Clinical care of childhood sexual abuse: a systematic review and critical appraisal of guidelines from European countries

Background: The clinical management of Child sexual abuse (CSA) demands specialised skills from healthcare professionals due to its sensitivity, legal implications, and serious physical health and mental health effects. Standardised, comprehensive clinical practice guidelines (CPGs) may be pivotal. In this systematic review, we examined existing CSA national CPGs (NCPGs) from European countries to assess their quality and reporting. Methods: We systematically searched six international databases and multiple grey literature sources, reporting by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards. Eligible guidelines were CSA guidance from national health agencies or societies in 34 COST Action 19106 Network Countries (CANC), published between January 2012 and November 2022. Two independent researchers searched, screened, reviewed, and extracted data. NCPGs were compared for completeness with reference WHO 2017 and 2019 guidelines. We used the Appraisal of Guidelines for Research and Evaluation (AGREE II) to appraise quality and reporting. PROSPERO: CRD42022320747. Findings: Of 2919 records identified by database searches, none met inclusion criteria. Of 4714 records identified by other methods, 24 NCPGs from 17 (50%) of CANC countries were included. In 17 (50%) of eligible countries, no NCPGs were found. Content varied significantly within and between countries. NCPGs lacked many components in state-of-the art clinical practice compared to WHO reference standards, particularly in safety and risk assessment, interactions with caregivers, and mental health interventions. Appraisal by AGREE II revealed shortcomings in NCPG development, regarding scientific rigour, stakeholder involvement, implementation and evaluation. Interpretation: A notable number of European countries lack an NCPG; existing NCPGs often fall short. The healthcare response to CSA in Europe requires a coordinated approach to develop and implement high-quality CPGs. We advocate for a multidisciplinary team to develop a pan-European CSA guideline to ensure quality care for survivors

Health sector and community response to child maltreatment in Sweden and in a European context

Background Child maltreatment is a public health problem of global magnitude. This thesis examined different aspects of the multi-sector response to child maltreatment in Sweden and in Europe. Aims To explore how child physical abuse (CPA) is disclosed and how adolescents perceive adult support when they report physical abuse. To examine how police-reported cases of suspected CPA were associated with criminal investigation procedures and prosecutions. To assess how physicians who care for maltreated children across Europe are organised to recognise and respond to child abuse and neglect. To investigate time trends in rates of childhood deaths in Sweden recorded as due to external, ill-defined and unknown causes, from 2000 to 2014. Methods We analysed data from a school-based national survey of adolescents, police records of reported suspected CPA in a metropolitan area, a purposeful survey of European child abuse physicians and individual-level data from the Swedish cause of death register. We used quantitative methods to calculate prevalence, descriptive statistics, odds ratios, logistic regression and trends in mortality rates. Qualitative methods included content analysis and narrative synthesis. Results Only a minority of reported CPA was brought to the attention of professionals and the most prominent barrier to disclosure was lack of trust in adults or authorities. The police-reported cases of suspected CPA were characterised by high severity, but only a small proportion of the 158 alleged child victims were physically examined and only half were forensically interviewed. All 88 responding physicians in 22 European countries described multidisciplinary involvement in the management of suspected child maltreatment, but wide variations in the organisational approaches were revealed. A sustained decline in childhood deaths from external causes during a 15-year period was observed. A sizeable number of infant deaths were recorded each year as ill-defined or with incomplete documentation from clinicians. Conclusions The results presented in this thesis suggest that the multi-sector response in Sweden and in Europe is insufficiently organised, with no clear mandate for the health sector to robustly combat child maltreatment, and that this may undermine the ability of society to adequately protect children

Health sector and community response to child maltreatment in Sweden and in a European context

Background Child maltreatment is a public health problem of global magnitude. This thesis examined different aspects of the multi-sector response to child maltreatment in Sweden and in Europe. Aims To explore how child physical abuse (CPA) is disclosed and how adolescents perceive adult support when they report physical abuse. To examine how police-reported cases of suspected CPA were associated with criminal investigation procedures and prosecutions. To assess how physicians who care for maltreated children across Europe are organised to recognise and respond to child abuse and neglect. To investigate time trends in rates of childhood deaths in Sweden recorded as due to external, ill-defined and unknown causes, from 2000 to 2014. Methods We analysed data from a school-based national survey of adolescents, police records of reported suspected CPA in a metropolitan area, a purposeful survey of European child abuse physicians and individual-level data from the Swedish cause of death register. We used quantitative methods to calculate prevalence, descriptive statistics, odds ratios, logistic regression and trends in mortality rates. Qualitative methods included content analysis and narrative synthesis. Results Only a minority of reported CPA was brought to the attention of professionals and the most prominent barrier to disclosure was lack of trust in adults or authorities. The police-reported cases of suspected CPA were characterised by high severity, but only a small proportion of the 158 alleged child victims were physically examined and only half were forensically interviewed. All 88 responding physicians in 22 European countries described multidisciplinary involvement in the management of suspected child maltreatment, but wide variations in the organisational approaches were revealed. A sustained decline in childhood deaths from external causes during a 15-year period was observed. A sizeable number of infant deaths were recorded each year as ill-defined or with incomplete documentation from clinicians. Conclusions The results presented in this thesis suggest that the multi-sector response in Sweden and in Europe is insufficiently organised, with no clear mandate for the health sector to robustly combat child maltreatment, and that this may undermine the ability of society to adequately protect children

Health sector and community response to child maltreatment in Sweden and in a European context

Background Child maltreatment is a public health problem of global magnitude. This thesis examined different aspects of the multi-sector response to child maltreatment in Sweden and in Europe. Aims To explore how child physical abuse (CPA) is disclosed and how adolescents perceive adult support when they report physical abuse. To examine how police-reported cases of suspected CPA were associated with criminal investigation procedures and prosecutions. To assess how physicians who care for maltreated children across Europe are organised to recognise and respond to child abuse and neglect. To investigate time trends in rates of childhood deaths in Sweden recorded as due to external, ill-defined and unknown causes, from 2000 to 2014. Methods We analysed data from a school-based national survey of adolescents, police records of reported suspected CPA in a metropolitan area, a purposeful survey of European child abuse physicians and individual-level data from the Swedish cause of death register. We used quantitative methods to calculate prevalence, descriptive statistics, odds ratios, logistic regression and trends in mortality rates. Qualitative methods included content analysis and narrative synthesis. Results Only a minority of reported CPA was brought to the attention of professionals and the most prominent barrier to disclosure was lack of trust in adults or authorities. The police-reported cases of suspected CPA were characterised by high severity, but only a small proportion of the 158 alleged child victims were physically examined and only half were forensically interviewed. All 88 responding physicians in 22 European countries described multidisciplinary involvement in the management of suspected child maltreatment, but wide variations in the organisational approaches were revealed. A sustained decline in childhood deaths from external causes during a 15-year period was observed. A sizeable number of infant deaths were recorded each year as ill-defined or with incomplete documentation from clinicians. Conclusions The results presented in this thesis suggest that the multi-sector response in Sweden and in Europe is insufficiently organised, with no clear mandate for the health sector to robustly combat child maltreatment, and that this may undermine the ability of society to adequately protect children

Paediatric approaches to child maltreatment are subject to wide organisational variations across Europe

AIM: Little is known about the organisation of child maltreatment practice in Europe. We therefore explored medical child protection systems and training across Europe. METHODS: An online survey was completed by physicians working in child maltreatment, identified through professional organisations in 28 member countries of the European Union, Iceland, Norway and Switzerland in 2012-2013. Respondents were questioned regarding management of suspected child maltreatment, mandatory reporting, professional training, patient referral and physician roles in multidisciplinary investigations. Responses underwent a narrative synthesis and descriptive enumerations. RESULTS: The survey was completed by 88 individuals, unevenly distributed in 22 of 31 countries. Physicians were mandated to report child maltreatment in 16 of 22 countries. All of 88 responding physicians described multidisciplinary involvement in the clinical and forensic management of suspected child maltreatment. Practitioners involved in physical examinations included general physicians, paediatricians, forensic medical examiners, gynaecologists and paediatric surgeons. Paediatricians were required to undergo child protection training according to 30 of 86 respondents in 14 of 22 countries. CONCLUSION: This survey demonstrates that there were wide variations in the organisation of child maltreatment paediatrics in Europe. The differing legislative frameworks and models of care are pertinent to consider when comparing epidemiology of maltreatment reported from across European countries

Amongst Norwegian paediatricians there is little agreement in management of cases of suspected child maltreatment

Aim Child maltreatment is not unusual in our society but little is known about the medical management of cases in the Nordic countries. This study investigated physician knowledge and practice in cases of suspected physical and sexual abuse and neglect. Methods Using a patient vignette questionnaire, we assessed paediatrician knowledge and clinical decision-making on paediatric wards at 17 hospitals in Norway. Experts and non-experts in child maltreatment responded to the survey which described six potential cases of physical and sexual abuse and neglect. Results A total of 156 paediatricians, 67% of whom were female and with a mean age of 40, responded. There was a high level of unanimity in recognition of abuse, but wide variation and little consensus in clinical decision-making and adherence to national guidelines, with Fleiss kappa ranging from −0.002 to 0.468. In cases involving physical abuse concerns in infants and toddlers, less than half of all paediatricians reported they would order a full radiologic skeletal survey and head MRI/CT imaging, and less than 30% would plan follow-up consultations. Conclusion This study shows little agreement in the paediatric management of child maltreatment cases. These findings suggest the need for a national plan ensuring appropriate paediatric care for maltreated children

Amongst Norwegian paediatricians there is little agreement in management of cases of suspected child maltreatment

Aim: Child maltreatment is not unusual in our society but little is known about the medical management of cases in the Nordic countries. This study investigated physician knowledge and practice in cases of suspected physical and sexual abuse and neglect. Methods: Using a patient vignette questionnaire, we assessed paediatrician knowledge and clinical decision-making on paediatric wards at 17 hospitals in Norway. Experts and non-experts in child maltreatment responded to the survey which described six potential cases of physical and sexual abuse and neglect. Results: A total of 156 paediatricians, 67% of whom were female and with a mean age of 40, responded. There was a high level of unanimity in recognition of abuse, but wide variation and little consensus in clinical decision-making and adherence to national guidelines, with Fleiss kappa ranging from -0.002 to 0.468. In cases involving physical abuse concerns in infants and toddlers, less than half of all paediatricians reported they would order a full radiologic skeletal survey and head MRI/CT imaging, and less than 30% would plan follow-up consultations. Conclusion: This study shows little agreement in the paediatric management of child maltreatment cases. These findings suggest the need for a national plan ensuring appropriate paediatric care for maltreated children

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

Current issues and challenges in the definition and operationalization of child maltreatment : A scoping review

Background: Studies show considerable variability in the definitions and operationalization of child maltreatment (CM), which limits research, policy formation, surveillance, and cross-country and cross-sector comparisons.Objective: To review the recent literature (2011-2021) to understand current issues and chal-lenges in defining CM, to assist in the planning, testing and implementing of CM conceptualizations.Methods: We searched eight international databases. Articles were included if the substantive content was related to issues, challenges, and debates in defining CM, and the article was an original study, review, commentary, report, or guideline. The review followed methodological guidance for the conduct of scoping reviews and was reported in accordance with the PRISMA-ScR checklist. Four experts in CM conducted a thematic analysis to summarize findings. Meth-odological rigor of the included studies was not formally assessed. Results: We identified 7372 potentially relevant articles; 55 full-text studies were assessed for eligibility, 25 satisfied the inclusion criteria. We identified three themes: 1) strategies to define CM, including the integration of child and victim perspectives; 2) difficulties in defining specific CM types; and 3) real-world implications for research, prevention and policy.Conclusions: Despite longstanding concerns, challenges regarding the definitions of CM persist. A small minority of studies have tested and implemented CM definitions and operationalizations inpractice. The findings will inform international multi-sectoral processes to develop uniform definitions of CM, for example by highlighting the need to acknowledge challenges in defining some CM types and emphasizing the importance of considering the perspectives of children and CM survivors.Peer reviewe