Audit of paediatrician recognition of children's vulnerability to harm at the Royal Children's Hospital, Melbourne

Abstract

Aim Vulnerable children can be defined as those at risk of child abuse and neglect and long‐term adverse health, neurodevelopmental and behavioural outcomes. This study examined whether a cohort of paediatricians and advanced trainees at the Royal Children's Hospital, Melbourne, recognised children's vulnerability. Methods We reviewed the clinical note in the electronic medical record (EMR) for 425 new patients presenting to five paediatric clinics between 1 July 2017 and 31 December 2017. We examined paediatrician documentation of adverse childhood experiences (ACE), risk and resilience factors, referrals for intervention to improve psychosocial well‐being and the application of ‘vulnerable child’ alert flags in the EMR to indicate vulnerability to harm. Children were deemed vulnerable if the paediatrician explicitly stated it in the EMR, if the child had a ‘vulnerable child’ alert placed in their record or had an appropriate referral for management of neurodevelopmental trauma. Results Of the original cohort, 8% was documented as vulnerable, 21% had a referral for intervention and 2% had a ‘vulnerable child’ alert. Overall, paediatricians infrequently documented ACE, risk and protective factors. The odds of identifying vulnerability increased with each added risk factor recorded (odds ratio (OR) 2.6, P < 0.001, 95% confidence interval (1.9–3.5)), with an ACE score was >4 (OR 72, P < 0.001 (14.3–361)) and decreased with each added protective factor recorded (OR 0.6, P < 0.001 (0.5–0.8)). Conclusion Paediatricians infrequently document ACE, risk and protective factors and rarely ‘flag’ children's vulnerability to harm. Identification of the vulnerable child is correlated with documentation of risk and resilience factors at the initial consultation.

Utility of screening for adverse childhood experiences (ACE) in children and young people attending clinical and healthcare settings: a systematic review

“… 38 60 In Barnett et al ’s 38 study, participants were most frequently referred to insurance enrolment services, childcare and housing services. In Mahindroo et al ’s 60 study, participants were referred to mental health services, Child FIRST or Child Protection, social workers, and alternative services or existing supports. None of the studies completed follow-ups thus the impact of accessing services or the percentage of participants who accessed services after referral is unknown.…”

“…Six studies4 5 54 55 60 61 specified that their participant samples included First Nations children (Māori children, Native American children and Aboriginal and Torres Strait Islander children). One study was conducted in the USA, 1 in New Zealand and 4 in Australia.…”

“…One study was conducted in the USA, 1 in New Zealand and 4 in Australia. Four studies5 54 60 61 were retrospective file reviews reporting on the prevalence of ACE in their sample populations and two used clinician-completed ACE questionnaires, completed after child clinic visits using routinely collected data (eg, referral information, previous medical reports) 4 55. Of these, only 3 Australian studies segregated data based on ethnicity 4 5 55.…”

“…Only 4 studies provided information on action taken following routine ACE enquiry 4 38 47 60. Two studies were conducted in the USA and 2 in Australia.…”

“…Neither study reported on the types of services accessed by participants. The 2 studies that did not report eligibility criteria for referrals did provide details on the services that participants were referred to 38 60. In Barnett et al ’s38 study, participants were most frequently referred to insurance enrolment services, childcare and housing services.…”