To report or not to report. Physicians' attitudes toward discipline and child abuse

Health Professionals: Identifying and Reporting Child Physical Abuse-a Scoping Review

Health professionals play a significant role in identifying and reporting child physical abuse (CPA). However, several studies have pointed out non-reporting behavior among these professionals, evidencing difficulties identifying and reporting suspected cases. This review aimed to explore the frequency and possible barriers in identifying and reporting CPA by health professionals worldwide and to identify associated factors. This scoping review was conducted in the Pubmed, Web Of Science, Scopus, and SciELO databases between July 2019 and December 2020. Analytical and qualitative observational epidemiological studies were selected and published in English, Portuguese, and Spanish, with data on the identification and/or reporting of CPA by health professionals. Twenty studies fulfilled the criteria of this review. The studies were conducted with dentists, nurses, pediatricians, and general practitioners. The frequency of identification of CPA ranged from 50% to 89%, while the frequency of reporting ranged from 8% to 47%. This review revealed that health professionals had a low frequency of reporting of CPA, especially for dentists. In addition, several associated factors and barriers in the identification and reporting of CPA were identified in the studies. These were discussed in five main themes: training and continuing education in CPA, impact on professional practice, experiences and perceptions about child protection services, the threshold for suspicion of the professional, and the professional category.

Mandatory Reporting and Adolescent Sexual Assault

Adolescents experience alarmingly high rates of sexual violence, higher than any other age-group. This is concerning as sexual violence can have detrimental effects on teens' personal and relational well-being, causing long-term consequences for the survivor. Still, adolescents are hesitant to report the assault or seek out services and resources. When an adolescent survivor does seek out services, they may interact with a provider who is a mandatory reporter. This scoping review sought to synthesize the current U.S.-based research on the role, challenges, and impact of mandatory reporting (MR) in the context of adolescent sexual assault. Database searches using key words related to MR, sexual assault, and adolescence identified 29 peer-reviewed articles. However, none of these articles reported on empirical investigations of the phenomenon of interest and instead consisted of case studies, commentaries, and position papers. The scoping review was expanded to provide a lay of the land of what we know about the intersection of adolescent sexual assault and MR. Results of the review indicate that though implemented broadly, MR policies vary between individuals, organizations, and states and have historically been challenging to implement due to this variation, conflicts with other laws, tension between these policies and providers' values, and other factors. Based on the available literature, the impact of MR in the context of adolescent sexual assault is unknown. There is a critical need for research and evaluation on the implementation and impact of MR policies, especially in the context of adolescents and sexual violence.

Tipping the Scales: Factors Influencing the Decision to Report Child Maltreatment in Primary Care

Child maltreatment (CM) is an important public health issue linked to significant physical and mental health complications across the life span. Given the association between CM and health, general practitioners (GPs) and primary care nurses (PNs) are well-placed to identify and respond to this issue and are mandated to report suspected CM in many jurisdictions. Research has found that primary care doctors and nurses need support when responding to CM. This scoping review sought to answer the following question: What factors influence GPs and PNs decision to report CM when fulfilling their mandatory reporting duty? By exploring these factors, areas where support is needed were pinpointed. A systematic search was run across four databases: Medline (Ovid), PsycINFO, Embase, and CINAHL. Articles that reported on studies conducted in a location that had mandatory reporting legislation specific to CM and had a study population sampled from primary care were included in analysis. Thirty-three articles met the inclusion criteria. This review found that four principal factors influenced the decision to report CM: personal threshold of suspicion of abuse, relationship with the family, faith in the child protection system, and education and discussion. We conclude that improving the support and training to address these four areas may be beneficial for GPs and PNs in responding to CM.

Training program for Japanese medical personnel to combat child maltreatment

BACKGROUND

In 2014, we created a training program for personnel in medical institutions in Japan to combat child maltreatment. The aim of the present study was to document the effectiveness of this program.

METHODS

Participants completed a questionnaire before and after the training lecture. The questionnaire designed for the training program included demographic questions such years of practice and area of specialty (i.e. physician, nurse, social worker, public health nurse, technician, and others), as well as experience of suspected child maltreatment cases and training in dealing with such cases. The questionnaire included 15 statements designed to ascertain practical knowledge and attitudes relevant to addressing child maltreatment. Baseline score measured before the lecture was compared with that obtained after the lecture.

RESULTS

A total of 760 participants completed the survey, including 227 physicians, 223 nurses, 38 technologists, 27 social workers, 11 public health nurses, and 174 with other occupations, and 60 participants who left their occupation as blank. There was a significant difference between the baseline score of participants with versus without experience in suspected child maltreatment or training to deal with child maltreatment (F = 16.3; P < 0.001). After the lecture, the average score rose above the baseline (11.18 vs 10.57). The rate of correct answers for nine questionnaire items increased significantly.

CONCLUSIONS

Professionals from a range of fields need clinical skills and judgement to decide if a child's injuries are due to maltreatment. The combination of increased clinical experience along with a high-quality didactic lecture, appears to be the most effective method of raising awareness and enhancing skills.

Risk factors for child abuse: levels of knowledge and difficulties in family medicine. A mixed method study

Background

Family physicians (FPs) have a central role in the detection and management of child abuse. According to the literature, only 2–5 % of initial reports of child abuse come from the medical profession.

Methods

The objective of this study was to assess levels of knowledge of risk factors for child abuse by Family Physicians (FPs) and the attention that the physicians pay to these risk factors. We conducted a mixed-method survey based on semi-structured interviews. 50 FPs practicing in the Somme County (northern France) were interviewed with closed and open questions. The FPs’ level of knowledge of risk factors for child abuse and obstacles in the detection of child abuse were assessed.

Results

The FPs’ level of knowledge of risk factors for child abuse was similar to that reported in the literature. However, FPs knew little about the significant role of prematurity. Likewise, the FP’s training did not seem to influence their knowledge of risk factors. Fear of an incorrect diagnosis was the main obstacle to reporting a suspected case. The FPs considered that they were often alone in dealing with a difficult situation and considered that the judicial system and the social services were not sufficiently active.

Conclusions

Few FPs had actually received specific training in the detection and management of child abuse but many stated their need for this type of training. FPs encounter many obstacles in the detection of child abuse, which sometimes make the FP reluctant to report a suspected or potential case. Medical education need to be improved in this field.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-015-1607-9) contains supplementary material, which is available to authorized users.

Missed cases of multiple forms of child abuse and neglect

Child abuse and neglect is a public health problem and usually associated with family dysfunction due to multiple psychosocial, individual, and environmental factors. The diagnosis of child abuse may be difficult and require a high index of suspicion on the part of the practitioners encountering the child and the family. System-related factors may also enable abuse or prevent the early recognition of abuse. Child abuse and neglect that goes undiagnosed may give rise to chronic abuse and increased morbidity-mortality. In this report, we present two siblings who missed early diagnosis and we emphasize the importance of systems issues to allow early recognition of child abuse and neglect.

Mandatory reporting of child abuse and neglect: crafting a positive process for health professionals and caregivers

Health professionals working with children and their families are often required by law to report to governmental authorities any reasonable suspicion of child abuse and/or neglect. Extant research has pointed toward various barriers to reporting, with scant attention to positive processes to support the reporting process. This paper focuses on the context for mandatory reporting and evidence-informed practice for supporting a more structured and purposeful process of mandatory reporting. These practical strategies discusses: (1) the factors that positively influence the relationship between a child's caregivers and the mandated health professional reporter; (2) a framework and specific skills for discussing concerns about maltreatment and reporting to child protective services with the caregiver(s); and (3) the need for further training and education of health professionals.

Diagnostic coding of abuse related fractures at two children's emergency departments

OBJECTIVES

Pediatric fractures suspicious for abuse are often evaluated in emergency departments (ED), although corresponding diagnostic coding for possible abuse may be lacking. Thus, the primary objective of this study was to determine the proportion of fracture cases investigated in the ED for abuse that had corresponding International Classification of Diseases (ICD) codes documenting abuse suspicion. Additional objectives were to determine the proportion of these fractures with admission ICD abuse coding, and physician text diagnoses recording abuse suspicion in the ED and/or admission notes. Factors possibly associated with abuse-related ED ICD codes were also examined.

METHODS

Children less than three years of age that presented primarily with a fracture to two large academic children's hospitals from 1997 to 2007 and were evaluated for suspicion of abuse by child protective services were included in this retrospective review. The main outcome measure was the proportion of the fracture cases that had abuse suspicion reflected in ED discharge ICD codes.

RESULTS

Of the 216 eligible patients, only 23 (11.5%) patients had ED ICD codes that included the possibility of abuse. Forty-nine (22.7%) had the possibility for abuse documented by physicians as an ED discharge diagnosis. In addition, 53/149 (35.6%) of all admitted patients and 34/55 (61.8%) of confirmed abuse cases included abuse-related admission ICD coding. Female gender was found to be a factor associated with ED ICD abuse codes.

CONCLUSION

Current standards of ICD coding result in a significant underestimate of the prevalence of children assessed in the ED and hospital wards for possible and confirmed abusive fracture(s).

Awareness and knowledge of child abuse amongst physicians - a descriptive study by a sample of rural Austria

This study with a selected sample of physicians was conducted to assess their awareness and knowledge of child abuse. Two thirds (66.7%) of all participants confirmed contact with obviously abused children in the course of their professional life, whereas 87.3% did not report any prior education or training in that field. In relation to general practitioners, pediatricians had significantly more contacts with abused children (p = 0.021) and more prior education (p = 0.012). Results indicate that physicians in rural regions of Austria possess basic knowledge. Better training and further specialization is needed to facilitate diagnosing, enhance reporting, strengthen cooperation with experts and reduce fears when handling abuse victims. Austria is a rich country with excellent health care and competitive research structures. However, child abuse research in Austria still has to fill gaps in order to keep up with international developments.

Child abuse suspicion masquerading new onset insulin dependent diabetes mellitus

The identification and diagnosis of child abuse is a challenging task to the pediatrician. The increased awareness among both the public and medical personnel, while improving attentiveness to this important subject, can sometimes result in misdiagnosing medical conditions, thus causing distress and delay in required treatment. Numerous reports have described conditions mimicking non-accidental injuries; most of these include dermatological findings related to skin diseases, medical conditions causing pathological fractures, and rare diseases with unusual physical findings. We present a case of a 9.5-year-old child in which the workup for a suspected abusive event led to a delay in the diagnosis of insulin dependent diabetes mellitus later presented as diabetic ketoacidosis.

Mandatory reporting of non-accidental injury in children

Policies aimed at improving detection and referrals of suspected child abuse have not been effective overall. Unless mandatory reporting by clinicians is legally enforced, existing organizational and professional barriers may hinder the ability of agencies to safeguard children from harm.

Establishment of interdisciplinary child protection teams in Turkey 2002-2006: identifying the strongest link can make a difference!

OBJECTIVES

The University of Iowa Child Protection Program collaborated with Turkish professionals to develop a training program on child abuse and neglect during 2002-2006 with the goals of increasing professional awareness and number of multidisciplinary teams (MDT), regional collaborations, and assessed cases. This paper summarizes the 5-year outcome.

METHODS

A team of instructors evaluated needs and held training activities in Turkey annually, and provided consultation when needed. Descriptive analysis was done via Excel and SPSS software.

RESULTS

Eighteen training activities were held with 3,570 attendees. Over the study period, the number of MDTs increased from 4 to 14. The MDTs got involved in organizing training activities in their institutions and communities. The number of medical curriculum lectures taught by MDTs to medical students/residents, conferences organized by the MDTs, and lectures to non-medical professional audiences increased significantly (R(2)=91.4%, 83.8%, and 69.2%, respectively). The number of abuse cases assessed by the MDTs increased by five times compared to pre-training period.

CONCLUSIONS

A culturally competent training program had a positive impact on professional attitudes and behaviors toward recognition and management of child abuse and neglect in Turkey. The need to partner with policy makers to revise current law in favor of a greater human services orientation became clear.

PRACTICE IMPLICATIONS

Pioneers in developing countries may benefit from collaborating with culturally competent instructors from countries with more developed child protection systems to develop training programs so that professional development can improve recognition and management of child abuse and neglect.

Primary care pediatricians' experience, comfort and competence in the evaluation and management of child maltreatment: do we need child abuse experts?

OBJECTIVE

We assessed the self-reported experience, comfort and competence of primary care pediatricians in evaluating and managing child maltreatment (CM), in rendering opinions regarding the likelihood of CM, and in providing court testimony. We examined pediatricians' need for expert consultation when evaluating possible maltreatment.

METHODS

A questionnaire was mailed to 520 randomly selected AAP members. Pediatricians were asked how frequently they evaluated and reported children for suspected maltreatment, and whether child abuse pediatricians were available to and used by them. Pediatricians were asked to rate their knowledge, comfort and competence in the management of CM. Demographic information was also gathered. Pediatricians' experience with CM, their comfort, self-reported competence, and need for expert assistance is described. Logistic regression was used to assess factors that predicted pediatricians' sense of competence while controlling for covariates found to be significant in bivariate analyses.

RESULTS

One hundred forty-seven questionnaires were eligible for analysis. The majority of respondents had little experience evaluating and reporting suspected CM, and was interested in having expert consultation. While pediatricians often felt competent in conducting medical exams for suspected maltreatment, they felt less competent in rendering a definitive opinion, and did not generally feel competent to testify in court. Sense of competence was particularly low for sexual abuse. Increased practice experience and more courses in CM led to increased sense of competence in some areas.

CONCLUSIONS

Pediatricians acknowledged many limitations to providing care to maltreated children, and expressed interest in subspecialist input.

PRACTICE IMPLICATIONS

These findings add additional support to the American Board of Pediatrics' decision to create a Child Abuse Pediatrics subspecialty. The findings also indicate a need to ensure funding for fellowship training programs in this field.

From suspicion of physical child abuse to reporting: primary care clinician decision-making

OBJECTIVES

The goals were to determine how frequently primary care clinicians reported suspected physical child abuse, the levels of suspicion associated with reporting, and what factors influenced reporting to child protective services.

METHODS

In this prospective observational study, 434 clinicians collected data on 15003 child injury visits, including information about the injury, child, family, likelihood that the injury was caused by child abuse (5-point scale), and whether the injury was reported to child protective services. Data on 327 clinicians indicating some suspicion of child abuse for 1683 injuries were analyzed.

RESULTS

Clinicians reported 95 (6%) of the 1683 patients to child protective services. Clinicians did not report 27% of injuries considered likely or very likely caused by child abuse and 76% of injuries considered possibly caused by child abuse. Reporting rates were increased if the clinician perceived the injury to be inconsistent with the history and if the patient was referred to the clinician for suspected child abuse. Patients who had an injury that was not a laceration, who had >1 family risk factor, who had a serious injury, who had a child risk factor other than an inconsistent injury, who were black, or who were unfamiliar to the clinician were more likely to be reported. Clinicians who had not reported all suspicious injuries during their career or who had lost families as patients because of previous reports were more likely to report suspicious injuries.

CONCLUSIONS

Clinicians had some degree of suspicion that approximately 10% of the injuries they evaluated were caused by child abuse. Clinicians did not report all suspicious injuries to child protective services, even if the level of suspicion was high (likely or very likely caused by child abuse). Child, family, and injury characteristics and clinician previous experiences influenced decisions to report.

Dentists' perceptions, attitudes, knowledge, and experience about child abuse and neglect in northeast Italy

OBJECTIVE

The aim of this study was to analyze dentists' perceptions, attitudes, knowledge and experience about child abuse and neglect (CAN) in an area of northeast Italy and the factors affecting the recognition and reporting of CAN cases.

MATERIAL AND METHODS

One hundred six dentists working in both public and private sectors in the provinces of Padua and Treviso were interviewed by a single operator. Descriptive and assessing association analyses were carried out.

RESULTS

Dentists' perceptions about CAN is low, and these professionals have a poor attitude toward confronting it according to the code of conduct and laws. Available information and education are also poor Education affects the detection and the reporting of CAN cases in a relevant way. Female gender is another factor that affects the attitude and the perception of CAN.

CONCLUSIONS

The results, which are consistent with other studies, show that there is a general lack of knowledge about CAN that prevents dentists from detecting and identifying suspected cases. Despite its frequent occurrence among dental patients, neglect is the least known and identified type of abuse. Education is the critical element in enhancing the ability of professionals to detect cases.

Assessment of abuse-related injuries: A comparative study of forensic physicians, emergency room physicians, emergency room nurses and medical students

A comparative study was made investigating whether emergency room physicians, emergency room nurses, forensic physicians, and interns are competent in describing, recognising and determining the possible cause of injuries. The injury assessment scores varied from good--adequate--fail and remained blank in various participant groups. Forensic physicians scored significantly better than emergency room staff and interns in the assessment of abuse-related injuries. There were almost no differences noted between emergency room physicians and emergency room nurses. For the functional group with more or less than 4 to 6 years of experience, no significant differences were noted for scoring good in all 5 cases. The fact that forensic physicians scored better than the emergency room staff is probably explained by the fact that almost all practicing forensic physicians have been officially qualified. Training in this field for all professionals involved in such assessment should be mandatory.

A survey of pediatricians' attitudes and experiences with court in cases of child maltreatment

OBJECTIVES

To explore pediatricians' attitudes and experiences with the court system in child maltreatment cases.

DESIGN

An anonymous, cross-sectional survey of a random sample of pediatricians registered with the North Carolina Medical Board.

RESULTS

The response rate of the study was 60% (N=270). Few pediatricians (10%) reported that they had "ever" suspected maltreatment but decided not to report it. Pediatricians were equally likely to recall positive and negative experiences in court for child abuse cases. Pediatricians with negative court experiences were more likely to view reporting as time-consuming and were more than twice as likely not to report suspected cases of maltreatment (OR 2.4, 95% CI 1.04, 6.0). Seventy-five percent of pediatricians felt that court is harmful or distressing for children.

CONCLUSIONS

The majority of pediatricians report suspected cases of child maltreatment. Pediatrician's court experiences play a role in the response to child maltreatment cases, influencing attitudes towards the legal system and the process of caring for maltreated children. Future research efforts should address physicians' concerns about the impact of court on children, ways to improve the working relationship between the legal system and physicians, and the training needs of physicians in child maltreatment, including testifying and understanding the court process.

Pediatrician characteristics associated with child abuse identification and reporting: results from a national survey of pediatricians

Pediatrician experience with child protective services (CPS) and factors associated with identifying and reporting suspected child physical abuse were examined by a survey of members of the American Academy of Pediatrics (AAP). Respondents provided information about their demographics and experience, attitudes and practices with child abuse. They indicated their diagnosis and management of a child in a purposely ambiguous clinical vignette. Pediatricians who had received recent child abuse education were more confident in their ability to identify and manage child abuse. High confidence in ability to manage child abuse and positive attitude about domestic violence screening and value of anticipatory guidance predicted that pediatricians would have high suspicion that the child in the vignette was abused and that they would report the child to CPS. Future efforts to improve medical intervention in child abuse should focus on physician attitudes and experience, as well as cognitive factors.

Attitudes of Turkish parents, pediatric residents, and medical students toward child disciplinary practices

OBJECTIVE

The aims of the study were to: determine the attitudes of parents, pediatric residents, and medical students from a Turkish population toward childhood disciplinary methods; ascertain the association of participants' abusive childhood history with their attitudes toward discipline; and assess their attitudes about disciplinary actions, which should be reported as abuse.

METHOD

A cross-sectional survey was conducted in Ankara University School of Medicine, Department of Social Pediatrics. Sixty-five parents, 39 pediatric residents, and 106 medical students completed a questionnaire (Survey of Standards of Discipline). This questionnaire was designed to measure sociodemographic characteristics, attitudes toward childhood disciplinary practices, and abusive childhood experiences. There were 43 different disciplinary acts in this questionnaire. The participants were expected to give responses to these acts in three categories: (a) acceptable as discipline; (b) unacceptable as discipline; and (c) unacceptable as discipline-would report to authorities as child abuse. Based on the responses to this questionnaire, we developed the Severity Scale. Using this scale, physical severity scores, verbal severity scores, and total severity scores were measured for each participant.

RESULTS

None of the participants accepted life-threatening practices as discipline, but some declared certain abusive disciplinary practices as acceptable. Some forceful disciplinary methods were not considered as reportable by participants. All severity scores of both residents and students were found to be higher than those of the parents (for verbal severity scores p=.042). Also, both verbal and physical severity scores of parents with one child were higher than those of parents with two children (for verbal severity scores p=.044). Ninety-one participants (43.3%) indicated that beating was an acceptable form of discipline. Of parents, 66.9% reported abusive childhood history by their own criteria. Of medical students with an abusive childhood experience, 56.5% accepted beating as appropriate (p=.001). Both verbal and physical severity scores were found to be higher in participants with abusive childhood history.

CONCLUSIONS

Abusive childhood history and lack of education regarding appropriate discipline techniques are linked to the acceptance of certain physical discipline practices. Turkey's cultural and traditional norms may be associated with the use of physical punishment, and in some cases, physical abuse. The lack of awareness of abusive discipline methods among physicians constitutes problems for child protection and must be addressed. Thus, educational programs on child disciplinary practices are required to provide an increased awareness of child abuse among health professional trainees and parents in Turkey.

Factors associated with nurses' intention to report child abuse: a national survey of Taiwanese nurses

OBJECTIVE

The objectives were to determine the experiences of Taiwanese nurses with a new child abuse reporting law and to assess attitudinal correlates of nurses' intention to report.

METHOD

A stratified quota sampling technique was used to select registered nurses working in pediatric, psychiatric and emergency care units in Taiwan. A total of 1400 (return rate 88%) questionnaires from 1617 nurses were used. The questionnaire includes demographic information, attitudes toward and knowledge of child abuse and reporting laws, and eight vignettes of child abuse.

RESULTS

Most nurses (86%) said they had never reported a child abuse case; 21% said they had failed to report a suspected case of child abuse. Most (80%) had never had any child abuse education. About 75% felt their nursing education and in-service training was inadequate or absent. Most had an inadequate knowledge of the reporting law (mean score: 60% correct). Nurses only answered 17-43% of the law-related questions correctly. The majority accepted the professional responsibility to report. There were some differences among pediatric, psychiatric and emergency care nurses. In general, these Taiwanese nurses had negative attitudes toward corporal punishment and toward parents who abuse their children. The study also identified a variety of attitudes related to intention to report relevant to the Theory of Planned Behavior.

CONCLUSIONS

Nurses accept responsibility for reporting but they believe their professional preparation for reporting is inadequate. There is a strong need for in-service and pre-service education about child abuse among nurses in Taiwan.

Barriers to physician identification and reporting of child abuse

Physicians systematically underidentify and underreport cases of child abuse. These medical errors may result in continued abuse, leading to potentially severe consequences. We have reviewed a number of studies that attempt to explain the reasons for these errors. The findings of these various studies suggest several priorities for improving the identification and reporting of child maltreatment: Improve continuing education about child maltreatment. Continuing education should focus not only on the identification of maltreatment but also on management and outcomes. This education should include an explanation of the role of CPS investigator and the physician's role in an investigation. The education should provide physicians with a better understanding of the overall outcome for children reported to CPS to help physicians gain perspective on the small number of maltreated children they may care for in their practice. This education should emphasize that the majority of maltreated children will benefit from CPS involvement. New York is the only state that mandates all physicians, as well as certain other professionals, take a 2-hour course called Identification and Reporting of Child Abuse and Maltreatment prior to licensing. Cited studies in this article suggest that such a mandate might be expected to improve identification and reporting, thereby encouraging other states to adopt similar regulations. Give physicians the opportunity to debrief with a trained professional after detecting and reporting child abuse. The concept of child abuse and the gravity of the decision to report can be troubling to the reporter. The debriefing could include discussions of uncomfortable feelings physicians may experience related to their own countertransference reactions. Provide resources to assist physicians in making the difficult determination of suspected maltreatment. The role of accessible telephone consultation should be evaluated, along with formalized collaborations with local Emergency Departments with pediatric expertise. Improve the relationship between CPS and medical providers. For example, CPS workers should systematically inform the reporting physician about the progress of their investigation and the outcome for the child and family. Several past reports have made specific suggestions to improve the working relationship. Warner and Hanson recommended that positive outcomes be programmed into the reporting process. They suggested that CPS have special phone lines staffed by well-trained employees for mandated reporters to call. Finkelhor and Zellman proposed a more radical change to improve the working relationship between CPS and mandated reporters. They suggested that certain professionals, with demonstrated expertise in the recognition and treatment of child abuse and registered as such, should have "flexible reporting options." Options include the ability to defer reporting, if there are no immediate threats to a child, or to make a report in confidence and defer the investigation until necessary. Finkelhor and Zellman emphasized that this model would improve physician-reporting compliance and enhance the role of CPS while reducing the work burden for CPS. Improve interaction with the legal system. Child abuse pediatric experts who have courtroom experience could provide education and support to physicians who have little preexisting experience with the legal system. Reimbursement for time spent supporting legal proceedings should be equitable and may reduce physician concerns about lost patient revenue. Retrospective studies and vignette analyses provide much information about some of the barriers to child maltreatment reporting and describe many of the reasons why physicians do not identify and report all child maltreatment. Future prospective examinations of physician decision-making may further explain the physician's decision-making process and the barriers he or she faces when identifying and reporting child abuse.

Availability and Perceived Competence of Pediatricians to Serve as Child Protection Team Medical Consultants: A Survey of Practicing Pediatricians

OBJECTIVES

The effectiveness of multidisciplinary child protection teams has been demonstrated. This study is an attempt to assess the level of this commitment and the perceived competence of primary care pediatricians to provide this service.

METHODS

A questionnaire survey was mailed to primary care pediatricians practicing in the state of Alabama.

RESULTS

Among respondents who did not consider themselves competent to conduct sexual abuse or physical abuse examinations, 27% and 19%, respectively, were called on to conduct such examinations. Approximately half of respondents expressed a willingness to serve as consultants under a time commitment obligation of less than 2 hours per week or 1 day per month, and under a reimbursement provision of $200 per examination or less. Respondents recognized a need for, and expressed a desire for, more training in this area.

CONCLUSIONS

Primary care pediatricians are willing to serve as multidisciplinary child protection team medical consultants if provided appropriate training and support.

Identifying non-accidental injury in children presenting to A&E departments: An overview of the literature

BACKGROUND

The need for an effective system of child protection, which is able to detect children at risk of physical abuse, has never been more urgent. The level of reporting of non-accidental injury (NAI) in young children is lower than would be expected from official statistics, which means that Accident and Emergency (A and E) nurses and clinicians have a special responsibility to improve detection of possible abuse, in what has become a very challenging area of medicine.

AIMS

In this paper, we review the main issues facing clinicians and nurses in the identification of children at risk of NAI and discuss the policy implications affecting A and E departments. In particular we ask the question: what are the factors that influence the identification and reporting of suspected NAI in young children and how can the under-recognition of NAI be improved?

CONCLUSION

We conclude that organisational changes, such as the creation of a shared national database and improved training for A and E staff so that they are aware of social as well as clinical risk factors, are needed to address the under-reporting of non-accidental injury in young children.

Factors Affecting Pediatricians' Reporting of Suspected Child Maltreatment

OBJECTIVE

To identify factors associated with pediatricians' decision not to report suspected child maltreatment.

DESIGN

A survey was distributed to a random sample of pediatricians in a single state. Participants were asked if they had ever suspected child abuse or neglect but did not report. In addition, all were asked to list all the considerations that pediatricians incorporate into their decisions not to report.

RESULTS

One hundred ninety-five pediatricians completed the survey (56% of those eligible). Twenty-eight percent of respondents stated that they had considered reporting an incident of suspected child maltreatment but had chosen not to. Providers who had chosen not to report were more likely to be men (P = .006), to have been in practice longer (P = .001), to have reported more cases (P = .001), to have been deposed (P = .001) or to have testified (P = .01) in child maltreatment cases, and to have been threatened with lawsuit (P = .02) than were pediatricians who had never declined to report. Multivariate logistic regression demonstrated that male gender (odds ratio [OR] 2.18; 95% confidence interval [CI] 1.05-4.49), years in practice (OR 1.23; 95% CI 1.05-1.44), and experience reporting (OR 1.28; 95% CI 1.02-1.60) were all independently associated with decisions not to report. Respondents who had declined to report were more likely to cite lack of knowledge about reporting laws and process (P = .05) and poor experiences with child service agencies (P = .03) as reasons for not reporting than were their counterparts who had never declined to report suspected maltreatment.

CONCLUSIONS

Many barriers exist to reporting suspected maltreatment. Specific educational interventions may be helpful in eliminating barriers to reporting.

The effect of personal characteristics on reporting child maltreatment

OBJECTIVE

This study examined the relationship between personal characteristics of 276 potential entry-level social service workers and their decision to report child maltreatment to Child Protective Services (CPS). The personal characteristics of interest were: age, gender, parenthood, mother's education, father's education, college major, ethnicity, and immigrant status. The study hypotheses were that personal characteristics would have: (1) an individual effect on reporting, (2) a combined effect on reporting, and (3) an effect on reporting beyond any effect mediated by approval of corporal punishment and perceptions of maltreatment.

METHOD

Data were collected by a self-report survey employing vignettes in multi-item scales. Respondents rated (1) their approval of corporal punishment, (2) the seriousness of incidents of probable maltreatment, and (3) their likelihood of reporting incidents of probable maltreatment to CPS.

RESULTS

Of the eight personal characteristics, only ethnicity and immigrant status had significant effects on reporting. Together with approval of corporal punishment and perception of maltreatment, ethnicity and immigrant status accounted for 32% of the variance in reporting (p <.001).

CONCLUSION

Independently and combined, ethnicity and immigrant status have considerable effect on reporting behavior. Findings suggest that human service agencies should address issues of diversity and establish clear criteria for responding to child maltreatment.

Child sexual abuse

Child sexual abuse is a worldwide concern. It is an insidious, persistent, and serious problem that, depending on the population studied and definition used, affects 2-62% of women and 3-16% of men as victims. Pain and tissue injury from child sexual abuse can completely heal in time, but psychological and medical consequences can persist through adulthood. Associated sexually transmitted diseases (such as HIV) and suicide attempts can be fatal. All physicians who treat children should be aware of the manifestations and consequences of child sexual abuse, and should be familiar with normal and abnormal genital and anal anatomy of children. This aim is best accomplished through training and routine examination of the anus and genitalia of children. Because as many as 96% of children assessed for suspected sexual abuse will have normal genital and anal examinations, a forensic interview by a trained professional must be relied on to document suspicion of abuse.

Index of suspicion: feeling not believing

Throughout the U.S., state laws require professionals who work with children to report cases of suspected child abuse to child protection services. Both practically and conceptually, however, significant problems arise from a lack of clarity regarding the threshold that has been set for reporting. Specifically, there is no consensus as to what constitutes reasonable suspicion, and little direction for how mandated reporters should gauge their legal and professional responsibilities when they harbor suspicion. In this paper we outline the context of the problem, discuss the nature and scope of its conceptual underpinnings, and offer recommendations for moving towards a concrete, practical solution.

Pediatricians' knowledge, attitudes and experience regarding child maltreatment in Kuwait

OBJECTIVES

This cross-sectional survey was conducted to evaluate the awareness and actual professional experience of pediatricians in Kuwait regarding child maltreatment, a topic rarely explored in this part of the world.

METHODS

Data were obtained from all pediatricians in public hospitals with pediatric emergency services using a structured detailed self-completed questionnaire.

RESULTS

The experience of child neglect was more common than that of child abuse in the clinical practice of surveyed pediatricians. Fifty percent of 117 pediatricians (69% of all eligible) reported having encountered at least 1 case of abuse and up to 3 cases of neglect in the past year. Women and younger doctors more commonly recognized hypothetical situations as maltreatment, and believed child abuse and neglect as being common or very common in Kuwait. Other demographic or professional variables did not affect recognition of maltreatment. Participants would most likely alert social workers about suspected maltreatment cases. More than 80% did not know whether there is a legal obligation to report or which legal authorities should receive reports of suspected cases.

DISCUSSION AND CONCLUSIONS

National ethical guidelines regarding reporting suspected cases of maltreatment must be established. Laws protecting maltreated children and reporting physicians must be immediately enacted. Additional training is required to help pediatricians, especially expatriates from other cultures, to diagnose with certainty cases of child maltreatment in their practice in Kuwait.

Attitudes towards corporal punishment and reporting of abuse

OBJECTIVES

To assess physicians' attitudes towards corporal punishment in childhood and their subsequent actions regarding the reporting of child abuse.

PARTICIPANTS

107 physicians (95 pediatricians and 12 family practitioners) who work in hospitals and community clinics in northern Israel were interviewed. Of the participants, 16% were new immigrants.

PROCEDURE

A structured interview was conducted by one of two pediatric residents.

RESULTS

Attitudes towards corporal punishment were not influenced by the physicians' sex or specialty. Corporal punishment was approved by 58% of the physicians. A significant difference in attitudes towards corporal punishment between immigrants and Israeli born physicians was found (p=.004). Family practitioners and especially senior ones were found significantly less tolerant towards corporal punishment than pediatricians (p=.04). While reporting behavior was not found to be associated with parental status and the past experience of the physicians with child abuse, a significant effect of attitudes towards corporal punishment on reporting behavior was found (p=.01).

CONCLUSIONS

(1) Corporal punishment is still perceived as an acceptable disciplinary act by a significant proportion of physicians responsible for the health care of children in our area. (2) Attitudes towards corporal punishment are different between immigrants and native born Israeli trained doctors and, unexpectedly, pediatricians were more tolerant of corporal punishment than family practitioners.

Fractures in young children: are physicians in the emergency department and orthopedic clinics adequately screening for possible abuse?

OBJECTIVES

1) To determine whether physicians are sufficiently investigating the cause of fractures in children younger than 3 years and 2) to find out what influences physicians' quality of history taking and documentation necessary to rule out inflicted trauma.

DESIGN

Descriptive, retrospective chart review.

SETTING

Pediatric emergency department and orthopedic clinic of an urban teaching hospital.

SUBJECTS

Children younger than 3 years treated between January 1, 1995, and December 31, 1998, presenting with a fracture.

RESULTS

A total of 653 charts met entry criteria. Information that was significantly lacking in the recorded history included witness presence, history of previous injury, review of past medical record, other injury description, and whether the injury was consistent with the development of the child. It was not possible to rule out inflicted injury in 42% of the patients. Four groups emerged from the entire cohort: group 1, accidental trauma, which made up 63% of the entire group (n = 413); group 2, inflicted trauma, which made up 13% (n = 85); group 3, missed inflicted trauma, which made up 23% (n = 151); and group 4, missed accidental trauma, which made up 0.6% (n = 4). Younger age of the child, multiple fractures, need for hospital admission, and the examining physician being a pediatrician positively influenced physicians' propensity to accurately report inflicted trauma.

CONCLUSIONS

A large percentage of the charts reviewed contained inadequate documentation to explain the cause of fractures and thereby rule out inflicted trauma. Information in 23% of the charts reviewed aroused suspicion of inflicted trauma. There is a need to ensure that adequate information is obtained and documented in hospital records to rule out inflicted injury. This will require changes in the knowledge, skills, and attitudes of physicians. The use of forms, protocols, and periodic chart review will help to ensure compliance.

Child maltreatment 2002: recognition, reporting and risk

BACKGROUND

Child abuse is a major cause of morbidity and mortality in the USA and in all other countries which have studied its incidence. It is the second leading cause of death of children in the USA. To decrease the incidence of child abuse and improve the welfare of children there must be international efforts to recognize, and report child abuse and to decrease those risk factors, which place children in jeopardy. In the USA, reports of child maltreatment have decreased each year since 1994 after nearly two decades of increase. The increase was associated with the passage of laws that mandated reporting child maltreatment and increased recognition of maltreatment.

RESULTS

Several theories have been proposed to explain the decrease. These include: improved economy with decreased caretaker stress and more vulnerable children in day-care, imprisonment of offenders, treatment of victims to prevent reactive abuse, decreased use of corporal punishment, earlier recognition and reporting, prevention programs including home visitors and less corporal punishment in schools. If early recognition is to occur there must be clearly defined and uniform laws that define abuse and the significant consequences to mandated reporters for failure to report. The laws must be concise, understandable and contain medically based definitions of abuse. A bruise should be considered a significant injury. The use of an instrument on a child, for any reason should be reportable as abusive. Society must be taught that a child's head and its contents are particularly susceptible to trauma. Heads should not be slapped, shaken, or struck. The purpose of a report of suspect maltreatment should be to obtain services for families. Without proper services, abuse will reoccur and victims will become victimizers. Any sexual act, including pornography, involving a child who is unable to give consent constitutes reportable sexual abuse. Recognition of what constitutes abuse would be simplified if all countries adopted laws that forbid corporal punishment in schools and homes. Parenting education, which offers alternatives to the use of corporal punishment and anger and stress management skills, should be universal and begun in preschool. In the older child, topics would include conflict management tactics, mate selection, child development, child health, and pregnancy planning.

DISCUSSION

Professional knowledge of child maltreatment is inadequate. This multidisciplinary topic must be incorporated into the undergraduate and graduate curricula in medicine and other professions dealing with children. Child victims are unable to represent themselves. In most other childhood diseases the parents rise up in arms to lobby for their children's rights and raise money for research, professional education and clinical services. In child maltreatment, government and private organizations must take on this task. The valuable resources of Federal Public Health Services become available when child maltreatment is declared to be a disease. Other countries should emulate countries that have eliminated corporal punishment of children. Countries that do not protect children from maltreatment including the ravages of war must be seen as perpetrators of child maltreatment and answerable to the international community. One may adhere to the adage that one is not one's brother's keeper. This should never be applied to children. As the world's most precious resource, we must be the keepers of all children.

Assessment of suspicion of abuse in the primary care setting

OBJECTIVES

To describe the primary care practitioner's assessment of the likelihood that an injury was caused by physical abuse. The hypotheses were 1) practitioners face great uncertainty as to the possibility that an injury may have been caused by abuse; a measure that assigns variable degrees of suspicion to childhood injuries can be developed that will reveal this uncertainty; and 2) practitioner factors and patient factors influence this suspicion.

METHODS

Primary care practitioners in a regional practice-based research network prospectively collected information about each consecutive office encounter during a 4-week study period. For injury-related visits, the practitioner described injury type, reported cause and severity, and the practitioner's assessment of the cause of injury. Practitioners also used a 5-point Suspicion Scale to identify their level of suspicion that the injury was caused by abuse, with 1 equating to impossible and 5 equating to virtually certain. A subset of practitioners gave information about child and family risk factors. The practitioner's reporting activity was not studied.

RESULTS

Participating practitioners (n = 85) in 17 practices collected information about 12 510 office encounters, including 659 injuries. Although the practitioners assessed no injuries as "caused by abuse," they rated 21% of the injuries as having "some suspicion" of abuse. Practitioners were more likely to have "some suspicion" of abuse for those children who were Hispanic or African-American (vs. White) (P =.001, chi(2)) and for those children whose mothers had no college education (P =.018, chi(2)). In multivariate logistic regression modeling, "some suspicion" of abuse was associated with higher injury severity (odds ratio [OR] 3.4, 95% confidence interval [CI] 1.7, 7.0), age <6 years (OR 2.9, 95% CI 1.5, 5.6), Medicaid or self-pay health care (OR 1.4, 95% CI 1.4, 5.3), practitioner identification of family risk factors (OR 4.8, 95% CI 1.6, 14.6), and more recent practitioner education about child abuse (OR 2.9, 95% CI 1.4, 5.8).

CONCLUSION

Primary care practitioners reported some degree of suspicion that 21% of injuries they evaluated were caused by abuse. Patient factors and practitioner factors influenced their suspicion.

Child sexual abuse evaluations: adherence to recommendations

Sixty-eight parents of children with alleged child sexual abuse (CSA) were surveyed 4 months after visiting an interdisciplinary CSA evaluation clinic in order to examine the extent to which recommendations were recalled and implemented. Of those parents for whom specific recommendations were provided, 9% recalled recommendations for medical follow-up, 79% recalled recommendations for child therapy, and 43% recalled recommendations for parental therapy. Families were more likely to receive and adhere to recommendations when there were behavioral problems and a strong indication of CSA. To improve communication with families, the reasons for recommendations must be clearly conveyed, and possible barriers to implementation should be anticipated and addressed. In addition, recommendations need to be realistic, and professionals need to facilitate the implementation of their treatment plan.

"You are hereby commanded to appear": pediatrician subpoena and court appearance in child maltreatment

OBJECTIVE

To determine the frequency of court appearance by pediatricians evaluating child abuse and neglect cases and to identify case characteristics associated with actual court appearance or case adjournment.

DESIGN

Retrospective review of subpoenas received between 1995 and 1999 for child maltreatment cases personally evaluated by 2 pediatricians during the years 1995 to 1998. Information was collected regarding patient age, gender, race/ethnicity, type of suspected maltreatment, date of evaluation, date of subpoena, type of court hearing, whether the pediatrician actually testified in court, and legal outcomes. Case characteristics were compared between pediatricians and were used to predict physician appearance and case continuance or adjournment in logistic regression models.

RESULTS

Four hundred forty-five subpoenas concerning 260 patients were received. Although significant differences were noted between the pediatricians in type of abuse, no differences were found in patient age, gender, ethnicity or legal outcomes. The pediatricians received subpoenas in <15% of child maltreatment cases, and <5% of children seen resulted in the physician being required to actually appear in court. No case characteristics significantly predicted court appearance or case continuance or adjournment.

CONCLUSIONS

Although pediatricians are sometimes subpoenaed to appear in court to explain the medical evaluation and the needs of the child in cases of child abuse and neglect, most court cases were continued, adjourned, or settled before physician testimony. Most subpoenas did not result in the pediatrician going to court, and it is unclear which child factors may predict court involvement. Pediatricians can take steps to minimize (but not eliminate) the potential dissatisfaction and inconvenience associated with receiving and responding to subpoenas in child maltreatment cases.

The relationship between attitudes toward corporal punishment and the perception and reporting of child maltreatment

OBJECTIVE

This study examined the effect of workers' attitudes toward corporal punishment on the workers' perception and reporting of child maltreatment. Three hundred twenty-five (325) potential entry level workers participated in this study.

METHOD

Responding to vignettes in multi-item scales, study participants 1) rated their approval of parental discipline involving corporal punishment; 2) rated the seriousness of incidents of probable maltreatment; and 3) indicated whether or not they would report the incidents of maltreatment to child protective services. Data were analyzed using correlation analyses and multiple regression procedures.

RESULTS

1) Respondents with higher scores for approval of corporal punishment were less likely to perceive maltreatment; 2) respondents with higher scores for approval of corporal punishment were less likely to report maltreatment; 3) the likelihood that a respondent would report maltreatment was a joint function of the respondent's perception of the seriousness of an incident and approval of corporal punishment.

CONCLUSION

Attitudes about corporal punishment are important predictors of reporting behavior. Social service agencies face a challenge to provide workers with training which will enable them to detect and report maltreatment despite workers' individual beliefs about discipline and punishment.

Physical abuse--physicians knowledge and reporting attitude in Israel

The objective of this study was to assess knowledge and attitudes towards physical child abuse among pediatricians and family physicians in northern Israel.

METHODS

An interview consisting of multiple choice questions and vignettes were employed. A stratified sample of 107 physicians from hospitals and community clinics and of different disciplines and educational cultural backgrounds was surveyed.

RESULTS

Child abuse diagnosis was considered infrequently or not at all by 43% of the participants and a proportion of them were hesitant in their reporting intentions. A low consistency in the approach to diagnosis and management was found. Medical discipline, sex and age of the physician as well as level of knowledge and the family's socioeconomic status were not significantly related to reporting behaviors. A significant effect of medical training/cultural background (p = 0.01) and medical discipline (p = 0.04) on knowledge of child abuse were found. No relationship between knowledge and reporting behaviour was found.

CONCLUSION

The results of this study are a reason for concern. A more active role of medical schools and health administrations in abuse-oriented education and training effort is required, particularly in societies in transition.

The child abuse lottery--will the doctor suspect and report? Physician attitudes towards and reporting of suspected child abuse and neglect

OBJECTIVE

To assess the responsiveness and attitudes of medical practitioners to the reporting of suspected child abuse or neglect. To determine whether characteristics of the medical practitioner (specialist or generalist, rural or urban based, age since graduation, gender, having children of their own) influenced the responsiveness to reporting.

METHOD

A survey of all members of the Australian College of Pediatrics in Queensland (Australia) and pediatric registrars at a tertiary training hospital in Brisbane (n = 124) and a random sample of Queensland general practitioners (n = 100). The survey requested demographic details, responses to three case vignettes suggestive of possible physical abuse or neglect, and details of suspected child abuse or neglect reporting behavior.

RESULTS

There were a wide range of responses to the case vignettes, but responses did not vary between specialties. Forty-three percent of all doctors had at some stage considered a case as suspected child abuse or neglect and decided not to report despite a legal mandate to do so. General practitioners were more cautious towards reporting. The reasons for not reporting were multiple but highlighted perceived problems in the services available for the child and family once a report was made.

CONCLUSIONS

There is need for continuing education of medical practitioners regarding symptoms and signs of physical abuse and the role of doctors in the multidisciplinary management of child abuse. To some extent children's outcome when presenting to medical practitioners as a result of child abuse or neglect is no better than a lottery, dependent on which doctor they happen to see.

Pediatricians in Israel: factors which affect the diagnosis and reporting of maltreated children

OBJECTIVES

First, to examine what Israeli pediatricians consider to be abuse or neglect of children, second, to examine their willingness to report child maltreatment, and third, to examine the factors which may affect their approach.

METHOD

A quantitative cross-sectional survey research design was employed. One hundred and thirty-five pediatricians responded to a specially constructed instrument sent to a systemic, randomly chosen sample. The participants rated 40 vignettes of abuse and neglect according to their perception of the extent of the risk to the welfare of the child and their willingness to report these situations. They also rated 15 signs according to their perception of the extent to which each sign could lead to a suspicion of maltreatment.

RESULTS

Situations which fell within the biomedical perspective were ranked as containing a higher level of risk to the child than situations which were not (i.e., psychological abuse and educational neglect). Situations describing explicit signs or negative consequences of an act were ranked higher than those in which rationalization by the parent was included. These findings indicate that concrete evidence affects pediatricians judgement of what constitute maltreatment. The pediatricians were less willing to report situations of child maltreatment to the police than to the welfare department.

CONCLUSIONS

Certain situations of abuse or neglect might be overlooked by pediatricians in the process of diagnosing maltreated children. This may be explained by inadequate awareness of the psychosocial factors needed to identify maltreated children. Pediatricians' willingness to report seemed to depend on their altitude toward the receiving professional, and situations requiring involvement of the police may be disregarded.

Child-care personnel's failure to report child maltreatment: some Swedish evidence

Professionals who are legally required to report suspicions of child abuse and neglect to child protective agencies have often been found not to do so. In this article, 341 child-care institutions in three suburbs of Stockholm were surveyed for suspected child abuse. Of the 3,737 children attending these child-care institutions, 3% (N = 112) were suspected of being maltreated. Of these suspected cases, only 37% were reported to the Child Protective Agencies (CPA). Furthermore, interviews with the directors of the nursery schools revealed that there was a considerable delay in reporting suspicions of child abuse to the CPA. A follow-up study conducted approximately 5 years after the suspicions were first identified showed that 43% of the suspected children were still unknown to the CPA. Data also indicates that one possible reason for the low degree of reporting is the way in which the reports have been processed by the CPA.

Interdisciplinary training in the evaluation of child sexual abuse

To increase their knowledge of the medical evaluation and reporting of child sexual abuse, medical students, pediatric resident physicians, fellows and attendings participated in an interdisciplinary team-based training program consisting of didactic lectures, case discussions, videotapes and direct participation in patient evaluation. Content focused on the medical knowledge and skills needed for an assessment of the child's interview, anogenital examination and the indications for case reporting to child protection authorities. We evaluated the results of this training in our outpatient child abuse clinic located in a university-affiliated, municipal hospital using a survey which assesses knowledge of female genital anatomy, sexually-acquired diseases and case reporting in a nonrandomized control trial. Fifteen medical students and pediatric physicians participated and were compared to a reference group of 127 participants who did not receive this training and 15 others who randomly repeated the survey instrument during the study period. The results showed that resident physicians demonstrated increased mean total scores in the survey instrument. We conclude that an interdisciplinary team using patient care exposure increases physician knowledge in the evaluation of child sexual abuse.

Family abuse and neglect: a case-based ethics model

The ethical dilemma of caring for the patient from a multiproblem family with suspected domestic violence is discussed. An ethical decision making model that organizes patient data and encourages systematic analysis of the case is reviewed to address the responsibility of the emergency physician to intervene and the options available. The analysis explores specific issues related to mandatory reporting laws, discretionary reporting, and factors to be weighed in deciding the best action for protecting various members within a family when abuse is known or suspected.

Factors that influence clinicians' assessment and management of family violence

OBJECTIVES

High rates of family violence and low rates of detection, report, and therapeutic intervention by health professionals are well documented. This study was undertaken to determine what factors influence clinicians' decision making about identifying abuse and intervening with victims.

METHODS

Survey data about clinicians' experiences with and attitudes toward family violence were gathered by mailed questionnaire from a random sample of practicing clinicians in six disciplines (n = 1521).

RESULTS

Data showed similarities within and wide differences among three groups of subjects: dentists/dental hygienists, nurses/physicians, and psychologists/social workers. Overall, a third of subjects reported having received no educational content on child, spouse, or elder abuse in their professional training programs. Subjects with education on the topic more commonly suspected abuse in their patients than those without; among all subjects, spouse abuse was suspected more often than child abuse while elder abuse was suspected infrequently. Significant numbers of subjects did not view themselves as responsible for dealing with problems of family violence. Subjects indicated low confidence in and low compliance with mandatory reporting laws.

CONCLUSIONS

There is a need for educators to expand curricula on family violence and for legislators to reexamine mandatory reporting laws.