title: Value of systematic detection of physical child abuse at emergency rooms: a cross-sectional diagnostic accuracy study.
abstract: OBJECTIVE
  The aim of our diagnostic accuracy study Child Abuse Inventory at Emergency Rooms (CHAIN-ER) was to establish whether a widely used checklist accurately detects or excludes physical abuse among children presenting to ERs with physical injury.
  
  
  METHODS
  A large multicentre study with a 6-month follow-up.
  
  
  METHODS
  4 ERs in The Netherlands.
  
  
  METHODS
  4290 children aged 0-7 years attending the ER because of physical injury. All children were systematically tested with an easy-to-use child abuse checklist (index test). A national expert panel (reference standard) retrospectively assessed all children with positive screens and a 15% random sample of the children with negative screens for physical abuse, using additional information, namely, an injury history taken by a paediatrician, information provided by the general practitioner, youth doctor and social services by structured questionnaires, and 6-month follow-up information.
  
  
  METHODS
  Physical child abuse.
  
  
  METHODS
  Injury due to neglect and need for help.
  
  
  RESULTS
  4253/4290 (99%) parents agreed to follow-up. At a prevalence of 0.07% (3/4253) for inflicted injury by expert panel decision, the positive predictive value of the checklist was 0.03 (95% CI 0.006 to 0.085), and the negative predictive value 1.0 (0.994 to 1.0). There was 100% (93 to 100) agreement about inflicted injury in children, with positive screens between the expert panel and child abuse experts.
  
  
  CONCLUSIONS
  Rare cases of inflicted injury among preschool children presenting at ERs for injury are very likely captured by easy-to-use checklists, but at very high false-positive rates. Subsequent assessment by child abuse experts can be safely restricted to children with positive screens at very low risk of missing cases of inflicted injury. Because of the high false positive rate, we do advise careful prior consideration of cost-effectiveness and clinical and societal implications before de novo implementation.
authors.affiliation: Department of Paediatrics, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, The Netherlands Mental Health Care 'GGZ Centraal', Hilversum, The Netherlands.
authors.forename: Judith S
authors.initials: JS
authors.lastname: Sittig
authors.affiliation: Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands.
authors.forename: Cuno S P M
authors.initials: CS
authors.lastname: Uiterwaal
authors.affiliation: Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands.
authors.forename: Karel G M
authors.initials: KG
authors.lastname: Moons
authors.affiliation: Department of Paediatrics, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, The Netherlands.
authors.forename: Ingrid M B
authors.initials: IM
authors.lastname: Russel
authors.affiliation: Department of Paediatric Radiology, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, The Netherlands.
authors.forename: Rutger A J
authors.initials: RA
authors.lastname: Nievelstein
authors.affiliation: Department of Paediatrics, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, The Netherlands.
authors.forename: Edward E S
authors.initials: EE
authors.lastname: Nieuwenhuis
authors.affiliation: Department of Paediatrics, Wilhelmina Children's Hospital, University Medical Centre Utrecht, Utrecht, The Netherlands.
authors.forename: Elise M
authors.initials: EM
authors.lastname: van de Putte
mesh_terms: D057189:Checklist / Q000592:standards*; D002648:Child; D002649:Child Abuse / Q000175:diagnosis*; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D005189:False Positive Reactions; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D009426:Netherlands; D010290:Parents; D010808:Physical Examination / Q000379:methods*; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D011795:Surveys and Questionnaires
keywords: ACCIDENT & EMERGENCY MEDICINE; EPIDEMIOLOGY