Elsevier

Child Abuse & Neglect

Volume 33, Issue 11, November 2009, Pages 791-808
Child Abuse & Neglect

The utility and challenges of using ICD codes in child maltreatment research: A review of existing literature

https://doi.org/10.1016/j.chiabu.2009.08.005Get rights and content

Abstract

Objective

The objectives of this article are to explore the extent to which the International Statistical Classification of Diseases and Related Health Problems (ICD) has been used in child abuse research, to describe how the ICD system has been applied, and to assess factors affecting the reliability of ICD coded data in child abuse research.

Methods

PubMed, CINAHL, PsychInfo and Google Scholar were searched for peer reviewed articles written since 1989 that used ICD as the classification system to identify cases and research child abuse using health databases. Snowballing strategies were also employed by searching the bibliographies of retrieved references to identify relevant associated articles. The papers identified through the search were independently screened by two authors for inclusion, resulting in 47 studies selected for the review. Due to heterogeneity of studies meta-analysis was not performed.

Results

This paper highlights both utility and limitations of ICD coded data. ICD codes have been widely used to conduct research into child maltreatment in health data systems. The codes appear to be used primarily to determine child maltreatment patterns within identified diagnoses or to identify child maltreatment cases for research.

Conclusions

A significant impediment to the use of ICD codes in child maltreatment research is the under ascertainment of child maltreatment by using coded data alone. This is most clearly identified and, to some degree, quantified, in research where data linkage is used.

Practice implications

The importance of improved child maltreatment identification will assist in identifying risk factors and creating programs that can prevent and treat child maltreatment and assist in meeting reporting obligations under the CRC.

Introduction

Intentional injury plays a significant role in childhood morbidity and mortality. The WHO estimates that 53,000 children died from intentional injury in 2002 and intentional injury is as much as twice as high in low-income (2.58/100,000) countries as it is in high-income countries (1.21/100,000) (World Health Organization, 2006). The Convention on the Rights of the Child (CRC) stresses the importance of reducing child mortality and ensuring the provision of necessary medical assistance and health care to all children with an emphasis on the development of primary health care (Article 24) (United Nations, 1990).

With the 20th anniversary and therefore renewed interest in the CRC it is most important that all professionals dealing with child health and development acknowledge the principles of this landmark document. Of relevance to the issues addressed in this paper is in particular Article 19, which highlights the importance of protecting children from maltreatment. The importance of applied research and surveillance in providing data to monitor and evaluate progress in diminishing child maltreatment related mortality and morbidity cannot be understated.

National statistics on the incidence and prevalence of child maltreatment rely on various disparate data sources, including child protection databases, morbidity and mortality data. Not all maltreatment is reported to children's services, and so will not be represented in jurisdictional protection data. Identification of inflicted injury in children in a clinical setting can be complex and confronting for medical and nursing staff. Some cases of child maltreatment are not identified and/or documented adequately and therefore may not be represented in morbidity or mortality statistics. Without standardized definitions of maltreatment and methods of capturing maltreatment in datasets it is difficult to gain a reliable estimate of the true magnitude of child abuse in the community. Definitions of what constitutes child abuse vary across organizations, jurisdictions, and cultures.

The International Statistical Classification of Diseases and Related Health Problems (ICD) is the standard system used to classify health conditions in health datasets. Morbidity and mortality data are coded using this classification and it is the standard diagnostic classification system for epidemiological research and health management purposes (World Health Organization, 2005). Trained clinical coders translate the written medical record into the alpha-numeric codes from the ICD. Using this system, conditions can be coded according to the clinical diagnosis and external cause of injury (environmental events and circumstances that caused the injury). The diagnosis code provides information on the clinical findings or chief reason/s for hospital admission. The basic ICD injury codes consist of three characters or digits, with additional digits added to the three character codes at fourth and sometimes fifth character level for added specificity. The injury diagnosis code “T74 Maltreatment syndromes” from ICD-10 can be assigned to indicate a clinical finding of abuse, with the fourth digits used to indicate different types of abuse (e.g., neglect, physical abuse, sexual abuse, psychological abuse, other and unspecified maltreatment) The external cause codes (E-Code) can be assigned in conjunction with injury diagnoses to describe what happened to cause the injury, the role of human intent in the injury, the activity of the person when they were injured and where the person was when they were injured, the use of the ICD to identify abuse in health datasets may assist in providing standardized estimates of the magnitude of child abuse.

Coding of any health condition or diagnosis relies on the clinical documentation. Documentation for morbidity data is generally collected from medical records and coded by clinical coders when the patient is discharged from hospital. Mortality data codes are assigned based on the cause of death documented when the death certificate is completed. If the information in the source documentation is complete and accurate, this enables the code assignment to be complete and accurate. A competent and well trained clinical coder will be aware of and comply with the rules and conventions designed to ensure standardized application of codes. Identification of diagnoses of fractures, SDH or illness relies on diagnostic criteria whereby clinicians can support and explain their diagnosis because they are familiar with the criteria for each condition. These codes are likely to be reliable and provide an accurate picture of the incidence and patterns of these diagnoses. Diagnostic criteria for child maltreatment are more ambiguous. Clinicians report they are inadequately trained to make that decision. Consequently the documentation of child abuse in hospital records is often incomplete (Benger and Pearce, 2002, Limbos and Berkowitz, 1998) and clinical coders may not have adequate information to assign codes for abuse from hospital records. The determination that a child death resulted from child maltreatment is a coronial issue in many jurisdictions and therefore, may or may not appear on a death certificate as the cause of death before the case has been fully investigated. If a determination of child maltreatment/assault has not been made when the statistics are compiled, and the death was a result of the injuries sustained, coders should assign the default code of accidental death, in accordance with the coding requirements of the ICD. These factors may result in an under-representation of child maltreatment in both morbidity and mortality data. Equally the coding process may lead to under enumeration of child abuse deaths or hospitalizations if external causes are not coded or if coding is limited to one diagnosis because of a lack of resources or perceived need to code more extensively. Thus, statistics or studies that rely exclusively on abuse codes may misrepresent populations at risk when only health data is used (Schnitzer, Covington, Wirtz, Verhoek-Oftedahl, & Palusci, 2008).

This study aimed to systematically review the use of ICD in child abuse research.

Section snippets

Study question

How is the ICD used in child abuse research in health databases, how has the ICD system been applied, and what factors have been identified that affect the reliability of ICD coded data in child abuse research?

Search strategy

The electronic databases PubMed, Google Scholar, PsychInfo and CINAHL were searched for peer reviewed papers using the following search phrase: [(“child maltreatment” or “child abuse”) and (ICD* or classification or coding) and (hospital or emergency department or ED or outpatient or

Results

The literature contains a number of papers where ICD codes in health databases have been used to research child maltreatment. Based on the aims of the papers, these clustered into four broad categories as follows:

  • 1.

    Estimates the incidence of child abuse.

  • 2.

    Describes patterns and characteristics of child abuse estimating risk of death or injury from documentation.

  • 3.

    Evaluates concordance between databases and/or evaluates the use of child abuse codes.

  • 4.

    Estimates the costs of child abuse.

These categories

Discussion

This review of the literature highlights both the utility and challenges of ICD coded data. ICD codes have been widely used to conduct research into child abuse in health data systems. The codes appear to be used primarily to identify diagnoses and conduct further research to identify child abuse patterns within those diagnoses and/or identify instances of child abuse by using the ICD codes assigned for maltreatment or external cause of assault and conduct the research on those children

Conclusion

Article 19 of the CRC highlights the importance of protecting children from maltreatment and Article 24 stresses the significance of reducing childhood mortality. This study illustrates that quality and consistency of data underpin research initiatives, and the value of applied research and surveillance in providing data to monitor and evaluate the incidence of child abuse and the impact of interventions cannot be understated.

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