The Effectiveness of Methods Designed to Identify Child Maltreatment in Social and Health Care: A Systematic Review

    

    

    Figure 1:  Data collection and selection procedure for systematic review.
    
    

The databases that were searched included the following: CINAHL, Medline, PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Campbell Library, PsycInfo, ERIC, Applied Social Sciences Index and Abstracts, SocINDEX with Full Text, Social Care Online, ProQuest Dissertations and Theses A&I: The Humanities and Social Sciences Collaboration, Sociological Abstracts, Social Services Abstracts, ProQuestHealth Management, PROSPERO, MEDIC, and MELINDA.

The search for unpublished studies and other materials included Internet searches to find the homepages of child maltreatmentrelated organizations, projects, child protection sites, etc. We also searched for papers that have not been commercially published, such as theses and dissertations, reports, blogs, technical notes, nonindependent research, or other documents produced and published by government agencies, academic institutions, or other groups that are not distributed or indexed by commercial publishers. No relevant studies were found.

The initial key words used were as follows, with the search strategies modified according to the database:

1. child abuse

2. (child*violence or child*abuse or child*maltreatment or child*neglect).mp (mp = title, abstract, original title, name of substance word, subject heading word, keyword heading word, protocol supplementary concept, rare disease supplementary concept, unique identifier)

3. 1 or 2

4. (violence* or physical abuse* or emotional abuse* or psychological abuse*).mp

5. (child* or adolescen*).mp

6. 4 and 5

7. 3 or 6

8. prevent* or interven* or diagnos* or screen* or identif* or recogn* or monitor* or scale* or evaluat* or measur*).mp

9. 7 and 8

10. (impact* or effective* or influen*).mp

11. 9 and 10

12. (systematic review* or controlled trial* or meta-analysis* or quasi-experiments* or before and after*).mp

13. 11 and 12

14. 9 and 12

15. limit 14 to yr=“2003-

Inclusion criteria

The types of participants: This review considered studies that included social welfare and health care settings, as well as other settings that children and their families visit (including child welfare clinics, maternity clinics, schools, kindergartens and day-care centers, physicians’offices, pediatric and adolescent units at hospitals, and child protection) and the professionals who take care of children, adolescents, and their families in those settings (including nurses, public health nurses, school health nurses, physicians, dentists, social workers, kindergarten teachers and other school teachers, physiotherapists, speech therapists, and psychologists). It is obvious that different professionals have very different roles in identifying child maltreatment. However, it is important to examine professionals’ positions together and help them integrate their work to best help children who are being maltreated. All professionals have skills that are useful in multiprofessional collaboration, and they can learn from each other. Children up to 18 years of age and their families were also considered the participants.

The types of interventions: This review considered studies that evaluated mechanisms or interventions designed to identify the physical or psychological/emotional abuse and/or neglect of children aged up to 18 years of age, including screening tools,tests,questionnaires, discussions with families, observations, home visits, physical and psychological examinations, diagnostic tools or criteria, risk evaluations, and other kinds of multi-professional work practices targeted at examining and identifying child maltreatment or evaluating the family situation. In addition,training for professionals can be seen as a method for increasing identification.

The types of studies included: This review considered experimental and epidemiological study designs (including Randomized Controlled Trials [RCTs], non-randomized controlled trials, quasi-experiments, before-and-after studies, prospective and retrospective cohort studies, case control studies, and analytical cross-sectional studies) concerning effective methods for identifying physical or psychological/emotional abuse or neglect of children age 0-18 for inclusion.

The exclusion criteria were studies on sexual abuse, therapies, and prevention. Sexual abuse is different in nature from the other types of abuse that are the focus of this review. Including studies of sexual abuse, therefore, would have broadened the scope of this review too greatly.

The types of outcomes included: This review considered studies that included the following outcome measures: the confirmed occurrence of child maltreatment (physical or psychological abuse or neglect), for example, a family’s home circumstances and their living conditions, the diagnosis of physical abuse or the observation of neglect, the effectiveness of multiple professionals’ work, the effectiveness of training, a delay in the physical or mental development of the child, and the risk behaviors of parents (the risk of physically or psychologically abusive or neglectful behavior). “No identification” was also a potential outcome.

In this review, the comparator was the lack of an intervention or the continuance of usual care. Here, “usual care” means that the professionals did not identify maltreatment or its risk. Instead, the professionals simply performed the tasks they usually perform, such as vaccinating children, conducting routine follow-up of the growth and development of a child, taking care of wounds or bruises, etc, without coming to believe that any injuries present may be the consequence of child maltreatment.

The broad database search of the literature yielded a total of 2,726 potentially relevant papers. After 981duplicates were excluded, 1,745 papers were left. After the titles and abstracts were reviewed, 1,351 papers were excluded. Three hundred and ninety-four full-text papers were retrieved for further review because additional reading was needed to determine whether the paper met the inclusion criteria. After the full-text papers were reviewed, 385 were excluded because they did not meet the inclusion criteria. Many of those studies seemed very promising at first, but after they were carefully read and evaluated, they usually only defined or described an intervention, without evaluating its impact. A total of nine papers were appraised for methodological quality. Figure 1 outlines the stages of the process used to identify relevant studies for inclusion in this systematic review.

Before being included in the review, the papers selected were assessed by two independent reviewers for methodological validity using standardized critical appraisal instruments from the Joanna Briggs Institute [17]. Based on this assessment, the RCT studies received 6 or 7 points out of 10, the case-control studies 5, 6, or 8 out of 9, and the descriptive studies from 4 to 7 out of 9 (Table 1). Any disagreements that arose between the reviewers were resolved through discussion.

Data analysis

Data were extracted from the papers in a narrative form and are presented as follows in the text and in Table 1. The extracted data included specific details about the study’s aim, methods, and results. The data were analyzed by extracting the content that was suitable given the aim of this review. The data were extracted by metaaggregation meaning presenting details of the included studies in a narrative form. After that, the synthesis was made by combining the similar results in themes. After that they are described in the results section.

Results

The results are presented under four themes: identifying physical abuse, the use of screening tools, multiprofessional working practices and education concerning the identification.

Identifying physical abuse

Barsness et al [18] explored rib fractures. Lindberg et al [19] explored hepatic transaminases in evaluating abdominal injuries. Pierce et al [20] explored bruises as markers of physical abuse. According to Barsness et al. [18], rib fractures in a child under 3 years of age should be investigated thoroughly. The predictive value of a rib injury as an indication of child maltreatment was 95%. Lindberg et al [19] showed that children evaluated for physical abuse with transaminase levels >80 IU/L should undergo definitive testing for abdominal injury. This provides further support for demonstrating abdominal injury in child physical abuse cases.

Use of screening tools

Pierce et al [20] provided an evaluation method for discriminating between abusive bruises and accidental trauma. The body regionand age-based bruising clinical decision rule model functions as a clinically sensible screening tool with which to identify young children who require further evaluation for abuse. Any bruises on an infant or bruises on the torso, ears, or neck of a child under 4 years old should be investigated.

Louwers et al [15] studied a screening tool developed especially for use in emergency care to identify physical child abuse. A screening checklist (the Escape Form) used by Emergency Department (ED) nurses during triage provides a potentially effective screening instrument for identifying physical child abuse in EDs. The systematic use of the checklist encouraged the detection of child maltreatment: The number of detected cases grew fivefold (0.5% vs 0.1%, p<.001) after the checklist was introduced. The use of the checklist was supported with training sessions.

Chan [21] developed and evaluated a screening tool, The Child Abuse Risk Assessment Scale (CARAS) for assessing child abuse risk. According to Chan [21], although several scales have been developed to measure child maltreatment risk, none has been shown to be valid in all situations (see also Bailhache et al [12]). CARAS provides a possible tool for measuring such risks.

Multiprofessional working practices

McKeown [22] and Wills et al [23] provided evidence of the importance of the development of multi-professional services when identifying child maltreatment. McKeown [22] studied interagency cooperation between services for children and families and concluded that an effective and inclusive inter-agency process is important in developing multi-professional services, as Wills et al [23] also concluded. Especially when policies, organizational changes, interagency cooperation, and effective leadership are developed as a process, they have an impact on child maltreatment identification.

Education concerning the identification

Dubowitz et al [24] and Smeekens et al [25] studied how educating staff influences their attitudes, knowledge, and skills concerning the identification of child maltreatment. Dubowitz et al [24] developed. The Safe Environment for Every Child (SEEK) Model, which includes education for staff and a checklist. According to Dubowitz et al [24], educating staff about such crucial issues as the risk factors for child maltreatment improves staff attitudes, knowledge, and skills in identifying child maltreatment. Improvements in identifying child maltreatment were observed in self and group evaluations. According to Smeekens et al [25], even a two-hour e-learning session for staff based on a clear checklist concerning the identification of child maltreatment (called SPUTOVAMO) has a clear impact on staff knowledge and skills, especially in addressing and handling risks such as stress, alcohol use, and violence. The SPUTOVAMO checklist is an acronym composed of the first letters of nine questions regarding the injury. The outcomes were long-lasting (36 months).

Discussion

Compelling evidence for methods for investigating rib fractures [18], bruises [20], and abdominal injuries [19] is available. The focus, according to previous studies included in this systematic review, has been on identifying child physical abuse. Child physical abuse causes perhaps clearer signs compared to emotional abuse of neglect. It seems that it is somewhat easier to define criteria concerning the diagnosis or identification of physical child abuse than other forms of maltreatment. Emotional or psychological abuse and neglect need further research, such as on how they are defined or identified.

Various instruments have been developed, and they are quite promising, especially when used in EDs [15,25] or risk assessment [21]. The efficacy of the instruments may depend on, for example, personal, professional, cultural, educational, and environmental issues. Testing different instruments in different contexts may be problematic because the backgrounds of the children, families, professionals, and interventions vary. However, the efficacy and sensitivity of the instruments should be tested in different countries, cultures, and contexts.

The results of the review support the conclusion that promising results indicate that health and social service providers can be effectively equipped to help them address maltreatment risk factors in families, increase the identification of maltreatment, and decrease the occurrence of maltreatment [24]. Child maltreatment should also be investigated more thoroughly in relation to other forms of family violence, especially intimate partner violence [6]. It is also crucial, according to Munro [26], to educate professionals in various fields so that they can better understand their roles in joint work and respect one another, especially in terms of taking others’ knowledge of the situation of a child seriously.

Focusing on effective mechanisms or interventions designed to identify child maltreatment seemed to have an impact on the small number of studies that could be included in this systematic review. This also may be because the sensitive issue of identifying child maltreatment is difficult to measure from the perspective of effectiveness. This systematic review did not find an effective, pivotal, and unambiguous instrument with which to identify child maltreatment. Therefore, perhaps it is not possible to solve the problem of identifying child maltreatment with one mechanism or tool. We need several mechanisms to be able to identify different combinations of child maltreatment, in several contexts where children and their families stay and visit. Forms of child maltreatment integrate, also with other forms of family violence, as Intimate Partner Violence (IPV) [6].

Implications for practice

Strong evidence is available concerning identifying rib fractures [18], bruises [20], and abdominal injuries [19] caused by physical child abuse. CARAS [21], the SEEK model [24], the bruising characteristics rule model [20], the Escape Form [15], and SPUTOVAMO-R [25] were shown to be simple, sensitive, empirically valid, user-friendly assessment tools for identifying child maltreatment or children or families who are at risk. Systematic screening, especially in EDs, proved to be effective in increasing the detection of suspected child abuse. These instruments may help especially health and social care professionals, but also day-care staff, and others who deal with children to address psychological, social, and psychosocial problems; issues of development; and safety-jeopardizing issues in the growth environments of children.

Improved multi-professional work, communication, and inter-agency processes, including the policy environment and data exchange, are needed. Multi-professional teams should work to deliver outcomes instead of services. The instruments should be practical, highly generalizable, non-stigmatizing, and user-friendly and should not label the children and their families. The instruments should be used while working with families, as a basis for starting discussions with families concerning their life situations. Enhancing the attitudes, knowledge, comfort, competence, and behavior of multi-professional staff is fundamental, in decreasing barriers to collaboration with families [3], at home and clinic visits.

Training in identifying child maltreatment, such as e-learning and case simulations, is effective in decreasing barriers between different professionals in dealing with child maltreatment issues. When professionals have more knowledge about child protective service procedures, these professionals have a better understanding of what happens in cases of maltreatment. Training should be made available to health care professionals, teachers, social workers, and others who deal with children and their families. It should also be included in practitioners’ basic and further training. A legal requirement and staff training are recommended to significantly increase the extent of screening [4,7,15].

Improvements in education regarding interventions into and the documentation of maltreatment and staff training are needed. It is important to develop an instrument for the early identification of cases in which there is a high risk of significant mortality [12,27].

Effective and inclusive inter-agency processes are necessary but not sufficient for improving high-quality child services, including systematic screening; reflective inter-agency and interpersonal processes, procedures, and practices; and training. Guidelines and national policy implementation are needed [4]. However, it is worth remembering that outcomes also depend on the target group (e.g, the capacity of the professionals to be effective helpers and supporters) [22].

The continuum of commitment, enrollment, and compliance with the use of guidelines among staff should be encouraged by their superiors and by clarifying staff members’ roles in inter-agency work [1,2]. Effective leadership is urgently needed in this regard. Anticipating resistance and developing strategies with which to identify enablers are critical to success. Organizational and personal barriers should be identified and overcome. Joint documentation systems in health and social care should be developed [1,2].

The implications for research

Additional development work and the testing of various instruments and methods are needed in various contexts and cultures [16]. These promising instruments should be further tested, including from a cost-effectiveness point of view. Sensitive topics, such as child maltreatment research, usually involve many limitations and biases. RCTs are especially needed and should be planned carefully. The further testing of screening tools in clinical use is needed [28,29]. Action research methodologies could be also useful, especially in developing identification and care practices.

Additional studies and further evaluation, testing, and validation in various clinical settings and contexts are needed. These studies should focus on the validation of screening instruments for child abuse identification. The wider implications of e-learning programs in various contexts and cultures should be evaluated.

Conclusion

Very promising identification mechanisms and tools were found concerning some central features of child maltreatment. These tools can be used to evaluate the situation of a child and his or her family. However, none of these tools provides a total or pivotal method for identifying child maltreatment because it is a complex issue. There remains the need to integrate different mechanisms for increasing systematic identification.

Acknowledgement

The authors wish to express their warmest gratitude and thanks to Information Specialist PiaPörtfors, National Institute for Health and Welfare who created the search strategy plan with the authors and conducted all the searches with the utmost expertise. We are also very grateful for the support of the Finnish Centre for Evidence-based Health Care, Nursing Research Foundation (NRF/HOTUS) during the process of writing the national guideline “Efficient methods for identifying child maltreatment in social and health care (2015).”

References

1. Paavilainen E, Helminen M, Flinck A, Lehtomäki L. How Public Health Nurses Identify and Intervene in Child Maltreatment Based on the National Clinical Guideline. Nurs Res Pract. 2014; 7.
2. Suzuki K, Paavilainen E, Helminen M, Flinck A, Hiroyama N, Hirose T, et al. Identifying and Intervening in Child Maltreatment and Implementing Related National Guidelines by Public Health Nurses in Finland and Japan. Nurs Res Pract. 2017; 2017.
3. Paavilainen E, Lepistö S, Flinck A. Ethical Issues in Family Violence Research in Health Care Settings. Nurs Ethics. 2014; 21: 43-52.
4. WHO. INSPIRE.
5. Appleton J, Glaser D. Suspecting Child Maltreatment. Community Pract. 2009; 82: 34-35.
6. Paavilainen E, Flinck A. Efficient Methods for Identifying Child Maltreatment in Social and Health Care. Finland: Nursing Research Foundation. 2015.
7. Paavilainen E, Flinck A. National Clinical Nursing Guideline for Identifying and Intervening in Child Maltreatment within the Family in Finland. Child Abuse Rev. 2013; 22: 209-220.
8. Gilbert R, Kemp A, Thoburn J, Sidebotham P, Radford L, Glaser D, et al. Recognizing and Responding to Child Maltreatment. Lancet. 2009; 373: 167- 180.
9. Taylor J, Lazenbatt A. Child Maltreatment and High Risk Families. Protecting Children and Young People Series. Edinburgh, Scotland: Dunedin Academic Press. 2014.
10. Konijnendijk A, Boere-Boonekamp M, Fleuren M, Haasnoot M, Need A. What Factors Increase Dutch Child Health Care Professionals’ Adherence to a National Guideline on Preventing Child Abuse and Neglect? Child Abuse Negl. 2016; 53: 118-127.
11. Leppäkoski T, Paavilainen E. Interventions for Women Exposed to Acute Intimate Partner Violence: Emergency Professionals’Perspective. J Clin Nurs. 2013; 22: 2273-2285.
12. Bailhache M, Leroy V, Pillet P, Salmi LR. Is Early Detection of Abused Children Possible?: A Systematic Review of the Diagnostic Accuracy of the Identification of Abused Children. BMC Pediatr. 2013; 13: 202.
13. Kent A, Waller G. The Impact of Childhood Emotional Abuse: An Extension of the Child Abuse Trauma Scale. Child Abuse Negl. 1998; 22: 393-399.
14. Dunne M, Zolotor A, Runyan D, Andreva-Miller I, Choo W, Dunne S. ISPCAN Child Abuse Screening Tools Retrospective Version. Child Abuse Negl. 2009; 33: 815-825.
15. Louwers E, Korfage I, Affourtit M, Scheewe D, van der Merwe M, Vooijs- Moulaert A, et al. Effects of Systematic Screening and Detection of Child Abuse in Emergency Departments. Pediatrics. 2012; 130: 457-464.
16. Harr C, Souza L, Fairchild S. International Models of Hospital Interdisciplinary Teams for the Identification, Assessment, and Treatment of Child Abuse. Soc Work Health Care. 2008; 46: 1-16.
17. The Joanna Briggs Institute. Joanna Briggs Institute Reviewers’ Manual. 2014.
18. Barsness K, Cha E-S, Bensard D, Calkins C, Partrick D, Karrer F, et al. The Positive Predictive Value of Rib Fractures as an Indicator of NonaccidentalTrauma in Children. J Trauma. 2003; 54: 1107-1110.
19. Lindberg D, Shapiro R, Blood E, Steiner R, Berger R. Utility of Hepatic Transaminases in Children with Concern for Abuse. Pediatrics. 2013; 131: 268-275.
20. Pierce M, Kaczor K, Aldridge S, O’Flynn J, Lorenz D. Bruising Characteristics Discriminating Physical Child Abuse from Accidental Trauma. Pediatrics. 2010; 125: 67-74.
21. Chan K. Evaluating the Risk of Child Abuse: The Child Abuse Risk Assessment Scale (CARAS). J Interpers Viol. 2012; 27: 951-973.
22. McKeown K. Inter-agency Cooperation between Services for Children and Families in Ireland: Does it Improve Outcomes? J Child Serv. 2012; 7: 191- 200.
23. Wills R, Ritchie M, Wilson M. Improving Detection and Quality of Assessment of Child Abuse and Partner Abuse Is Achievable with a Formal Organisational Change Approach. J Paediatr Child Health. 2008; 44: 92-98.
24. Dubowitz H, Lane W, Semiatin J, Magder L, Venepally M, Jans M. The Safe Environment for Every Kid Model: Impact on Pediatric Primary Care Professionals. Pediatrics. 2011; 127: 962-970.
25. Smeekens A, Broekhuisen-van Henten D, Sittig J, Russel I, Cate O, Turner N, et al. Successful E-learning Programme on the Detection of Child Abuse in Emergency Departments: ARandomisedControlled Trial. Arch Dis Child. 2011; 96: 330-334.
26. Munro E. Common Errors of Reasoning in Child Protection Work. Child Abuse Negl. 1999; 23: 745-758.
27. Aho AL, Remahl A, Paavilainen E. Homicide in the western family and background factors of a perpetrator. Scand J Publ Health. 2017; 45: 555-568.
28. Lepistö S, Ellonen N, Helminen M, Paavilainen E. The family health, functioning, social support and child maltreatment risk of families expecting a baby. J Clin Nurs. 2017; 26: 2439-2451.
29. Ellonen N, Lepistö S, Helminen M, Paavilainen E. Cross-cultural validation of the Child Abuse Potential Inventory in Finland: Preliminary findings of the study among parents expecting a baby. J Soc Serv. 2017.