Letson, M. M., Cooper, J. N., Deans, K. J., Scribano, P. V., Makoroff, K. L., Feldman, K. W., & Berger, R. P. (2016). Prior opportunities to identify abuse in children with abusive head trauma. Child Abuse & Neglect, 60, 36-45.
Infants who suffer from minor abusive injuries are at greater risk for more serious abusive injuries including abusive head trauma (AHT). AHT has been argued to be the leading cause of death in young children. The objective of this study was to determine if children who suffered from AHT had prior opportunities for abuse detection.
The authors conducted a secondary data analysis using medical information from four paediatric hospitals that constituted the AHT consortium. Subjects were included in the study if they were diagnosed with AHT, younger than 5 years of age and if they received a diagnosis between 7/1/2009 and 12/13/11. Information on the child’s medical history, and child protection services (CPS) involvement or law enforcement involvement were gathered from the children’s medical records. Demographic data on the child’s age, gender, race, ethnicity, and insurance status were analyzed in this study. The outcome measure of the study was to determine if there was a presence or absence of prior opportunities to prevent AHT. A prior opportunity was considered as: (1) the child was previously evaluated by CPS, (2) the child had symptoms or a referral consistent with physical abuse and (3) abuse was not identified or an alternate explanation was given.
The mortality rate of these children was 10%. Among the cases involving mortality, 31% (73 cases) had a total of 120 prior opportunities for detection of physical abuse in a medical setting.
In the medical setting, 64% of cases had one prior opportunity for detection, 20% had two opportunities for prior detection and 15% has three or more opportunities for prior detection. Within the medical setting, 49% of missed opportunities occurred in the emergency department, 35% in a primary care office and 9% at other locations. The most common symptoms exhibited by the children were isolated vomiting without diarrhea followed by the prior referral to CPS.
Group comparisons among those with and without prior detection opportunities revealed no differences among children’s age, gender, race, ethnicity, insurance status, mortality or study site. A multivariate logistic regression demonstrated that children, who had either a subdural haemorrhage or acute subdural haemorrhage or subarachnoid haemorrhage at the time of AHT diagnosis, were more likely to have had a prior opportunity for detection. Children who were healing from fractures were also more likely to have had a missed opportunity for detection. Children who suffered from only bruising were less likely to have had previous opportunities for detection.
The association between AHT and prior opportunity for detection of child abuse observed in this study indicated that education on AHT for physicians and CPS workers alike might help with earlier detection of abusive injuries. Education would include being able to identify when to be concerned and include more mandated reporting to CPS agencies.
Furthermore, the use of computer-assisted assessment might help standardize assessments to determine the likelihood of abuse.
The sample was only comprised of four hospitals making it difficult to generalize these findings to the population at large. Furthermore, in a Canadian context it would be useful to understand what type of early detection is used when children present with head injuries.