Dr
Paul Hotton
Vulnerable Child Fellow at Liverpool Hospital
South Western Sydney Local Health District
Dual Trainee in Community Child Health and General Paediatrics
Dr Shanti Raman
Community Paediatrician: Child Protection
South Western Sydney Local Health District
Improving the clinical
assessment of acute
presentations of child
maltreatment using a quality
Child Maltreatment (CM)
Major public health & social-welfare problem
CM associated with:
Child health/developmental problems
Adult mortality and morbidity (cf ACE)
Strong evidence-base for medical examination in the
assessment of CM.
Little known about the health & social outcomes for
Why Clinical Assessments for CM are
Important
Children at risk of abuse/neglect: utilize health services +++
Frontline health services (Emergency Dept. & Paediatrics)
Not ideal venues for acute CM assessments
Screening tools for ED poor evidence base
Good evidence for comprehensive clinical assessment
Clinical guidelines exist for acute CM assessment
South Western Sydney Local Health
District (SWSLHD)
Area of 6,243 square km
Population 919,787
rapidly growing
Culturally & Linguistically
diverse
Many sub-populations with ↑
social risk:
Small & disadvantaged
Aboriginal population
Newly arriving
Acute CM Assessments in SWS
Unique service
Population & Community
responsive
Not a tertiary Paediatric
Hospital Service
Committed to Child & Family
focussed assessment /
management
Community
Paediatrics
Sexual Assault
(SA) Services
Hospital Social
Work
General
Paediatrics
Joint Work
Collaboration
Previous Study Addressing Clinical
Assessments for CM
CM in 2 – 5 % of Paediatric ED presentations
Gaps & good local practice
Aims of the Study
1.
Describe acute presentations of CM in SWS, to one
unique hospital service, during 2013-2014
2.
Identify health & social outcomes for children following
medical assessment
Support or Refute Allegations of CM
Identify support and intervention needs
3.
Determine if the cases fulfil established minimal
standards for clinical assessment of CM.
4.
Identify if acute assessments supports a child rights
Methods
Gathered data from Acute Child Protection Database
(Community Paediatrics & SA)
For all referrals for acute assessment <16 yrs, between 1st
January 2013 - 31st December 2014.
Performed simple descriptive analysis on clinical data.
To identify Health / Social Outcomes
Findings – Types of CM
TYPE OF CM
NUMBER
PERCENTAGE
Physical Assault (PA)
18
9 %
PA + Other CM (excluding SA)
17
8 %
Sexual Assault (SA)
74
36 %
SA + other CM including PA
70
34 %
Neglect
2
1 %
Review of Sibling of Index case
6
3 %
204 cases referred – 187 assessed
Demographics – Age & Gender
TYPE
FEMALE
MALE
SA
85%
15%
NON SA
36%
64%
AGE
GENDER
3
1
Type
Mean Age
Range
SA
9
1 – 16 yrs.
NON SA
4.7
3wk – 13yr
Demographics – Ethnicity
0
5
10
15
20
25
30
35
TOTAL %
SA %
NON SA %
Area
Indigenous
Born Overseas
Middle East
Europe
Asian
SWS
1.7 %
32.7%
15%
8%
12%
NSW
2.5 %
34.2%
-
8%
-
Who Referred?
59%
12%
10%
9%
8%
2%
Joint Investigation
Response Team (JIRT)
Police
Emergency
Community Services (CS)
Paediatricians
Who Assessed?
16%
26%
46%
2%
3%
7%
Community Paediatrics
(CP)
Joint Assessment (CP/SA)
Sexual Assault (SA)
Phone consultation SA
General Paediatricians +
Comm Paeds advice
Phone consultation CP
Types of Examination Done
47%
47%
6%
Forensic
Medical
Refused
46%
54%
Forensic
Medical
Outcome of SA Assessments
OUTCOME
Number
(n = 148)
%
No SA issues
29
20
No SA, other CM concerns
10
7
SA - no injury, CM concerns
21
14
SA - no injury
43
29
SA – injury documented
10
7
SA - confirmed
26
17
Outcome of Non SA Assessments
OUTCOME
Number
(n = 39)
%
No Injury
3
8
Accident
8
20
Unclear
4
10
Inflicted injury
21
54
Other CM
3
8
Outcomes – Social & Family
51 % home with no Child Protection agency involvement
17 % home with Child Protection agency involvement
28 % were placed into Out of Home Care (OOHC)
Some already removed before assessment
46% of Non SA were placed into OOCH
Large proportion had JIRT (Forensic) Investigation
Majority unknown outcome
More Than Just a CM Assessment
58 % of CM assessments lead to other health concerns:
Chronic Medical Conditions
Developmental Delays
Dental Cavities
Hearing and Vision concerns
Behavioural issues
School Difficulties
Mental Health concerns
Minimum Standards Achieved?
MINIMAL STANDARDS (MS)
Results
%
Trained Doctors
187 / 187
100
Social Worker present
179 / 187
95
Protocol used
186 /187
99.5
Report generated
170 / 187
91
Report Counter signed
170 / 170
100
Report in the Medical Records
170 / 170
100
Medical follow up assessment
82 / 187
44
Psychosocial follow up
80 / 187
43
Is the Child in Mind?
After hours
96 % of Out of Hours: SA
Child accompanied by:
28%
72%
OUT of
HOURS
IN HOURS
32%
4%
54%
10%
No Carer
Support
person
Long Term
Carer
Relative
Discussion
Types of CM
70% Acute referral SA related
42% had >2 or more CM issues
17% of cases referred had no CM concerns
Largely due to overcalling SA cases
Neglect – 1% of cases
Other pathways for referrals and assessments
Hard to determine
Discussion
Girls higher risk of CM – 75% compare to 25%
Majority are SA Reflects published data
Ethnicity breakdown
•
Incompletely documented for SA only
•
Aboriginal over representation
Siblings
3% of siblings reviewed as a result of CM in another sibling
SWS has alternative pathways/clinics
Discussion
Health concerns identified in many
Reflects growing international evidence
Identification improved with joint / collaborative assessment
Social Outcomes
Unsure if acute assessments make a difference
Minimum Standards
Overwhelmingly achieved but…Only 44 % had medical follow up
Child Rights
28 % occurred out of hours Forensic need
32 % occurred with no carer/support person
Conclusion
First study of its kind describing acute CM
presentations
Minimum standards for CM assessment
fulfilled in most
Improvements needed in follow up after
acute assessment
Better identification of neglect essential
Difficult to determine how child rights
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