The COVID-19 pandemic has forced a re-evaluation of the role of emergency physicians in reporting suspected abuse.
According to the Child Maltreatment Report, an estimated 1,770 children died of abuse or neglect in 2018, indicating a rate of 2.39 per 100,000 children in the United States.
Non-fatal incidents of abuse or neglect from the same report indicate a rate of 9.2 victims per every 1,000 children. With such staggering numbers, the importance of third-party reporting cannot be overstated. A single-center, observational and retrospective study conducted from 2008 to 2017 determined that only 0.07% of child abuse cases are diagnosed in the ED, but the current COVID-19 pandemic has forced a re-evaluation of the role of ED physicians in reporting suspected abuse.1 There is now a heavy responsibility placed on those working in the ED, as the usual methods of reporting have become limited.
Prior to 2020, the majority of child abuse reports were received from teachers and other school personnel. The U.S. Department of Health and Human Services estimates that educators historically account for nearly 21% of child abuse or neglect referrals.2 However, since the eruption of the COVID-19 pandemic in early 2020, calls to the child protective services for suspected child abuse have significantly declined, likely due to the stay-at-home orders and school closures that have limited teacher-student interactions. A report by the Maryland Department of Human Services reveals a 62% decrease in potential abuse calls from the time in-school sessions ended until March 2020, in only a couple of weeks. Unfortunately, this sudden drop in reporting is likely more indicative that children are suffering in silence, rather than of a legitimate downturn in cases. In fact, it is far more likely that cases of abuse have increased secondary to the pandemic.
Sudden spikes in abuse cases following a major crisis or event is not a new phenomenon, especially when those events bring novel forms of stress. For example, following Hurricane Katrina, reports of partner physical abuse among women nearly doubled in the southernmost Mississippi counties.3 COVID-19 has caused panic as well as financial uncertainty, which are conditions that may create violence where it did not exist or exacerbate already unstable households.4 Despite what is known about major events and abuse, a unique hurdle faced today is the stay-at-home order and recommendation of strict social distancing, forcing victims to be effectively trapped with their abusers for extended periods of time. This results in countless missed opportunities for reporting, which going to public places such as schools, restaurants, and shopping centers would otherwise allow. Knowing that abuse victims are without their typical resources and likely facing new or increased abuse, the question becomes: What can be done about it?
This unprecedented time has not ceased in challenging emergency physicians, but it does not end with COVID patients. It must become second nature to recognize signs of child abuse in all pediatric patients that present to the department, regardless of the chief complaint. Through a thorough assessment of pediatric patients, the emergency department may be one of the few places that abuse cases can be caught during the pandemic, necessitating an efficient screening method.
The Escape questionnaire seems to be the best option for this purpose, as it is a successfully vetted assessment tool that can be applied to all pediatric patients.5
The Escape questionnaire was established in 2013 by Louwers et al. and determined via diagnostic accuracy study in 2017 to have an accuracy of 99.2% and a sensitivity of 100% (95% confidence interval 87.6-100).6 The Escape questionnaire consists of 6 questions, with one or more abnormal answers indicating a positive screen.
- Is the history consistent?
- Was seeking medical help unnecessarily delayed?
- Does the onset of the injury fit with the development level of the child?
- Is the behavior of the child, his or her caregivers and their interaction appropriate?
- Are findings of the head-to-toe examination in accordance with the history?
- Are there signals that make you doubt the safety of the child or other family members?
By evaluating each pediatric patient with this questionnaire, abuse cases can be identified with overwhelming confidence. The need for a widely accepted screening tool with a high sensitivity has never been more called for than during the current pandemic. The recommendation that all EDs adopt this tool could save lives and prevent tragedy.
While the ED can be hectic, especially during the pandemic, adding this questionnaire to the triage and intake process can allow it to be implemented by support staff before a physician begins their interactions with the patient. While it is never easy to add to the plate of anyone in the ED, the benefits significantly outweigh the effort when proper training and protocols are utilized.
COVID-19 has brought challenges that those in emergency medicine have worked tirelessly to address. The challenge of the increased pediatric abuse cases and limitations on reporting is no different, and it deserves to be met with the same tenacity as all others. During a global pandemic, an emergency department physician may be the only resource that a child has to be rescued from an abusive situation, so every visit must be assessed. The Escape questionnaire has proven its effectiveness as a simple and sensitive screening tool. It takes only minutes to ask 6 questions, but those 6 questions could be the difference between life and death.
- Solís-García G, Marañón R, Medina Muñoz M, de Lucas Volle S, García-Morín M, Rivas García A. Child abuse in the emergency department: Epidemiology, management, and follow-up. An Pediatr (Barc). 2019;91(1):37-41.
- U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children's Bureau. Child Maltreatment 2018. 2020.
- Schumacher JA, Coffey SF, Norris FH, Tracy M, Clements K, Galea S. Intimate partner violence and Hurricane Katrina: predictors and associated mental health outcomes. Violence and Victims. 2010;25(5):588–603.
- Abramson A. American Psychological Association. How COVID-19 may increase domestic violence and child abuse. April 8, 2020.
- Louwers EC, Korfage IJ, Affourtit MJ, et al. Accuracy of a screening instrument to identify potential child abuse in emergency departments. Child Abuse Negl. 2014;38(7):1275-1281.
- Dinpanah H, Akbarzadeh Pasha A. Potential Child Abuse Screening in Emergency Department; a Diagnostic Accuracy Study. Emerg (Tehran). 2017;5(1):e8.
- WUSA. Child abuse is likely going to underreported during the coronavirus pandemic. Here's what you can do to help. 2020.