This study is the first to comprehensively assess CM cases in CHIRPP, including text field data. A total of 2 200 CM cases were identified for children under 16 years between 1997/98 and 2010/11. Our time trend analysis revealed a significant decrease in the capture of CM cases between 1999 and 2005. Text fields captured unique information such as types of CM resulting from direct physical injury as well as perpetrator characteristics and other details surrounding the injury event.
Joinpoint regression analysis was used to assess the trends in the capture of CM cases over the 14-year period. The main finding was a significant decrease in capture between 1999/00 and 2005/06. Child maltreatment (and other intentional injuries) has traditionally been difficult to capture in CHIRPP since the system was mainly designed to capture unintentional pediatric injuries [21, 22, 23]. It is possible that the decrease was partially due to difficulty in capturing these cases in some CHIRPP sites due to administrative and sensitivity issues. Recent improvements in the CHIRPP system [23] and efforts to understand and increase acquisition of intentional injuries [21, 27] will help to improve case capture. The increasing, but not significant, trend in the last segment 2005/06 to 2010/11 suggests that case identification may be increasing, but continued surveillance is needed to analyze the trend beyond the study period.
Physical abuse was the most common type of CM captured in CHIRPP, followed by sexual assault. Our findings regarding the distribution of CM types are somewhat consistent with both Canadian and international ED studies that examine multiple types of CM [28,29,30]; although differences in timing of studies, sample size, age-ranges, and categories of maltreatment assessed, make direct comparisons challenging. Comparisons with child welfare data are also challenging since they illustrate a different picture of CM in Canada. In our study the prevalence of physical abuse and sexual assault were higher than reported in Canadian child welfare data, while exposure to family violence and neglect were comparatively low [7]. In CHIRPP, emotional maltreatment was rarely identified, and never in isolation, but made up 9% of substantiated child welfare investigations in 2008 [7]. Emotional maltreatment and neglect are difficult to capture in an ED setting [31]. For instance, neglect can present as physical injury from ingestions or inappropriate supervision [16], but intent is challenging to capture and emotional maltreatment rarely manifests in physical injury. Cases of co-occurring CM are well established in the literature, [7, 32, 33, 34,36, 36] but were not well captured in CHIRPP. The low prevalence of co-occurring abuse in CHIRPP may be due to the fact that cases are identified through a specific injury event that requires immediate medical attention, and not through an investigation or assessment of a household.
In this study, a minority of cases indicated involvement with child welfare and 1% of children were removed from their homes. As CHIRPP does not usually provide information as to whether the child is receiving services from child welfare, or information regarding what happen after the initial injury event, our findings are likely underestimates. Our findings are however consistent with studies regarding health care professionals under-reporting CM to child welfare services [9] although an Ontario study found that the proportion of referrals to child welfare agencies for CM investigations from hospitals doubled between 1993 and 2013 [37]. An unexpected finding in our study was the number of cases that indicated injury due to CM during a visitation with a parent or step-parent. Although we did not find studies that dealt with this issue directly, child welfare data indicates that 13% of CM related investigations noted a child custody dispute [38].
Some patterns identified in our study were consistent with previous studies. As supported by the literature from Western countries, girls were significantly more likely to experience sexual assault [8,28,32,39,40]. In our study, sexual assaults increased for children age 1-7 years and increased again for adolescents 12-15 years. This may demonstrate a pattern whereby family members perpetrating sexual assault are more likely to abuse younger children and non-family members, such as peers, dating or romantic partners, became the predominant perpetrators of sexual assault in adolescents. Abuse perpetrated against older children could also indicate a pattern of re-victimization [41,42]. Consistent with previous studies our study also found that in cases of sexual assault perpetrators were more likely to be relatives, or known peers or adults, than strangers [43,44].
Alcohol and drug use were identified in CM cases among both victims and perpetrators, especially in cases involving sexual assault. Child welfare data indicates that alcohol and drug abuse are risk factors for perpetrators in substantiated CM investigations [7,45]. Previous research has shown a strong relationship between alcohol and sexual assault among female college students, and some evidence indicates that adolescent girls are more likely to experience physical force in alcohol-related sexual assaults than non-alcohol-related assaults [46].
In this study, fatal injuries occurred almost exclusively among young male children (< 4 years) from head related trauma. These findings are consistent with previously published Canadian studies, [18,19,20] and international studies [5,28,30,47] that examined head injuries highlighting the young age and gender of patients. Traumatic brain injury in particular is associated with high mortality and morbidity in infants. Younger children are also more likely to experience prolonged consequences from their injuries [18,48]. Also consistent with previous hospital studies [49], we found that fatalities among children in maltreatment categories were higher than other unintentional injury cases in CHIRPP (0.4% vs. 0.1%). The higher prevalence of fatalities among children admitted to the ED due to CM in CHIRPP speaks to its importance as a surveillance tool for this vulnerable population.
Limitations
There are a number of limitations to this study. CHIRPP is not representative of the Canadian population making it challenging to compare with other CM data. Information provided in text fields are based on patients’ interpretations of the questions and could be written or censored by patient’s caregivers. Further, accounts of the injury event could be potentially flawed from recall errors and omissions. Lack of training of hospital staff and clinicians may impact their ability to recognize all types of CM and can result in under-reporting [50]. In addition, CM that does not result in serious injury is not captured in CHIRPP. It is also possible that less severe cases were misclassified and not identified by our search strategy. Physical assault directed toward children and adolescents from non-family members, or those not in a caregiving role, could be missed due to current CM intent codes. Although fatalities were captured in our study, CHIRPP is generally a poor source of fatalities because of the lack of information of cases past the initial injury event and because some cases bypass the ED altogether due to the severity of injuries.
Strengths
CHIRPP provides on-going, timely and detailed clinical data on different types of CM. Our study was conducted on a broader age-range of children and adolescents than previous studies. In addition to providing clinical details, CHIRPP text fields offer unique, case specific data which can provide details of the complexities of the injury event, including risk and protective factors [23]. Text fields serve to identify rare events and to increase the granularity of coding.
The examination of both CM codes and the accompanying text fields allows for a more detailed understanding of other CHIRPP categories (e.g. fatalities). At the time that these cases were recorded (1997/98-2010/11), text fields were limited to 120 characters. The electronic application of CHIRPP (eCHIRPP) launched in April of 2011, has an extended text field of 4000 characters providing the opportunity for more detailed information of the injury event. This expanded text field provides further opportunity to present details of complex cases.
Recommendations
The electronic application of CHIRPP, including its integrated data management tools, has enhanced timeliness and flexibility providing opportunities to enhance CHIRPP data collection [23]. In future, exploring the feasibility of expanding eCHIRPP to include all 5 types of CM intent code classifications would be valuable. Once CM has been identified using eCHIRPP, health care providers could be presented with a “mark all that apply” check list of each type of CM. This would allow for more in-depth capture of different types of CM and identify cases of co-occurring maltreatment. In addition, the term “sexual assault” could be reviewed and redefined as “sexual violence” to better reflect the diversity of cases perpetrated against children and adolescents. The analysis of CM in CHIRPP, however, should also include an analysis of text field data taking advantage of new techniques such as machine learning whenever possible. Our study has shown that they provide valuable details, and context, not available from the CHIRPP survey checklist alone.