 79.8%; aged 18 years and older). Physical abuse only (16.8%) was the most prevalent child abuse experience reported with the exposure to specific combinations of two or more types of child abuse ranging from 0.4% to 3.7%. Only 7.6% of the adult population with a history of child abuse reported having had contact with child protection organizations. Experiencing all three types of child abuse was associated with the greatest odds of contact with child protection organizations (AOR = 15.8; 95% CI = 10.1 to 24.6). Physical abuse only was associated with one of the lowest odds of contact with child protection organizations. Preventing child abuse is widely acknowledged as an important, but challenging public health goal. Strategies to increase reporting of child abuse may help to protect children and to connect families with necessary services. One obvious priority would be physical abuse.     

The child protection and juvenile justice nexus in Australia: A longitudinal examination of the relationship between maltreatment and offending

There is convincing evidence that many young people who are in the justice system have had contact with child protection services and that victims of childhood maltreatment are at increased risk of subsequent youth justice involvement. In Australia, however, there have been few longitudinal studies that have examined these associations and relatively less is known in this area. This study examines the overlap between the child protection and youth justice involvement in South Australia, and determines how substantiated maltreatment and variations in these experiences (e.g., the type, timing and recurrence of maltreatment) relate to criminal convictions as a youth. The results show that although the majority of child-protection involved youth do not become convicted offenders, the odds of subsequent convictions are significantly greater both for those with notifications and substantiated maltreatment and for those who had been placed in out-of-home care. Multivariate analyses revealed that the strongest predictors for receiving a conviction among maltreated youth were: male gender, Aboriginal and Torres Strait Islander ethnicity, experiences of physical abuse and emotional abuse, a greater number of substantiations (recurrence), experiencing maltreatment that commenced in childhood and continued into adolescence, and placement in out-of-home care. The mechanisms through which maltreatment might be linked with behavior are then considered, along with directions for future research in this area.     

Entryway into the child protection system: The impacts of child maltreatment reporting policies and reporting system structures

This study was designed to assess the impacts of maltreatment reporting policies and reporting system structures on four aspects of entry into the child protection system (the maltreatment referral rate, the percentage of referrals screened in for investigation, the screened-in report rate and the substantiated report rate). Using secondary data from several sources, eight multiple linear regression models were created and analyzed. Results from a sample of 44 states indicated significant effects for system structure but no effects for reporting policies. Specifically, states with decentralized reporting system structures were significantly more restrictive in access than other states. These results have implications for child welfare administrators and policymakers seeking to maximize access for maltreated children and their families.     

Child protective services utilization of child abuse pediatricians: A mixed methods study

Several children’s hospitals and medical schools across Texas have child abuse pediatricians (CAPs) who work closely with child protection workers to help ensure accurate assessments of the likelihood of maltreatment in cases of suspected abuse and neglect. Since the state does not mandate which cases should be referred to a CAP center, we were interested in studying factors that may influence workers’ decisions to consult a CAP. We used a mixed methods study design consisting of a focus group followed by a survey. The focus group identified multiple factors that impact workers’ decision-making, including several that involve medical providers. Responses from 436 completed surveys were compared to employees’ number of years of employment and to the state region in which they worked. Focus group findings and survey responses revealed frustration among many workers when dealing with medical providers, and moderate levels of confidence in workers’ abilities to make accurate determinations in cases involving medical information. Workers were more likely to refer cases involving serious physical injury than other types of cases. Among workers who reported prior interactions with a CAP, experiences and attitudes regarding CAPs were typically positive. The survey also revealed significant variability in referral practices by state region. Our results suggest that standard guidelines regarding CAP referrals may help workers who deal with cases involving medical information. Future research and quality improvement efforts to improve transfers of information and to better understand the qualities that CPS workers appreciate in CAP teams should improve CAP-CPS coordination.     

Physicians and medical neglect: Variables that affect reporting

Variables that affect the propensity to report medical neglect were surveyed among 52 physicians on the staff of a pediatric hospital. Death was one of the 52 potential consequences of neglect listed for 7 of the 46 diseases analyzed. The time allotted before neglect would be considered varied with the stage and seriousness of the disease. Caretakers were less likely to be considered neglectful if the symptoms of the disease were minor, not obvious, or required technical sophistication for recognition. The number of acceptable reasons for missing appointments varied. The natural course of the disease process, efficacy and safety of treatment, parents' religion, intellectual level, and economic situation affected neglect reporting propensity. Definitions of medical neglect for common diseases must be standardized. Training of lay caretakers of ill children and communication of clear and reasonable expectations are necessary to help prevent medical neglect.     

Fatal child neglect: Characteristics,causation, and strategies for prevention

Research in child fatalities because of abuse and neglect has continued to increase, yet the mechanisms of the death incident and risk factors for these deaths remain unclear. The purpose of this study was to systematically examine the types of neglect that resulted in children's deaths as determined by child welfare and a child death review board. This case review study reviewed 22 years of data (n = 372) of child fatalities attributed solely to neglect taken from a larger sample (N = 754) of abuse and neglect death cases spanning the years 1987–2008. The file information reviewed was provided by the Oklahoma Child Death Review Board (CDRB) and the Oklahoma Department of Human Services (DHS) Division of Children and Family Services. Variables of interest were child age, ethnicity, and birth order; parental age and ethnicity; cause of death as determined by child protective services (CPS); and involvement with DHS at the time of the fatal event. Three categories of fatal neglect – supervisory neglect, deprivation of needs, and medical neglect – were identified and analyzed. Results found an overwhelming presence of supervisory neglect in child neglect fatalities and indicated no significant differences between children living in rural and urban settings. Young children and male children comprised the majority of fatalities, and African American and Native American children were over-represented in the sample when compared to the state population. This study underscores the critical need for prevention and educational programming related to appropriate adult supervision and adequate safety measures to prevent a child's death because of neglect.     

Pediatric response to a large-scale child protection intervention

Objective

In a rural area of the US state of Texas, in April 2008, the Texas Department of Family and Protective Services (DFPS) responded to evidence of widespread child abuse in an isolated religious compound by removing 463 individuals into state custody. This mass child protection intervention is the largest such action that has ever occurred in the United States. The objective of this paper is to characterize the burdens placed on the area's community resources, healthcare providers, and legal system, the limitations encountered by the forensic and public health professionals, and how these might be minimized in future large-scale child protection interventions.

Methods

Drawing on publicly available information, this article describes the child abuse investigation, legal outcomes, experiences of pediatric healthcare providers directly affected by the mass removal, and the roles of regional child abuse pediatric specialists.

Results

Because the compound's residents refused to cooperate with the investigation and the population of the compound was eight times higher than expected, law enforcement and child protection resources were insufficient to conduct standard child abuse investigations. Local medical and public health resources were also quickly overwhelmed. Consulting child abuse pediatricians were asked to recommend laboratory and radiologic studies that could assist in identifying signs of child abuse, but the lack of cooperation from patients and parents, inadequate medical histories, and limited physical examinations precluded full implementation of the recommendations.

Conclusions

Although most children in danger of abuse were removed from the high-risk environment for several months and some suspected abusers were found guilty in criminal trials, the overall success of the child protection intervention was reduced by the limitations imposed by insufficient resources and lack of cooperation from the compound's residents.

Practice implications

Recommendations for community and child abuse pediatricians who may become involved in future large child-protection interventions are presented.     

Child protection workers dealing with child abuse: The contribution of personal,social and organizational resources to secondary traumatization

The present study compared secondary traumatization among child protection social workers versus social workers employed at social service departments. In addition, based on Conservation of Resources (COR) theory, the study examined the contribution of working in the field of child protection as well as the contribution of background variables, personal resources (mastery), and resources in the workers’ social and organizational environment (social support, effectiveness of supervision, and role stress) to secondary traumatization. The findings indicate that levels of mastery and years of work experience contributed negatively to secondary traumatization, whereas exposure to child maltreatment, trauma history, and role stress contributed positively to secondary traumatization. However, no significant contribution was found for social support and effectiveness of supervision. The study identifies factors that can prevent distress among professionals such as child protection workers, who are exposed to the trauma of child abuse victims. Recommendations are provided accordingly.     

The handicapped child and child abuse

For a group of children with handicaps, growth and development are also affected by abuse or neglect. Our understanding of the problems of the abused, handicapped child emerges from experience with 37 children with cerebral palsy who have been maltreated, coupled with a review of the literature in related areas. We identify the following four problems as crucial to the study of abuse and neglect to the child with handicaps: (1) abuse that causes handicaps, (2) abuse that occurs to the handicapped child, (3) compromises in care that can occur when the handicapped child becomes involved with the medical and legal systems, and (4) arrangements for foster care or other out-of-home placement for the child with handicaps. We conclude that the very systems designed to protect and care for the child often fail, leaving the handicapped child without opportunity to reach developmental potential. In light of our observations, we recommend that the pediatrician not only be aware of the existence of abuse and neglect in the population of handicapped children, but also serve in the dual role of coordinator of services and advocate for these children.     

Responding to abuse: Children's experiences of child protection in a central district,Uganda

Part of a comprehensive response to violence against children involves child protection systems, but there are few data available on such systems in low-income countries. This study describes the characteristics and help seeking behavior of children referred to local child protection services and the quality of the first-line response in one district in Uganda. Participants included 3,706 children from 42 primary schools who participated in a baseline survey on violence as part of the Good Schools Study (NCT01678846, clinicaltrial.gov). Children who disclosed violence were referred according to predefined criteria based on the type, severity, and timeframe of their experiences. Children were followed up to 4 months after the study ended. First-line responses by receiving agencies were classified into 3 categories: plan for action only, some action taken, and no plan and no action taken. Appropriateness of responses was based on which agency responded, timeliness of the response, quality of the documentation, and final status of the case. From the baseline survey, 529 children (14%) were referred. Girls were more likely to be referred and to meet the criteria for a serious case (9% girls, 4% boys). In total, 104 referrals (20%) had some kind of concrete action taken, but only 20 (3.8%) cases met all criteria for having received an adequate response. Nearly half (43%) of referred children had ever sought help by disclosing their experiences of violence prior to the baseline survey. In our study areas, the first-line response to children's reports of abuse was poor even though some referral structures are in place.     

The case for integration of the investigator and helper roles in child protection

Social workers who have both investigative and helping roles in child protective cases may find the roles to be in conflict and difficult to integrate. This problem has been exacerbated by recent changes in U.S. law and court procedure which place more emphasis on the quality of child abuse investigations. While it may not be easy for social workers to integrate the roles of investigator and helper, this paper draws on social work theory to show that it is possible and beneficial to their clients when they are able to do so. Social workers who are able to perform successfully in both roles are best prepared to help clients recognize and overcome problems. Division of the investigator and helper roles, on the other hand, may create significant difficulties including staff conflict, denial of problems by clients, and distortion of clients' expectations of the professional and the agency.     

Using simulation to identify sources of medical diagnostic error in child physical abuse

Little is known regarding sources of diagnostic error at the provider level in cases of possible child physical abuse. This study examines medical diagnosis as part of medical management and not as part of legal investigation. Simulation offers the opportunity to evaluate diagnostic accuracy and identify error sources. We aimed to identify sources of medical diagnostic error in cases of possible abuse by assessing diagnostic accuracy, identifying gaps in evaluation, and characterizing information used by medical providers to reach their diagnoses. Eight femur fracture simulation cases, half of which were abuse and half accident, were created. Providers from a tertiary pediatric emergency department participated in a simulation exercise involving 1 of the 8 cases. Performance was evaluated using structured scoring tools and debriefing, and qualitative analysis characterized participants’ rationales for their diagnoses. Overall, 39% of the 43 participants made an incorrect diagnosis regarding abuse. An incorrect diagnosis was over 8 times more likely to occur in accident than in abuse cases (OR = 8.8; 95% CI 2 to 39). Only 58% of participants correctly identified the fracture morphology, 60% correctly identified the mechanics necessary to generate the morphology, and 30% of ordered all appropriate tests for occult injury. In misdiagnoses, participants frequently falsely believed the injury did not match the proposed mechanism and the history provided by the caregiver had changed. Education programs targeting the identified error sources may result in fewer diagnostic errors and improve outcomes. The findings also support the need for referral to child abuse experts in many cases.     

Getting evidence into action to tackle institutional child abuse

The Australian Royal Commission into Institutional Responses to Child Sexual Abuse is an example of a government response to survivors’ demands to address the harm they suffered. It is also a major response by a national government to improve child safety in the future. Facing up to child abuse is difficult and in other countries similar inquiries have suffered delays and derailing. This commentary uses an evidence-to-action lens to explore why clear evidence of child sexual abuse may be ignored and side-lined. It argues that where evidence challenges the powerful, is surprising and shocking, or undercuts current institutional and policy arrangements, then that evidence is likely to be ignored, undermined or refuted – all factors which are present in the case of historical institutional child sexual abuse.     

The complexity of child protection recurrence: The case for a systems approach

ObjectiveResearch on child protection recurrence has found consistent child, family, and case characteristics associated with repeated involvement with the child protection system. Despite the considerable body of empirical research, knowledge about why recurrence occurs, and what can be done to reduce it, is limited.MethodThis paper reviews the empirical literature and analyses the approaches of prior recurrence research. Four related conceptual challenges are identified: (1) a tendency to conflate child protection recurrence with repeated child maltreatment; (2) uncertainty about how best to operationalize and measure child protection recurrence in research; (3) inconsistency between prevailing explanations for the most frequently observed patterns of recurrence; and (4) difficulty in developing coherent strategies to address child protection recurrence based on research.ResultsAddressing these challenges requires a greater consideration of the effects of decision-making in the child protection system on recurrence. This paper proposes a methodology based in systems theory and drawing on existing administrative data to examine the characteristics of the child protection system that may also produce recurrence.     

Evaluation of second step child protection videos: A randomized controlled trial

This randomized controlled trial (RCT) examined the effects of the Second Step Child Protection Unit videos on parents’ knowledge, motivation, and self-reported communication with their child about personal safety and childhood sexual abuse prevention. Parents of children between the ages of 3–11 years were randomly assigned to the intervention (watching the Second Step videos) or the control (watching videos on child obesity) groups. They completed measures assessing their knowledge of child sexual abuse (CSA), motivation to discuss CSA, self-reported discussions of CSA, child history of victimization, parent exposure to CSA, and comparable measures on topics of health and nutrition at pre-test. Participants viewed the videos one week later and immediately completed post-test 1, and then two months later completed the measures again. Multivariate Analyses of Covariance (MANCOVAs) and serial mediation analyses were conducted with the final sample of 438. The intervention group, compared to the control group, had significant increases in knowledge (specifically, less restrictive stereotype beliefs about CSA) and motivation to talk with their children about CSA both immediately after the intervention and at the two-month follow-up. Although the intervention did not have a direct effect on parent self-reported conversations with their children about CSA, it had a mediated effect. The intervention increased knowledge regarding CSA, which then predicted motivation, which in turn predicted conversations. The most pronounced effect was the intervention’s direct effect of increasing motivation immediately after the intervention, which then increased self-reported conversations with children about personal safety and CSA two months later.     

Factors associated with child protection recurrence in Australia

The aim of the current research was to advance understanding of child protection in Australia by examining the factors associated with recurrence of child protection notifications to the formal child protection system. Extant research has been primarily undertaken in the USA and it is important to understand whether similar factors associated with recurrence actually hold in the Australian context. Administrative data were obtained for a sample of 9608 children first subject to a screened-in report in 2011–12. Children were followed for 12 months. Cox Proportional Hazard models were used to measure associations between 26 independent variables and four types of recurrence: subsequent reports, subsequent investigations, subsequent substantiations, and subsequent intervention. Factors associated with recurrence in Australia were broadly similar to those identified in other jurisdictions, including reports and substantiation for neglect, younger age, prior child protection involvement in the household, and parental characteristics including drug use, mental health problems, and history of maltreatment as a child. As in previous studies, post-investigative service provision was positively associated with recurrence. In prior US research, race did not predict recurrence. However, in the present study, Indigenous Australian children were significantly more likely to be subject to all types of recurrence measured. Future research on recurrence should aim to disentangle the complex relationships between child protection recurrence, child maltreatment, and service delivery. Recurrence is not a good proxy indicator of child safety. The findings have implications for the equity of recurrence-based risk assessment tools as they are applied to indigenous populations.     

Physical or psychological child abuse and neglect: Experiences,reporting behavior and positions toward mandatory reporting of pediatricians in Berlin,Germany

BackgroundChild abuse and neglect (CAN) are common, with a high number of undetected victims. Since 2012, the German Federal Child Protection Act grants doctors an opportunity to circumvent their duty of confidentiality if they suspect CAN may be occurring, despite the reporting of CAN not being mandatory.ObjectiveThis study examines pediatricians’ reporting behavior in cases of CAN and what their attitudes are toward mandatory reporting.Participants and settingAll 378 primary care pediatricians and pediatric psychiatrists in the German capital of Berlin were asked to complete a questionnaire anonymously. The questionnaire was sent by mail to all primary care pediatricians (N = 302) and pediatric psychiatrists (N = 76) in private practice.MethodsPatterns of reporting, response tendencies, and correlations with socio-economic factors were described and statistically examined.ResultsThe response rate was 42% (N = 157). Of the pediatricians, 28% report every suspected case to the authorities. The majority, namely 73%, has difficulties in detecting CAN, and 64% would like additional training. Furthermore, 52% are aware of legally guaranteed counseling options being available if CAN is suspected. Whereas 71% consider mandatory reporting necessary to protect children more effectively, 57% are sure it would simplify their work.ConclusionsMore training on diagnosing CAN should be offered to pediatricians. It is necessary to have a full and frank discussion about making reporting mandatory in cases where there is a reasonable suspicion of CAN. Doctors believe that mandatory reporting standardizes and simplifies working procedures. It may possibly reduce the number of undetected cases of CAN and would allow more children and families access to early protection and supporting measures.