High-risk presentations of child maltreatment

1 Overview

Domain / Phenotype

High-risk presentation of child maltreatment

Sex

Both

Age Range

Child (0-18y) (Note: Age thresholds like ≤3y and ≤10y apply to specific indicators)

Individual

Child Parent

Coding System

READ SNOMED CT ICD-10 ICD-9

Data Sources

CPRD Aurum CPRD GOLD HES-APC

2 Definition

This domain includes indicators consistent with NICE Clinical guidelines CG89 and NG76 on alerting features (risk presentations) that should raise clinical suspicions for CM.

These indicators are designed to be interpreted as warning signs of maltreatment in the face of uncertainty and the absence of definitive evidence for CM. All indicators are recorded in the child's EHR, except for "non-attendance of child appointments" which leverages both maternal and child records.

3 Clinical Codelist

Download HRP-CM Codelist (1774 codes)

See the ACEsinEHRs Control documentation for code processing rules and release information.

Indicator Structure & Taxonomy

Domain	Indicator Code	Indicator Name	No. Codes
HRP-CM	HRPCM1	Bruising & contusions ≤3y†	114
HRP-CM	HRPCM2	Superficial injuries of head, neck or multiple body parts ≤3y†	37
HRP-CM	HRPCM3	Thermal injuries - head, face or neck ≤3y†	161
HRP-CM	HRPCM4	Thermal injuries - trunk, back or trachea ≤3y†	53
HRP-CM	HRPCM5	Skull fractures or intracranial crush injury ≤3y†	16
HRP-CM	HRPCM6	Child harm by undetermined intent - rare injuries & life-threatening events (retinal haemorrhages, drownings, SUDI, firearm etc.) ≤10y†	239
HRP-CM	HRPCM7	Child harm by undetermined intent - exposure to unspecified factor ≤10y†	4
HRP-CM	HRPCM8	Failure to thrive (excessive thirst, suspected malnutrition) ≤10y†	48
HRP-CM	HRPCM9	Non-attendance of child appointment (≥3 appts. within 2-years) ≤10y†	16

Browse & Search Clinical Codelist (Preview)

High-risk presentations of CM | ALL CODING SYSTEMS

Code	Description	Coding System	Indicator
SN272100	Unexplained bruising	SNOMED CT	HRPCM1
T75.1	Unspecified effects of drowning	ICD-10	HRPCM6
8H74.	Did not attend child health clinic	READ	HRPCM9

4 Implementation

Certain specific indicators within this domain require rule-based algorithms to prevent misclassification and account for accident-related exclusions based on NICE Guidelines [CG89].

Algorithm 1 General HRP-CM: Exclude Accidental Injuries (+/- 15 days)

Applies to: Undetermined intent, Lacerations/scars/abrasions, Thermal injuries, Unknown/unspecified morbidity, Unspecified abdominal pain, and Observations for suspected diseases.

Include as HRP-CM only when co-occurring accident-related injuries are excluded within +/-15 days of the event. The time frame is selected based on the median time difference between data sources for some accidental injuries.

R Script / Logic

# Exclude cases with known accidental injuries within 15 days
hrpcm_algo_1 <- merged_data %>%
  filter(indicator %in% c("Lacerations", "Thermal injuries", "Undetermined intent")) %>%
  mutate(
    is_hrpcm = ifelse(
      (has_accidental_injury == TRUE & abs(days_to_accident) <= 15), 
      FALSE, TRUE
    )
  )

Algorithm 2 Head & Eye Trauma: Exclude Birth Injuries (< 2 days post-birth)

Applies to: Eye trauma NOS, Subarachnoid haemorrhage, Subdural haematoma/retinal haemorrhage, Intracranial injuries.

Include as HRP-CM when excluded co-occurring accident-related injuries recorded within +/-15 days of the event, AND when excluded birth-related injuries recorded <2 days post birth.

R Script / Logic

# Exclude accidents (15d) and birth injuries (<2 days old)
hrpcm_algo_2 <- head_trauma_data %>%
  mutate(
    is_hrpcm = TRUE,
    is_hrpcm = ifelse((has_accident == TRUE & abs(days_to_accident) <= 15), FALSE, is_hrpcm),
    is_hrpcm = ifelse((age_in_days < 2 & has_birth_injury == TRUE), FALSE, is_hrpcm)
  )

Algorithm 3 Fractures & Abdominal: Exclude Fragile Bone Disease

Applies to: Fractures, Intra-abdominal injuries, Spinal injuries.

Include as HRP-CM when excluded co-occurring accident-related injuries (+/-15 days), birth-related injuries (<2 days post birth), AND when excluded children with fragile bone disease (Osteoporosis) — unless definitive CM is recorded within +/-30 days.

R Script / Logic

# Exclude accidents, birth injuries, and fragile bone disease (unless CM confirmed)
hrpcm_algo_3 <- fracture_data %>%
  mutate(
    is_hrpcm = TRUE,
    is_hrpcm = ifelse((has_accident & abs(days_to_accident) <= 15), FALSE, is_hrpcm),
    is_hrpcm = ifelse((age_in_days < 2 & has_birth_injury), FALSE, is_hrpcm),
    # Exclude if fragile bone disease, but override if definitive CM is nearby
    is_hrpcm = ifelse((has_osteoporosis == TRUE & !(has_cm & abs(days_to_cm) <= 30)), FALSE, is_hrpcm)
  )

5 Publications

Core research outputs associated with the High-risk presentation of child maltreatment domain.

Family adversity and health characteristics associated with intimate partner violence in children and parents presenting to health care: a population-based birth cohort study in England.

Syed S, Gilbert R, Feder G, Howe LD, Powell C, Howarth E, Deighton J, Lacey RE. The Lancet Public Health. 2023.

Identifying adverse childhood experiences with electronic health records of linked mothers and children in England: a multistage development and validation study.

Syed S, Gonzalez-Izquierdo A, Allister J, Feder G, Li L, Gilbert R. The Lancet Digital Health. 2022.

Predictive value of indicators for identifying child maltreatment and intimate partner violence in coded electronic health records: a systematic review and meta-analysis.

Syed S, Ashwick R, Schlosser M, Gonzalez-Izquierdo A, Li L, Gilbert R. Archives of Disease in Childhood. 2021.

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