SPUTOVAMO is a 9-item checklist consisting of physical abuse risk factors used in the ED setting to detect child abuse. An acronym with each letter representing one of the nine questions in Dutch, it was first implemented in the Netherlands in 1996. SPUTOVAMO was more universally applied in 2009 when all Dutch EDs were legally required to screen every child for child abuse and finally validated in 2019 [11,12,13].

The SPUTOVAMO validation study included 12,198 patients under 18 years who were admitted to the ED of a large tertiary hospital over the course of 2.5 years. The triage nurse performed the SPUTOVAMO checklist and either a physician or nurse performed a complete physical examination (tip-to-toe inspection (TTI)). SPUTOVAMO is positive if at least one question scored abnormal. The TTI is positive when unexplained injuries, inadequate care/hygiene, failure to thrive, or abnormal child or parent–child interaction were observed. A positive screening test is followed by a direct referral to a specialized pediatrician for further assessment and sending a report to the Child Abuse and Neglect Team.

This prospective study estimated the individual performance of SPUTOVAMO and TTI as well as the accuracy of combining them. For SPUTOVAMO, the positive predictive value (PPV) was calculated at 45% and the negative predictive value (NPV) at 99%, and for TTI, the PPV was calculated at 41% and NPV at 99%; for the combination, PPV was calculated at 41% (Table 1) [11]. Using data provided in the original manuscript, Stilwell and colleagues calculated the sensitivity of SPUTOVAMO at 79% and specificity at 98% [14]. The question with the highest PPV (41%) asked whether the injury location is usual.

Limitations of this tool include its length to complete as well as subjectivity. Though intended to screen every patient admitted to the ED, SPUTOVAMO was performed in only 46% of patients, and the TTI was completed in 33% in its validation study. Per ED staff meetings, these were most often not performed due to lack of time and space. Additionally, while most questions in the SPUTOVAMO are injury-based, one question was subjective in asking if the measures taken by caregivers were appropriate.

SPUTOVAMO-R is a revised 6-item checklist containing binary questions, one of which refers to a TTI, also used in the ED setting to detect physical abuse. Questions include if the injury is consistent with the history and developmental ability of the child, if the history is consistent when repeated, if seeking medical help was unexplainably delayed, if the TTI examination is suspicious, if there are unexplained injuries in the history, and if the child and caregiver behavior and interaction are appropriate.

Its validation study was conducted over 1.5 years and included 4290 patients aged 7 years and younger seen in the ED of one of four hospitals. The SPUTOVAMO-R was a compulsory field in the electronic health record (EHR) of all patients who presented to the ED. A positive screen, if at least one question scored abnormal, is followed by a systematic workup including the evaluation by the Child Abuse Assessment Team with possible referral to social services. The PPV of the SPUTOVAMO-R was calculated at 3%, NPV at 100%, sensitivity at 100%, and specificity at 86.5% (Table 1) [12].

Like its predecessor, SPUTOVAMO-R also relies on subjective assessment of the “appropriateness” of caregiver and child behaviors; it has a very high false-positive rate which could lead to more referrals to the child protection team and unnecessary laboratory and radiographic screening. These unwarranted interventions can negatively impact children and their families with increased scrutiny and inaccurate suspicions of child maltreatment.

Escape is also a 6-item checklist containing binary questions addressing risk factors for child abuse used in the ED setting and includes a TTI. Compared with SPUTOVAMO-R, in place of a question regarding consistency of the history on repetition, Escape asks if there are other “signals” causing doubt for the safety of the child or other family members.

To assess the validity of Escape, Louwers et al. included 18,275 patients aged 18 years and younger who visited the ED in three hospitals over 18 months. The triage nurse completed the Escape instrument and was scored positive if at least one checklist item, which included a physical examination, was abnormal. The nurse would then inform the ED physician of the positive result. The PPV of Escape was calculated at 10%, NPV at 99%, sensitivity at 80%, and specificity at 98% (Table 1) [15].

The Escape tool has several limitations akin to the previous tools. Similar to the SPUTOVAMO, it was intended to screen every patient admitted to the ED but was completed for only 48% of patients. Additionally, it included the subjective question on other “signals” causing doubt on the safety of the child. This creates many opportunities for bias by relying on triage nursing selection on who is screened and their perception on family safety. Similar to the SPUTOVAMO-R, Escape also has a high false-positive rate which could result in harmful investigations.

SCAN is a brief 4-item child abuse checklist developed, validated, and implemented based on the existing databases from three previous validation studies including 24,963 patients and eight EDs. Questions from the SPUTOVAMO, SPUTOVAMO-R, and Escape checklists were linked with those with the same meaning. The final screening instrument, SCAN, included those questions with the best predictive value. The goal of creating this shorter screening instrument was to improve adherence by eliminating redundant questions and excluding a complete physical examination, thereby reducing the time it takes to complete the tool.

Questions include if the behavior/interaction of the child and caregivers is appropriate (aOR 14.67, 95% CI: 7.93–27.13), if the injury is compatible with the history and if it corresponds to the child’s developmental level (aOR 10.40, 95% CI: 5.69–19.02), and if there was unnecessary delay in seeking medical care (aOR 3.45, 95% CI: 1.73–6.88); the SCAN had a pooled area under the curve (AUC) of 75% (Table 1) [16]. The question of other “signals” causing doubt for the safety of the child or other family members (OR 182.9; 95% CI 102.3–327.4) was added by consensus to the final SCAN tool as it was available in only the Escape tool. Despite the subjectivity of this question, the authors stated it was included because it covers more subtle signals for child maltreatment that are difficult to identify [16]. A positive screen should result in a thorough workup for child abuse, including a more complete history and physical examination. As the SCAN tool was published in 2022, a study evaluating its implementation and validity is not yet available.

The Pediatric Hurt-Insult-Threaten-Scream-Sex (PedHITSS) is a 5-item Likert-scaled questionnaire for all caregivers to complete in the clinic setting to help detect physical and sexual abuse in children. The PedHITSS is adapted from the 4-item family violence HITS tool, repeatedly validated in adult primary care populations, by adding a question about sexual abuse [17]. Questions include how often an immediate family member did each of the following: physically hurt the child, insulted or talked down to the child, threatened the child with physical harm, screamed or cursed at the child, or forced the child to have sex. Scaled scores were calculated by summing responses, and higher scores indicated more frequent abusive behavior.

Shakil et al. studied the validity of PedHITSS by recruiting 422 patients aged 12 years and younger from ambulatory care settings over 4 years. Caregivers were asked to complete both PedHITSS and the Conflict Tactics Scale: Parent–Child Version, a lengthy questionnaire often used for research purposes on types of discipline parents utilize. Responses to the two measures were compared and showed strong concurrent validity, rs = 0.70 (P < 0.01). A positive screen, when there is at least one positive answer, requires physician follow-up and further discussion about the responses. False positives were eliminated at a score of 8.5 out of 20. The PedHITSS AUC was 85% (Table 1) [17]. A major limitation of this tool is that it is completed by the caregiver who may inaccurately report.