Background

Checklists and protocols are used in UK accident and emergency (A&E) departments to screen for physical abuse but information is lacking on the performance of these tests.

Objectives

To determine the effectiveness of screening tests for physical abuse in injured children attending A&E departments in the UK.

Methods

We used a simple decision-analytic model to integrate the findings of nine systematic reviews. We reviewed the incidence of physical abuse, the characteristics of abused and non-abused children attending A&E, and the performance of screening tests for physical abuse that could be universally applied to injured children in A&E. Strategies involved the standard clinical screening assessment combined with a checklist, a community liaison nurse to scrutinise A&E attendance records of all children and discuss findings at a multidisciplinary team meeting, and protocols requiring paediatric assessment of specific groups of children defined by age, type of injury, repeat attendances for injury, child protection registration and whether allocated to social services.

Results

We examined 7383 articles, retrieved 448 papers and included 66 studies, including 11 unpublished studies, in the nine systematic reviews used to inform the parameters for the model. Overall the quality of the studies was poor.

We found consistent evidence that physical abuse affects about 1 in 11 children in the UK each year. The proportion of abused children who require medical attention is small but poorly quantified. We estimated that approximately 1% of all child attendances for injury at A&E are for physical abuse, amounting to just under 1 in 50 of all physical abuse episodes in the community.

We found clear evidence that physically abused children attending A&E are missed but the performance of the clinical screening assessment was poorly quantified. We found no evidence that any test was highly predictive of physical abuse. We found no clear evidence that repeated A&E attendance or type of injury was predictive of physical abuse. Among severely injured children admitted to hospital, those aged under 1 year were more likely to be abused than older children. Evidence that young age was a risk factor for abuse among all injured children attending A&E was inconsistent. There was weak evidence that a community liaison nurse improved the performance of the screening assessment in A&E. We estimated that a strategy involving the standard clinical assessment screen combined with a community liaison nurse would result in referral to social services of about half the physically abused children attending A&E. Given the poor quality of the data, this result is highly uncertain.

The addition of screening protocols to the clinical screening assessment offered only marginal benefits and the number of additional false-positive referrals exceeded the number of additional abused children detected. The benefits of protocols declined as the accuracy of the clinical screening assessment improved. The most effective protocol involved referral of all injured infants and all injured children who were social work active.

Implications for practice

Research recommendations

It was striking how little high-quality research had been generated in the UK compared with North America. Part of the reason may be the lack of electronic databases that allow linkage between social services and health databases. With the current enormous investment in data systems in both arenas in the UK, there is scope for large-scale studies.

1. Well-designed, large-scale studies are required to evaluate the effectiveness of assessments that are currently used in A&E for identifying abused children and initiating appropriate interventions. In particular, the role and effectiveness of the community liaison nurse warrants further research. Investigation is also required into which information obtained from other sources in the community is most effective for informing decisions about management of possible abuse or neglect.
2. Studies are needed to evaluate the feasibility, acceptability and effectiveness of new tests such as direct questioning of school-age children about injuries, assessment of bruising on the head and face, timing of attendance at A&E, assessment of information from the cumulative record of health-care use, and assessment of information from agencies outside health.
3. Monitoring is needed of the incidence of abuse identified by professionals working with children and how this is changing over time. National data on reasons for child protection registration should be extended to referrals to social services and analysed alongside studies of abuse identified by professionals to determine how much is referred.
4. Research is required to investigate the reasons for referral to social services and for completion of the CAF form, subsequent actions and re-referrals. Such a study would be important to gain a more accurate picture of the extent of abuse dealt with by social services, much of which may be labelled under non-abuse categories, or dealt with by information sharing via CAFs without involvement of social services.
5. Periodic local hospital A&E audits of patients with suspected abuse or neglect, actions taken within hospital, and contacts made with other agencies should be encouraged.
6. A working party should be established to determine the research priorities across health, social services, education and police. With the introduction of electronic records in health and social services there will be considerable scope for high-quality large-scale studies based on a combination of routine records and primary data collection. The working group should include expertise in population research and epidemiology, the different service areas and policy priorities and should build on and complement the existing research agenda developed by the Department for Children, Schools and Families. For too long, interventions in child abuse have followed investigations of high-profile cases. A population-based approach is needed to generate high-quality research to underpin the effectiveness of the extremely costly services that exist to address this serious and common condition.

Publication

• Woodman J, Pitt M, Wentz R, Taylor B, Hodes D, Gilbert RE. Performance of screening tests for child physical abuse in accident and emergency departments. Health Technol Assess 2008;12(33). [PubMed: 18992184]

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