During a 6-month study period, a suspicion of child abuse arose in 0.2% of children aged ≤18 years who visited the emergency departments of seven hospitals, and in 0.3% of children aged ≤4 years. The significantly higher detection rate in hospitals complying with screening guidelines for child abuse (0.3%) compared to those not complying (0.1%) shows the importance of increased situational awareness for improving detection of child abuse. Checklists were completed in 40 (77%) of the 52 cases of suspected abuse but in only 19% of the total population, although the use of checklists in suspected cases might have been intentional selection.
Implementation of a structured screening protocol, therefore increasing the situational awareness of child abuse, might result in a higher detection rate of suspected child abuse. A checklist of warning signs of child abuse could be part of such a protocol, but a validated checklist is currently not available.12
If a checklist were used, it might result in more cases of suspected child abuse being identified and would be a first step in improving the detection rate of actual cases of child abuse. The use of a checklist in every child visiting the emergency department would result in universal screening to identify a high risk group.13
Unfortunately, an increase in the sensitivity of child abuse detection would lead to a decrease in specificity. Therefore, a protocol with clear guidelines on how to manage suspicions of child abuse is required. Where a case is suspected, it is very important that the physician informs the parents about his or her concerns without accusing anyone. Unfortunately, fear among physicians and other emergency department staff of making a false accusation can lead to failure to report cases of suspected abuse.
Screening for child abuse in the emergency department is not standard policy in most countries (eg, USA, Canada and the UK), but did become mandatory in the Netherlands in 2009.14
Earlier studies on screening (each including 2000–4422 patients) reported higher detection rates of suspected abuse (range 1.1–1.4%) than the 0.3% rate identified in the present study.15–17
We found that the detection rate of suspected child abuse was much higher when a checklist of warning signs of abuse was completed. Comparison of screened cases with those not screened showed that emergency department staff completed the checklist more often in children who were younger, were referred by a general practitioner or were treated for a paediatric complaint.
In the present study, children suspected of being abused were younger than the average child in the emergency department. The younger the child, the more vulnerable he or she is, the higher the risk that an injury requires medical attention, and the higher the chance that emergency department staff suspect abuse.18
However, because child abuse can affect children of all ages, emergency department staff must be aware of the risk in all children visiting the emergency department to avoid missing cases of child abuse.19
Physical abuse is the most common type of child abuse detected in the emergency department,6
as shown in the present study. Neglect and emotional and sexual abuse are more difficult to identify in an emergency department setting but also require attention. Overall, child abuse remains an under-reported problem. This can be attributed to, for example, inadequate knowledge and training of professionals regarding recognition of abuse injuries, unwillingness to report suspicions of abuse, and variations in what is considered to be abuse.18
Some limitations of the present study need to be addressed. First, we present cases of suspected abuse. Since abuse was not yet confirmed, this could have led to an overestimation of the detection rate of child abuse. Second, cases of suspected abuse might have been missed because only one of the hospitals systematically registered such cases. Finally, for optimal data comparison the same time period should have been used in all hospitals. However, due to logistical problems this was not possible in two of the participating centres.
The strengths of this study are the relatively long observational period, the large number of children, the inclusion of all patients (≤18 years old) who visited the emergency departments with a new complaint, and the fact that of the results are representative of various emergency department settings.
In summary, the detection rates of suspected child abuse in children who visited an emergency department were very low (0.2%). However, the detection rate of suspected abuse was higher in hospitals where emergency department staff complied with screening guidelines than in hospitals with non-compliant emergency department staff. We recommend that hospitals encourage compliance with screening guidelines, implement strict policies to improve the detection rate of suspected child abuse in emergency departments, and use the results of these interventions to develop an optimal screening protocol for emergency departments. Further research is recommended on how to identify genuine cases of child abuse among the high risk group of suspected cases identified by screening.