The time I have spent at The Children’s Hospital of Philadelphia (CHOP) this week has been academically very stimulating. I’ve been working with clinicians who are real experts in their fields – many of whom have lectured and advised internationally and given evidence, as experts, in Court proceedings throughout the world. As with all of the other places I’ve visited so far, the welcome I have received here has been brilliant.
CHOP is one of the leading children’s hospitals in the USA and has earned the No. 1 spot on U.S.News & World Report‘s 2013-14 Honour Roll of the nation’s Best Children’s Hospitals. CHOP was also ranked in the top four for all 10 paediatric specialties surveyed. Only 10 children’s centres in the USA earned a place on the 2013-14 U.S. News Honour Roll. The chief executive of CHOP believes that, “this recognition is a tribute to the exceptional work of our staff and their tireless dedication to our patients”.
I have seen at first-hand this week that dedication in action, a clear commitment to innovation and research and a multi-disciplinary team that functions efficiently and expertly as one unit, continually focussing on what is best for the patient(s) concerned.
CHOP was the USA’s first children’s hospital and has a long history of innovation and excellence. The 535-bedded hospital in central Philadelphia treats more than 1.2 million children a year through hospital admissions and outpatient visits and earned its high marks for its dedication and expertise across multiple specialties, the quality of its treatment, superior nurse-patient ratios, survival rates and ongoing research.
I was pleased to be able to attend the Grand Round at CHOP this week (an 8am start with donuts and bagels) which was delivered by Professor Harriet MacMillan from McMaster University, Ontario. Professor MacMillan is a paediatrician and child psychiatrist conducting family violence research, including trials of interventions aimed at prevention of child maltreatment and intimate partner violence (or domestic violence (DV) as we refer to it in the UK). Harriet gave an excellent presentation looking at the evidence base, or lack of it, behind some of the interventions that are often used for children who are at risk of child abuse or who have suffered from maltreatment. I was even more delighted to be able to join Harriet and the CHOP CARE Team for lunch so that we could discuss the potential applicability of her work to the UK health system with a particular focus on what may be appropriate for clinicians working in paediatric (and general) emergency departments.
Interventions to prevent child maltreatment
Work published in the Lancet focussing on interventions to prevent child maltreatment and associated impairment has shown mixed results. Although a broad range of programmes for prevention of child maltreatment exist, the effectiveness of most of the programmes is unknown. The Nurse-Family Partnership, which is available in the UK, and Early Start-have been shown to prevent child maltreatment and associated outcomes such as injuries. Whether school-based educational programmes prevent child sexual abuse is unknown, and there are currently no known approaches to prevent emotional abuse or exposure to intimate-partner violence. No intervention has yet been shown to be effective in preventing recurrence of neglect. Cognitive-behavioural therapy for sexually abused children with symptoms of post-traumatic stress shows the best evidence for reduction in mental-health conditions. The research team recommend that future research should ensure that interventions are assessed in controlled trials, using actual outcomes of maltreatment and associated health measures.
In serious case reviews of children who have suffered from significant harm in the UK, the toxic triad of Domestic Violence, Adverse Parental Mental Health and Alcohol/Substance Misuse are found in over a third of cases. Dr MacMillan’s team have focussed on domestic violence to determine the effectiveness of DV screening and whether it reduces violence or improves health outcomes for women (although we must remember that men, too, can suffer from DV). The team’s results were interesting and provide a focus for future work as they did not provide sufficient evidence to support DV screening in health care settings (there was no demonstrable benefit or harm) but, instead, they recommended that evaluation of services for women after identification of DV should remain a priority.
What can we do to reduce the risks of child abuse?
1:3 adults in Canada retrospectively report some form of exposure to child maltreatment and thsse figures are comparable to data from the USA. What we really need to identify are those factors in society which put children at such increased risk of harm and, once those risks have been identified, we need clearly evaluated and effective strategies in place to deal with those risks to reduce the number of cases of child abuse that do occur and to improve the outcomes for those children who have suffered from maltreatment.
I don’t think we need any more studies working out if poverty is a bad thing for children and families – we know it is and rather than invest further scarce funds in re-identifying that fact which has been known now for some time, money should be invested in resolving that poverty so that, as a direct consequence, it is likely that the harm which stems from it which is, of course, multi-faceted but includes an increased risk of child maltreatment, will be reduced.
As I’ve travelled around the three states that I have visited so far I’ve been trying to work out what it is about the society that exists in the USA which seems to have so much more child abuse contained within it than I would ever expect to see where I work in the UK. It is not a case of us missing all of those cases in the UK, and having an artificially lower rate, but my subjective opinion having seen a shockingly large number of incredibly serious cases of child abuse over the last three weeks is that we must have lower rates in the UK as I’ve seen more horrendous cases of child maltreatment here than I would expect to see in a very bad 3 months in the UK or, more likely, in 6 months – and I’m confident that those cases I have seen here would have been identified where I work.
I have seen a theme developing over the last three weeks and it will be interesting to see how this further develops as I move cities again at the weekend. Key factors which appear to be associated with the cases of abuse I’ve seen so far here in the USA can be broadly summarised as:
- Social isolation
- Estranged families
- Violence – both in the home and in society
- Chronic stress
- Lack of parenting capacity and skills
Identification of those factors which appear to be associated with such high rates of abuse in the USA may help us two-fold in the UK.
Firstly, knowing those factors will help to identify suitable sociological models which could be put into place to try to address them with the hope that this will minimise the risk of child maltreatment and reduce cases even further. Secondly, when people present to emergency departments having knowledge of what those factors are will help to guide clinicians into more in-depth targeted assessments of patients (both adults and children) where a risk factor is identified.
Tomorrow is my last day in Pennsylvania before I move on to Colorado, and I’m taking the day off work (after several pre-dawn starts this week) to have a look around Philadelphia to learn more about American history.
I’m looking forward to seeing Independence Hall, the Liberty Bell and sampling a Philly Cheesesteak (whiz wit) for lunch. I must remember to re-activate my gym membership when I get home in the summer…!