Our experience suggests that a screening tool is essential and productive for the early recognition of victims of suspected abuse through a standardized method, such as a clinical pathway, allowed reaching the diagnosis in a more accurate and precise manner, especially in emergency setting, decreasing the portion of abuse victims who remain underdiagnosed. In our study, the introduction of screening tools led to a diagnostic improvement due to the increase of sensitivity of health workers to the phenomenon and standardization of diagnostic path. In our hospital after the modification of the screening criteria, after 3 years of experience (Table 2), we noticed a conspicuous increase in the ability of interception. Another improvement was made to highlight at first point the anamnestic declarations or incongruences.
One of the main difficulties, when comparing between the incidences detected in different countries, is that the phenomenon of the abuse is not unequivocally defined, but it is experienced and recognised differently depending on the social and cultural background.
Carelessness and neglect represent the most susceptible situations for different cultural interpretations, changing meaning not only from place to place, but also in different times.
Therefore, it may be important to compare literature data from countries with similar cultural collective values to truly understand the dynamics under every founding.
Various researchers have therefore taken steps to codify “indicators of abuse” and to measure their sensitivity and specificity. Following there are some examples of how some of the indicators have been used and tested, and the success they have reported. The introduction of a checklist of 10 questions administered by ED nurses to Canadian patients with trauma was able to increase the ability of recognition from 0.86% to 1.13% (95% CI 0.72 OR 1:32 to 2:40). This increase in sensitivity, however, was not statistically significant and was not able to effectively intensify the capability of the screening [19]. In a UK study, using certain indicators in clinical practice with a prospective study of 2345 patients, was demonstrated that using a screening method increased the recognition ability of abused victims [20]. The indicators were: whether the patients had already been in the ED, if there was an inconsistent medical history, physical examination and clinical history not consistent with each other, if there had been a delay in bringing the child to the ED compared to the trauma and if there were skull fractures in children below one year of age [20]. A next study showed that the use of 8 items, from nurses at the ED, increased awareness and vigilance of health professionals and proposed a flow chart on how to behave in case of positive indicators [14]. Also in the UK, two studiesreviewed and evaluated the sensitivity of screening without finding a test with high sensitivity to physical abuse and the only item found to aid clinicians in assessing the abuse victim was the "type" of injury [21, 22].
A Netherlands study brought to light that the use of 9 questions as indicators of abuse could improve the recognition of cases on 220 suspected cases. [23] A Dutch study showed that 6 simple questions could get a 80% sensitivity and 98% specificity for abuse; in fact, on a sample of 420 children with positive screening, 44 had been confirmed; on 17,855 children with negative screening, only 11 were instead victims of abuse [24]. The indicators applied were if the history was consistent, if there was a delay in seeking for medical help, if the onset of the injury fit with the development level of the child, if the behaviour of the child and his/her careers were appropriate, in the head-to-toe examination was in accordance with the history and if other signals could make the nurse doubt on the safety of the child or other family members.
A previous work suggested a checklist consisting of 9 questions, defined SPUTOVAMO, associated to a combination of both a complete physical inspection of every child (called ‘top–toe’ inspection) presenting at the ED, and a system of standard referral of all children from parents who attend the ED for intoxication, severe psychiatric disorders or with injuries due to intimate partner violence. This was presented by the Authors as the most promising procedure for the early diagnosis of CAN in the emergency setting [25]. Most recently the same group confirmed that combining screening test (SPUTOVAMO screening checklist, complete physical examination and their combination) significantly increases the number of test positives and led to more child abuse cases being detected than using either method on its own [26]. It would be desirable for each emergency department to have its own screening tool.
Susceptibility to maltreatment decreases with age placing younger children at the greatest risk for abuse and neglect [27]. In agreement, in our study we observed that visits for maltreatment most often involved children who were significantly younger (Table 3). This is likely a result of the limited verbal aptitude of young children to articulate their maltreatment experience, as observed in other study [27]. The clinical practice of asking parents or caregivers for information about the event, especially valid in case of uncertainty about the circumstances of the "symptoms of possible maltreatment", represents a limit, especially in young children, considering that parents and caregivers are the possible main perpetrators of the maltreatment, as already reported by other Authors [27, 28]. The application of a clinical pathway and the possibility of having a multidisciplinary team in the hospital may certainly contribute to identify maltreatment in children with suspicious or unexplainable injuries, increasing objectivity and standardization, as happened in our study.
In agreement with other previous studies [27, 29], our study identified a difference in the distribution of child sex maltreatment (Table 4); specifically, females are more likely to experience sexual abuse, while males are more likely to experience physical abuse.
To screen the totality of the patients that access to the hospital is necessary to early recognize suspected CAN. If one or more items are found to be positive it is important for us that a multidisciplinary team performs the clinical pathway. Our clinical pathways provide different approaches depending on which item results positive after the screening process and the different specialists involved in the clinical assessment depending on the type of considered CAN category (sexual abuse, neglect/carelessness, maltreatment) (Table 3). In these terms, the importance of an already codified pathway helps bringing together the different specialties in a more productive and efficient collaboration (Fig. 1).
Limitations
Mostly because of retrospective design and study setting, our study suffers at least two limitations that could affect our conclusion. First, data have been extracted from ED medical records. Albeit many patients received multidisciplinary consultations in the ED, accuracy of CAN assessment may have been partially limited by the emergency setting. Moreover, several patients (especially non-hospitalized patients) did not receive a definite diagnosis for their disturbance, reflecting the lack of information about the diagnostic work-up after ED discharge. Second, the generability may be limited because this study was conducted in a ED of a pediatric tertiary hospital with all specialties, and in Italy as in other country [e.g., United States [30] many children are conducted directly in general ED, many of which may not specifically access to pediatric multidisciplinary team, comprising social work team, specialized for CAN.