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* Divisions of Pediatric Emergency Medicine
General Pediatrics, Boston University School of Medicine/Boston Medical Center, Boston, Massachusetts
Department of Pediatrics, Floating Hospital for Children, Boston, Massachusetts
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Methods. A self-administered survey was mailed to child abuse contact leaders at institutions that were members of the National Association of Children’s Hospitals and Related Institutions in 2001. Responses from rehabilitation hospitals and those that did not indicate whether a CPT was present were excluded.
Results. One hundred thirty-four of 157 leaders responded. One hundred twenty-two (91%) met study criteria. Eighty-eight hospitals (72%) had a CPT—54% were pediatric facilities, 59% had >100 beds, and 89% had a pediatric residency. Compared with institutions without a CPT, institutions with a CPT were less likely to be located in the South (28% vs 70%) and more likely to have >200 beds (26% vs 1%), a medical school affiliation (92% vs 74%), and a pediatric residency (98% vs 68%).
Sixty-one percent of institutions cared for <300 suspected CAN cases, and 66% had 5 or fewer CAN-associated deaths the previous year. Institutions with a CPT used more comprehensive documentation for CAN, including special CAN forms (55% vs 21%) and photographs (77% vs 53%). They also more commonly referred CAN cases to law enforcement (58% vs 35%) or a CAN clinic for follow-up (52% vs 26%).
Fifty-two percent of CPTs had an annual budget of $500 000 or less. The most common primary source of financial support for CPTs was the hospital (51%), although funding was usually composed of a combination of funds from the hospital, patient fees, and state government.
Functions performed by CPTs included consulting on cases of CAN (89%), functioning as a liaison with child protective services (85%), tracking cases of abuse or neglect (70%), providing quality assurance on CAN cases (63%), and filing reports with child protective services (61%). Twenty-four hour consultative coverage was provided by most CPTs (79%), for which 94% provided phone consultation and 81% provided in-person consultation when necessary.
Conclusions. The institutions surveyed cared for many children suspected of abuse and neglect. Thirty-eight percent did >300 evaluations per year. In general, institutions with CPTs provided more comprehensive documentation and follow-up of children suspected of having been abused or neglected than institutions without CPTs. Whether this is associated with better outcomes for children suspected of abuse or neglect is unknown.
Key Words: child abuse and neglect • child protection teams
Abbreviations: CPT, child protection team • CPS, child protective services • CAN, children with suspected abuse or neglect • NACHRI, National Association of Children’s Hospitals and Related Institutions
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Hospital-based child protection teams (CPTs) have been organized to assist the clinician in evaluating and managing abused and neglected children. Many of these teams have been formed with only limited institutional fiscal support.7 A limited number of studies have been published describing how individual CPTs interact with clinicians in their institutions and local child protective services (CPS).8–17 The goals of this study were to describe the number of children with suspected abuse or neglect (CAN) cared for in selected children’s hospitals, to determine how they are tracked and followed, and to better describe the composition, function, and financial support of CPTs.
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METHODS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Study Outcomes
The study outcomes focused on providing a description of the following: 1) institutional experiences with CAN during the previous year and 2) the status of CPTs in these institutions.
Variables describing each institution’s experience with CAN the previous year included the number of cases and related fatalities, parties contacted for CAN evaluation, the CAN tracking system at the institution, composition of CAN data tracked, who performed follow-up, and the presence of a CAN clinic.
If a CPT existed in the institution at the time of survey administration, the respondent was asked questions regarding the number of years the CPT had been in existence, its composition, funding, and function, and whether there was regular participation by CPS (questionnaire available on request).
Proportional comparisons on the outcome variables were made between institutions with and without a CPT using 
2 and Fisher exact statistics where appropriate. Statistical significance was considered attained at a P < .05.
This study was approved by the institutional review board of Boston University School of Medicine.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Institution Demographics
The majority of responding institutions were pediatric hospitals (54%) in a non-Southern state (69%) with >100 beds (59%), a medical school affiliation (87%), a pediatric residency (89%), and no child abuse fellowship (84%; Table 1).
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Institutional CAN Experience
Sixty-one percent of the institutions cared for 300 or less cases of suspected CAN, and 66% had 5 or fewer CAN-related fatalities during the previous year (Table 2). Social workers and child protective services were contacted by a majority of institutions for cases of suspected CAN (85% and 84%, respectively). Thirty-eight percent of the systems used a CPT-based computerized database, 38% used a paper logbook, and 37% used the CPS tracking system to track cases. Fourteen (11%) hospitals, however, stated that they had no CAN tracking system. Data documented on the children included a description of the incident (66%); follow-up care (30%); and medical (40%), legal (20%), and guardianship (31%) outcomes. Routine CAN documentation was most commonly done using the medical record (86%) or photographs (70%). Abused and neglected children were most commonly followed up by CPS (85%). Sixty-five (53%) institutions had a CAN clinic.
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Characteristics and Funding of CPTs
Fifty-six percent of CPTs had been in existence for over 10 years (Table 3). Most commonly, CPTs were composed of a physician (94%), social worker (92%), and registered nurse (73%). The physician was most commonly the chairperson (45%), although this was not uncommonly the position of the social worker (24%) or a shared position with the social worker (18%). Most CPTs had regular meeting participation by CPS (55%).
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The reported amount of funding and the number of CAN cases the previous year appeared to be related. For example, 62% (23 of 37) of CPTs with $250 000 or less in support were in institutions that cared for <300 CAN cases the same year. However, 73% (11 of 15) of the CPTs with more than $750 000 in funding were in institutions who cared for >400 CAN cases the same year.
CPT Functioning
The function of CPTs was varied but most commonly consisted of consulting on CAN cases (89%), functioning as a liaison with CPS (85%), tracking cases of CAN (70%), providing quality assurance on CAN cases (63%), and filing reports with CPS (61%; Table 4 ). CPTs were most commonly consulted on unclear cases of CAN (60%) or those requiring mediation between the institution and CPS (41%). The majority of CPTs reported that they were consulted on over 75% of CAN cases seen in their institutions (51%). On-call consultative coverage was provided by 79% of CPTs 24 hours a day, 7 days a week and was most commonly contacted by pager (91%) or phone (91%). The on-call pager was carried most commonly by a physician (77%) or social worker (67%) from the CPT. Ninety-four percent provided on-call phone consultation and 81% in-person consultation when necessary. Forty-three percent of CPTs used nonlocal consultant services for CAN cases.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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There have been a limited number of published studies describing individual CPTs.8–15 These reports describe significant variation in the form and function of their CPTs, which is similar to our results. However, they only detailed their own experiences in the context of providing a model for other institutions to emulate. We are aware of 2 studies that have described a sample of child protection teams.16,17 Dubowitz16 surveyed pediatric residency directors in 1985 and asked questions regarding team composition and sources of funding. Many of the findings reported were similar to our results. First, he noted that a majority of the 167 hospitals affiliated with the pediatric residencies that he surveyed had a CPT (81%). In addition, the vast majority of teams included a social worker (99%), pediatrician (98%), and nurse (90%). With regard to budget, the majority of teams studied reported either no budget or an annual budget of less than $100 000. The size of the budget also correlated significantly with the number of pediatric beds and number of case reports for child maltreatment handled at the hospital each year. Dubowitz’s results did differ from ours with respect to the types of hospitals and regions of the country more likely to have CPTs. He reported that university-affiliation and region of the country were not significantly associated with the presence of a CPT. Our study, however, noted that CPTs were more likely to exist in university-affiliated hospitals and in a non-Southern region. It is possible that the increased proportion of CPTs being present in a university versus nonuniversity-affiliated hospital may be attributable to an increased number of abused and neglected children cared for in university-affiliated hospitals, which tend to be larger. Why institutions in Southern states are less likely to have CPTs is difficult to determine. The rates of response, proportion of children’s hospitals, number of pediatric beds, and number of cases of CAN were very similar between the different regions. However, the South had the smallest proportion of pediatric residency-affiliated hospitals (78%) compared with the Northeast (92%), Midwest (92%), or West (95%). Perhaps residency-affiliated hospitals are more likely to attract physician-experts in the field of child abuse and neglect or there is an increased need for CAN resources for physicians-in-training.
Giardino et al17 described similar CPT compositions to our study. One hundred percent of their sample of 72 teams had physicians on them, 90% had social workers, and 49% had nurses. They also reported similar sources of funding including patient fees, state government funding, and hospital support. We have tried to provide a larger snapshot of how institutions care for children suspected of abuse and neglect by including not only the composition and characteristics of funding for CPTs, but also how children’s institutions care for abused and neglected children and how CPTs fit into their care where they exist.
The field of health services research systematically studies the quality of health care delivery. Quality of patient care is defined by the Institute of Medicine as the degree to which health services for individuals and populations increase the likelihood for desired health outcomes and are consistent with current professional knowledge.18 Part of health services research is to define the quality of care by accurately assessing the 3 constituents of quality surrounding a health problem or patient group of interest: structure, process, and outcome.19 With regard to child abuse and neglect, improvements in the quality of care have been difficult to address partly because of a lack of systematically gathered information regarding these 3 components. Basic components of the structure of CAN care include facilities, equipment, financial support, number and types of personnel, as well as the organizational structure including medical staff organization, methods of peer review, and methods of reimbursement. The most important assessment is the impact of these services on health outcomes.20 This is the most comprehensive study to date to address some of the descriptive issues regarding the structure of child protection teams and their relation to the hospital’s CAN experience.
One limitation of this study relates to its generalizability. The experience of the facilities surveyed may not be the same for institutions that are not members of NACHRI. This sample is not nationally representative because a majority of respondents were from children’s hospitals. A second limitation relates to the reliability of the responses to the survey. Surveys are always limited by the knowledge and honesty of the respondents. However, we have no reason to believe that the responses don’t reflect each institution’s experience. The response rate of 84% was very good, suggesting that this survey is representative of NACHRI-associated institutions.
This study is a first step in providing information on the CAN experience of a broad number of children’s institutions and their associated CPTs. Future studies should describe what characteristics allow for CPT systems to perform more effectively in the identification and management of CAN cases and what services are associated with improved outcomes for these children.
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ACKNOWLEDGMENTS |
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We thank William Adams, MD, and Robert Vinci, MD, for their help in preparing this manuscript. We would also like to thank NACHRI for providing the contact list of child abuse leaders at their member institutions.
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FOOTNOTES |
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Address correspondence to Irene Tien, MD, Division of Pediatric Emergency Medicine, Boston Medical Center, 1 Boston Medical Center Place, MAT 6, Boston, MA 02118. E-mail: irene.tien{at}bmc.org
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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This article has been cited by other articles:
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  J. L. Bonkowsky, E. Guenther, F. M. Filloux, and R. Srivastava Death, Child Abuse, and Adverse Neurological Outcome of Infants After an Apparent Life-Threatening Event Pediatrics, July 1, 2008; 122(1): 125 - 131. [Abstract] [Full Text] [PDF]
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