Child and adult holding hands in black and white

CHOC studies child maltreatment during COVID-19, adopts new tools to better recognize signs of abuse

With COVID-19 restrictions keeping more families at home, a critical question has emerged:

Are children suffering more physical and emotional maltreatment because they’re spending more time with parents who are dealing with extra stress in their lives?

A recently completed study by clinicians in the Julia and George Argyros Emergency Department at CHOC Hospital sheds some light on whether child abuse cases are rising because of stay-at-home orders. The study comes as CHOC ED personnel are using two new screening tools to help clinicians better recognize signs of abuse as well as victims of human sex trafficking.

COVID’s effect on child maltreatment

CHOC ED personnel studied whether the incidence of child maltreatment – which includes physical, sexual and emotional abuse, plus neglect – among patients being admitted to the emergency department has risen since the pandemic began in mid-March 2020.

They reviewed records of ED visits of patients up to 18 years old during a 3 ½-month period from March to July 2020 and reviewed the Child Protective Services database, then compared that period to the same time frame in 2019, 2018 and 2017.

Result: More reports of child mistreatment – 215 – were filed during the COVID-19 pandemic, compared to 204 during the same period in 2019, 199 in 2018 and 158 in 2017.

This is especially significant because CHOC’s ED has experienced a significantly lower ED patient census during the pandemic compared to pre-COVID days, says Dr. Mary Jane Piroutek, a CHOC ED attending physician.

Dr. Mary Jane Piroutek, CHOC ED attending physician

While sexual and physical abuse cases were down in the 3 ½-month period in 2020, cases of general neglect and medical neglect, as well as emotional abuse, were higher during COVID compared to the previous years.

Erika Jewell, manager of Case Management and Social Services at CHOC, put some of these numbers in context. In 2017, she reports, the rate of children in Orange County suffering abuse or neglect was 43.8 per 1,000, compared to 33.5 in 2012.

Of the 4,451 substantiated case of child abuse and neglect in Orange County in 2017, the vast majority – 3,204 – were cases of general neglect. Sexual abuse cases, in comparison, totaled 191.

“Our findings suggest the incidence of child neglect increased during the implementation of the stay-at-home guidelines,” says Dr. Piroutek, who spoke with Jewell and others on a panel on Research Day on Nov. 18, 2020.

Knowledge of such a trend, Dr. Piroutek explains, could help providers identify children at risk for maltreatment and, ultimately, provide an impetus to shape public policy and to improve the effectiveness with which resources are allocated to address the COVID-19 public health crisis.

Two new screening tools

Beginning in October 2019, the CHOC ED rolled out the first of two new screening tools aimed at making it easier for nurses and doctors to better identify patients at risk of abuse.

The first new screening tool being used in CHOC’s ED is TRAIN, for Timely Recognition of Abusive Injuries Collaborative. It is used to screen patients 6 months and younger.

The second screening tool, launched in July 2020, is CA-CDS, for Child Abuse – Clinical Decision Support. It is used to screen patients 11 years or younger. Components include a triage screen where nurses or doctors answer five questions, a pop-up computer alert that flags which patients may be at risk for physical abuse, a link to order sets and CHOC’s computerized suspected child abuse form.

With these two new tools, the CHOC ED estimates it can detect 50 percent more sentinel injuries than before. A sentinel injury is a seemingly trivial one that can be viewed as a “sentinel event” for much worse injuries in the future. Research shows that one-quarter of abused children had previous sentinel injuries.

The ED is collecting data through December 2021 to evaluate how well the new screening tools are helping healthcare workers detect cases of maltreatment, Dr. Piroutek says.

“It’s a more data-based and methodical approach; you have a computer that’s looking at data and flagging concerning patterns for you: ‘Hey, there’s something that might be abuse here,’” Dr. Piroutek explains.

The new screening tools will help CHOC better comply with treatment guidelines set forth by the American Academy of Pediatrics (AAP), Dr. Piroutek notes.

“CHOC is committed to research for the betterment of our patients and children,” Dr. Piroutek says. “With the implementation of these new screening tools I am confident we can provide the best care for our patients.”

Screening for human sex trafficking has also become an important part of CHOC nursing care.

Sheryl Riccardi, Emergency Department manager at CHOC, says a steering group of about 20 associates has been established to help healthcare workers better identify, intervene and advocate for these victims, many of whom are minors and most of whom come from the Unites States.

Santa Ana is the largest hub of human sex trafficking in the state, she notes. The ED has begun screening 12- to 18-year-olds – regardless of their chief complaint for possible further evaluation – if a child reports a complaint indicating a high risk of abuse, Riccardi says.

CHOC, she adds, recently became a partner with the Orange County Human Trafficking Task Force, a law enforcement-led coalition that is committed to combating all forms of human trafficking through the rescue and long-term support of victims, prosecution of offenders, training of fellow law enforcement professionals, community awareness and effective public/private partnerships.

According to Waymakers and the Salvation Army, in 2019 there were 415 identified victims of human trafficking in Orange County, with sex trafficking victims totaling 359. The other victims were trafficked for labor.

CHOC is determined to do what it can to find and help these victims.

“We’ve very passionate about this,” Riccardi says.

Learn more about how to identify child abuse.