RESUMEN
OBJECTIVE: We aimed to refine a natural language processing (NLP) algorithm that identified injuries associated with child abuse and identify areas in which integration into a real-time clinical decision support (CDS) tool may improve clinical care. METHODS: We applied an NLP algorithm in "silent mode" to all emergency department (ED) provider notes between July 2021 and December 2022 (n = 353) at 1 pediatric and 8 general EDs. We refined triggers for the NLP, assessed adherence to clinical guidelines, and evaluated disparities in degree of evaluation by examining associations between demographic variables and abuse evaluation or reporting to child protective services. RESULTS: Seventy-three cases falsely triggered the NLP, often due to errors in interpreting linguistic context. We identified common false-positive scenarios and refined the algorithm to improve NLP specificity. Adherence to recommended evaluation standards for injuries defined by nationally accepted clinical guidelines was 63%. There were significant demographic differences in evaluation and reporting based on presenting ED type, insurance status, and race and ethnicity. CONCLUSIONS: Analysis of an NLP algorithm in "silent mode" allowed for refinement of the algorithm and highlighted areas in which real-time CDS may help ED providers identify and pursue appropriate evaluation of injuries associated with child physical abuse.
Asunto(s)
Maltrato a los Niños , Sistemas de Apoyo a Decisiones Clínicas , Humanos , Niño , Procesamiento de Lenguaje Natural , Maltrato a los Niños/diagnóstico , Algoritmos , Servicio de Urgencia en Hospital , Registros Electrónicos de SaludRESUMEN
BACKGROUND: Child protection teams (CPTs) are established in many countries with an intent to safeguard children at risk for maltreatment. However, the tasks and effectiveness of CPTs in Taiwan and many countries remain unclear. OBJECTIVE: A two-step, descriptive correlational study aimed to explore the implementation status and needs concerning the structure, functions, tasks, and effectiveness of hospital-based CPTs using a self-developed evaluation tool in Taiwan. PARTICIPANTS AND SETTING: Five experts and 10 CPT members were evaluated the psychometric properties of the evaluation tool. The main study participants comprised 153 CPT members in Taiwan in 2020. METHODS: Content validity, factor analysis, test-retest reliability, and internal consistency were used to evaluate the psychometric properties of the instrument. Descriptive and correlational statistics were to describe the implementation status and needs of the structure, functions, tasks, and effectiveness of hospital-based CPTs and their relationships. RESULTS: The psychometric properties of the tool were acceptable and satisfactory. The mean scores for each dimension of CPT implementation status were 2.77-2.93 (potential range 0-4) with the lowest for collaboration (mean = 1.97) and incentive (mean = 1.93). The average need scores for each dimension ranged 7.96-8.12 (potential range 0-10), indicating high needs for each dimension, particularly in support, cohesion, and incentive. The implementation status was significantly, weakly correlated with the needs. CONCLUSIONS: There is a need to further strengthen the structure and function of the CPTs and to improve its implementation in Taiwan. It is important to improve inter-agency collaboration and to establish an incentive mechanism for hospital CPTs. Working closely with community agencies is also needed to provide a good quality of care to the maltreated child and the family.
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Protección a la Infancia , Hospitales , Humanos , Niño , Taiwán , Reproducibilidad de los Resultados , Encuestas y Cuestionarios , Psicometría/métodosRESUMEN
BACKGROUND: Despite the potential efficacy of hospital-based multidisciplinary child protection team (CPTs), research analyzing Japanese CPT databases is scarce. OBJECTIVE: We aimed to describe the characteristics of children and families reported to a CPT in Japan and investigate factors associated with the substantiation of maltreatment. PARTICIPANTS AND SETTING: This retrospective, cross-sectional study took place in a national children's hospital in Japan and included 350 children who were reported to CPTs between April 2014 and March 2018. METHODS: Univariable and multivariable logistic regression analyses were conducted using the CPT database and medical records. RESULTS: Among 350 cases, 33.4 % were substantiated. Children of <6 years of age comprised 73.4 % of the cases. The majority (67.7 %) received an injury-related diagnosis and physical maltreatment was suspected in 68.3 % of cases. In the univariable analysis, older age, a primary diagnosis other than injury, reporting department, psychological maltreatment, witnessing intimate partner violence, maltreatment by relatives other than biological father or mother, developmental disability, emotional/behavioral difficulty or psychological disorder, maternal/paternal psychological difficulty, and maternal history of maltreatment were significantly associated with substantiation. When adjusted for demographic, child and familial factors, a diagnosis other than injury (AOR 2.02, 95 % CI = 1. 11-3.65) and parental psychological difficulties (AOR 2.49, 95 % CI = 1.37-4.55) were independently associated with substantiation. CONCLUSION: Most cases reported to our CPT were young children with an injury-related diagnosis. Substantiation was associated with a diagnosis other than injury and parental psychological difficulties. Further prospective and comprehensive studies are needed to establish universal guidelines for databases of hospital-based CPTs.
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Maltrato a los Niños , Violencia de Pareja , Niño , Femenino , Humanos , Preescolar , Estudios Retrospectivos , Maltrato a los Niños/psicología , Japón/epidemiología , Estudios Transversales , Violencia de Pareja/psicologíaRESUMEN
OBJECTIVE: To describe the components of an approach to the consultation for suspected child physical abuse beyond the history, physical findings, and laboratory and radiographic data. METHOD: Description of both a baseline organizational structure and recommended behaviors. RESULTS: We describe four domains of the approach to the consultation for suspected child physical abuse by child abuse clinicians: (1)components to have in place before a consultation, (2) components of a quality consultation, (3) sharing a final opinion, and (4) inevitable pitfalls. CONCLUSION: In proposing this approach, we aim both to make transparent and spark discussion about the way we work and to answer questions about the role of child abuse clinicians raised by recent interest in this subject by the mass media.
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Maltrato a los Niños/diagnóstico , Abuso Físico , Niño , Humanos , Examen Físico , Derivación y ConsultaRESUMEN
This study aimed to investigate the penetration rate of child protection teams (CPTs) in medical institutions and associations between CPT functions and hospital services. We collected data in October of 2015 from 377 hospitals in Japan offering pediatric organ transplantation. The questionnaire included questions regarding the existence of a CPT, the number of child maltreatment cases discussed and reported per year, CPT functions including 21 items about staffing, manuals, meeting, prevention, education, and collaboration, and the services provided by the hospital. Of the 377 institutions, 122 (32.4%) answered the survey. There were significant associations between CPT functions and the number of pediatric beds (râ¯=â¯.27), number of pediatricians (râ¯=â¯.27), number of outpatients (râ¯=â¯.39), number of emergency outpatients (râ¯=â¯.28), and emergency medical care (pâ¯=â¯.009). In a multiple regression analysis, CPT functions were significantly associated with the number of CPT members, pediatric outpatient numbers, and pediatric emergency outpatient numbers. Japan has no CPT guidelines that outline what CPTs should offer in terms of structure, staffing, functions, and systems. Hospitals with many pediatric and emergency outpatients are expected to play major roles in providing services such as specialty care, intensive care, and education. They are also expected to play a role in detecting and managing child maltreatment, and have, by their own initiative, improved their capacities to achieve these goals.
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Maltrato a los Niños/prevención & control , Servicios de Protección Infantil/estadística & datos numéricos , Grupo de Atención al Paciente/organización & administración , Niño , Maltrato a los Niños/estadística & datos numéricos , Protección a la Infancia/estadística & datos numéricos , Estudios Transversales , Hospitales/estadística & datos numéricos , Humanos , Japón , Cuerpo Médico de Hospitales/estadística & datos numéricos , Pacientes Ambulatorios/estadística & datos numéricos , Grupo de Atención al Paciente/estadística & datos numéricos , Rol Profesional , Encuestas y CuestionariosRESUMEN
BACKGROUND: There have been no previous studies on the adequacy of combined evaluation of possible abusive head trauma cases by frontline medical personnel, hospital-based child protection teams, and child protective services in local districts of Japan. METHODS: We conducted a questionnaire survey of hospitalized patients under 24 months old with a diagnosis of intracranial hemorrhage (ICH) from January 2011 to December 2013. Eleven large-scale general hospitals in Yokohama, Japan were surveyed, which provide centralized inpatient care to moderately-severely ill children. RESULTS: A total of 51 ICH patients were listed from eight hospitals. Median patient age was 7 months, and 84% were younger than 12 months. The most common diagnosis on computed tomography was subdural hematoma (n = 26; 51%). Of a total of 51 cases, 31 (61%) occurred inside the home; the injury scene was unknown in six cases (12%). We reviewed these 37 cases from the viewpoint of evaluation with concern for suspected child abuse. Three out of 37 patients (8%) were not examined for inflicted skin lesions, and skeletal surveys and funduscopy were not conducted in 14 (38%) and 15 (41%), respectively. Thirteen out of 37 cases (35%) were not reported to hospital-based child protection teams and 22 (59%) were not reported to regional child protective services. CONCLUSION: The sociomedical evaluation of possible child abuse appears to be systematically inadequate in Yokohama.
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Maltrato a los Niños , Niño Hospitalizado , Traumatismos Craneocerebrales/etiología , Preescolar , Traumatismos Craneocerebrales/diagnóstico , Traumatismos Craneocerebrales/epidemiología , Femenino , Humanos , Incidencia , Lactante , Japón/epidemiología , Masculino , Estudios Retrospectivos , Encuestas y Cuestionarios , Tomografía Computarizada por Rayos X , Índices de Gravedad del TraumaRESUMEN
BACKGROUND: Medical child abuse occurs when a child receives unnecessary and harmful, or potentially harmful, medical care at the instigation of a caretaker through exaggeration, falsification, or induction of symptoms of illness in a child. Neurological manifestations are common with this type of maltreatment. OBJECTIVES: We sought to review common reported neurological manifestations that may alert the clinician to consider medical child abuse. In addition, the possible sequelae of this form of child maltreatment is discussed, as well as practice recommendations for establishing the diagnosis and stopping the abuse once it is identified. METHODS: A review of the medical literature was conducted regarding the reported neurological presentations of this entity. RESULTS: Neurological manifestations of medical child abuse include false reports of apparent life-threatening events and seizures and reports of induction of symptoms from poisoning. Failure to correlate objective findings with subjective complaints may lead to unnecessary and potentially harmful testing or treatment. This form of child maltreatment puts a child at significant risk of long-term morbidity and mortality. CONCLUSIONS: A wide variety of neurological manifestations have been reported in cases of medical child abuse. It is important for the practicing neurologist to include medical child abuse on the differential diagnosis.
Asunto(s)
Maltrato a los Niños , Síndromes de Neurotoxicidad/fisiopatología , Mal Uso de Medicamentos de Venta con Receta , Niño , Maltrato a los Niños/diagnóstico , Maltrato a los Niños/prevención & control , Humanos , Síndromes de Neurotoxicidad/diagnóstico , Síndromes de Neurotoxicidad/prevención & control , Mal Uso de Medicamentos de Venta con Receta/prevención & controlRESUMEN
OBJECT At presentation, children who have experienced abusive head trauma (AHT) often have subdural hemorrhage (SDH) that is acute, chronic, or both. Controversy exists whether the acute SDH associated with chronic SDH results from trauma or from spontaneous rebleeding. The authors compared the clinical presentations of children with AHT and acute SDH with those having acute and chronic SDH (acute/chronic SDH). METHODS The study was a multicenter retrospective review of children who had experienced AHT during 2004-2009. The authors compared the clinical and radiological characteristics of children with acute SDH to those of children with acute/chronic SDH. RESULTS The study included 383 children with AHT and either acute SDH (n = 291) or acute/chronic SDH (n = 92). The children with acute/chronic SDH were younger, had higher initial Glasgow Coma Scale scores, fewer deaths, fewer skull fractures, less parenchymal brain injury, and fewer acute noncranial fractures than did children with acute SDH. No between-group differences were found for the proportion with retinal hemorrhages, healing noncranial fractures, or acute abusive bruises. A similar proportion (approximately 80%) of children with acute/chronic SDH and with acute SDH had retinal hemorrhages or acute or healing extracranial injures. Of children with acute/chronic SDH, 20% were neurologically asymptomatic at presentation; almost half of these children were seen for macrocephaly, and for all of them, the acute SDH was completely within the area of the chronic SDH. CONCLUSIONS Overall, the presenting clinical and radiological characteristics of children with acute SDH and acute/chronic SDH caused by AHT did not differ, suggesting that repeated abuse, rather than spontaneous rebleeding, is the etiology of most acute SDH in children with chronic SDH. However, more severe neurological symptoms were more common among children with acute SDH. Children with acute/chronic SDH and asymptomatic macrocephaly have unique risks and distinct radiological and clinical characteristics.
Asunto(s)
Hematoma Subdural/diagnóstico , Maltrato a los Niños , Preescolar , Femenino , Hematoma Subdural/etiología , Hematoma Subdural Agudo/diagnóstico , Hematoma Subdural Agudo/etiología , Hematoma Subdural Crónico/diagnóstico , Hematoma Subdural Crónico/etiología , Humanos , Lactante , Recién Nacido , Masculino , Estudios RetrospectivosRESUMEN
Caregiver-fabricated illness in a child is a form of child maltreatment caused by a caregiver who falsifies and/or induces a child's illness, leading to unnecessary and potentially harmful medical investigations and/or treatment. This condition can result in significant morbidity and mortality. Although caregiver-fabricated illness in a child has been widely known as Munchausen syndrome by proxy, there is ongoing discussion about alternative names, including pediatric condition falsification, factitious disorder (illness) by proxy, child abuse in the medical setting, and medical child abuse. Because it is a relatively uncommon form of maltreatment, pediatricians need to have a high index of suspicion when faced with a persistent or recurrent illness that cannot be explained and that results in multiple medical procedures or when there are discrepancies between the history, physical examination, and health of a child. This report updates the previous clinical report "Beyond Munchausen Syndrome by Proxy: Identification and Treatment of Child Abuse in the Medical Setting" The authors discuss the need to agree on appropriate terminology, provide an update on published reports of new manifestations of fabricated medical conditions, and discuss approaches to assessment, diagnosis, and management, including how best to protect the child from further harm.