Article, Pediatrics

Evaluation of suspected child abuse at the ED; implementation of American Academy of Pediatrics guidelines in the Netherlands

a b s t r a c t

:Emergency departments (EDs) are important to detect child Physical abuse. A structured approach will contribute to an adequate detection of abused children at the ED. The American Academy of Pediatrics (AAP) provided guidance in the Clinical approach to the evaluation of suspected physical abuse in children. In the Netherlands, these American Academy of Pediatrics guidelines have been adopted for the clinical process of child abuse detection. Here, we describe the outcome of the clinical process in the year 2010 with 65 cases of suspected child abuse out of 3660 children presenting at an ED, and we discuss the strengths and pitfalls of this current clinical approach.

(C) 2013


In high-income countries, every year, approximately 3% to 16% of children are physically abused, and 10% are neglected or psycholog- ically abused [1,2]. Of the injured children attending the emergency department (ED), 1% or less is estimated to be physically abused [3]. Although this proportion is small, detection of physically abused children might prevent detrimental influence on education, mental health, physical health, and violence, or criminal abuse may prevent further abusive trauma in infants and adults [4], thus reiterating the importance of detection of child maltreatment at EDs.

It is commonly thought that a structured approach could be useful to adequately detect maltreated children at the ED. In 2007, the American Academy of Pediatrics (AAP) provided guidance in the clinical approach to the evaluation of suspected physical abuse in children [5]. In the Netherlands, these AAP guidelines are adopted in the clinical process. We will describe the outcome of the clinical process in the year 2010 with 65 cases of suspected child abuse of 3660 children presenting at an ED of an academic hospital.

Clinical procedure

The clinical child abuse detection procedure at the ED of the University Medical Center Utrecht consists of several steps (Fig. 1).

? Financial disclosure: This study was funded by the Netherlands Institution for Health research and development (ZonMw 15700.1008). The authors were completely independent from funders in conducting this study and writing this manuscript.

* Corresponding author. Tel.: +31 (0)88 755 4555.

E-mail address: [email protected] (J.S. Sittig).

This detection policy is in line with the requirements of the Dutch Health Care Inspectorate [6], the mandatory code on reporting child abuse of the Royal Dutch Medical Association [7], and the guidelines of the AAP [5,8].

In 2007, the Dutch Health Care Inspectorate has evaluated child abuse detection procedures at EDs of all Dutch hospitals and formulated a set of child abuse detection requirements for all hospitals, to be met by the beginning of 2009 [6]. One of these requirements is the use of a child abuse detection instrument, for instance, the widely used SPUTOVAMO-R questionnaire (Fig. 2).

Emergency department

The Diagnostic procedure starts with taking a detailed medical history and performing a physical examination. In 2010, 3660 children (0-18 years) attended the ED because of a medical problem. For every child, an ED nurse and/or physician fill out SPUTOVAMO-R. The result of completing SPUTOVAMO-R will predominantly deter- mine the consecutive workup for the potentially maltreated child. For all 3660 children, SPUTOVAMO-R was filled out (100%). Of these, 65 cases (1.78%) were considered to be suspected of child abuse. Most often (24/65), emotional neglect was suspected (eg, inadequate parental-child interaction), followed by physical neglect (21/65, eg, inadequate preventive measures such as the presence of a safety baby gate) and physical abuse (19/65, eg, inflicted traumatic brain injury).

A positive SPUTOVAMO-R test result is followed by a systematic workup starting with an instant pediatric consultation in the ED. The pediatrician obtains an additional Detailed history from the parents or

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J.S. Sittig et al. / American Journal of Emergency Medicine 32 (2014) 6466 65

Emergency department: n = 3660

History, physical examination, SPUTOVAMO-R

Suspicion: n = 65

Consultation of pediatrician

Additional history and physical examination

Hospital registration

Investigation /evaluation during monthly CAAT meeting

Suspicion rejected: n = 0

Suspicion still present: n = 65

Consultation CAAT pediatrician

Suspicion rejected: n = 40

Estimation of safety

Ambulant follow up

Suspicion still present: n = 25 Admission because of medical

or safety reasons: n = 37

(In)voluntary hospitalization

Decision CAAT

Suspicion substantiated: n = 9

Not substantiated, but real concerns present: n = 16

Registration CPS: n = 2

Fig. 1. Clinical process of child abuse detection.

caregivers and–if possible–from the child itself. A full physical examination is performed. The pediatrician is also able to consult a child abuse expert 24/7, a pediatrician specialized in child abuse, and member of the hospital Child Abuse Assessment Team (CAAT).

Child abuse assessment team

Suspicions of any form of child abuse are evaluated and eventually rejected or substantiated by the CAAT. The CAAT is a team of

Injury compatible with history and corresponding with age of child?



History consistent when repeated?



Delay in ED attendance without satisfactory explanation ?



Top-to-toe examination: suspect?



Unexplained (other) injury in history?



Father / mother and child: Appropriate behaviour / interaction?



No suspicion child abuse

Suspicion child abuse.

Consult a pediatrician or contact the ’24-hour child abuse team’


66 J.S. Sittig et al. / American Journal of Emergency Medicine 32 (2014) 6466


Composition of the CAAT

Composition of CAAT

Pediatrician specialized in child abuse (chairman) Social worker (coordinator)

Pediatrician (main practitioner) Pediatric surgeon

Pediatric radiologist

Pediatric psychiatrist and psychologist Forensic psychiatrist

Emergency physician and emergency nurse CPS doctor

Advisor forensic medicine

Pediatric dermatologist (on demand) Lawyer (on demand)

pediatricians and other professionals specialized in child abuse (Table). Monthly, the CAAT gathers to evaluate the management of all recent cases regarding child abuse suspicion. Professionals from other hospitals and primary care can also consult a CAAT pediatrician. As stated in the AAP guidelines, involving a CAAT early in the process can ensure accurate and comprehensive assessment and sharing of information among the medical and nonmedical disciplines involved. The CAAT can provide intermediate and long-term man- agement of the child and family [4]. In the University Medical Center Utrecht, in approximately 60% of the children with a suspicion of child abuse, an intervention was initiated. Of all children, 25% received support from psychologists or social work within our own hospital, and in approximately 35% of the cases, the parents were referred to other organizations, such as pedagogical support institutions, com- munity programs, and other resources that will provide effective

prevention or intervention.


One of the CAAT’s goals is to ensure that the child’s immediate medical and safety needs are met. When necessary for medical or safety reasons, the child is admitted to the hospital. If parents do not agree with hospital admission, the child welfare council will ask the judge for a child protection measure. When hospital admission is not needed, the CAAT pediatrician ensures ambulatory follow-up. In 2010, 37 of the 65 children with a suspicion of child abuse were admitted because of medical or safety reasons.

After the workup, in 25 (38%) of the 65 suspected child abuse cases, actual concerns were present and/or were substantiated by the CAAT, and in 60%, any form of extra support was given. When necessary, a case is transferred to child protection services, which happened 2 times (3.1%) in 2010.


Detection of any form of child abuse at an ED is highly important but difficult as well. Our structured child abuse detection approach includes the use of the detection instrument SPUTOVAMO-R. Like with other detection instruments, one of the pitfalls is that the predictive value of this instrument has never been evaluated. In 2010,

a minority of the SPUTOVAMO-R positively screened cases were substantiated by the CAAT, which suggests a low specificity and low positive predictive value of this child abuse detection instrument.

Nevertheless, although the predictive value is not known, the use of a detection instrument as part of a detection procedure could be useful. Professionals are urged to be explicitly aware of child abuse as one of the differential diagnoses. Previous studies showed that following a structured child abuse detection procedure could increase the detection rate by improving the awareness [9,10-12].

In all situations of suspicions, satisfactory communication with parents or caregivers is crucial. To develop adequate communication skills, educational programs such as The Next Page [13] could be useful. In our hospital, all ED professionals are adequately trained by this educational e-learning program, which is to be translated into English in order to be internationally available soon.

Another strength of the detection procedure is the fact that the percentage of completed SPUTOVAMO-R forms is 100%. Because filling out SPUTOVAMO-R is a mandatory field in our electronic file of all pediatric patients, this ultimate percentage is guaranteed. Before SPUTOVAMO-R was a mandatory field in the medical chart of children, only approximately 34% of the form was filled out. To ensure good quality of assessments, adequate education is crucial because a mandatory field does not necessarily guarantee quality of the assessments.


The authors thank Arend Groot for providing assistance with database management.


  1. Gilbert R, Widom CS, Browne K, et al. Burden and consequences of child maltreatment in high-income countries. Lancet 2009;373:68-81.
  2. Alink L, Bakermans-Kranenburg MJ, Pannebakker F, et al. De Tweede Nationale Prevalentiestudie Mishandeling van Kinderen en Jeugdigen (NPM-2010) 2011.
  3. Woodman J, Pitt M, Wentz R, et al. Performance of Screening tests for child physical abuse in accident and emergency departments. Health TechnolAssess 2008;12:iii, xi-iiixiii.
  4. Jenny C, Hymel KP, Ritzen A, et al. Analysis of missed cases of abusive head trauma.

    JAMA 1999;281:621-6.

    Kellogg ND. Evaluation of suspected child physical abuse. Pediatrics 2007;119: 1232-41.

  5. van der Wal G. Afdeling spoedeisende hulp van ziekenhuizen signaleert kindermishandeling nog onvoldoende: gebroken arm nog te vaak een ongelukje. The Hague: Inspectie voor de Gezondheidszorg; 2008; 1-48.

    kindermishandeling.htm, 2008.

    Flaherty EG, Stirling Jr J. Clinical report–the pediatrician’s role in child maltreatment prevention. Pediatrics 2010;126:833-41.

  7. Bleeker G, Vet NJ, Haumann TJ, et al. Toename van het aantal gemelde gevallen van kindermishandeling na een gestructureerde aanpak in het VU Medisch Centrum, Amsterdam, 2001/’04. Ned Tijdschr Geneeskd 2005;149:1620-4.
  8. Clark KD, Tepper D, Jenny C. Effect of a screening profile on the diagnosis of nonaccidental burns in children. Pediatr Emerg Care 1997;13:259-61.
  9. Louwers EC, Affourtit MJ, Moll HA, et al. Screening for child abuse at emergency departments: a systematic review. Arch Dis Child 2009;95(3):214-8.
  10. Pless IB, Sibald AD, Smith MA, et al. A reappraisal of the frequency of child abuse seen in pediatric emergency rooms. Child Abuse Negl 1987;11:193-200.
  11. Smeekens AE, Broekhuijsen-van Henten DM, Sittig JS, et al. Successful e-learning programme on the detection of child abuse in emergency departments: a randomised controlled trial. Arch Dis Child 2011;96:330-4.