The economic burden of child maltreatment in the United States and implications for prevention

Exploring the relationship between adverse childhood experiences and HPV vaccination in a national sample of adults

BACKGROUND

Over 60 % of U.S. adults report adverse childhood experience (ACE), which correlate with risky health behaviors and lower utilization of healthcare preventive measures, potentially leading to chronic diseases in later life.

OBJECTIVE

This study investigates the relationship between ACEs and human papillomavirus (HPV) vaccination in a national U.S. adult sample.

PARTICIPANTS AND SETTING

We used data from selected states from the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System collected in years 2019 (Mississippi, South Carolina, and Tennessee), 2020 (Georgia, Mississippi, North Dakota, South Carolina), 2021 (Mississippi), and 2022 (Arkansas) (N = 3578, 4392, 904, and 810, respectively).

METHODS

We conducted descriptive, univariate, and multivariable regression analysis using SAS 9.4. Independent and dependent variables were ACEs and HPV vaccination, respectively.

RESULTS

Individuals with ≥4 ACEs, versus no ACEs, were significantly more likely to report HPV vaccination in 2019, 2020, and 2021 (OR = 1.40, 1.77, 2.80, all p < 0.05 respectively), except in 2022 (OR = 1.54, p = 0.165). In 2019, specific ACE types, emotional abuse, and household mental illness were associated with HPV vaccination, whereas in 2021, emotional abuse, household mental illness, incarcerated household member, and substance abuse in household, and in 2022, emotional abuse was associated with HPV vaccination.

CONCLUSIONS

We found mostly positive association between ACEs and HPV vaccination, particularly in initial three years. However, findings in 2022 were not significant, except for emotional abuse. Diverse patterns in relationship between ACEs and HPV vaccination was observed overtime, highlighting the need for consistency in ACEs and HPV vaccination data collection, including vaccination timing, to better understand the underlying mechanisms and plan for interventions to prevent HPV-related cancers among these populations.

The Barriers to Recognizing and Reporting Child Physical Abuse by Emergency Physicians and Associated Factors

BACKGROUND

Although the reporting rate of child abuse is increasing every year, the child abuse detection rate is 3.81% as of 2019 in Korea, which is significantly lower than that of developed countries for child rights.

OBJECTIVE

We investigated the associated factors with barriers that emergency physicians face in recognizing and reporting cases of child abuse.

METHODS

From May to July 2022, 240 emergency physicians working in the 15 emergency department were asked to participate in the survey via email. The questionnaire included the respondent's basic information, treatment experience for child abuse, reasons for reporting or not reporting, and opinions on measures to increase the reporting rate. We conducted a logistic regression analysis to discern the factors contributing to underreporting.

RESULTS

Seventy-one individuals were included in the analysis, after excluding those who had never encountered suspected cases of child abuse. A multivariable logistic regression was performed with the above variables, and although it was not statistically significant, there was a tendency for workers to report well when working at a pediatric emergency department (odds ratio [95% confidence interval], 3.97 [0.98-16.09]). The primary reason for reporting suspected abuse was the pattern of damage suspected of abuse. The first reason for not reporting suspected abuse was because they were not sure it was child abuse. Respondents answered that to report better, a quick and appropriate response from the police and confidentiality of the reporter were needed.

CONCLUSIONS

Physicians in pediatric emergency departments demonstrated a tendency for more proactive reporting suspected cases of child abuse.

Characteristics and associations of ocular and non-ocular manifestations of shaken baby syndrome

OBJECTIVES

Shaken baby syndrome (SBS), a subset of abusive head trauma, results from non-accidental, violent head shaking. Most survivors suffer permanent neurological sequelae. Accurate diagnosis is imperative and remains challenging. The purpose of this study is to describe ocular injuries and associated neurotrauma in suspected SBS.

METHODS

We retrospectively surveyed the National Trauma Data Bank 2008-2014 for patients ≤ 3 years old admitted for suspected SBS. Statistical analysis was performed with SPSS software. Significance was set at p < 0.05.

RESULTS

Three hundred forty-seven (13.9%) of 2495 patients who were ≤ 3 years old were admitted with abusive head trauma and ocular injuries which resulted from suspected SBS. Most were < 1 year old (87.9%) and male (54.2%). Common eye injuries were retinal hemorrhages (30.5%), eye/adnexa contusion (14.7%), and retinal edema (10.7%). Common neurotrauma were subdural (75.5%), subarachnoid (23.9%), and intracerebral hemorrhage (ICH) (10.4%). Mean (SD) Injury Severity Score was severe, 20.2 (8.2), and Glasgow Coma Score was moderate, 9.2 (12.8). The mortality rate was 16.7%. Retinal hemorrhages were not significantly associated with one type of neurotrauma over others. Ocular/adnexa contusion (OR 4.06; p < 0.001) and commotio retinae/Berlin's edema (OR 5.27; p < 0.001) had the greatest association with ICH than other neurotrauma. Optic neuropathy (OR 21.33; p < 0.001) and ICH (OR 3.34; p < 0.001) had the highest associated with mortality.

CONCLUSIONS

Our study supports previous studies showing that retinal and subdural hemorrhages were the most common ocular injury and neurotrauma in SBS, respectively. However, we did not find a significant propensity for their concurrence. Commotio retinae/Berlin's edema was significantly associated with both intracerebral and subdural hemorrhages.

The impact of SARS-Co-V pandemic on violence against children: one institution's experience

Violence against children (VAC) is a global issue due to its biological, psychological, and social effects. Research in this field is valuable for understanding unknown aspects of VAC and for defining updated intervention strategies. Until now, there have been no clear indications about the possible effects of the SARS-CoV-2 pandemic on VAC. In this study, the authors compared quantitative and qualitative variables of pre-pandemic and pandemic cases evaluated at an Italian center specialized in VAC. The aims were to determine if the cases referred for VAC changed during the pandemic and if there were statistically significant differences in variables' distributions between pre-pandemic and pandemic periods. The referrals during the first 13 months of the 2020 SARS-CoV-2 pandemic were compared to cases referred over 13 months (2018-2019) to the same center. The analysis showed no statistical differences between age distributions and most qualitative variables. A decrease in the number of cases was observed. The comparison of frequency distributions of most variables between pre and post-pandemic samples did not differ. The most important result of the analysis is that the volume of observed VAC cases decreased during the pandemic period, confirming the indications of the scientific literature. It could not be excluded that the decrease was due to the negative impact of the pandemic on the child protection system. The above data could help develop innovative prevention tools and corrective intervention programs for future emergencies.

An evaluation of a trauma-informed educational intervention to enhance therapeutic engagement and reduce coercive practices in a child and adolescent inpatient mental health unit

High-risk behaviours are sometimes encountered in Child and Adolescent inpatient mental health units and can prompt the use of coercive practices to maintain safety. Coercive practices may lead to re-traumatisation of young people and deteriorating therapeutic relationships. Trauma-informed practice (TIP) has successfully reduced coercive practices. While education is identified as foundational to implementation, evaluations of programmes remain minimal. The aim of this study was to explore mental health professionals' views and experiences of a trauma-informed education programme and its likely impact on their approach to practice. Five mental health professionals agreed to participate, four contributed in a focus group and one in an individual interview. Data were analysed thematically using the Braun and Clarke Framework. Three main themes were identified. Firstly, shifting attitudes and perceptions of trauma-informed practice. Participants believed they had developed more compassion towards clients and these attitudes were reflected in their clinical practice. Secondly, challenges associated with trauma-informed practice educational intervention. Staffing issues and shift work made it difficult for participants to attend education sessions regularly. Participants identified barriers to practicing in a trauma-informed manner in the current clinical environment. Finally, the need for interdisciplinary communication and support was identified. Participants saw the need for all professionals, not only nurses, to take responsibility for changing practice, and for stronger support at the organisational level. Trauma-informed practice is crucial to recovery-focused mental health nursing practice. These findings highlight the importance of TIP education and suggest areas for further improvement to enhance positive mental health outcomes for young people.

Population-Level Surveillance of Domestic Assaults in the Home Using the National Emergency Medical Services Information System (NEMSIS)

Violence in the home, including partner violence, child abuse, and elder abuse, is pervasive in the United States. An informatics approach allowing automated analysis of administrative data to identify domestic assaults and release timely and localized data would assist preventionists to identify geographic and demographic populations of need and design tailored interventions. This study examines the use of an established national dataset, the NEMSIS 2019, as a potential annual automated data source for domestic assault surveillance. An algorithm was used to identify individuals who utilized emergency medical services (EMS) for a physical assault in a private residence (N = 176,931). Descriptive analyses were conducted to define the identified population and disposition of patients. A logistic regression was performed to predict which characteristics were associated with consistent domestic assault identification by the on-scene EMS clinician and dispatcher. The sample was majority female (52.2%), White (44.7%), urban (85.5%), and 21-29 years old (24.4%). A disproportionate number of those found dead on scene were men (74.5%), and female patients more often refused treatment (57.8%) or were treated and then released against medical advice (58.4%). Domestic assaults against children and seniors had higher odds of being consistently identified by both the dispatcher and EMS clinician than those 21-49, and women had lower odds of consistent identification than men. While a more specific field to identify the type of domestic assault (e.g., intimate partner) would help inform specialized intervention planning, these data indicate an opportunity to systematically track domestic assaults in communities and describe population-specific needs.

Receipt of parenting, disability, unemployment, and other income support payments in persons aged 16 to 33 years - the associations with child maltreatment

BACKGROUND

Child maltreatment (CM) is a major public health concern with life-long effects. Its impact on income support has rarely been studied.

OBJECTIVE

To examine the association between CM and receipt of income support payments and the budgetary impact for persons 16 to 33 years.

PARTICIPANTS AND SETTING

A South Australian birth cohort, born 1986 to 2004 (n = 339,411).

METHODS

We linked child protection (CP) administrative records with national welfare payment records, ending March 2020. Receipt of income support payments and mean payment amounts were described by CP contact (adjusted for child and family attributes). Budget impact was modelled at the national level.

RESULTS

Adjusted odds ratio (AOR) for receipt of any income support payment was 3.01 (2.95-3.07) for individuals with any CP contact versus no CP contact. Among those receiving any payment, adjusted annualised mean benefit payment was $3754 (US$1446) among individuals with no CP contact, $6262 (US$4,307) in persons with any CP contact, and $9,747 in persons who'd been in OOHC. Cumulative payments modelled from age 16 to 33 years totalled $38,570 (US$26,652) for individuals with no CP contact, and $181,743 (US$125,003) for individuals who'd been in OOHC. Modelled for the Australian population to age 33, the extra cost associated with CP contact added 39 % to the government income support budget.

CONCLUSION

CM is strongly associated with receipt of income support payments. Investment in effective preventive and protective strategies for CP involved children could address this core social determinant of health, while providing budget savings.

Associations between adverse childhood experiences and pain in middle-aged and older adults: findings from the China Health and Retirement Longitudinal Study

OBJECTIVE

Adverse childhood experiences (ACEs) have been associated with a range of adverse health outcomes, with pain being potentially one of them. This population-based cross-sectional study aimed to investigate the associations between Adverse Childhood Experiences (ACEs) and pain in Chinese adults and evaluate whether physical activity and demographic and socioeconomic characteristics modify this associations.

METHODS

Cross-sectional data from the China Health and Retirement Longitudinal Study (CHARLS), were utilized in this study. A total of 9923 respondents with information on 12 ACE indicators and 15 self-reported body pains were included. Logistic regression models were used to assess associations of the ACEs and pain. Modification of the associations by physical activity, demographic and socioeconomic characteristics was assessed by stratified analyses and tests for interaction.

RESULTS

Among the 9923 individuals included in the primary analyses, 5098 (51.4%) males and the mean (SD) age was 61.18 (10·.44) years. Compared with individuals with 0 ACEs, those who with ≥ 5 ACEs had increased risk of single pains and multiple pain. A dose-response association was found between the number of ACEs and the risk of pain (e.g. neck pain for ≥ 5 ACEs vs. none: OR, 1.107; 95% CI, 0.903-1.356; p < 0.001 for trend). In the associations of each body pain with each ACE indicator, most ACE indicators were associated with an increased risk of pain. In addition, physical activity, sociodemographic and socioeconomic characteristics, such as age, sex, educational level, area of residence, childhood economic hardship, did not demonstrate a significant modify on the associations between ACEs and pain.

CONCLUSIONS

These findings indicate that cumulative ACE exposure is associated with increased odds of self-reported pain in Chinese adults, regardless of adult physical activity, sociodemographic and socioeconomic characteristics.

The effectiveness of interventions to prevent and reduce child maltreatment in high-income countries: An umbrella review

BACKGROUND

In recent decades, many interventions targeting the occurrence (primary prevention) or the recurrence (secondary prevention) of child abuse and neglect have been tested. Findings have been synthesized in several meta-analyses and systematic reviews. However, the range of interventions addressed in these studies is very broad, and an integrative assessment of this large spectrum is lacking.

OBJECTIVE

Focusing on high-income countries, we ask (i) what is known about the effectiveness of interventions to prevent or reduce child abuse and neglect and (ii) how robust this evidence is.

METHODS

A systematic review of systematic reviews, called an umbrella review, was conducted. Ten databases on OvidSP and Web of Science were searched up until April 2023. Narrative synthesis was used to document the publications' findings.

RESULTS

44 publications were included in the umbrella review. We did not find that any type of intervention had a clear, consistent, and robust track record of preventing or reducing the occurrence of child abuse and neglect. Rather, publications examining the effectiveness of interventions in all areas frequently reported non-existent, small or inconsistent effects. However, positive effects for particular interventions in specific settings did emerge. Research methodologies showed several and often severe problems.

CONCLUSIONS

We suggest several measures to improve the quality of research and call on practitioners to be persistent in developing more effective interventions.

Effect of Routine Child Physical Abuse Screening Tool on Emergency Department Efficiency

OBJECTIVES

Physical abuse is a significant cause of morbidity and mortality for children. Routine screening by emergency nurses has been proposed to improve recognition, but the effect on emergency department (ED) workflow has not yet been assessed. We sought to evaluate the feasibility of routine screening and its effect on length of stay in a network of general EDs.

METHODS

A 2-question child physical abuse screening tool was deployed for children <6 years old who presented for care in a system of 27 general EDs. Data were compared for the 6 months before and after screening was deployed (4/1/2019-10/2/2019 vs 10/3/2019-3/31/2020). The main outcome was ED length of stay in minutes.

RESULTS

There were 14,133 eligible visits in the prescreening period and 16,993 in the screening period. Screening was completed for 13,404 visits (78.9%), with 116 (0.7%) screening positive. The mean ED length of stay was not significantly different in the prescreening (95.9 minutes) and screening periods (95.2 minutes; difference, 0.7 minutes; 95% CI, -1.5, 2.8). Among those who screened positive, 29% were reported to child protective services. On multivariable analysis, implementation of the screening tool did not impact overall ED length of stay. There were no significant differences in resource utilization between the prescreening and screening periods.

CONCLUSIONS

Routine screening identifies children at high risk of physical abuse without increasing ED length of stay or resource utilization. Next steps will include determining rates of subsequent serious physical abuse in children with or without routine screening.

Incidence of child maltreatment diagnosis in electronic health records of a large integrated healthcare system: 2001-2018

The purpose of this study was to identify the number of children (<18years old) with an International Classification of Disease (ICD) diagnosis code for child maltreatment each year from 2001-2018 and examine differences by age, gender, and race/ethnicity. Data were drawn from the electronic health records of children (birth to <18years old) who were members of a large integrated healthcare system in California. We calculated the incidence rate (1 per 1000 children) for each year from 2001-2018 separately by age groups, gender, and race/ethnicity. Adolescents (11-15years old) had the overall highest incidence of all ages groups. Females had nearly twice the rate of males for the past 5years. Lastly, for race/ethnicity Black children had the highest incidence and Asian children the lowest. The findings demonstrate that maltreatment diagnosis in medical settings may be underused. Understanding the trends of these ICD codes by demographic characteristics yields information that health care providers may use to both increase the identification and documentation of child maltreatment.

Linking child adjustment difficulties with mother's maladaptive parental behavior: The mediating roles of parental cognitions and parenting stress

Child abuse is prevalent worldwide, with most of the burden in developing countries. To reduce and prevent child abuse occurrence, many efforts are directed toward reducing maladaptive parental behaviors (MPBs), a predictor of parents' risk of engaging in child abusive behaviors. MPBs have been associated with child (e.g., behavioral difficulties) and parent characteristics (e.g., parenting stress and parental cognitions), although little research tested for mediational pathways. This study aimed to test the pathways through which child and parent characteristics are linked to MPB. Consistent with the social information processing model of parenting, we hypothesized that child behavioral difficulties would exert an indirect influence on MPB through parenting stress and that parenting stress will exert a direct and indirect effect on MPB through parental cognitions (i.e., expectations, attitudes, and attributions). This study used data from 243 mothers of children aged between 2 and 9 years in Romania. Two-stage structural equation modeling was employed to test the hypothesized model. Results support the role of child behavior, parenting stress, and parental cognitions in predicting MPB (R2 = 0.69). Significant indirect effects were found from child behavior to MPB via parenting stress and parental cognitions. Direct effects from parenting stress and parental cognitions to MPB were significant. Findings show that parenting stress and parental cognitions are important mechanisms through which child behavioral difficulties influence maladaptive parental behavior, underscoring the need to focus on these mechanisms when assessing or intervening with families at risk for child abuse.

Early identification and awareness of child abuse and neglect among physicians and teachers

BACKGROUND

Child abuse and neglect (CAN) causes enormous suffering for those affected.

OBJECTIVE

The study investigated the current state of knowledge concerning the recognition of CAN and protocols for suspected cases amongst physicians and teachers.

METHODS

In a pilot study conducted in Mecklenburg-Western Pomerania from May 2020 to June 2021, we invited teachers and physicians working with children to complete an online questionnaire containing mainly multiple-choice-questions.

RESULTS

In total, 45 physicians and 57 teachers responded. Altogether, 84% of physicians and 44% of teachers were aware of cases in which CAN had occurred in the context of their professional activity. Further, 31% of physicians and 23% of teachers stated that specific instructions on CAN did not exist in their professional institution or that they were not aware of them. All physicians and 98% of teachers were in favor of mandatory training on CAN for pediatric residents and trainee teachers. Although 13% of physicians and 49% of teachers considered a discussion of a suspected case of CAN to constitute a breach of confidentiality, 87% of physicians and 60% of teachers stated that they would discuss a suspected case with colleagues.

CONCLUSION

Despite the fact that a large proportion of respondents had already been confronted with suspected cases of CAN, further guidelines for reporting procedures and training seem necessary. There is still uncertainty in both professions on dealing with cases of suspected CAN.

Association between adverse childhood experiences and self-reported health-risk behaviors among cancer survivors: A population-based study

AIMS

Existing evidence shows that people who report Adverse Childhood Experiences (ACEs) are more likely to exhibit health-risk behaviors. However, limited research on this topic pertains to oncology population. We aim to address this knowledge gap by estimating the prevalence of ACEs and investigating their association with self-reported health-risk behaviors among adult cancer survivors living in the U.S.

METHODS

We conducted a secondary analysis using cross-sectional data from the 2021 Behavioral Risk Factor Surveillance System ACE module. We included 4,126 adults, aged ≥18 years, with a history of cancer. The outcome variable was self-reported health-risk behaviors, which included cigarette smoking, e-cigarette use, and binge alcohol drinking. Self-reported ACEs history was the primary independent variable, comprised of 11 questions regarding child abuse and dysfunctional households. We conducted descriptive statistics and multivariable logistic regression to describe the relationship between the ACE history and health-risk behaviors.

RESULTS

Overall, 84.2% of cancer survivors self-reported as White, 58.4% were women, and 76.6% were aged 65+ years. Nearly two-thirds of the sample (63.2%) self-reported at least one ACE (prior to age 18) and 21.7% engaged in ≥1 health-risk-behaviors, such as cigarette smoking, binge alcohol drinking, or e-cigarette use. Experiencing ≥3 ACEs was associated with 145% increased odds of reporting at least one health-risk behavior (OR = 2.45, 95% CI [1.78-3.38]) when compared to those without a history of ACEs. Besides, survivors who were younger, divorced, less educated, and had low income had higher odds of reporting at least one health-risk behavior.

CONCLUSIONS

Overall, a history of ACEs is associated with health-risk behaviors. These all can negatively impact cancer survivors' overall well-being. Early screening for ACE during oncologic visits can be a protective measure for preventing health-risk behaviors among cancer survivors.

Protective role of informal social support and early childhood programs in reducing likelihood of subsequent reports of child maltreatment

BACKGROUND

While past research has suggested the importance of informal social support and early childhood programs for the well-being of child welfare supervised families and children, little is known about whether or not these mechanisms function as protective factors for child welfare involved families and mediate the likelihood of repeat child maltreatment.

OBJECTIVE

The study examined the role of informal social support and early childhood program participation in mediating the effects of initial report of child neglect on subsequent child maltreatment reports.

PARTICIPANTS & SETTING

The study sample of children ages 0-6 (N = 1963) was drawn from the NSCAW-II dataset, a nationally representative longitudinal dataset of 5872 child welfare supervised children and their families.

METHODS

Structural Equation Modeling was used to examine the direct and indirect pathways: from initial report of neglect to all subsequent child maltreatment reports and from initial report of neglect to all subsequent child maltreatment reports through mediating variables such as informal social support and early childhood programs.

RESULTS

Results showed that informal social support plays an important role in reducing the likelihood of subsequent reports (b = -0.00, p = 0.005). One unit increase in informal social support reduced the odds of a child maltreatment re-report by 0.3 % (odds ratio for informal social support OR = 0.997).

IMPLICATIONS

It is important that child welfare supervised families are supported in enhancing their informal networks with their family members and friends and expanding non-familial informal networks in the community.

Systematic Review of Per Person Violence Costs

INTRODUCTION

Data on the long-term and comprehensive cost of violence are essential for informed decision making regarding the future benefits of resources directed toward violence prevention. This review aimed to summarize original per-person estimates of the attributable cost of interpersonal violence to support public health economic research and decision making.

METHODS

In 2023, English-language peer-reviewed journal articles published in 2000-2022 with a focus on high-income countries reporting original per-person average cost of violence estimates were identified using index terms in multiple databases. Study contents, including violence type (e.g., adverse childhood experiences), timeline and payer cost perspective (e.g., hospitalization event-only healthcare payer cost), and associated per-person cost estimates, were summarized. Costs were in 2022 U.S. dollars.

RESULTS

Per-person cost estimates related to adverse childhood experiences, community violence, sexual violence, intimate partner violence, homicide, firearm violence, youth violence, workplace violence, and bullying from 73 studies (majority focusing on the U.S.) were summarized. For example, among 23 studies with a focus on adverse childhood experiences, monetary estimates ranged from $390 for adverse childhood experience-related annual healthcare out-of-pocket costs per U.S. adult with ≥3 adverse childhood experiences to $20.2 million for the lifetime societal economic burden of a U.S. child maltreatment fatality.

CONCLUSIONS

This review provides a descriptive summary of available per-person cost of violence estimates. Results can help public health professionals to describe the economic burden of violence, identify the best available estimate for a particular public health question, and address data gaps. Ultimately, understanding the long-term and comprehensive cost of violence is necessary to anticipate the economic benefits of prevention.

Child Health Needs and the Child Abuse Pediatrics Workforce: 2020-2040

Child abuse pediatrics (CAP) subspecialists evaluate, diagnose, and treat children when abuse or neglect is suspected. Despite the high rates of child maltreatment across the United States, CAP remains the smallest pediatric subspecialty. The CAP workforce faces numerous challenges, including few fellows entering the field, decreased financial compensation compared with other fields of medicine, and threats to workforce retention, including secondary trauma and harmful exposure in the media. A microsimulation model that estimates the future of the US CAP workforce over the next 20 years shows that, although the number of child abuse pediatricians in the field is expected to increase, the growth is smaller than that of every other pediatric subspecialty. In addition to the low overall CAP workforce in the United States, other workforce issues include the need to increase CAP subspecialists who are underrepresented in medicine and unequal geographic distribution across the country. To meet the medical needs of suspected victims of maltreatment, especially in CAP-underserved areas, many children are evaluated by providers who are not board-certified in CAP, such as general pediatricians, family medicine physicians, emergency medicine physicians, and advanced practice providers, whose CAP experience and training may vary. Current child abuse pediatricians should continue introducing the field to medical students and residents, especially those who identify as underrepresented in medicine or are from CAP-underserved areas, and offer mentorship, continuing education, and oversight to non-CAP physicians meeting this population's medical needs.

Sex Stereotypes and Child Physical Abuse: Mediating Effects of Attitudes on Beliefs about Consequences for Abusive Parents

We hypothesized that (a) sex stereotypes would influence individuals' attitudes toward and beliefs about physically abusive parents and (b) these attitudes would mediate the connection between sex stereotypes and beliefs. Participants read one of four scenarios in which (a) sex of parents and sex of children were systematically varied while (b) holding constant the actions of parents and children as well as surrounding circumstances. Participants then expressed their attitudes about those parents and their beliefs about appropriate consequences for these parents. As expected, participants held more unfavorable attitudes about fathers than mothers and believed lenient consequences were more appropriate for mothers than fathers. Moreover, the linkage between parents' sex and participants' beliefs was mediated by participants' attitudes such that the effects of sex stereotypes on beliefs were all indirect rather than direct. Limitations (e.g., cross-sectional design, sample representativeness) and future directions (e.g., alternative parental and child behaviors, individual differences as moderators) are discussed.

Child Maltreatment as a Risk Factor for Rejection Sensitivity: A Three-Level Meta-Analytic Review

Theoretical and empirical evidence has suggested that child maltreatment victimization is associated with rejection sensitivity. However, empirical evidence on this association is inconsistent. Therefore, this meta-analysis aimed to examine the overall association between child maltreatment and rejection sensitivity, and to investigate variables that may affect the strength of this association. Studies eligible for inclusion were searched in the databases: Web of Science, Science Direct, PubMed, MEDLINE, and China National Knowledge Infrastructure after which relevant studies were coded. Studies were synthesized in advanced three-level meta-analytic models in R. A total of 16 studies (N = 5,335 participants) yielding 41 effect sizes were included. Results showed that child maltreatment is significantly and positively related to rejection sensitivity (mean r = 0.230; p < .001), and to a small extent. Furthermore, this association is stronger for emotional abuse (r = 0.275) than for physical abuse (r = 0.157). It is not affected by the mean age and gender distribution of primary study samples nor by sample type (community sample versus clinical sample). It is concluded that child maltreatment is a risk factor for developing rejection sensitivity later in life. Therefore, interventions for rejection sensitivity should consider potential trauma resulting from prior child maltreatment experiences.

The Association Between Child Maltreatment and Pathological Narcissism: A Three-Level Meta-Analytic Review

Emerging evidence has documented the positive association between child maltreatment and both phenotypes of pathological narcissism (i.e., vulnerable and grandiose narcissism). However, results across these studies are inconsistent. Therefore, the present meta-analysis aimed to examine the extent to which child maltreatment is associated with vulnerable and grandiose narcissism, and whether these associations differed by study or sample characteristics. A systematic literature review was conducted in Web of Science, ScienceDirect, PubMed, Google Scholar, and China National Knowledge Infrastructure. Three-level meta-analyses were performed in R to synthesize the effect sizes. A total of 15 studies (N = 9,141 participants) producing 129 effect sizes were included. Results showed that child maltreatment was positively related to both vulnerable narcissism (mean r = .198; p < .001) and grandiose narcissism (mean r = .087; p < .001), but only to a small extent. Further, the association between child maltreatment and vulnerable narcissism was stronger for neglect (r = .278) than for physical abuse (r = .130). The strength of the association between child maltreatment and grandiose narcissism was larger for samples that were on average younger than 18 years (r = .187) than for samples that were on average older than 18 years (r = .068). Also, the strength of the association was stronger for females than for males. Child maltreatment is a risk factor for developing both vulnerable and grandiose narcissism. Interventions targeting pathological narcissism should be aware of potential trauma resulting from victimization of child maltreatment.

Agent-based simulation and child protection systems: Rationale, implementation, and verification

BACKGROUND AND OBJECTIVE

Simulation models are an important tool used in health care and other disciplines to support operational research and decision-making. In the child protection literature, simulation models are an under-utilized source of research evidence.

PARTICIPANTS AND SETTING

In this paper, we describe the rationale for and the development of an agent-based simulation of a child protection system in the US. Using the investigation, prevention service, and placement histories of 600,000 children served in an urban child welfare system, we walk the reader through the development of a prototype known as OSPEDALE.

METHODS

The governing equations built into OSPEDALE probabilistically simulate the onset of investigations. Then, drawing from empirical survival distributions, the governing equations trace the probability of subsequent interactions with the system (recurrence of maltreatment, service referrals, and placement) conditional on the characteristics of children, their assessed risk level, and prior child protection system involvement.

RESULTS

As an initial test of OSPEDALE's utility, we compare empirical admission counts with counts generated from OSPEDALE. Though the verification step is admittedly simple, the comparison shows that OSPEDALE replicates the empirical count of new admissions closely enough to justify further investment in OSPEDALE.

CONCLUSIONS

Management of public child protection systems is increasingly research evidence-dependent. The emphasis on research evidence as a decision-support tool has elevated evidence acquired through randomized clinical trials. Though important, the evidence from clinical trials represents only one type of research evidence. Properly specified, simulation models are another source of evidence with real-world relevance.

Policies to Reduce Child Poverty and Child Maltreatment: A Scoping Review and Preliminary Estimates of Indirect Effects

This study includes a scoping review of prior studies investigating the effects of policy changes on child poverty rates. It further conducts an empirical analysis to estimate the relationship between child poverty rates and child maltreatment report (CMR) rates, utilizing national county-level data. The study then calculates the indirect effects of policy changes on CMR rates, mediated through child poverty rates, by integrating information from previous studies with its own empirical findings. Among the policy changes explored in prior studies, those related to a child allowance and a fully refundable Child Tax Credit demonstrate the largest indirect effects but also the highest costs. The expansion of in-kinds and near-cash benefits, such as the Supplemental Nutrition Assistance Program benefits and housing vouchers, shows moderate effects with moderate costs. Tax credits like the Earned Income Tax Credit exhibit lower effects and costs when targeted at the lowest earners, and moderate effects and costs for broader expansion. Focused tax credits, such as the Child and Dependent Care Tax Credit, had lower effects and costs, even if made fully refundable. Despite certain limitations, the study's approach yields consistent estimates with a recent simulation study, indicating its potential validity. While some proposed policy changes may seem expensive, implementing them is anticipated to substantially reduce CMR rates, with the benefits outweighing the associated costs. Overall, the findings suggest that addressing child poverty to reduce CMRs is an attractive strategy with numerous potential benefits.

Does a child maltreatment report source predict differences in immediate and subsequent report outcomes?

BACKGROUND

Mandated reporting policies, a core response to the identification of child maltreatment, are widely debated. Currently, there are calls to abolish or scale back these policies to include only certain professionals. These calls warrant evaluation of whether there are any differences in child welfare outcomes based on report source.

OBJECTIVE

To determine if the initial report source predicts immediate and long-term risk of re-referral, substantiation, and placement.

PARTICIPANTS AND SETTING

We used yearly National Child Abuse and Neglect Data System (NCANDS) hotline report and placement data. Children (0-14y) with a first ever hotline report in 2012-2014 were followed for three years. The final sample included 2,101,397 children from 32 states.

METHODS

We use descriptive and bivariate statistics to show initial report outcomes by reporter source type and logistic regression models to evaluate the effect of report source on immediate and subsequent report outcomes.

RESULTS

Professional sources varied in levels of substantiation and placement, with law enforcement, medical, and social service sources showing much higher rates. Reports from professional sources have higher odds of initial report substantiation and foster care entry, and slightly lower odds of later re-report than nonprofessional sources. We found no differences between professional and nonprofessional sources in subsequent foster care entry.

CONCLUSIONS

Reports from professional, nonprofessional, and unclassified sources have varying levels of risk in some of their short- and long-term outcomes. To the degree that child protective services embrace a long-term preventative role, reports by nonprofessional report sources may provide opportunities for prevention.

Initial development of tools to identify child abuse and neglect in pediatric primary care

BACKGROUND

Child abuse and neglect (CAN) is prevalent, associated with long-term adversities, and often undetected. Primary care settings offer a unique opportunity to identify CAN and facilitate referrals, when warranted. Electronic health records (EHR) contain extensive information to support healthcare decisions, yet time constraints preclude most providers from thorough EHR reviews that could indicate CAN. Strategies that summarize EHR data to identify CAN and convey this to providers has potential to mitigate CAN-related sequelae. This study used expert review/consensus and Natural Language Processing (NLP) to develop and test a lexicon to characterize children who have experienced or are at risk for CAN and compared machine learning methods to the lexicon + NLP approach to determine the algorithm's performance for identifying CAN.

METHODS

Study investigators identified 90 CAN terms and invited an interdisciplinary group of child abuse experts for review and validation. We then used NLP to develop pipelines to finalize the CAN lexicon. Data for pipeline development and refinement were drawn from a randomly selected sample of EHR from patients seen at pediatric primary care clinics within a U.S. academic health center. To explore a machine learning approach for CAN identification, we used Support Vector Machine algorithms.

RESULTS

The investigator-generated list of 90 CAN terms were reviewed and validated by 25 invited experts, resulting in a final pool of 133 terms. NLP utilized a randomly selected sample of 14,393 clinical notes from 153 patients to test the lexicon, and .03% of notes were identified as CAN positive. CAN identification varied by clinical note type, with few differences found by provider type (physicians versus nurses, social workers, etc.). An evaluation of the final NLP pipelines indicated 93.8% positive CAN rate for the training set and 71.4% for the test set, with decreased precision attributed primarily to false positives. For the machine learning approach, SVM pipeline performance was 92% for CAN + and 100% for non-CAN, indicating higher sensitivity than specificity.

CONCLUSIONS

The NLP algorithm's development and refinement suggest that innovative tools can identify youth at risk for CAN. The next key step is to refine the NLP algorithm to eventually funnel this information to care providers to guide clinical decision making.

Early predictors for maltreatment-related injuries in infancy and long-term mortality: a population-based study

INTRODUCTION

Incidence, health consequences, and social burden associated with child maltreatment appeared to be borne disproportionately by very young children. We conducted a population-based data linkage study to explore child- and family-level factors that affect receiving different diagnoses of maltreatment injuries and investigate excessive mortality throughout toddlerhood.

METHODS

We conducted a retrospective cohort study comprising 2.2 million infants born in 2004-2014 in Taiwan. Incident cases of child maltreatment were defined by hospitalization or emergency department visits for three heterogeneous diagnostic groups of maltreatment-related injuries (i.e., maltreatment syndrome, assaults, and undetermined causes) within 12 months after birth. The generalized linear model and landmark survival analyses were used to evaluate risk factors.

RESULTS

An estimated 2.9‰ of infants experienced at least one maltreatment-related injury, with a three-year mortality rate of 1.3%. Low birthweight was associated with increased risk of receiving the diagnosis of three maltreatment injuries, particularly maltreatment syndrome (adjusted Incidence Rate Ratio [aIRR] = 4.08, 95% confidence interval [CI]: 2.93-5.68). Socially advantaged family condition was inversely linked with receiving the diagnosis of maltreatment syndrome and assaults (e.g., high income: aIRR = 0.55 and 0.47), yet positively linked with undetermined cause (aIRR = 2.05, 95% CI: 1.89-2.23). For infants exposed to maltreatment, low birth weight and non-attendance of postnatal care were highly predictive of fatality; low birthweight served as a vital predictor for premature death during toddlerhood (aIRR = 6.17, 95% CI: 2.36-15.4).

CONCLUSIONS

Raising awareness of maltreatment-related injuries in infancy and predictors should be a priority for appropriate follow-up assessment and timely intervention.

Caregivers' Perceptions of Child Trauma Symptomatology, Stress, and Child Abuse Disclosures

Caregivers consider child abuse disclosures stressful life events, but research has not investigated whether this stress affects caregiver ratings of child trauma symptomatology. Secondary data from a Child Advocacy Center in the Midwestern United States between the period of January 1, 2018, and April 31, 2019, stepwise logistic regression models, and change in estimate calculations were used to assess (1) the relationship between child abuse disclosure(s) and caregiver stress and (2) the association between caregiver stress disclosure and clinically significant ratings on the Trauma Symptom Checklist for Young Children (TSCYC). While a child's physical abuse disclosure was associated with caregiver stress and caregiver stress was significantly associated with clinically significant ratings for child depression and anger/aggression TSCYC scales, abuse disclosure did not affect the relationship between caregiver stress and TSCYC scale ratings. Moving forward, caregiver-reported stress should be considered when utilizing caregiver-completed child trauma symptom screens.

Associations between childhood maltreatment and physiological dysregulation in adulthood: Methodological decisions and implications

BACKGROUND

Childhood maltreatment is linked with health problems in adulthood. Theoretical models suggest that maltreatment leads to dysregulation in several bodily systems, and this has been corroborated using measures of physiological function (i.e., biomarkers). Methodological decisions involving the measurement of maltreatment and dimension reduction with respect to biomarkers (i.e., combining information across multiple measures) may influence research findings.

OBJECTIVE

The present study compares associations between childhood maltreatment and adult physiological dysregulation using multiple dimension reduction approaches and measures of maltreatment.

PARTICIPANTS AND SETTING

Participants were recruited, as children, to a prospective study of the correlates and consequences of childhood maltreatment. 253 participants were retained and provided biomarker data at midlife. Physiological dysregulation was operationalized with a conventional allostatic load approach and a novel statistical distance approach.

METHODS

Regression models were employed with allostatic load or statistical distance as the outcome and prospectively or retrospectively measured child maltreatment as the primary predictor.

RESULTS

When using allostatic load as the outcome, prospectively measured childhood maltreatment was positively associated with physiological dysregulation (b = 0.70, SE = 0.31, p = 0.02). When using statistical distance as the outcome, retrospectively measured childhood maltreatment was positively associated with physiological dysregulation (b = 0.69, SE = 0.19 p < 0.001).

CONCLUSIONS

We report a positive association between childhood maltreatment and physiological dysregulation at midlife. However, the significance and magnitude of effects varied with different maltreatment and physiological dysregulation measures. Further review of the methods used to study adult health conditions and their relation to childhood maltreatment is needed.

Therapists' Perceived Competence in Delivering Trauma-Focused Cognitive Behavioral Therapy During Statewide Learning Collaboratives

The learning collaborative (LC), a multi-component training and implementation model, is one promising approach to address the need for increased availability of trauma-focused evidence-based practices. The current study used data from four cohorts of a statewide LC on Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) to 1) evaluate pre- to post-LC changes in therapists' perceived competence in delivering TF-CBT and 2) explore therapist and contextual factors related to therapists' perceived TF-CBT competence. Therapists (N = 237) completed pre- and post-LC measures of practice information, interprofessional collaboration, organizational climate, and TF-CBT knowledge, perceived competence, and use. Findings indicated therapists' perceived TF-CBT competence significantly increased, pre- to post-LC (d = 1.31), with greater use of trauma-focused practices at pre-training and more TF-CBT training cases completed predicting greater pre- to post-LC gains in perceived TF-CBT competence. These findings highlight the need to assist therapists in identifying and completing training cases to promote competence and implementation.

Revictimization Risk Factors Following Childhood Maltreatment: A Literature Review

Revictimization research, to date, has primarily focused on sexual revictimization (i.e., child sexual abuse and adult sexual assault), which has resulted in a lack of understanding of trauma revictimization more generally. Specifically, it is unclear what factors are placing individuals with a history of child maltreatment (i.e., sexual abuse, physical abuse, and witnessing intimate partner violence [IPV]) at greater risk for subsequent adult victimization (i.e., sexual assault and IPV). Existing theoretical and empirical work on revictimization suggest that multiple risk factors are likely present within this framework (e.g., posttraumatic stress symptoms [PTSS], emotion dysregulation, and risk-taking behaviors). Prior research has suggested that PTSS are often linked with these other risk factors, and it is possible that the development of PTSS following child maltreatment may be related to the development or maintenance of additional factors that increase the likelihood of revictimization. The purpose of this review was to synthesize findings regarding risk factors that place maltreated individuals at greater risk for adult revictimization. Approximately 228 studies were identified following a thorough search of the peer-reviewed literature using multiple databases (PsycINFO, PILOTS, and Google Scholar). Each study was critically analyzed for relevance. The included studies were used in our review of prevalence, specific risk factors that have been identified, and unanswered questions in this literature. PTSS were noted to be particularly important in the revictimization framework, and thus, a novel model of revictimization was also proposed where PTSS are illustrated as being associated with the development and maintenance of other factors within the revictimization framework.

A Systematic Review on Evaluating Responsiveness of Parent- or Caregiver-Reported Child Maltreatment Measures for Interventions

Aims: Child maltreatment (CM) is a global public health and social problem, resulting in serious long-term health and socioeconomic consequences. As parents are the most common perpetrators of CM, parenting interventions are appropriate strategies to prevent CM. However, research on parenting interventions on CM has been hampered by lack of consensus on what measures are most responsive to detect a reduction in parental maltreating behaviours after parenting intervention. This systematic review aimed to evaluate the responsiveness of all current parent- or caregiver-reported CM measures. Methods: A systematic search was conducted in CINAHL, Embase, ERIC, PsycINFO, PubMed and Sociological Abstracts. The quality of studies and responsiveness of the measures were evaluated using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines for systematic reviews of patient-reported outcome measures. Only measures developed and published in English were included. Studies reporting data on responsiveness of the included measures were selected. Results: Sixty-nine articles reported on responsiveness of 15 identified measures. The study quality was overall adequate. The responsiveness of the measures was overall insufficient or not reported; high-quality evidence on responsiveness was limited. Conclusions: Only the Physical Abuse subscale of the ISPCAN Child Abuse Screening Tool for use in Trials (ICAST-Trial) can be recommended as most responsive for use in parenting interventions, with high-quality evidence supporting sufficient responsiveness. All other overall scales or subscales of the 15 included measures were identified as promising based on current data on responsiveness. Additional psychometric evidence is required before they can be recommended.

The feasibility and utility of trauma screening for children involved in the juvenile justice system

Childhood exposure to potentially traumatic events and adversity is highly prevalent and linked to adverse outcomes. Many children suffering from symptoms related to traumatic stress are not identified or do not receive appropriate trauma-focused treatment, including evidence-based treatments. Trauma screening is a promising strategy to improve identification, but many child-serving staff members have concerns about asking youth and caregivers about trauma. This study aimed to describe staff perceptions about the feasibility, utility, and potential for distress associated with trauma screening. Between 2014 and 2019, the Child Trauma Screen was used in 1,272 trauma screenings completed by juvenile probation officers or mental health clinicians as part of routine practice with youth in the juvenile justice system. Further, 1,190 caregiver reports about youth trauma were completed for youth in the juvenile justice system. Staff completed a brief postscreening survey about the feasibility and utility of the screening and the perceived level of child or caregiver distress. Across staff roles, trauma screening was deemed to be feasible and worthwhile to practice, with very few staff members reporting that children or caregivers appeared very uncomfortable as a result of screening, although some differences in feasibility and utility by staff role did occur. Trauma screening measures appear to be useful and practical in juvenile justice settings when appropriate support is provided, including when administered by nonclinical staff. Nonclinical staff may benefit from additional training, consultation, or support with trauma screening.

Creating an Interdisciplinary Collaborative Network of Scholars in Child Maltreatment Prevention: A Network Analysis of the Doris Duke Fellowships for the Promotion of Child Well-Being

Background

Child maltreatment is a complex problem requiring interdisciplinary collaborative research to generate innovative solutions. The Doris Duke Fellowships for the Promotion of Child Well-Being were designed to identify and nurture emerging scholars committed to child maltreatment prevention and create a supportive interdisciplinary learning network.

Objective

This paper examines connectivity within the collaborative network created by the fellowships program using longitudinal social network data.

Participants and Setting

Participants were 120 individuals selected as Doris Duke Fellows during their doctoral training at universities in the United States.

Methods

Fellows completed annual, voluntary web-based surveys to assess their interactions with other fellows during the past year. Social network analysis methods were used to assess the strength and quality of the learning network over a four-year period.

Results

Across four years of data, there were increases in the number of connections, proportion of cross-cohort connections, and proportion of interdisciplinary connections. Network analyses showed a highly connected network consisting of primarily medium- and high-quality connections between fellows from different disciplines. The number of scientific journal articles authored by two or more fellows grew substantially over time.

Conclusions

Findings indicate the collaborative network created by the fellowships program is growing and strengthening over time. The new Child Well-Being Research Network extends the fellowships network to a broader group of scholars and professionals to advance diversity, equity, inclusion, and justice in the field of child well-being research.

Post-Natal Short-Term Home Visiting Programs: An Overview and a Volunteers-Based Program Pilot

Post-natal home visits have been shown to be one of the most effective ways to prevent child maltreatment and reduce risks among children. Unfortunately, these programs tend to be expensive and thus not accessible or practical in many contexts. To address this problem, this paper reviews the literature on home visits conducted shortly after giving birth, considering different types of programs and their outcomes, while focusing on short-term and volunteer-based programs, two approaches that can answer the gap in accessibility. It then introduces a new, innovative, short-term, home visiting program that was developed in Israel. This post-natal program is uniquely structured as volunteer-based to allow it to be culturally informed and inexpensive and therefore accessible to municipalities. The paper describes how experts in the field developed the program and how the volunteers were trained. It elaborates on the protocol for the three defined home visits, each with a specific focus: (1) preventing risks at home, (2) providing parents with emotional support and tools to deal with stress, and (3) connecting them to community resources. We detail the pilot implementation process and some of the challenges that arise. Finally, we describe the design of the evaluation study that is currently collecting data in an Arab town in the north of Israel, with a final discussion on insights gained thus far from the overall process in light of the literature.

Cohort analysis of child abuse and neglect cases treated during the initial 2 years of a programme to support hospital-based child protection work in Austria

OBJECTIVE

To describe characteristics of suspected child abuse and neglect (CAN) cases associated with the decision of paediatric departments (PDs) in Vienna, Austria, to involve services of a regional tertiary child protection service programme (Forensische Kinder- und JugendUntersuchungsStelle, FOKUS).

DESIGN

Retrospective cohort analysis of a regional data collection of CAN cases over the first 2 years of FOKUS's operational period (1 July 2015-30 June 2017).

SETTING

All CAN cases reported to the PDs of six public hospitals in Vienna. Five of these public hospitals were secondary heath care centres and one was a tertiary healthcare centre.

RESULTS

Overall, 231 cases (59.1%) were treated without and 160 (40.9%) with additional involvement of the FOKUS service programme. The odds of a case to be treated without FOKUS involvement were higher if neglect was suspected (OR 3.233, 95% CI 2.024 to 5.279). In contrast, when sexual abuse was suspected, the odds for involvement with FOKUS were significantly higher (OR 7.577, 95% CI 4.580 to 12.879). The odds of being managed with FOKUS services nearly doubled when multiple forms of abuse were suspected (OR 1.926, 95% CI 1.136 to 3.285). The odds for additional FOKUS involvement were significantly lower for patients treated as inpatients (OR 0.239, 95% CI 0.151 to 0.373). CAN patients managed with FOKUS involvement were significantly more often reported to law enforcement (LE) (OR 3.234, 95% CI 2.078 to 5.002). Concurrently, suspected sexual abuse cases and cases reported to LE were more frequently treated in the PD of the tertiary centre than in other PDs (χ2 p<0.001).

CONCLUSION

CAN case characteristics significantly influenced if PDs involved a tertiary child protection programme. Suspected sexual abuse, if more than one form of CAN was suspected and cases reported to LE required additional specialist expertise. For suspected neglect involvement of tertiary services seemed less important.

Economic evaluations of interventions focusing on child abuse and neglect in high-income countries: a systematic review

Introduction

Child abuse and neglect are together considered to be an important public health problem with a high individual and societal burden. Different interventions have been developed to prevent, diagnose, or treat maltreatment. While their effectiveness has been synthesized in prior reviews, the analysis of their cost-effectiveness is less common. The aim of this study is to synthesize and analyse economic evaluations of interventions focusing on child abuse and neglect in high-income countries.

Methods

A systematic literature review was performed using MEDLINE, EMBASE, EconLit, PsycInfo and NHS EED. This study follows the PRISMA guidelines and double scoring was performed. The review includes trial- and model-based economic evaluations of preventive, diagnostic, and treatment related interventions in children up to 18 years or their caregivers. Risk of bias was assessed using the CHEC-extended checklist. The results are presented in a cost-effectiveness plane.

Results

Of 5,865 search results, the full texts of 81 were analyzed, resulting in the inclusion of 11 economic evaluations. Eight of the included studies focus on prevention of child abuse and neglect, one study on diagnosis, and two on treatment. The heterogeneity between studies did not allow for the quantitative pooling of results. Most interventions were cost-effective, with the exception of one preventive and one diagnostic intervention.

Conclusion

This study was subject to some limitations, as no gray literature was included, and the selection of studies may have been arbitrary due to varying terminologies and methodologies in the field. However, the quality of studies was high, and several interventions showed promising results.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021248485, identifier: CRD42021248485.

Comparative effectiveness of psychological interventions for treating the psychological consequences of sexual abuse in children and adolescents: a network meta-analysis

BACKGROUND

Following sexual abuse, children and young people may develop a range of psychological problems, including anxiety, depression, post-traumatic stress disorder (PTSD), and a range of behaviour problems. Those working with children and young people experiencing these problems may use one or more of a range of psychological approaches.

OBJECTIVES

To assess the relative effectiveness of psychological interventions compared to other treatments or no treatment controls, to overcome psychological consequences of sexual abuse in children and young people up to 18 years of age. Secondary objectives To rank psychotherapies according to their effectiveness. To compare different 'doses' of the same intervention.

SEARCH METHODS

In November 2022 we searched CENTRAL, MEDLINE, Embase, PsycINFO, 12 other databases and two trials registers. We reviewed the reference lists of included studies, alongside other work in the field, and communicated with the authors of included studies.

SELECTION CRITERIA

We included randomised controlled trials comparing psychological interventions for sexually abused children and young people up to 18 years old with other treatments or no treatments. Interventions included: cognitive behavioural therapy (CBT), psychodynamic therapy, family therapy, child centred therapy (CCT), and eye movement desensitisation and reprocessing (EMDR). We included both individual and group formats.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data and assessed the risk of bias for our primary outcomes (psychological distress/mental health, behaviour, social functioning, relationships with family and others) and secondary outcomes (substance misuse, delinquency, resilience, carer distress and efficacy). We considered the effects of the interventions on all outcomes at post-treatment, six months follow-up and 12 months follow-up. For each outcome and time point with sufficient data, we performed random-effects network and pairwise meta-analyses to determine an overall effect estimate for each possible pair of therapies. Where meta-analysis was not possible, we report the summaries from single studies. Due to the low number of studies in each network, we did not attempt to determine the probabilities of each treatment being the most effective relative to the others for each outcome at each time point. We rated the certainty of evidence with GRADE for each outcome.

MAIN RESULTS

We included 22 studies (1478 participants) in this review. Most of the participants were female (range: 52% to 100%), and were mainly white. Limited information was provided on socioeconomic status of participants. Seventeen studies were conducted in North America, with the remaining studies conducted in the UK (N = 2), Iran (N = 1), Australia (N = 1) and Democratic Republic of Congo (N = 1). CBT was explored in 14 studies and CCT in eight studies; psychodynamic therapy, family therapy and EMDR were each explored in two studies. Management as usual (MAU) was the comparator in three studies and a waiting list was the comparator in five studies. For all outcomes, comparisons were informed by low numbers of studies (one to three per comparison), sample sizes were small (median = 52, range 11 to 229) and networks were poorly connected. Our estimates were all imprecise and uncertain. Primary outcomes At post-treatment, network meta-analysis (NMA) was possible for measures of psychological distress and behaviour, but not for social functioning. Relative to MAU, there was very low certainty evidence that CCT involving parent and child reduced PTSD (standardised mean difference (SMD) -0.87, 95% confidence intervals (CI) -1.64 to -0.10), and CBT with only the child reduced PTSD symptoms (SMD -0.96, 95% CI -1.72 to -0.20). There was no clear evidence of an effect of any therapy relative to MAU for other primary outcomes or at any other time point. Secondary outcomes Compared to MAU, there was very low certainty evidence that, at post-treatment, CBT delivered to the child and the carer might reduce parents' emotional reactions (SMD -6.95, 95% CI -10.11 to -3.80), and that CCT might reduce parents' stress. However, there is high uncertainty in these effect estimates and both comparisons were informed only by one study. There was no evidence that the other therapies improved any other secondary outcome. We attributed very low levels of confidence for all NMA and pairwise estimates for the following reasons. Reporting limitations resulted in judgements of 'unclear' to 'high' risk of bias in relation to selection, detection, performance, attrition and reporting bias; the effect estimates we derived were imprecise, and small or close to no change; our networks were underpowered due to the low number of studies informing them; and whilst studies were broadly comparable with regard to settings, the use of a manual, the training of the therapists, the duration of treatment and number of sessions offered, there was considerable variability in the age of participants and the format in which the interventions were delivered (individual or group).

AUTHORS' CONCLUSIONS

There was weak evidence that both CCT (delivered to child and carer) and CBT (delivered to the child) might reduce PTSD symptoms at post-treatment. However, the effect estimates are uncertain and imprecise. For the remaining outcomes examined, none of the estimates suggested that any of the interventions reduced symptoms compared to management as usual. Weaknesses in the evidence base include the dearth of evidence from low- and middle-income countries. Further, not all interventions have been evaluated to the same extent, and there is little evidence regarding the effectiveness of interventions for male participants or those from different ethnicities. In 18 studies, the age ranges of participants ranged from 4 to 16 years old or 5 to 17 years old. This may have influenced the way in which the interventions were delivered, received, and consequently influenced outcomes. Many of the included studies evaluated interventions that were developed by members of the research team. In others, developers were involved in monitoring the delivery of the treatment. It remains the case that evaluations conducted by independent research teams are needed to reduce the potential for investigator bias. Studies addressing these gaps would help to establish the relative effectiveness of interventions currently used with this vulnerable population.

Early childhood maltreatment and profiles of resilience among child welfare-involved children

Given the high burden of child maltreatment, there is an urgent need to know more about resilient functioning among those who have experienced maltreatment. The aims of the study were to: 1) identify distinct profiles of resilience across cognitive, emotional, behavioral, and social domains in young children involved in the child welfare system; and 2) examine maltreatment characteristics and family protective factors in relation to the identified resilience profiles. A secondary analysis was conducted using data from the National Survey of Child and Adolescent Well-Being (NSCAW-II). Latent profile analysis was performed on a sample of 827 children aged 3-5 years (46% girls, Mean age = 3.96). Three distinct resilience profiles were identified: 1) low cognitive resilience (24%); 2) low emotional and behavioral resilience (20%); and 3) multidomain resilience (56%). Caregiver cognitive stimulation, no out-of-home placement, higher caregiver education level, older child age, and being a girl were associated with the multidomain resilience profile. The findings provide empirical support for the multifaceted nature of resilience and suggest that practitioners need to help children achieve optimal and balanced development by assessing, identifying, and targeting those domains in which children struggle to obtain competence.

Using natural language processing to identify child maltreatment in health systems

BACKGROUND

Rates of child maltreatment (CM) obtained from electronic health records are much lower than national child welfare prevalence rates indicate. There is a need to understand how CM is documented to improve reporting and surveillance.

OBJECTIVES

To examine whether using natural language processing (NLP) in outpatient chart notes can identify cases of CM not documented by ICD diagnosis code, the overlap between the coding of child maltreatment by ICD and NLP, and any differences by age, gender, or race/ethnicity.

METHODS

Outpatient chart notes of children age 0-18 years old within Kaiser Permanente Washington (KPWA) 2018-2020 were used to examine a selected set of maltreatment-related terms categorized into concept unique identifiers (CUI). Manual review of text snippets for each CUI was completed to flag for validated cases and retrain the NLP algorithm.

RESULTS

The NLP results indicated a crude rate of 1.55 % to 2.36 % (2018-2020) of notes with reference to CM. The rate of CM identified by ICD code was 3.32 per 1000 children, whereas the rate identified by NLP was 37.38 per 1000 children. The groups that increased the most in identification of maltreatment from ICD to NLP were adolescents (13-18 yrs. old), females, Native American children, and those on Medicaid. Of note, all subgroups had substantially higher rates of maltreatment when using NLP.

CONCLUSIONS

Use of NLP substantially increased the estimated number of children who have been impacted by CM. Accurately capturing this population will improve identification of vulnerable youth at high risk for mental health symptoms.

Child Abuse Pediatrics Research Network: The CAPNET Core Data Project

OBJECTIVE

Examine the epidemiology of subspecialty physical abuse evaluations within CAPNET, a multicenter child abuse pediatrics research network.

METHODS

We conducted a cross-sectional study of children <10 years old who underwent an evaluation (in-person or remote) by a child abuse pediatrician (CAP) due to concerns for physical abuse at ten CAPNET hospital systems from February 2021 through December 2021.

RESULTS

Among 3667 patients with 3721 encounters, 69.4% were <3 years old; 44.3% <1 year old, 59.1% male; 27.1% Black; 57.8% White, 17.0% Hispanic; and 71.0 % had public insurance. The highest level of care was outpatient/emergency department in 60.7%, inpatient unit in 28.0% and intensive care in 11.4%. CAPs performed 79.1% in-person consultations and 20.9% remote consultations. Overall, the most frequent injuries were bruises (35.2%), fractures (29.0%), and traumatic brain injuries (TBI) (16.2%). Abdominal (1.2%) and spine injuries (1.6%) were uncommon. TBI was diagnosed in 30.6% of infants but only 8.4% of 1-year old children. In 68.2% of cases a report to child protective services (CPS) was made prior to CAP consultation; in 12.4% a report was made after CAP consultation. CAPs reported no concern for abuse in 43.0% of cases and mild/intermediate concern in 22.3%. Only 14.2% were categorized as definite abuse.

CONCLUSION

Most children in CAPNET were <3 years old with bruises, fractures, or intracranial injuries. CPS reports were frequently made prior to CAP consultation. CAPs had a low level of concern for abuse in majority of cases.

The non-specific nature of mental health and structural brain outcomes following childhood trauma

BACKGROUND

Childhood trauma (CT) is associated with an increased risk of mental health disorders; however, it is unknown whether this represents a diagnosis-specific risk factor for specific psychopathology mediated by structural brain changes. Our aim was to explore whether (i) a predictive CT pattern for transdiagnostic psychopathology exists, and whether (ii) CT can differentiate between distinct diagnosis-dependent psychopathology. Furthermore, we aimed to identify the association between CT, psychopathology and brain structure.

METHODS

We used multivariate pattern analysis in data from 643 participants of the Personalised Prognostic Tools for Early Psychosis Management study (PRONIA), including healthy controls (HC), recent onset psychosis (ROP), recent onset depression (ROD), and patients clinically at high-risk for psychosis (CHR). Participants completed structured interviews and self-report measures including the Childhood Trauma Questionnaire, SCID diagnostic interview, BDI-II, PANSS, Schizophrenia Proneness Instrument, Structured Interview for Prodromal Symptoms and structural MRI, analyzed by voxel-based morphometry.

RESULTS

(i) Patients and HC could be distinguished by their CT pattern with a reasonable precision [balanced accuracy of 71.2% (sensitivity = 72.1%, specificity = 70.4%, p ≤ 0.001]. (ii) Subdomains 'emotional neglect' and 'emotional abuse' were most predictive for CHR and ROP, while in ROD 'physical abuse' and 'sexual abuse' were most important. The CT pattern was significantly associated with the severity of depressive symptoms in ROD, ROP, and CHR, as well as with the PANSS total and negative domain scores in the CHR patients. No associations between group-separating CT patterns and brain structure were found.

CONCLUSIONS

These results indicate that CT poses a transdiagnostic risk factor for mental health disorders, possibly related to depressive symptoms. While differences in the quality of CT exposure exist, diagnostic differentiation was not possible suggesting a multi-factorial pathogenesis.

State-level education policies: Opportunities for secondary prevention of child maltreatment

BACKGROUND

Exposure to child maltreatment creates risk for adverse social, health, and economic outcomes across generations. The socioecological model posits the well-being of individuals, including children and youth, is shaped by the larger systems they exist in. Employing state-level policies to position school settings to effectively identify and intervene in instances of child maltreatment is an important secondary prevention opportunity.

OBJECTIVE

This study examines the relationship between state-level policies that call for school based trainings to promote the recognition of and response to child maltreatment, and states' annual rates of substantiated child maltreatment reports.

METHODS

Relevant policies were identified and abstracted to generate measures of policy presence and comprehensiveness. The National Child Abuse and Neglect Data System was used to derive rates of substantiated child maltreatment reports by state and year. Child maltreatment rates were the dependent variable and policy measures were the primary explanatory variables in a difference-in-differences (DD) model series with state-level clustering and year-fixed effects.

RESULTS

The DD model series suggest significant, positive relationships between the presence of policies calling for school-based recognition and response training and child abuse (IRR 1.140, p = 0.04) as well as child physical abuse outcomes (IRR 1.150, p = 0.05). Sensitivity analyses suggest the relationships between policy presence and abuse outcomes were stronger for children than for adolescents.

CONCLUSION

These findings suggest that related policies may be effective secondary prevention tools for child maltreatment.

The Economic Burden of Intimate Partner Violence in Colombia: Estimated Health Costs Among Females Aged 13-24

BACKGROUND

Intimate partner violence (IPV) is the most pervasive form of gender-based violence, often first experienced in adolescence. While the prevalence of IPV is known to be exacerbated in humanitarian settings, little is known in regard to the economic burden of IPV between conflict-affected and non-conflicted-affected groups of women and girls. This top-down costing study examines the total health burden of physical IPV in Colombia, and whether these costs differ by conflict exposure.

METHODS

We utilized a nationally representative sample of 13-24-year-old females from the Violence Against Children Surveys (VACS) in Colombia conducted in 2018. Using physical IPV prevalence, the analysis was conducted in four steps: 1) estimate the relative risk of seven IPV-associated health outcomes among the sample and subgroups, 2) estimate the population attributable fraction of IPV for each health outcome, 3) quantify the burden of IPV in disability-adjusted life years (DALYs), and 4) assign health costs in US dollars to the estimated DALYs.

RESULTS

We found that the single year health burden associated with physical IPV was $90.6 million USD. Moreover, nearly 40% of the economic burden of physical IPV among females aged 13-24 in Colombia was from those who were conflict-affected (24%).

CONCLUSION

Our findings demonstrate that at least 16% of the overall health costs among females 13-24 in Colombia is from the preventable epidemic of physical IPV. In order to prevent and mitigate the costs of gender-based violence, multi-lateral and government investment is critically needed to prevent IPV and support women and girls.

The NIH childhood adversity portfolio: unmet needs, emerging challenges

Despite the significant increase in pediatric funding, an important question is whether recent changes in the burden of disease and conditions (child and adolescent mortality and nonfatal health loss) are reflected in the National Institutes of Health's (NIH) allocation process. As it sets future priorities, NIH acknowledges "a need to scan the landscape for unmet needs and emerging challenges" so that supported "research translates into meaningful health benefits." Our focus is to scan the pediatric budgetary landscape, report research funding for childhood adversity and adverse childhood experiences, and to illuminate gun violence, suicide, and drug abuse/overdose as prime examples of pediatric unmet needs and emerging challenges. Our findings suggest that pediatric researchers must reconceptualize gun violence as a form of childhood adversity and adverse childhood experiences, as we also need to do for other leading causes of child and adolescent mortality such as suicide and drug abuse/overdose. As it relates to the leading cause of death for children and adolescents, pediatric-related gun violence research spending remains only 0.0017% of the NIH pediatric portfolio. IMPACT: New data on NIH spending on ACEs and childhood adversity. New data to assess the relationship of spending to pediatric burden of disease. New data on pediatrics-related gun violence, suicide and drug abuse/overdose spending.

Inventory of U.S. Public Data Sources to Measure the Socioeconomic Impact of Experiencing Interpersonal Violence

Introduction

There is limited recent information regarding the impact of interpersonal violence on an individual's non-health-related experiences and attainment, including criminal activity, education, employment, family status, housing, income, quality of life, or wealth. This study aimed to identify publicly available representative data sources to measure the socioeconomic impact of experiencing interpersonal violence in the U.S.

Methods

In 2022, the authors reviewed data sources indexed in Data.gov, the Inter-university Consortium for Political and Social Research data archive, and the U.S. Census Bureau's Federal Statistical Research Data Center network to identify sources that reported both nonfatal violence exposure and socioeconomic status-or data sources linking opportunities to achieve both measures-over time (i.e., longitudinal/repeated cross-sections) at the individual level. Relevant data sources were characterized in terms of data type (e.g., survey), violence measure type (e.g., intimate partner violence), socioeconomic measure type (e.g., income), data years, and geographic coverage.

Results

Sixteen data sources were identified. Adverse childhood experiences, intimate partner violence, and sexual violence were the most common types of violence faced. Income, education, and family status were the most common socioeconomic measures. Linked administrative data offered the broadest and the most in-depth analytical opportunities.

Conclusions

Currently, linked administrative data appears to offer the most comprehensive opportunities to examine the long-term impact of violence on individuals' livelihoods. This type of data infrastructure may provide cost-effective research opportunities to better understand the elements of the economic burden of violence and improve targeting of prevention strategies.

Newspaper Coverage of Adverse Childhood Experiences and Toxic Stress in the United States, 2014-2020: Consequences, Causes, and Solutions

News media can shape public opinion about child adversity and influence the translation of research into public policy. Research about adverse childhood experiences (ACEs) and toxic stress has increased dramatically in recent years, but little is known about how these concepts are covered in news media. We reviewed how newspapers in the United States have portrayed the consequences of, causes of, and solutions to address ACEs and toxic stress, examined trends in newspaper coverage, and assessed differences in coverage of ACEs versus toxic stress. Quantitative content analysis was conducted of 746 newspaper articles mentioning "adverse childhood experience(s)" and/or "toxic stress" published in 25 U.S. newspapers between January 1, 2014, and May 30, 2020. κ statistics of interrater reliability were calculated, and variables with κ ≥ .60 were retained for quantitative analysis. We found that newspaper coverage of ACEs and toxic stress increased dramatically between 2014 and 2018 and then sharply declined. Only 13.3% of articles mentioned both ACEs and toxic stress. There were many statistically significant (p < .05) differences in the causes, consequences, and solutions identified in articles focused on ACEs versus toxic stress. Coverage of both concepts predominantly focused on consequences for individuals, not society. However, 54.6% of articles identified a structural cause of ACEs and/or toxic stress. Increased volume in newspaper coverage about ACEs and toxic stress could increase public awareness about the relationship between childhood adversity and adult outcomes. There is a need to portray ACEs and toxic stress as complementary concepts more coherently in news media.

Diagnosis codes dramatically underestimate the burden of abuse

BACKGROUND

International Classification of Diseases (ICD) billing codes are not well-suited to estimate physical abuse prevalence among hospitalized patients and may be even less accurate in emergency departments (EDs). The Centers for Disease Control and Prevention (CDC) has recently published a child abuse and neglect syndromic surveillance definition to more accurately examine national abuse trends among ED visits.

OBJECTIVE

To retrospectively apply the CDC syndromic definition to a population of physically abused children and determine its sensitivity for abuse in an ED and at hospital discharge.

PARTICIPANTS AND SETTING

All physically abused children <5 years seen in the ED and evaluated by the child protection team from 2016 to 2020 at a large Midwestern children's hospital.

METHODS

Retrospective cross-sectional study utilizing the hospital's child protection team administrative database, the Pediatric Health Information System and the electronic health record to identify the study sample, chief complaint, and abuse-specific codes assigned in the ED and at hospital discharge. Abuse-specific codes were defined as all ICD-10-CM and Systematized Nomenclature of Medicine - Clinical Terms (SNOMED CT) codes included in the CDC syndromic definition, which was applied to the sample and its sensitivity determined.

RESULTS

Among the 550 abused patients identified, most were male (58.4 %), white (65.1 %), <2 years old (80.4 %), and had public insurance (81.6 %). When applying the CDC syndromic definition, only 11.6 % were identified as abused in the ED and 65.3 % were identified at hospital discharge.

CONCLUSIONS

The CDC syndrome surveillance definition lacks sensitivity in identifying abuse in the ED or at hospital discharge.

Adverse childhood experiences affect the health of middle-aged and older people in China: The multiple mediating roles of sleep duration and life satisfaction

Background

Although a significant amount of literature has examined the association between childhood adversity and adverse health outcomes, which may be affected by sleep duration and life satisfaction. However, this relationship has not been researched in the Chinese population. This study aimed to assess the association between childhood adversity and health outcomes, with sleep duration and life satisfaction as mediators.

Methods

A total of 14,693 subjects aged 45 and over from the 2018 China Health and Retirement Longitudinal Study (CHARLS) were included. Taking childhood adversity as the independent variable, the health level of middle-aged and older individuals as the dependent variable, and sleep time and satisfaction as the mediating factors, Mplus 8.0 software was used to establish a structural equation model (SEM) to analyze the link between childhood adversity and health level and to explore the mediating effect of target mediators between childhood adversity and health level.

Results

In this study, childhood adversity was positively associated with depression symptoms, activities of daily living (ADL), and the number of chronic diseases (r = 0.116, 0.026 and 0.050, respectively, P < 0.001). Associations between adverse childhood experiences (ACEs) and depressive symptoms, ADL, and number of chronic diseases were mediated by sleep duration and life satisfaction, respectively.

Conclusion

Adversity experienced in childhood can affect the health status of middle-aged and older people. By ensuring adequate sleep and improving life satisfaction, health outcomes can be improved, and the negative effects of childhood adversity can be reduced.

Excess hospital costs incurred by individuals with child abuse and neglect history in South Australia: A birth-cohort study

Child abuse and neglect is a serious public health issue across the globe, with documented impacts on health, but the impact on hospital costs, at the population level, is unknown. We aimed to estimate the additional public hospital costs for emergency department visits and admitted patient hospitalizations, for persons with reported child protection concerns, from birth to 31 years and modelled to age 65. Using linked hospital data from 2003 to 2017 for a population birth-cohort of all individuals born in South Australia from 1986 to 2017, we estimated costs of public hospital care. Mean cost and cost differences (adjusted and unadjusted) in 2018 Australian dollars (AU$) were calculated for persons with child protection contact vs none, per person and at the population level. Persons with child protection contact had higher annualized mean hospital costs than those with no contact, with cost differentials increasing with age. Unadjusted differential cost per person was AU$338 (95% CI AU$204-AU$473) from birth to 12 years; increasing to AU$2242 (AU$2074-AU$2411) at ages 25 to 31 years, equating to an additional AU$124 (US$100) million for public hospital services from birth to 31 years, an 18% cost penalty (33% from 13 to 31 years). Modelled to age 65 years, excess costs were estimated at AU$415 (US$337, adjusted: AU$365 and US$296) million, a 27% cost impost. There is a considerable hospital cost penalty associated with persons with reported child protection concerns, especially from adolescence into adulthood, highlighting an opportunity for cost savings by preventive investment in effective early-in-life interventions.

Effectiveness of abbreviated trauma-focused cognitive behavioural therapy for South African adolescents: a randomized controlled trial

Background: In low- and middle- income countries (LMICs) trauma exposure among youth is high, but mental health services are critically under-resourced. In such contexts, abbreviated trauma treatments are needed.Objective: To evaluate the efficacy of an abbreviated eight-session version of Trauma-Focused Cognitive Behavioural Therapy (TF-CBT) for improving posttraumatic stress disorder (PTSD) and depression symptoms in a sample of South African adolescents.Method: 75 trauma-exposed adolescents (21 males, 54 females; mean age = 14.92, range = 11-19) with posttraumatic stress disorder (PTSD) symptoms were randomly assigned to eight sessions of TF-CBT or to usual services. At baseline, post-treatment and three-month follow-up, participants completed the Child PTSD Symptom Scale for DSM 5 (CPSS-5) and the Beck Depression Inventory II (BDI-II). The trial is registered on the Pan African Trial Registry (PACTR202011506380839).6.Results: 95% of TF-CBT participants completed treatment while only 47% of TAU participants accessed treatment. Intention-to-treat analyses found that the TF-CBT group had a significantly greater reduction in CPSS-5 PTSD symptom severity at post-treatment (Cohen's d = 0. 60, p < .01) and three-month follow-up (Cohen's d = 0.62, p < . 01), and a greater reduction in the proportion of participants meeting the CPSS-5 clinical cut-off for PTSD at both time points (p = .02 and p = .03, respectively). There was also a significantly greater reduction in depression symptom severity in the TF-CBT group at post-treatment (Cohen's d = 0.51, p = .03) and three-month follow-up (Cohen's d = 0.41, p = .05), and a greater reduction in the proportion of TF-CBT participants meeting the BDI clinical cut-off for depression at both time points (p = .02 and p = .03, respectively).Conclusion: The findings provide preliminary evidence of the efficacy of an abbreviated eight-session version of TF-CBT for reducing PTSD and depression symptoms in a LMIC sample of adolescents with multiple trauma exposure.