Medical neglect at a tertiary paediatric hospital

Medical neglect is under-researched and the extent of the problem in Australia is unknown. We conducted a review of the referrals for medical neglect to the Child Protection Unit (CPU) at a tertiary children’s hospital in Sydney over a 5 years period, from 2011 to 2016, to determine what medical conditions are being referred, the reason for the medical neglect concern and whether cases are managed in line with American Academy of Pediatrics (AAP) guideline on medical neglect.61 cases of medical neglect were identified, constituting 4.1% of all referrals to the Child Protection Unit for physical abuse and neglect. There was a wide variety of medical conditions. Most were chronic medical conditions (87%). The top two medical conditions were chronic and complex multi-system disorders (37.7%) and endocrine disorders (18%). The majority of medical neglect were related to concerns that the caregivers were unwilling to follow medical advice (45.9%) or unable to provide necessary medical care (26.2%). In line with the AAP guideline on medical neglect, all cases were managed by addressing communication difficulties (100%) and resource issues were addressed in 80% of cases. A report to statutory child protection agencies was made in 50% of cases. Directly observed therapy and medical contracts were used in 30% and 26% of cases. We conclude that children with chronic medical conditions may be at risk of medical neglect. Communication difficulties were a factor in all cases. Statutory agency intervention is often required.     

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.     

Oral health in children investigated by Social services on suspicion of child abuse and neglect

Child abuse and neglect (CAN) are likely to have negative consequences on health; however, for oral health, studies on associated outcomes are sparse. The purpose of this study was to assess oral health and oral health behaviors in relation to suspected CAN among children being investigated by the Swedish Social Services. The material comprised data from the Social Services and dental records; the sample, 86 children and 172 matched controls. The children in the study group had a higher prevalence of dental caries than the control group; in addition, levels of non-attendance and dental avoidance were high, as was parental failure to promote good oral health. We found four factors that, taken together, indicated a high probability of being investigated because of suspected CAN: prevalence of dental caries in primary teeth, fillings in permanent teeth, dental health service avoidance, and referral to specialist pediatric dentistry clinics. If all four factors were present, the cumulative probability of being investigated was 0.918. In conclusion, there is a high prevalence of dental caries, irregular attendance, and a need for referral a pediatric dental clinic among Swedish children under investigation due to suspected CAN. Social context is an important factor in assessing the risk of developing dental caries, the inclination to follow treatment plans, and the prerequisites for cooperation during treatment. Routinely requesting dental records during an investigation would provide important information for social workers on parental skills and abilities to fulfill the basic needs of children.     

Exploring policies for the reduction of child physical abuse and neglect

Policies can be powerful tools for prevention given their potential to affect conditions that can improve population-level health. Given the dearth of empirical research on policies’ impacts on child maltreatment, this article (a) identifies 37 state policies that might have impacts on the social determinants of child maltreatment; (b) identifies available data sources documenting the implementation of 31 policies; and (c) utilizes the available data to explore effects of 11 policies (selected because they had little missing data) on child maltreatment rates. These include two policies aimed at reducing poverty, two temporary assistance to needy families policies, two policies aimed at increasing access to child care, three policies aimed at increasing access to high quality pre-K, and three policies aimed at increasing access to health care. Multi-level regression analyses between within-state trends of child maltreatment investigation rates and these 11 policies, controlling for states’ childhood poverty, adults without a high school diploma, unemployment, child burden, and race/ethnicity, identified two that were significantly associated with decreased child maltreatment rates: lack of waitlists to access subsidized child care and policies that facilitate continuity of child health care. These findings are correlational and are limited by the quality and availability of the data. Future research might focus on a reduced number of states that have good quality administrative data or population-based survey data on child maltreatment or reasonable proxies for child maltreatment and where data on the actual implementation of specific policies of interest can be documented.     

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.     

Answering the big questions about differential response in Colorado: Safety and cost outcomes from a randomized controlled trial

Over the past 20 years, jurisdictions across the United States have implemented differential response (DR), which provides child protective services with the flexibility to tailor their response to reports of child abuse or neglect based on the level of risk. Given the widespread adoption of DR, there has been an increasing demand from policymakers, practitioners, and community stakeholders to build the evidence base for this innovative child welfare approach. This study was designed to answer the big questions regarding the effect of differential response on child welfare outcomes and costs using a randomized controlled trial in five Colorado counties. Specifically, the study examined the safety outcomes and costs of families who were randomly assigned to either a family assessment response (FAR) or an investigation response (IR). According to the regression results, there were no differences between the tracks on measures of system re-involvement. However, survival analysis findings indicate that FAR families were 18% less likely, over time, to have a high risk assessment after their initial accepted referral than were IR families. The cost study revealed no differences between the tracks on initial costs for caseworker contacts, services, and out-of-home placements. However, the results suggest that follow-up costs for IR cases were significantly higher (p < 0.001) than for FAR cases. The authors discuss policy and practice implications for jurisdictions considering DR.     

The prevention of child abuse and neglect: A review of the literature with recommendations for application

Families at high risk for inadequate parenting can be identified during the perinatal period, or during later health care visits. Effective intervention can be implemented for these special families. During the maternity ward stay, intervention can include early delivery room contact, rooming-in arrangements, and increased teaching sessions on child care. The primary physician can provide frequent office visits, telephone contacts and helpful advice during acute illnesses and developmental phases which might precipitate child abuse. The physician can seek assistance from outreach workers such as public health nurses, lay health visitors, and child welfare caseworkers. Community prevention programs such as parenting classes, Parent's Anonymous groups, crisis nurseries and crisis hotlines should also be integrated into the family's treatment. When provided in concert, these actions can stabilize most dysfunctional families.     

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.     

Malingering-by-proxy: Need for child protection and guidance for reporting

The feigning of disabling illness for compensation at the direction or pressure by others, which is called malingering by proxy (MBP), has been the subject of several spirited articles. Chafetz and Prentkowski (2011) suggested that MBP has the potential for real harm to the child. In a poster at the AACN scientific session in 2011, Chafetz and Binder (2011) pursued a case of MBP that showed the child had clearly suffered and failed to progress in the 6 years that had passed since she was first evaluated as an 11 year old. In the present article, we identify three cases that compare and contrast effects of MBP, illustrating that child abuse and/or neglect can be a serious and reportable consequence of MBP behavior. To illustrate how MBP behavior can cause child abuse, we compare MBP behavior with Munchausen Syndrome by Proxy (MSBP), another condition of volitional noncredible behavior produced in a vulnerable person at the direction or pressure by others. Guidance criteria for reporting MBP as child abuse/neglect are introduced in this article.     

Interdisciplinary Training Program (ITP) in child abuse and neglect: Long term effects

BackgroundUniversity of Oklahoma Health Sciences Center has offered Interdisciplinary Training Program (ITP) for Child Abuse and Neglect since 1987. However, there are limited evaluations on multidisciplinary/interprofessional training for early professionals in the field of child abuse and neglect.ObjectiveThis study aimed to examine the effects of the ITP on young professionals in developing their careers and taking leadership roles in the field of child abuse and neglect.MethodsThe anonymous online survey was conducted for students who completed in the ITP from 1989 to 2016 (n = 405, with contact information out of total 508 graduates). One hundred seventy nine alumni (44.2%) responded to the survey.ResultsSatisfaction for the ITP was high (m = 9.3, sd = 0.97 on a 10 point scale with higher numbers being positive). Their current contributions to the field of child abuse and neglect were widely seen in child advocacy (43.0%), clinical treatment (39.1%), primary prevention (29.6%), or research (27.9%). Graduates reported they made 133 presentations to civic or professional groups and published 69 articles since they finished the ITP.ConclusionThe ITP trainees have made significant contributions to the field in clinical treatment, research, and child advocacy. Alumni were highly satisfied with their experience and continue to see the importance of the ITP to their jobs and career.     

Predicting the decisions of hospital based child protection teams to report to child protective services,police and community welfare services

This study examines judgments made by hospital-based child protection teams (CPTs) when determining if there is reasonable suspicion that a child has been maltreated, and whether to report the case to a community welfare agency, to child protective services (CPS) and/or to the police. A prospective multi-center study of all 968 consecutive cases referred to CPTs during 2010–2011 in six medical centers in Israel. Centers were purposefully selected to represent the heterogeneity of medical centers in Israel in terms of size, geographical location and population characteristics. A structured questionnaire was designed to capture relevant information and judgments on each child referred to the team. Bivariate associations and multivariate multinomial logistic regressions were conducted to predict whether the decisions would be (a) to close the case, (b) to refer the case to community welfare services, or (c) to report it to CPS and/or the police. Bivariate and multivariate analyses identified a large number of case characteristics associated with higher probability of reporting to CPS/police or of referral to community welfare services. Case characteristics associated with the decisions include socio-demographic (e.g., ethnicity and financial status), parental functioning (e.g., mental health), previous contacts with authorities and hospital, current referral characteristics (e.g., parental referral vs. child referral), physical findings, and suspicious behaviors of child and parent. Most of the findings suggest that decisions of CPTs are based on indices that have strong support in the professional literature. Existing heterogeneity between cases, practitioners and medical centers had an impact on the overall predictability of the decision to report. Attending to collaboration between hospitals and community agencies is suggested to support learning and quality improvement.     

Children's views on child abuse and neglect: findings from an exploratory study with Chinese children in Hong Kong

Objectives

This research study explored children's views on issues about child abuse in Hong Kong and examined their implications on child protection work and research in Chinese societies.

Method

Six primary schools were recruited from different districts of Hong Kong. Five vignettes of child maltreatment in the form of flash movies were presented to 87 children in 12 focus groups for discussion. The process was video-taped and the data were transcribed verbatim for data analysis by NUDIST.

Results

(1) Children do not have a homogeneous view on issues about child abuse and neglect, and their awareness and sensitivity to different kinds of child abuse are also different; (2) some of their views on child abuse and neglect are uniquely their own and are markedly different from those of adults; (3) some of the views expressed by children, however, are very much akin to those of adults, such as the factors they would consider in deciding whether a case is child abuse or not; (4) children's disclosure of abuse in Hong Kong is often affected by the Chinese culture in which they live, like filial piety and loyalty to parents.

Conclusion

Children's views on issues of child abuse and neglect, no matter they are the same or different from those of adults, serve to inform and improve child protection work. Children are not only victims in need of protection. They are also valuable partners with whom adult practitioners should closely work.

Practice implications

Children have, and are able to give, views on child abuse. They should be listened to in any child protection work no matter their views are same with or different from those of adults. As this study suggests, the relatively low sensitivity of the children to child neglect and sexual abuse, and their reluctance to disclose abuse and neglect due to their loyalty to parents are areas to focus on in preventive child protection work in a Chinese society like Hong Kong.     

Complex health concerns among child welfare populations and the benefit of pediatric medical homes

Children referred to child welfare have higher-than-average rates of physical, mental, and developmental health conditions, yet coordinating medical care to address their complex needs is challenging. This study investigates complex health characteristics of child welfare-involved children to inform evolving patient-centered medical homes that incorporate multidisciplinary care and social health determinants. Study questions include: (1) To what degree do child welfare-involved children present with complex physical, behavioral, and developmental conditions? (2) How does the clustering of complex health concerns vary according to developmental stage? (3) What demographic factors relate to complex health concerns? Data are from 5873 children (birth to 18) who participated in the National Survey of Child and Adolescent Well-being II. Latent class analyses were conducted for children in four developmental groups (infants, preschool-age, elementary school-age, and adolescents), including up to 11 indicators from standardized health measures. For all developmental groups, the best fitting model indicated a complex health concern class and a class with fewer health concerns. Multivariate logistic regressions revealed that membership in the complex health concerns class was associated with: increased age, poverty, poor caregiver health, out-of-home placement, gender, and race/ethnicity; although some developmental differences in predictors were observed. Results suggest that for younger children, preventive approaches and integration of developmental specialists in primary care is needed, while school-age children and adolescents demonstrate greater need for integrated behavioral health. All developmental groups would benefit from multidisciplinary teams that address complex health issues related to environmental risks common among children involved in child welfare.     

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.     

Neighborhood inequality in the prevalence of reported and substantiated child maltreatment

BackgroundPrior research documents spatial concentration in the incidence of child maltreatment reported to and confirmed by Child Protective Services (CPS), but without estimates of the prevalence of such reports, the extent of CPS contact in different communities is unknown.ObjectiveTo estimate the prevalence of CPS reports during early childhood and substantiated investigations during childhood for children living in different types of neighborhoods.Participants and settingChildren who experienced CPS reports and substantiated investigations in Connecticut.MethodsThis study uses synthetic cohort life tables to estimate the cumulative risk of CPS reports before age five and substantiated CPS investigations before age 18, by neighborhood poverty rate and neighborhood racial composition.ResultsThe analysis reveals substantial stratification in the prevalence of CPS contact by the demographic characteristics of children’s residential neighborhoods. For example, while 7% of children in low-poverty neighborhoods (under 10% poor) experience a substantiated CPS investigation at some point during childhood at 2014 and 2015 rates, this risk more than doubles to 17% for their peers in moderate-poverty neighborhoods (10–20% poor) and more than triples to 26% for their peers in high-poverty neighborhoods (over 20% poor). Similar trends emerge when examining CPS reports in early childhood as well as when comparing neighborhoods with different proportions of White residents.ConclusionsCPS reports and substantiated investigations are a widespread and disproportionately experienced life event for children in poor neighborhoods and children in non-White neighborhoods.     

Identifying and evaluating teachers’ knowledge in relation to child abuse and neglect: A qualitative study with Australian early childhood teachers

Child abuse and neglect are serious social problems that make extraordinary demands on teachers’ knowledge and professionalism. Yet the field of education has been slow to develop a discipline-specific knowledge base about child abuse and neglect for teachers and teacher education programmes and there is a paucity empirical research into teachers’ knowledge in relation to child abuse and neglect. This paper describes a qualitative study of eight purposively selected early childhood teachers. To identify and evaluate their child abuse and neglect knowledge, Grossman's [(1990). The making of a teacher: Teacher knowledge and teacher education. New York: Teachers College Press; (1995). Teachers’ knowledge. In L. W. Anderson (Ed.), International encyclopedia of teaching and teacher education (2nd ed., pp. 20–24). Tarrytown, NY: Pergamon] typology of teachers’ knowledge is used as an analytic framework on which to map the teachers’ interview data. Findings reveal that, in the absence of preservice and inservice education specifically about child abuse and neglect, early childhood teachers held and deployed knowledge in resourceful ways. They used, as a basis, their existing early childhood knowledge and adapted this knowledge by augmenting it with a range of personal and professional knowledge resources to fit their particular challenges and situations. This approach, however competent and innovative, also reveals shortfalls in knowledge. Implications of this research are drawn for child abuse and neglect curriculum development in initial and continuing teacher education including the case for specialist knowledge needed to establish teachers’ professional reputation for dealing capably with cases of child abuse and neglect.     

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.     

Prevention of child abuse and neglect through early diagnosis of serious disturbances in the mother-child relationship in Italy

At the obstetrical clinic of Modena University and a family center of the same municipality during the first six months of 1980 a questionnaire based on "Risks of Child Abuse" by Kempe, Gray and others was administered to 33 expectant mothers during the third trimester of pregnancy, a few days after delivery, and a month and one-half after childbirth, for the purpose of examining the mother-child relationship. Two principal groups of "risk factors" which may lead to child abuse and neglect appeared: mothers with preceding personal and social experiences, and cases of medical intervention (e.g., prematurity, caesarean). Use of a questionnaire that permitted early diagnosis made possible help in establishing a good mother-child relationship in the first months of life. Such help can be given by the hospital and public centers both before and after birth.     

Pilot study of a program delivered within the regular service system in Germany: Effect of a short-term attachment-based intervention on maternal sensitivity in mothers at risk for child abuse and neglect

This pilot study examined the effectiveness of a short-term attachment-based intervention, the Ulm Model, in a German population at risk for child abuse and neglect. The intervention used home visits and video feedback to promote maternal sensitivity, and was implemented by trained staff within the health care and youth welfare systems. Mothers in the control group (n = 33) received standard services only, while those in the intervention group (n = 63) additionally the Ulm Model intervention. The outcomes measured were maternal sensitivity, as assessed by the CARE-Index at pre-intervention, after the last session, and at about 6 and 12 months of age; and infant socio-emotional development, as assessed by the ET6-6 development test at about 6 and 12 months of age. The moderating effects on treatment outcomes of two variables were examined: risk for child abuse (moderate vs. high) and type of maternal attachment representation (secure vs. insecure). Among participants at moderate risk for child abuse, no differences were found between the intervention group and control group in either maternal sensitivity or infant development. Among those considered high risk, mothers in the intervention group showed a significant increase in maternal sensitivity from pre- to post-intervention; however, no group differences were seen at follow-up. There were some indications that infants of mothers in the intervention group showed better emotional development. The variable of maternal attachment representation was not a significant moderator for the intervention effect, but post hoc analysis indicated that the mean sensitivity of secure mothers was significant higher at the 6-month follow-up.