Date on Paper


Document Type

Doctoral Paper

Degree Name




Committee Chair

Robertson, Sara

Committee Member

Hall, Lynne

Author's Keywords

hair toxicology testing; child maltreatment; physical abuse; indeterminate findings of physical abuse


Background: Despite a complete medical evaluation for child physical abuse, many suspected victims have indeterminant findings. The lack of a definitive diagnosis can impede child protection agencies’ ability to protect those children at high risk for abuse, leaving them vulnerable to subsequent injuries and potentially escalating violence by caregivers. Oftentimes, allegations of child physical abuse are accompanied by concerns for substance abuse by the caregiver as well. While we know that children living in homes where caregivers use illicit substances are at substantially higher risk for physical abuse, drug testing children for environmental exposure to illicit substances is not yet widely accepted as part of the overall maltreatment evaluation. Drug testing has traditionally revolved around testing adult caregivers in the child’s life. However, testing adults cannot determine whether the caregiver was intoxicated while in a caregiving role which is often necessary for investigators to prove risk of harm or neglect of the child. When hair testing is used in the evaluation of children, positive results can provide child protection agencies with concrete evidence of child drug endangerment, potentially changing the outcome of the maltreatment investigation.

Setting: This project was a retrospective review of cases using the database in a child abuse pediatrics sub-specialty office associated with a children’s hospital in an urban area where approximately 1,100-1,200 children are evaluated yearly for physical abuse, sexual abuse, and neglect.

Purpose: The purpose of this project was to evaluate the yield of positivity for hair toxicology tests among children five years of age and younger who were evaluated for physical abuse over a 2-year period.

Procedure: The project used the current patient database to identify patients less than six years of age who were evaluated for maltreatment in 2019 and 2020 and underwent hair toxicology testing as part of the maltreatment evaluation.

Results: One hundred-fifty-five children met inclusion criteria for the study. Overall hair toxicology positivity rate was 91% for at least one illicit substance. Among children specifically evaluated for physical abuse, all children with injuries independently diagnostic for child physical abuse had positive hair tests. Among children with injuries that were inconclusive for physical abuse diagnostic criteria, 82.8% had positive hair tests.

Conclusions: Hair testing should be considered as an adjunct to the maltreatment medical work-up in cases of suspected abuse where there are family risk factors. If positive, hair testing can affect the outcome of the investigation by providing definitive proof of drug endangerment.

Included in

Nursing Commons