Child Abuse Prevention Team Activities in a General Hospital in Tochigi,Japan

Introduction

Child abuse is a major public health and social welfare problem in Western high-income countries such as the United Kingdom, the United States, Canada, and Australia.^1,2 Also in Japan, recently, the number of child abuse cases reported to child guidance centers (CGCs), which are equivalent to child protection agencies in other countries, has been increasing significantly. There are 209 CGCs located throughout the country, which have expressed concern about the expanding and serious social problem of child abuse, with the number of reported cases of child abuse exceeding 100 000 in the year 2016.

Physical abuse is often associated with external injuries, manifesting with various symptoms such as severe headache or stomachache, and such subjects often visit hospitals.^3,4 In recent years, child abuse prevention teams (CAPTs) have been established at most university hospitals or large children’s hospitals for the investigation of suspected cases of abuse or neglect. On the other hand, the number of general hospitals that have established CAPTs still remain low.

A CAPT was established at our hospital in December 2011, after the Revised Organ Transplant Law was enforced in July 2010. Although the law allowed organ donation after brain death by persons younger than 15 years of age, it prohibited inclusion of abused children as donors. Since our hospital is a designated emergency and critical care center and an organ donation hospital as well, our CAPT has the task of excluding abused children as organ donors. We report on the activities of our CAPT during the past 5 years and discuss the significance of a CAPT in a general hospital in our country.

Method

The Japanese Red Cross Ashikaga Hospital is a general hospital located in Tochigi prefecture 70 km north of Tokyo, the capital city of Japan. The emergency room (ER) at our hospital annually deals with approximately 2300 patients under 15 years of age, and approximately 30% are accident victims. The doctors on night duty are required to report patients who are suspected to be victims of abuse or neglect to the CAPT. The CAPT consists of pediatrician (chairperson), ER doctor, neurosurgeon, orthopedist, plastic surgeon, gynecologist, certified nurse specialist, social worker, and clerical staff. After referral of the patients, the CAPT discusses the background of the abuse or neglect and decides about notification of the case to the CGC and/or police, as necessary.

Of the cases of abused children reported to the CAPT between January 2012 and December 2016, the patient profile, type of abuse, related clinical department, abuser, notification to the CGC, and the survival/death of the child were reviewed.

Results

Table 1 shows the profiles of 20 patients under 18 years of age that were reported to the CAPT because of suspected abuse or neglect. The following were the types of abuse reported: physical abuse (13 cases), sexual abuse (4 cases), neglect (2 cases), and psychological abuse (1 case; Table 2). Of the aforementioned 20 cases, 13 cases (including 12 cases of physical abuse and 1 case of sexual abuse) visited the ER at nighttime or on holidays, and they were referred to the CAPT by the following day. At our ER, 2909 accident victims under 16 years of age were seen between January 2012 and December 2016. Consequently, the ratio of abuse or neglect was approximately 0.4% of all pediatric accident victims.

Table 1.

Profiles of the Patients Reported to the CAPT.

Case	Date of Occurrence	Age/Gender	Type of Abuse	Clinical Department	Abuser	Admit	Hospitalization (Duration)	Notification	Survival	Comments
1	January 2012	5 months/male	Physical (scald burn)	Plastic surgery	Mother	O	+ (21 days)	CGC	Survival	Occipital scald burn with hot water
2	February 2012	7 years/female	Sexual	Gynecology	Boyfriend of mother	C	−	CGC, police	Survival	Abuser was arrested
3	May 2012	9 months/male	Physical (head trauma)	Neurosurgery	Mother	—	−	CGC	Survival	Acute and chronic subdural hematoma by accidental fall
4	May 2012	17 years/female	Sexual	Psychiatry	Father	O	+ (2 days)	CGC	Survival	Forced to have sexual relationship and escaped from father
5	July 2012	17 years/female	Sexual	Gynecology	Acquaintance	—	−	CGC, police	Survival	Sexual assault by 2 men and emergency contraceptive was prescribed
6	November 2012	17 years/male	Physical (facial bruise)	Neurosurgery	Father	O	−	No	Survival	Punishment for breaking a promise
7	December 2012	4 years/male	Physical (fracture of both feet)	Orthopedics	None	—	−	No	Survival	Jumped off the second floor; voluntarily imitated Superman
8	February 2013	1 year/male	Physical (facial bruise)	Plastic surgery	Mother	—	−	No	Survival	Fell down accidentally while holding her son
9	April 2013	17 years/female	Psychological	Emergency	Mother, elder brother	O	−	Police	Survival	Hyperventilation after abusive words by family
10	September 2013	7 years/male	Physical (head trauma)	Pediatrics	Father	A	+ (3 days)	No	Survival	Flung away after quarrel with father
11	November 2014	10 months/female	Physical (drowning)	Pediatrics	Mother	—	+ (3 days)	CGC	Survival	Fell to bathtub when mother was away for 5 minutes
12	December 2014	3 years/female	Physical (facial bruise)	Pediatrics	Mother	—	−	CGC	Survival	Facial subcutaneous hemorrhage noticed by pediatrician
13	March 2015	8 months/female	Physical (left femoral fracture)	Orthopedics	Parents	—	+ (31 days)	Public health nurse	Survival	Parents noticed their baby cried loud when diaper was changed
14	May 2015	2 years/male	Physical (abdominal injury)	Emergency	Father	C	−	CGC, police	Death	Hemorrhagic shock due to rupture of mesenteric artery
15	June 2015	15 years/female	Physical (head trauma)	Neurosurgery	Father	O	−	CGC	Survival	Father hit a head to encourage his daughter as an athlete
16	September 2015	8 years/male	Physical (abdominal injury)	Pediatrics	Stepfather	A	+ (4 days)	CGC	Survival	Transferred from hospital to shelter house
17	September 2015	13 years/male	Neglect	Pediatrics	Mother	O	−	CGC	Survival	Grandmother claimed mother did not take care of son
18	April 2016	17 years/female	Physical (right humeral fracture)	Psychiatry	Mother	—	+ (42 days)	CGC	Survival	Jumped off the third floor to attempt suicide after trouble with mother
19	November 2016	7 years/female	Neglect	Pediatrics	Parents	O	−	CGC	Survival	Medical neglect in patient with refractory nephrotic syndrome requiring essential treatment
20	December 2016	14 years/female	Sexual	Gynecology	Unknown	—	−	Police	Survival	After sexual assault, emergency contraceptive was prescribed by gynecologist

Abbreviations: CAPT, child abuse prevention team; CGC, child guidance center; O, observed guilt; C, convicted; A, admitted guilt.

Table 2.

Summary of the 20 Patients.

Age	5 months to 17 years (median = 7 years)
Gender	9 Males and 11 females
Type of abuse and abuser	Physical 13 (mother 6, father 4, parents 1, stepfather 1, none 1)
	Sexual 4 (person except family 3, father 1)
	Neglect 2 (mother 1, parents 1)
	Psychological 1 (mother and elder brother)
Related departments	Pediatrics 6, neurosurgery 3, gynecology 3, orthopedics 2, plastic surgery 2, psychiatry 2, emergency 2
Hospitalization	7
Notification	Child Guidance Center 13, Ashikaga Police 5 (3 overlap with Child Guidance Center), public health nurse 1, no notification 4

In 16 of the 20 cases (80%), the mother, father, or another family member was the abuser or suspected abuser. In 3 cases of sexual abuse, the abuser was a person outside the family, and in the remaining 1 case of physical abuse, no abuser was identified. Seven clinical departments, including the departments of pediatrics, neurosurgery, gynecology, orthopedics, plastic surgery, psychiatry, and emergency medicine were involved in the care of the patients reported to the CAPT. Six cases of physical abuse and 1 case of sexual abuse needed hospitalization, with the duration of hospitalization ranging from 2 to 42 days. Sixteen of the 20 cases (80%) were notified to the CGC, the public health nurse at the Ashikaga City Office, or the Ashikaga Police. The remaining 4 cases were not notified to any of these administrative agencies, based on the judgment of the CAPT. In these 4 cases of physical abuse (cases 3, 8, 11, and 12), a closer scrutiny revealed that they were cases of true accidents. Later, the parents of these 4 patients of accidental injury received appropriate instructions.

Discussion

It was found from this study that the CAPT in a general hospital, comprising staff from various medical departments, was effective in detecting and communicating child abuse and neglect. Previously, cases of abuse or neglect were handled individually rather than systematically at our hospital. As they were not required to be reported prior to the establishment of the CAPT, the true incidence of victims of abuse or neglect that visited our hospital remained unclear. The number of reports of abuse or neglect increased after the CAPT was established. The burden on the doctors in charge or on night duty also significantly reduced, because the CAPT took over handling of all the problems of the cases after they were reported to the CAPT.

Through the activities of the CAPT, it was recognized that the CAPT took care of not only nonaccidental serious abuse but also of the 4 cases of accidental injuries after careful scrutiny. In general, accidental injury or harm in childhood seems to result from a caregiver’s carelessness or lack of knowledge concerning nursing.^5,6 In such cases, appropriate instruction to the caregivers may help in preventing recurrence of injury or maltreatment.

This study showed that 13 of the 20 cases were first seen in the ER of our hospital. Many patients visit the ER of a general hospital, irrespective of the age or nature of the diseases. Even under such busy conditions, careful attention should be paid not to overlook child abuse or neglect when we see pediatric patients, notably pediatric injuries.^4,7 For this purpose, improved awareness of ordinary hospital staff about the CAPT should be promoted.

Seven clinical departments were involved in the care of the patients reported to the CAPT in this study. The department of pediatrics, the most frequently involved of the 7 clinical departments in the care of victims of abuse, was involved in the management of 6 cases. In many other cases too, the pediatricians were consulted by the doctors of various other clinical departments. Thus, today’s pediatricians are often confronted with victims of child abuse and neglect.^8,9 Since the remarkable increase in the number of child abuse reports is expected to persist in this country, the pediatrician of the next generation should be more aware of the magnitude of the child abuse problem. ¹⁰ Pediatricians working in general hospitals in Japan, as well as those working in other Western countries, are required to play a leading role in the detection, diagnosis, and protection of suspected victims of child abuse.