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

Turning Towards the Affective: Medical Semiotics of Child Maltreatment in Denmark

Signs of child maltreatment may be physical and detectable by clinical examination but may also arise as a feeling of strangeness that sparks uncertainty. Based on fieldwork in Danish general practice, and thinking along recent discussions around semiotics and affect, the article explores how feelings of "strangeness" arise in child consultations. It focuses on how subjective, embodied, and interpersonal reactions arise, how signs, however tactile and arbitrary, are felt and experienced, and how engaging with affective aspects when doing diagnosis, could expand the medical semiotics of child maltreatment.

'There's a will, but not a way': Norwegian GPs' experiences of collaboration with child welfare services - a grounded theory study

BACKGROUND

Adverse childhood experiences can have immediate effects on a child's wellbeing and health and may also result in disorders and illness in adult life. General practitioners are in a good position to identify and support vulnerable children and parents and to collaborate with other agencies such as child welfare services. There is a need for better integration of relevant services. The aim of this study is to explore GPs' experiences of the collaboration process with child welfare services.

METHOD

This is a qualitative grounded theory study, with data consisting of ten semi-structured interviews with general practitioners across Norway.

RESULTS

The doctors' main concern was: 'There's a will, but not a way'. Three subordinate stages of the collaboration process were identified: (I) Familiar territory, with a whole-person approach to care by the doctor. (II) Unfamiliar territory, when child welfare becomes involved. Here, a one-way window of information and a closed door to dialogue perpetuate the doctors' lack of knowledge about child welfare services and uncertainty about what is happening to their patients. (III) Fragmented territory, where doctors experience lost opportunities to help and missing pieces in the patient's history.

CONCLUSION

General practitioners are willing to contribute to a collaborative process with child welfare, but this is hampered by factors such as poor information flow and opportunities for dialogue, and limited knowledge of the partner. This implies lost opportunities for doctors to help families and contribute their knowledge and potential actions to a child welfare case. It can also impede whole-person care and lead to fragmentation of patient pathways. To counteract this, electronic two-way communication could enable a collaborative process and relationships that enhance coordination between the parties. Making space for all parties and their individual roles was considered important to create a positive collaborative environment.

Knowledge, attitude, and practice regarding child maltreatment amongst Iranian medical students through internship course: an 18-month longitudinal study

BACKGROUND

Child maltreatment has been a major worldwide problem and has remained a persistent public health challenge in all countries. Physicians have a significant role in the prevention and intervention of child maltreatment. An educated physician that can effectively identify and report child maltreatment can fill one of the most significant gaps in reducing child abuse. This study was performed to examine the knowledge, attitude, and practice regarding child maltreatment among Iranian medical students through an internship course.

METHOD

All the medical students (235 students) of the Iran University of Medical Sciences who passed the internship entrance exam in the 2019-2020 academic year participated in this study. The participants completed a 49-item scale questionnaire built by combining three other validated questionnaires that evaluate their attitude, knowledge, and practice skills in the first month of their internship course and then completed the same questionnaire 18 months later, at the end-point of the internship period.

RESULTS

One-hundred thirty nine (59.1%) participants were female, and 96 (40.9%) were male. The mean age of the subjects was 24.35 ± 0.76. Only 7 (3%) of them formerly received any education about child maltreatment. There was a significant improvement in scores of the knowledge of prevention (p-value = 0.001), the practice of prevention (p-value < 0.001) and the general subscale of the practice section (p-value < 0.001) during the internship course. However, the performance of participants decreased significantly in the subscales of the attitude towards diagnosis (p-value = 0.001) and the attitude towards reporting (p-value < 0.001) of child maltreatment. At the end of the study, the result of graduated physicians was: The total knowledge and attitude of participants were satisfactory, and the majority were at reasonable levels. Although in the practice subscale, 70.6% of the participants didn't identify, 84.7% didn't refer, and 86.4% didn't report a child abuse case in the past year.

CONCLUSION

The knowledge and attitude of Iranian physicians regarding child maltreatment are at a satisfactory level. Although, the practice level has deficiencies. In addition, our findings show that Iranian interns have a shallow experience regarding child maltreatment, particularly despite the higher scores in attitude and knowledge, which can be the reason for deficiencies in the practice level.

Perceived Child Abuse and Neglect in Hospitalized Children with Special Health Care Needs in Iran

BACKGROUND

Child Abuse and Neglect (CAN) is an important public health concern. Nurses play a key role in caring for the children and keeping them safe from abuse and neglect. The aim of this study was to determine the rate of perceived CAN in Hospitalized Children with Special Health Care Needs (CSHCN) as well as the relationship between the rate and some effective factors.

MATERIALS AND METHODS

This is a descriptive cross-sectional study on 199 CSHCN aged 6-18 years old, admitted to the pediatric wards in an educational hospital, in Isfahan, Iran, in 2018. Children were selected through convenience sampling method and assessed for CAN through a child abuse questionnaire. The Pearson correlation coefficient and Kruskal-Wallis and Mann-Whitney U tests were used to analyze the data. The p values smaller than 0.05 were regarded as significant.

RESULTS

According to the findings, 173 children (86.93%) had perceived CAN, the average total score of which was 9.36 contributing commonly to malnutrition 3.01 (2.36) followed by psycho-emotional abuse 2.71 (1.76), neglect 1.62 (1.23), and physical 1.52 (1.08) and sexual 0.54 (0.31) abuse based on mean (SD). Statistical analysis indicated a significant effect of child's age, economic situation of the family, mother's education and occupation, and parents' illness on the total score of perceived CAN (p < 0.05).

CONCLUSIONS

Malnutrition was found to be the most common type of perceived CAN. Therefore, parents and the health system are advised to prioritize nutritional needs when planning their nutrition.

Amongst Norwegian paediatricians there is little agreement in management of cases of suspected child maltreatment

AIM

Child maltreatment is not unusual in our society but little is known about the medical management of cases in the Nordic countries. This study investigated physician knowledge and practice in cases of suspected physical and sexual abuse and neglect.

METHODS

Using a patient vignette questionnaire, we assessed paediatrician knowledge and clinical decision-making on paediatric wards at 17 hospitals in Norway. Experts and non-experts in child maltreatment responded to the survey which described six potential cases of physical and sexual abuse and neglect.

RESULTS

A total of 156 paediatricians, 67% of whom were female and with a mean age of 40, responded. There was a high level of unanimity in recognition of abuse, but wide variation and little consensus in clinical decision-making and adherence to national guidelines, with Fleiss kappa ranging from -0.002 to 0.468. In cases involving physical abuse concerns in infants and toddlers, less than half of all paediatricians reported they would order a full radiologic skeletal survey and head MRI/CT imaging, and less than 30% would plan follow-up consultations.

CONCLUSION

This study shows little agreement in the paediatric management of child maltreatment cases. These findings suggest the need for a national plan ensuring appropriate paediatric care for maltreated children.

How child health care physicians struggle from gut feelings to managing suspicions of child abuse

Aim

We examined how gut feelings of child health care physicians’ (CHCPs) contribute to the development of a suspicion of child abuse, how they act upon this suspicion and what barriers they experience in their management. To gain insight into the youth health care chain, we compared the diagnostic reasoning and management regarding this issue by CHCPs and family physicians (FPs).

Methods

Three focus groups, 20 CHCPs, thematic content analysis.

Results

A gut feeling acted as an early alert to look for the triggering cue(s), by observing more closely and asking relevant questions. CHCPs struggled to distinguish whether the situation involved child abuse or a lack of parenting skills, and how to communicate their concerns with parents. They tried to motivate parents to improve the situation, avoiding the term child abuse and considered involving the Child Abuse Counselling and Reporting Centre (CACRC) a measure of last resort only.

Conclusion

As with FPs, gut feelings support CHCPs in becoming attentive to child abuse and to situations which can lead to child abuse. The next step, discussing their suspicion with the parents, is a difficult one, and the CACRC might actually help to make this step easier.

Knowledge and Attitude Regarding Child Abuse Among Primary Healthcare Physicians and Interns in Al Qassim, Saudi Arabia

Introduction

Child abuse can include physical abuse, psychological abuse, sexual assault, neglect, or failure to meet the child's basic needs. It can lead to major psychosocial problems resulting in long-lasting consequences for the child.

Objective

This study aimed to assess the knowledge and attitude (KA) of primary healthcare physicians and interns regarding child abuse in Al Qassim, Saudi Arabia.

Materials and methods

This multicenter, cross-sectional study was conducted among primary healthcare physicians and interns in the Qassim region, Saudi Arabia, from July to October 2020. A self-administered questionnaire was distributed among the targeted physicians using either an online platform or face-to-face interviews. The questionnaire was devised from the pre-tested literature and formal discussions with experts. A total of 292 primary healthcare physicians and interns participated in our study. A consent form and brief details of the study were given ahead of the recruitment. Data were tabulated in a Microsoft Excel spreadsheet (Microsoft Corporation, Redmond, WA); a separate codebook was prepared with a description of the variables and corresponding codes, and all statistical analyses were performed using IBM SPSS Statistics for Windows, Version 21.0 (IBM Corp., Armonk, NY).

Results

A total of 292 respondents were involved in the study. Among them, 45% (n=131) were medical interns, 39.4% (n=115) were residents, and the rest were either specialists (n=34; 11.6%) or consultants (n=12; 4.1%). Among the respondents, the KA level was found to be moderate, high, and low in 68.8%, 28.4%, and 2.7%, respectively. The overall mean KA score was 81.1 [standard deviation (SD): 9.56] out of a possible 115 points. Factors associated with high KA were age (>30 years), non-Saudi nationality, having children, and having studied outside Saudi Arabia; The only factor significantly associated with low levels of KA was being a pediatrician (p<0.001).

Conclusion

Overall, the participants displayed adequate levels of KA regarding child abuse. Better KA was observed among expatriate physicians who were parents themselves and had earned their degrees outside the Kingdom of Saudi Arabia. However, pediatricians demonstrated poor knowledge with regard to child abuse.

GPs' suspicion of child abuse: how does it arise and what is the follow-up?

Background: Child abuse is widespread, occurs in all cultures and communities, remains undiscovered in 90% of cases and has serious long-term effects. Physicians generally underidentify and underreport child abuse. To understand this low reporting rate and how the suspicion of child abuse arises, we examined GPs' experiences.Research questions: How does the suspicion of child abuse arise in GPs' diagnostic reasoning? How do they act upon their suspicion and which barriers do they encounter in their management?Methods: Twenty-six GPs participated in four focus groups. We used purposive sampling to include GPs with different levels of experience. We performed a thematic content analysis.Results: Suspicion of child abuse arose from common triggers and a gut feeling that 'something is wrong here'. GPs acted upon their suspicion by gathering more data, through history taking and physical examination. They often found it difficult to decide whether a child was abused, because parents, despite good intentions, may simply lack parenting skills and have different values. Clear signs of sexual abuse and physical violence were institutionally reported by GPs, whereas in less clear-cut cases they followed them up and built a supporting network of professionals around the family.Conclusions: A low child abuse reporting rate by GPs to CACRC does not mean a low detection rate. In trying to improve a child's situation, GPs make use of patients' trust in their doctor by involving other professionals. Awareness of the role of gut feelings in developing a suspicion may increase early detection and preventive actions.Key pointsPhysicians generally underidentify and underreport child abuse.Suspicion of child abuse arose from common triggers and a gut feeling that 'something is wrong here'.GPs acted upon their suspicion by gathering more data, through history taking and physical examination.GPs found it difficult to decide whether a child was abused, because parents, despite good intentions, may lack parenting skills.

Factors associated with physicians' assessment and management of child abuse and neglect: A mixed method study

Physicians are a professional group that is highly likely to encounter abused or at-risk children. The aim of this study is to investigate physicians' experiences with abuse cases, their evaluations of abuse risk factors, and their attitudes toward becoming more educated on the subject. One-hundred-sixty-four family physicians at family health centers and public health centers completed a questionnaire, and a group of residents at a university training and research hospital were interviewed in a semi-structured format. One-fifth of the participants had managed a child abuse case at least once. Nearly half of the participants reported acting alone in diagnosing and managing abuse cases. Sixty-eight percent of these physicians stated they would like to receive training on this subject. Gender and having children did not make a difference as to the abuse-management experience of these medical professionals. Female participants placed more importance on risk factors related to "children with mental disabilities" and "alcohol and substance abuse in parents" than their male counterparts. Difficulties in diagnosis, concerns about handling the abuse cases, the impact of culture, various risk factors, the importance of teamwork and a holistic approach, the need for practical training, and the importance of primary prevention were themes that emerged from this survey. This study provides inferences as to which of the physician competencies should be targeted in undergraduate medical education.

Factors influencing child protection professionals' decision-making and multidisciplinary collaboration in suspected abusive head trauma cases: A qualitative study

Clinicians face unique challenges when assessing suspected child abuse cases. The majority of the literature exploring diagnostic decision-making in this field is anecdotal or survey-based and there is a lack of studies exploring decision-making around suspected abusive head trauma (AHT). We aimed to determine factors influencing decision-making and multidisciplinary collaboration in suspected AHT cases, amongst 56 child protection professionals. Semi-structured interviews were conducted with clinicians (25), child protection social workers (10), legal practitioners (9, including 4 judges), police officers (8), and pathologists (4), purposively sampled across southwest United Kingdom. Interviews were recorded, transcribed and imported into NVivo for thematic analysis (38% double-coded). We identified six themes influencing decision-making: 'professional', 'medical', 'circumstantial', 'family', 'psychological' and 'legal' factors. Participants diagnose AHT based on clinical features, the history, and the social history, after excluding potential differential diagnoses. Participants find these cases emotionally challenging but are aware of potential biases in their evaluations and strive to overcome these. Barriers to decision-making include lack of experience, uncertainty, the impact on the family, the pressure of making the correct diagnosis, and disagreements between professionals. Legal barriers include alternative theories of causation proposed in court. Facilitators include support from colleagues and knowledge of the evidence-base. Participants' experiences with multidisciplinary collaboration are generally positive, however child protection social workers and police officers are heavily reliant on clinicians to guide their decision-making, suggesting the need for training on the medical aspects of physical abuse for these professionals and multidisciplinary training that provides knowledge about the roles of each agency.

A cross-sectional exploratory study of knowledge, attitudes, and practices of emergency health care providers in the assessment of child maltreatment in Maputo, Mozambique

BACKGROUND

In Mozambique, and other low-income countries (LICs), there is little information on the burden of child maltreatment (CM). Emergency care services (ECS) play an important role in recognizing, treating, and intervening in situations of CM. We aim to identify knowledge, attitudes, and practices regarding CM among health care providers in ECS at Mavalane General Hospital in Maputo, Mozambique.

METHODS

This exploratory cross-sectional study evaluates the knowledge, attitudes, and practices of health care providers to diagnose and treat cases of CM. A 25 min, pilot-tested verbal interview questionnaire was administered to 49 physicians and nurses working in ECS at Mavalane General Hospital. Interviews were completed between October-November 2010. Data were managed and analyzed in SPSS 14.0 and descriptive statistics were generated.

RESULTS

Of 49 health care providers, 83.6% reporting receiving no, or very little CM education or training. Only 61.2% had knowledge of physical abuse as a main form of child maltreatment and 38.8% were able to identify corresponding symptoms of physical abuse. Sexual abuse as a main form of CM was mentioned by 26.5 and 2% cited its symptoms. While 87.7% of health care providers strongly agreed or agreed that they hold an important role in preventing CM, 51.1% also strongly disagreed or disagreed that they feel confident diagnosing and treating CM cases. In regards to follow-up, 14.3% strongly disagreed or disagreed that they know where to refer victims for further follow-up and an additional 14.3% did not know whether they agreed or disagreed.

CONCLUSION

This study revealed knowledge gaps in emergency health care provider knowledge of the main forms of CM and their symptoms. The fact that a majority of health care providers in our sample did not receive information specific to CM in their medical education and training could explain this gap, as well as their unawareness of where to refer victims. Given that health care providers believe they play an important role in identifying and treating CM, future research should focus on raising physician awareness of CM and developing education and training materials grounded in cultural contexts to build response capacity in Mozambique and other LICs.

Knowledge, attitudes, and behaviours of healthcare professionals regarding child maltreatment in China

BACKGROUND

A new, recently issued national law and regulation in China conferred the responsibility of healthcare professionals in child maltreatment intervention. However, few studies have reported on the recognition and reporting of child maltreatment by healthcare professionals in China. The aim of this study was to assess healthcare professionals' knowledge, attitudes, and self-perceived behaviour in terms of identifying, assessing, and reporting child maltreatment cases in China.

METHODS

A cross-sectional survey of 877 healthcare professionals from four provinces was conducted using a structured questionnaire.

RESULTS

The respondents demonstrated insufficient knowledge on identifying potential child maltreatment cases. Over 30% of them were less than confident in the medical examination, evaluation, and treatment of child maltreatment cases, especially with regard to cases involving sexual abuse. Only 3.19% of respondents had ever received training on child maltreatment intervention, and as a result, lack of knowledge with regard to dealing with child maltreatment cases, referral procedures, and regulations was indicated to be the main cause of underreporting.

CONCLUSIONS

Healthcare professionals in China have insufficient knowledge, skills, and confidence when it comes to dealing with all aspects of child maltreatment. Although participants reported a positive attitude towards their role in detecting and reporting child maltreatment cases, there are obstacles that hinder them from doing so. Appropriate training courses should be developed to empower professionals with knowledge and skills, as well as increase their confidence in dealing with suspected child maltreatment cases.