The Impact of Stay-at-Home Orders on the Rate of Emergency Department Child Maltreatment Diagnoses

• In Event: Child Maltreatment, Child Welfare Involvement and Predictors of Youth Risk and Resilience

Abstract

Background: A global report on child abuse from the World Health Organization demonstrates the enormous impact that the COVID-19 pandemic has had on the rates of violence against children. The increased challenges for parents because of pandemic-related stressors such as fear of infection, loss of employment, and lack of childcare likely increased rates of abuse (i.e., sexual, physical, or emotional abuse) and neglect, yet instead there was a concerning drop in the number of reports of suspected child abuse across the US. Medical providers are one of the top sources of mandated reports for abuse and an important safety net for children. However, there are only a few reports regarding the rates and severity of child maltreatment diagnosed in medical settings during the COVID-19 pandemic, and the data are somewhat contradictory.
Objective: To advance our understanding of child maltreatment risk during the COVID-19 pandemic by examining the impact of the public health stay-at-home order on ED child maltreatment diagnoses and conversion to hospitalization, and describe any potential disparities by age, sex, Medicaid status, and race/ethnicity.
Methods: A retrospective pre-post interrupted time series was conducted using data from the electronic health records of Children (<18 years) with at least one emergency department visit between January 1, 2019 and September 30, 2021. Enactment of the Stay-at-home order in California, March 2020 was used to determine a change in trend of rates of diagnosis of CM in the ED. Additionally, conversion to hospitalization was examined as an index of severity of abuse. For the proportion of CM-related ED encounters, we also ran models within subgroups defined by age (0-4yrs, 5-10yrs, 11-17yrs), gender, race/ethnicity, and Medicaid insurance.
Results: Overall our study included 407,228 pediatric ED visits. The observed proportion of CM encounters per 100,000 ED encounters increased considerably from 254.8 in March 2020 to a peak of 400.1 in May 2020 (Figure 1a). This proportion fluctuated and remained elevated for the first year of the pandemic, but began to decrease in May 2021, reaching 216.3 per 100,000 ED encounters by September 2021. From the modeling, the monthly trend prior to the stay-at-home order was generally stable (OR 1.01, 95% CI 0.98, 1.03), but doubled the month immediately after the order was implemented (OR 2.14, 95% CI 1.64, 2.78), then slowly decreased to nearly baseline rates after 17 months with a negative change in trend (OR 0.96, 95% CI 0.93, 0.98) (Figure 1b). This significant increase was driven by higher risk for children <4 years old. The increased rate of CM in the first month after the stay-at-home order was also elevated for female, Black, and Hispanic children (Figure 2).
Conclusions: The rate of CM diagnoses in the ED doubled after the March 2020 stay-at-home order in California. Additionally, our findings suggest that some children may be at higher risk than others, which supports the importance of social safety nets for children in times of national emergency.

Authors

• Sonya Negriff, Kaiser Permanente Southern California
  Presenting Author

• Mercie DiGangi, Kaiser Permanente Southern California