Kristine A. Campbell

Screening homeless youth for histories of abuse: Prevalence, enduring effects, and interest in treatment

OBJECTIVES To identify the incidence of self-reported physical and sexual child abuse among homeless youth, the self-perceived effects of past abuse, and current interest in treatment for past abuse among homeless youth with histories of abuse. METHODS Homeless and street-involved persons aged 18-23 filled out a questionnaire and participated in a structured assessment of histories of abuse, tobacco use and substance abuse. RESULTS Sixty-four homeless youth in Salt Lake City, Utah completed the study, 43 males and 21 females. Eighty-four percent screened positive for childhood physical and/or sexual abuse occurring before the age of 18; 42% screened positive for both physical and sexual abuse; 72% reported still being affected by their abuse. Among all abuse victims, 44% were interested in treatment for their abuse history and 62% of homeless youth who reported still being affected by their abuse were interested in treatment. Individuals were more likely to be interested in treatment if they were female, had not completed high school or had been previously asked about family dysfunction. Many victims who declined treatment offered spontaneous insight into their decision. Interest in treatment was similar to interest in treatment for other behaviors such as smoking and substance abuse. CONCLUSIONS Histories of abuse are common among homeless youth. A majority of those reporting a history of abuse are still affected by their abuse. Interest in treatment for a history of abuse was comparable to interest in treatment for other morbidities in the homeless youth population such as tobacco use and substance abuse. Our finding that homeless youth continue to be impacted by their abuse and are interested in treatment should prompt more screening for histories of abuse.

Follow-up skeletal surveys for nonaccidental trauma: can a more limited survey be performed?

BackgroundStudies have demonstrated the value of the follow-up skeletal survey in identifying additional fractures, clarifying indeterminate findings, and improving dating of skeletal injuries in victims of physical abuse.ObjectiveTo determine whether a more limited follow-up survey could yield the same radiologic data as a full follow-up survey.Materials and methodsThe study cohort comprised 101 children who had follow-up surveys that met our inclusion criteria. Consensus readings of both original and follow-up surveys were performed by two pediatric radiologists. These results were compared to determine additional findings from the follow-up surveys. Limited skeletal survey protocols were evaluated to determine whether they would detect the same fractures seen with a complete osseous survey.ResultsIn the 101 children 244 fractures were identified on the initial osseous survey. Follow-up surveys demonstrated new information in 38 children (37.6%). A 15-view limited follow-up survey identified all additional information seen on the complete follow-up survey.ConclusionOur data demonstrate that a 15-view limited follow-up skeletal survey could be performed without missing clinically significant new fractures and still allow proper identification of confirmed fractures or normal findings. A limited survey would decrease radiation dose in children.

Household, Family, and Child Risk Factors After an Investigation for Suspected Child Maltreatment: A Missed Opportunity for Prevention

OBJECTIVE To determine whether a Child Protection Services investigation for suspected child maltreatment is associated with subsequent improvements in household, caregiver, and child risk factors. DESIGN Retrospective cohort study. SETTING The Longitudinal Studies of Child Abuse and Neglect, a multicenter cohort study of the antecedents and consequences of child maltreatment. PARTICIPANTS A total of 595 children with the same maternal caregiver responding to Longitudinal Studies of Child Abuse and Neglect surveys at ages 4 and 8 years. MAIN EXPOSURE Investigation for suspected child maltreatment between ages 4 and 8 years. MAIN OUTCOME MEASURES Adjusted differences in 7 modifiable risk factors (social support, family functioning, poverty, maternal education, maternal depressive symptoms, anxious or depressive child behaviors, and aggressive or destructive child behaviors) at age 8 years. RESULTS Of 595 subjects, 164 (27.6%) experienced an investigation for suspected child maltreatment between ages 4 and 8 years. At age 8 years, investigated subjects were not perceptibly different from noninvestigated subjects in social support, family functioning, poverty, maternal education, or child behavior problems after adjusting for baseline risk factors. Mothers of investigated subjects did have more depressive symptoms than mothers of noninvestigated peers at the childs age of 8 years. Substantiation of child maltreatment by Child Protective Services did not alter these findings. CONCLUSIONS Our finding that an investigation for suspected child maltreatment is not associated with relative improvements in common, modifiable risk factors suggests that we may be missing an opportunity for secondary prevention of maltreatment and maltreatment consequences.

Cost-effectiveness of Head Computed Tomography in Infants With Possible Inflicted Traumatic Brain Injury

OBJECTIVE. Early diagnosis of inflicted traumatic brain injury may reduce morbidity and mortality associated with repeated inflicted traumatic brain injuries. We undertook this study to estimate the cost-effectiveness of a policy of head computed tomography (CT) for inflicted traumatic brain injury in selected infants seen in an emergency department. METHODS. We constructed Markov models to compare a policy of CT to no CT in an asymptomatic 5-week-old infant with either (1) unexplained scalp bruising or (2) a history of an apparent life-threatening event. Health states modeled were no inflicted traumatic brain injury, misdiagnosed inflicted traumatic brain injury, mild inflicted traumatic brain injury (diagnosed or undiagnosed), and severe and fatal inflicted traumatic brain injury. Infants with undiagnosed inflicted traumatic brain injury were at increased risk of repeat inflicted traumatic brain injury. We used available literature to estimate probabilities, costs, and outcomes. The models terminated at death or at 52 weeks of age. Outcomes considered were severe and fatal inflicted traumatic brain injury cases averted through early detection of mild inflicted traumatic brain injury. DATA SOURCES. We conducted a literature review for estimates of inflicted traumatic brain injury incidence, outcome probabilities, and medical and societal costs. Wide ranges were set for sensitivity and Monte Carlo analyses. RESULTS. From a medical payer perspective, head CT for inflicted traumatic brain injury in infants with unexplained scalp bruising saved money. Sensitivity analysis demonstrated costs less than

Critical Elements in the Medical Evaluation of Suspected Child Physical Abuse

50000 per severe or fatal inflicted traumatic brain injury averted in scenarios in which initial inflicted traumatic brain injury prevalence was >3%. From a societal perspective, costs of child protection made head CT for inflicted traumatic brain injury more expensive. CONCLUSIONS. From a medical payer perspective, our models demonstrate that CT for inflicted traumatic brain injury can be cost-effective and improve outcomes. The finding of higher societal cost reflects the substantial short-term costs of child protection. Our study supports a low medical threshold for CT screening and highlights the need for improved understanding of long-term costs and outcomes of child abuse.

Outpatient Management of Patients with Bronchiolitis Discharged Home on Oxygen A Survey of General Pediatricians

BACKGROUND: Previous research has described variability in medical evaluation of suspected abuse. The objective of this study was to identify, through expert consensus, required and highly recommended elements of a child abuse pediatrics (CAP) evaluation for 3 common presentations of suspected physical abuse in children aged 0 to 60 months. METHODS: Twenty-eight CAPs recruited from 2 national organizations formed the expert panel for this modified Delphi Process. An initial survey was developed for each presentation based on demographics, history of present illness, past medical, family and social history, laboratory, radiology, and consultation elements present in at least 10% of CAP consultations collected for a larger study. CAPs ranked each element on a 9-point scale then reviewed and discussed summary results through a project blog over 3 rounds. Required and highly recommended elements were defined as elements ranked as 9 and 8, respectively, by ≥75% of experts after the final round. RESULTS: From 96 elements in the initial surveys, experts identified 30 Required elements and 37 Highly Recommended elements for CAP evaluation of intracranial hemorrhage, 21 Required and 33 Highly Recommended elements for CAP evaluation of long bone fracture, and 18 Required and 16 Highly Recommended elements for CAP evaluation of isolated skull fracture. CONCLUSIONS: This guideline reflects expert consensus and provides a starting point for development of child abuse assessment protocols for quality improvement or research. Additional research is required to determine whether this guideline can reduce variability and/or improve reliability in the evaluation and diagnosis of child physical abuse.

Longitudinal Experiences of Children Remaining at Home after a First-Time Investigation for Suspected Maltreatment

Objective. To describe the experience of general pediatricians in weaning bronchiolitis patients, treated as outpatients, from oxygen. Methods. The authors surveyed members of the American Academy of Pediatrics’ Council on Community Pediatrics regarding management of outpatient oxygen for bronchiolitis. Results. The survey had 214 (28.4%) responses from pediatricians, of whom 172 (80.3%) practiced outpatient pediatrics. Among those, 27 (15.7%) cared for bronchiolitis patients discharged on oxygen. Pediatricians managing home oxygen practiced at higher altitude (5000 vs 339 ft, P < .001). No clear weaning protocol was reported. Over half (61.5%) of the pediatricians managing home oxygen acknowledged difficulty in deciding when to stop oxygen. A median of 2 (interquartile range [IQR] = 2-2) outpatient visits and 6 (IQR = 4-7) outpatient days on home oxygen were needed prior to oxygen discontinuation. Conclusion. Pediatricians are not routinely managing home oxygen for hypoxic bronchiolitis patients. Variable weaning process, difficulties in determining oxygen stoppage, multiple follow-up visits, and prolonged home oxygen usage highlight the need to evaluate the impact of this emerging practice.

Social Intuition and Social Information in Physical Child Abuse Evaluation and Diagnosis

OBJECTIVE To describe longitudinal change in risk for children remaining at home following a first-time investigation for suspected maltreatment. STUDY DESIGN A retrospective cohort study of children remaining at home following first-time investigation for maltreatment using a nationally representative sample of households involved with Child Protective Services. Outcomes include poverty, social support, caregiver depression, intimate partner violence (IPV), drug/alcohol dependence, corporal punishment, and child behavior problems at baseline, 18, and 36 months following first-time Child Protective Services investigation. We present longitudinal models to (1) estimate prevalence of risk factors at each timepoint; and (2) examine associations between risk-specific service referrals and longitudinal change in risk factor prevalence. RESULTS Our sample represented 1057056 US children remaining at home following first-time investigation for maltreatment. Almost 100000 (9.2%) children experienced out-of-home placement within 36 months. The prevalence of poverty (44.3%), poor social support (36.3%), caregiver depression (24.4%), IPV (22.1%), and internalizing (30.0%) and externalizing (35.8%) child behavior problems was above general population prevalence at baseline and remained high over the next 36 months. Referral to risk-specific services occurred in a minority of cases, but was associated with significant longitudinal reductions in IPV, drug/alcohol dependence, and externalizing child behavior problems. CONCLUSIONS Children remaining at home following a first-time investigation for maltreatment live with persistent risk factors for repeat maltreatment. Appropriate service referrals are uncommon, but may be associated with meaningful reduction in risk over time. Pediatricians and policy makers may be able to improve outcomes in these families with appropriate service provision and referrals.

Perceived social risk in medical decision-making for physical child abuse: a mixed-methods study

In this prospective study, we explore the role of social intuition and social information in the evaluation and diagnosis of physical child abuse. BACKGROUND: Poor and minority children with injuries concerning for abuse are evaluated and diagnosed for abuse differentially. We hypothesized that 2 steps in the decision-making process would influence evaluation and diagnosis: social intuition from meeting the family and objective social information associated with child abuse risk. METHODS: Between 2009 and 2013, 32 child abuse pediatricians (CAPs) submitted 730 child abuse consultations including original medical evaluations and diagnoses. CAPs evaluated and diagnosed each other’s cases. Comparisons of evaluations and diagnoses were made by levels of social understanding available to the CAP: meeting the family (social intuition and information), reading the case (social information), and reading the case without social information. Evaluations were compared with a consensus gold standard by using logistic regression modeling adjusting for child and CAP characteristics. Diagnostic categories were compared by level of social understanding and diagnostic certainty by using contingency tables. RESULTS: CAPs without access to social intuition were approximately twice as likely to perform gold standard evaluations for neurotrauma and long bone fracture compared with CAPs who met families. Diagnostic agreement fell from 73.3% (95% confidence interval [CI]: 70.1%–76.5%) when social information was present to 66.5% (95% CI: 63.1%–70.0%) when social information was restricted. In cases with less certainty, agreement dropped to 51.3% (95% CI: 46.0%–56.7%). CONCLUSIONS: Social intuition and information play a role in the physical child abuse decision-making process, which may contribute to differential diagnosis. Simple interventions including decision tools, check lists, and peer review may structure evaluations to ensure children’s equal treatment.

Predictors of Screening and Injury in Contacts of Physically Abused Children

BackgroundThe medical literature reports differential decision-making for children with suspected physical abuse based on race and socioeconomic status. Differential evaluation may be related to differences of risk indicators in these populations or differences in physicians’ perceptions of abuse risk. Our objective was to understand the contribution of the child’s social ecology to child abuse pediatricians’ perception of abuse risk and to test whether risk perception influences diagnostic decision-making.MethodsThirty-two child abuse pediatrician participants prospectively contributed 746 consultations from for children referred for physical abuse evaluation (2009–2013). Participants entered consultations to a web-based interface. Participants noted their perception of child race, family SES, abuse diagnosis. Participants rated their perception of social risk for abuse and diagnostic certainty on a 1–100 scale. Consultations (n = 730) meeting inclusion criteria were qualitatively analyzed for social risk indicators, social and non-social cues. Using a linear mixed-effects model, we examined the associations of social risk indicators with participant social risk perception. We reversed social risk indicators in 102 cases whilst leaving all injury mechanism and medical information unchanged. Participants reviewed these reversed cases and recorded their social risk perception, diagnosis and diagnostic certainty.ResultsAfter adjustment for physician characteristics and social risk indicators, social risk perception was highest in the poorest non-minority families (24.9 points, 95%CI: 19.2, 30.6) and minority families (17.9 points, 95%CI, 12.8, 23.0). Diagnostic certainty and perceived social risk were associated: certainty increased as social risk perception increased (Spearman correlation 0.21, p < 0.001) in probable abuse cases; certainty decreased as risk perception increased (Spearman correlation (−)0.19, p = 0.003) in probable not abuse cases. Diagnostic decisions changed in 40% of cases when social risk indicators were reversed.ConclusionsCAP risk perception that poverty is associated with higher abuse risk may explain documented race and class disparities in the medical evaluation and diagnosis of suspected child physical abuse. Social risk perception may act by influencing CAP certainty in their diagnosis.