Trends in U.S. Emergency Department Visits Related to Suspected or Confirmed Child Abuse and Neglect Among Children and Adolescents Aged <18 Years Before and During the COVID-19 Pandemic

United States, January 2019-September 2020

Elizabeth Swedo, MD; Nimi Idaikkadar, MPH; Ruth Leemis, MPH; Taylor Dias, MPH; Lakshmi Radhakrishnan, MPH; Zachary Stein, MPH; May Chen, PhD; Nickolas Agathis, MD; Kristin Holland, PhD

Disclosures

Morbidity and Mortality Weekly Report. 2020;69(41):1841-1847. 

In This Article

Abstract and Introduction

Introduction

Heightened stress, school closures, loss of income, and social isolation resulting from the coronavirus disease 2019 (COVID-19) pandemic have increased the risk for child abuse and neglect.[1] Using National Syndromic Surveillance Program (NSSP) data from January 6, 2019–September 6, 2020, CDC tabulated weekly numbers of emergency department (ED) visits related to child abuse and neglect and calculated the proportions of such visits per 100,000 ED visits, as well as the percentage of suspected or confirmed ED visits related to child abuse and neglect ending in hospitalization, overall and stratified by age group (0–4, 5–11, and 12–17 years). The total number of ED visits related to child abuse and neglect began decreasing below the corresponding 2019 period during week 11 (March 15–March 22, 2020) for all age groups examined, coinciding with the declaration of a national emergency on March 13;[2] simultaneously, the proportion of these visits per 100,000 ED visits began increasing above the 2019 baseline for all age groups. Despite decreases in the weekly number of ED visits related to child abuse and neglect, the weekly number of these visits resulting in hospitalization remained stable in 2020; however, the yearly percentage of ED visits related to child abuse and neglect resulting in hospitalization increased significantly among all age groups. Although the increased proportion of ED visits related to child abuse and neglect might be associated with a decrease in the overall number of ED visits, these findings also suggest that health care–seeking patterns have shifted during the pandemic. Hospitalizations for child abuse and neglect did not decrease in 2020, suggesting that injury severity did not decrease during the pandemic, despite decreased ED visits. Child abuse is preventable; implementation of strategies including strengthening household economic supports and creating family-friendly work policies can reduce stress during difficult times and increase children's opportunities to thrive in safe, stable, and nurturing relationships and environments.[3]

Despite known risk for child abuse and neglect during pandemics[4] and preliminary reports of increased severity of child abuse and neglect in some facilities,[5] official reports to child protection agencies have declined across the United States by 20%–70%, attributed to decreased in-person contact between children and mandated reporters (e.g., teachers, social workers, and physicians).[6] Lack of timely data on child abuse and neglect in the context of COVID-19 highlights the value of near real-time data from NSSP, which provide the opportunity to examine trends in ED visits and hospitalizations for suspected or confirmed child abuse and neglect before and during the COVID-19 pandemic.

Data for U.S. ED visits among children and adolescents aged <18 years were obtained from NSSP's BioSense Platform using a query for suspected and confirmed ED visits related to child abuse and neglect developed by NSSP, CDC's Division of Violence Prevention, and local and state health departments.[7] NSSP is a collaboration among CDC, federal partners, local and state health departments, and academic and private sector partners to support the collection and analysis of electronic health data from EDs, urgent and ambulatory care centers, inpatient health care facilities, and laboratories. As of March 31, 2020, a total of 3,310 EDs in 47 states and the District of Columbia contributed data to the platform daily, providing information on approximately 73% of all ED visits in the United States. Visits were included if the ED provider or facility documented suspected or confirmed physical, sexual, or emotional abuse or physical or emotional neglect of a child or adolescent aged <18 years by a parent or other caregiver.[8] To limit the impact of data quality on resulting trends, only visits from facilities that consistently sent informative* discharge diagnoses for ≥70% of cases with ≤20% standard deviation were included; the number of facilities meeting these criteria varied from week to week but averaged 2,970 facilities during the study period (approximately 90% of NSSP's participating EDs).

Data were analyzed to examine national trends in ED visits for suspected or confirmed child abuse and neglect during January 6, 2019–September 6, 2020, the period before and during the U.S. COVID-19 pandemic. Weekly numbers and proportions of visits related to child abuse and neglect per 100,000 ED visits were computed overall and stratified by age group (0–4, 5–11, and 12–17 years). In addition, weekly and annual percentages of ED visits related to child abuse and neglect resulting in hospitalization were calculated. The change in mean ED visits related to child abuse and neglect per week during the early pandemic period (March 31–April 27, 2020) and the comparison period (March 29–April 25, 2019) was calculated as the mean difference in total ED visits related to child abuse and neglect between the two 4-week periods. Statistically significant differences in annual percentages of ED visits related to child abuse and neglect ending in hospitalizations were assessed using t-tests. All analyses were performed using R software (version 4.0.2; The R Foundation). This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.§

The total number of 2020 ED visits meeting the syndrome definition for child abuse and neglect (Table) began decreasing to below the number of visits that occurred during the corresponding 2019 prepandemic period in week 11 (March 15–March 22), coinciding with the president's Proclamation Declaring a National Emergency Concerning the Novel Coronavirus Disease (COVID-19) Outbreak on March 13, 2020 (Figure 1). This pattern was observed for all age groups examined (Supplementary Figure, https://stacks.cdc.gov/view/cdc/98213). At the same time, the proportion of ED visits related to child abuse and neglect per 100,000 ED visits began increasing above the proportion seen during the corresponding period in 2019 (Figure 1). ED visits related to child abuse and neglect among children and adolescents aged <18 years reached their nadir during week 13 (March 29–April 4, 2020). During the 4-week period following this early pandemic nadir (March 29–April 25), the number of ED visits related to child abuse and neglect among children and adolescents aged <18 years averaged 53% less than the number that occurred during the corresponding period in 2019 (March 31–April 27) (Figure 1). The number of ED visits related to child abuse and neglect was lower during this period in 2020, compared with visits during the corresponding period in 2019 for every age group, with the largest proportional declines in number of visits by children aged 5–11 years (61%) (Supplementary Figure, https://stacks.cdc.gov/view/cdc/98213).

Figure 1.

Number (A) and proportion (B) of emergency department (ED) visits related to suspected and confirmed child abuse and neglect among children and adolescents aged <18 years, by week — National Syndromic Surveillance Program, United States, 2019–2020

Despite decreases in the total number of ED visits related to child abuse and neglect, the number of these ED visits resulting in hospitalization did not decline in 2020 (Figure 2). As a result of the consistent number of hospitalizations and the decrease in the number of overall ED visits, the percentage of ED visits related to child abuse and neglect ending in hospitalization increased significantly among children and adolescents aged <18 years, from 2.1% in 2019 to 3.2% in 2020 (p<0.001) (Figure 2). Significant increases in the percentage of ED visits related to child abuse and neglect ending in hospitalization were also observed for children aged 0–4 years (3.5% in 2019 versus 5.3% in 2020; p<0.001) and 5–11 years (0.7% in 2019 versus 1.3% in 2020; p<0.001), and adolescents aged 12–17 years (1.6% in 2019 versus 2.2% in 2020; p = 0.002) (Supplementary Figure, https://stacks.cdc.gov/view/cdc/98213).

Figure 2.

Number (A) and percentage (B) of emergency department (ED) visits related to suspected and confirmed child abuse and neglect ending in hospitalization among children and adolescents aged <18 years, by week — National Syndromic Surveillance Program, United States, 2019–2020

*Discharge diagnoses were not null or did not simply include terms like "unknown."
Complete year for 2019 compared with partial year for 2020.
§45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.

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