Child Abuse and Neglect

It is important for surgeons to be able to accurately assess and diagnose child abuse. While they are generally not the only medical professionals involved in the care of children with suspected abuse, they are highly regarded by hospital and social service staff, and their input regarding the cause of injury is unlikely to be ignored. Appropriate diagnosis of abusive injury can prevent future morbidity and mortality in these vulnerable patients, and can also reduce the trauma to families from false accusations of abuse. A sensitive and open-ended history, thorough physical examination, appropriate diagnostic workup with consideration of child abuse as an underlying cause, appropriate documentation of findings, and determination of safety for discharge can greatly improve an abused child's current and future health and safety.

Father involvement and children's functioning at age 6 years: a multisite study

Research suggests that fathers' involvement in their children's lives is associated with enhanced child functioning. The current study examined (a) whether presence of a father was associated with better child functioning, (b) whether children's perceptions of fathers' support was associated with better functioning, and (c) whether the above association was moderated by the father's relationship to the child, the child's race, and the child's gender. Participants included 855 six-year-old children and their caregivers. Father presence was associated with better cognitive development and greater perceived competence by the children. For children with a father figure, those who described greater father support had a stronger sense of social competence and fewer depressive symptoms. The associations did not differ by child's gender, race, or relationship to the father figure. These findings support the value of fathers' presence and support to their children's functioning. Priorities for future research include clarifying what motivates fathers to be positively involved in their children's lives and finding strategies to achieve this.

Type and timing of mothers' victimization: effects on mothers and children

OBJECTIVES

There is mounting concern about how mothers' own victimization experiences affect their children. This study examines the effects of mothers' victimization on their own mental health and parenting and on their children's behavior, development, and health. The effects of both timing and type of victimization are assessed. A related objective was to determine if there was a cumulative risk effect produced by victimization during both childhood and adulthood, or both physical and sexual.

SETTING

Urban families in an eastern state and urban and rural families in a southern state.

PARTICIPANTS

A total of 419 mothers and their children 6 to 7 years old were identified from 2 sites. The eastern sample was recruited in the first 2 years of life from 3 pediatric clinics: 1 for children at high risk for human immunodeficiency virus disease, 1 for children with failure to thrive, and a third providing pediatric primary care. The southern sample was derived from a cohort of children at risk for adverse health or developmental outcomes, plus a systematic sampling of controls, recruited from area hospitals. At age 4, a random sample of children from the original cohort who had been maltreated along with a matched comparison group of nonmaltreated children were selected.

RESULTS

In general, mothers victimized during both childhood and adulthood had poorer outcomes than mothers victimized during either childhood/adolescence or adulthood who in turn had worse outcomes than mothers with no history of victimization. This manifested as more maternal depressive symptoms, harsher parenting, and more externalizing and internalizing behavior problems in their children. There were no significant differences in maternal functioning or child outcomes between those abused in childhood and those abused in adulthood. These findings were similar for type of victimization. Mothers' depression and harsh parenting were directly associated with their children's internalizing and externalizing behavior problems.

CONCLUSIONS

Maternal victimization appears to be a highly prevalent problem in high-risk samples and is associated with harmful implications for mental health and parenting, as well as for the offspring. Pediatricians need to consider past and current victimization of mothers. Routine screening for these problems, followed by appropriate evaluation and intervention may reduce maternal depression, improve parenting, and reduce the incidence of behavior problems in children.

Health care needs of children in the foster care system

Nearly 750 000 children are currently in foster care in the United States. Recent trends in foster care include reliance on extended family members to care for children in kinship care placements, increased efforts to reduce the length of placement, acceleration of termination of parental rights proceedings, and emphasis on adoption. It is not clear what impact welfare reform may have on the number of children who may require foster care placement. Although most children enter foster care with medical, mental health, or developmental problems, many do not receive adequate or appropriate care while in placement. Psychological and emotional problems, in particular, may worsen rather than improve. Multiple barriers to adequate health care for this population exist. Health care practitioners can help to improve the health and well-being of children in foster care by performing timely and thorough admission evaluations, providing continuity of care, and playing an active advocacy role. Potential areas for health services research include study of the impact of different models of health care delivery, the role of a medical home in providing continuity of care, the perception of the foster care experience by the child, children's adjustment to foster care, and foster parent education on health outcomes.

Fathers and child neglect

OBJECTIVE

To examine the association between father involvement and child neglect.

DESIGN

Cohort study.

SETTING

Participants were recruited from an inner-city pediatric primary care clinic and a clinic for children at risk for human immunodeficiency virus infection in a teaching hospital.

PARTICIPANTS

Mothers and fathers or father figures, and 244 five-year olds participating in a longitudinal study.

MAIN OUTCOME MEASURES

Child neglect measured via home observation, a videotaped mother-child interaction, and child protective services reports.

RESULTS

A father or father figure was identified for 72% of the children. Rates of neglect ranged between 11% and 30%. Father absence alone was not associated with neglect. However, in families with an identified and interviewed father, a longer duration of involvement (P<.01), a greater sense of parenting efficacy (P<.01), more involvement with household tasks (P<.05), and less involvement with child care (P<.05) were associated with less neglect. The overall model explained 26.5% of the variance in neglect.

CONCLUSIONS

There is substantial involvement of fathers in a subset of this high-risk sample, although more than a quarter of the children lacked a father or father figure. The mere presence of a father did not significantly influence the neglect of the children; rather, the nature of his involvement did. Fathers who felt more effective as parents were less likely to have neglected their children. A greater sense of efficacy may reflect parenting skills and be important in enhancing the contribution of fathers to their children's well-being. Pediatric health care providers can play a valuable role in enhancing the involvement and skills of fathers.

African American fathers in low income, urban families: development, behavior, and home environment of their three-year-old children

This study examined the relationship between paternal roles, regardless of residence, and the well-being of 175 3-year-old children from low income, African American families. There were no differences in children's cognition, receptive language, behavior, or home environment related to father presence. Fathers (or father figures) were identified in 73% of the families, and 64% participated in an interview and videotaped observation. The relationships between paternal roles (parenting satisfaction, economic support, nurturance during play, child care, and household responsibilities) and children's cognitive skills, receptive language, behavior, and home environment were examined. After controlling for maternal age, education, and parenting satisfaction, there were significant relationships between paternal roles and each index of children's well-being, suggesting that fathers' contributions were unique. Fathers who were satisfied with parenting, contributed financially to the family, and were nurturant during play had children with better cognitive and language competence; fathers who were satisfied with parenting and employed, had children with fewer behavior problems; and when fathers were living with the child, the home was more child-centered. Neither the biological relationship of the father nor the parents' marital status entered into the models. These findings support ecological theories linking paternal involvement with children's well-being and argue for the institution of family-oriented policies that promote positive father involvement.

Child neglect: relation to child temperament and family context

Relationships among neglect and child and family characteristics were examined in a sample of 121 urban, low-income families with a child under 30 months. Maternal reports of more difficult child temperament predicted emotional neglect; family context was indirectly related, as mothers in well functioning families with more support reported their children as being less difficult. Neither child temperament nor family context was related to physical neglect.

Children who prosper in unfavorable environments: the relationship to social capital

OBJECTIVE

Social capital describes the benefits that are derived from personal social relationships (within families and communities) and social affiliations. This investigation examined the extent to which social capital is associated with positive developmental and behavioral outcomes in high-risk preschool children.

DESIGN

A cross-sectional case-control analysis of young children "doing well" and "not doing well" at baseline in four coordinated longitudinal studies.

PARTICIPANTS

A total of 667 2- to 5-year-old children (mean age, 4.4 years) and their maternal caregivers who are participating in the Longitudinal Studies of Child Abuse and Neglect Consortium. At recruitment, all children were characterized by unfavorable social or economic circumstances that contributed to the identification of the children as high risk.

MEASURES

Social capital was defined as benefits that accrue from social relationships within communities and families. A social capital index was created by assigning one point to each of the following indicators: 1) two parents or parent-figures in the home; 2) social support of the maternal caregiver; 3) no more than two children in the family; 4) neighborhood support; and 5) regular church attendance. Outcomes were measured with the Child Behavior Checklist, a widely used measure of behavioral/emotional problems, and with the Battelle Developmental Inventory Screening Test, a standardized test that identifies developmental deficits. Children were classified as doing well if their scores on these instruments indicated neither behavioral nor developmental problems.

RESULTS

Only 13% of the children were classified as doing well. The individual indicators that best discriminated between levels of child functioning were the most direct measures of social capital-church affiliation, perception of personal social support, and support within the neighborhood. The social capital index was strongly associated with child well-being, more so than any single indicator. The presence of any social capital indicator increased the odds of doing well by 29%; adding any two increased the odds of doing well by 66%.

CONCLUSIONS

Our findings suggest that social capital may have an impact on children's well-being as early as the preschool years. In these years it seems to be the parents' social capital that confers benefits on their offspring, just as children benefit from their parents' financial and human capital. Social capital may be most crucial for families who have fewer financial and educational resources. Our findings suggest that those interested in the healthy development of children, particularly children most at risk for poor developmental outcomes, must search for new and creative ways of supporting interpersonal relationships and strengthening the communities in which families carry out the daily activities of their lives.

Risk status and home intervention among children with failure-to-thrive: follow-up at age 4

Examined the moderating effects of risk status on the impact of home intervention in a follow-up study of children with failure-to-thrive (FTT). Two types of risk (demographic and maternal negative affectivity) and two levels of intervention were examined. In this randomized clinical trial, all children received services in a multidisciplinary growth and nutrition clinic, and half the children also received home visits from a lay home visitor for 1 year. There were no effects of demographic risk, maternal negative affectivity, or intervention status on child outcome at the close of the home intervention. However, at age 4, more than 1 year after the home intervention ended, there were effects of the home intervention on motor development among all children and on cognitive development and behavior during play among children of mothers who reported low levels of negative affectivity. Results highlight the importance of conducting follow-up assessments in the evaluation of home intervention services, and suggest that among low-SES families of children with FTT, home intervention may be most useful among mothers with low negative affectivity.

Sources of health care and health needs among children in kinship care

OBJECTIVES

To determine the characteristics of children in kinship care and their caregivers who have access to health care (a single source of health care or a single provider), and to determine the relation between indicators of access and health needs.

DESIGN

Cross-sectional.

SETTING

A large eastern city.

SUBJECTS

Two hundred ten children selected from households with children in kinship care in April 1989.

METHODS

Data were obtained from medical records, access and demographic questionnaires, and a medical and psychologic evaluation.

RESULTS

A single facility for health care was reported by 93% of the sample; two thirds of those identified one health care provider. One source of care or one provider was associated with variables such as young age at placement and medical assistance insurance. Children who did not have a single source of care were more likely to have unmet health needs (87% vs 61%, P < .05), especially unmet mental health needs (60% vs 31%, P < .05).

CONCLUSIONS

Children in kinship care had good access to health care, but the level of unmet health needs was high. Children who did not have a single source of health care were more likely to have unmet health needs, especially unmet mental health needs. These findings have implications for future health care planning for children in out-of-home care.

A randomized clinical trial of home intervention for children with failure to thrive

OBJECTIVE

To evaluate the efficacy of a home-based intervention on the growth and development of children with nonorganic failure to thrive (NOFTT).

DESIGN

Randomized clinical trial.

PARTICIPANTS

The NOFTT sample included 130 children (mean age, 12.7 months; SD, 6.4) recruited from urban pediatric primary care clinics serving low income families. All children were younger than 25 months with weight for age below the fifth percentile. Eligibility criteria included gestational age of at least 36 weeks, birth weight appropriate for gestational age, and no significant history of perinatal complications, congenital disorders, chronic illnesses, or developmental disabilities. Children were randomized into two groups: clinic plus home intervention (HI) (n = 64) or clinic only (n = 66). There were no group differences in children's age, gender, race, or growth parameters, or on any of the family background variables. Most children were raised by single, African-American mothers who received public assistance. Eighty-nine percent of the families (116 of 130) completed the 1-year evaluation.

INTERVENTIONS

All children received services in a multidisciplinary growth and nutrition clinic. A community-based agency provided the home intervention. Families in the HI group were scheduled to receive weekly home visits for 1 year by lay home visitors, supervised by a community health nurse. The intervention provided maternal support and promoted parenting, child development, use of informal and formal resources, and parent advocacy.

MEASUREMENTS

Growth was measured by standard procedures and converted to z scores for weight for height and height for age to assess wasting and stunting. Cognitive and motor development were measured with the Bayley Scales of Infant Development, and language development was measured by the Receptive/Expressive Emergent Language Scale. Both scales were administered at recruitment and at the 12-month follow-up. Parent-child interaction was measured by observing mothers and children during feeding at recruitment and at the 12-month follow-up, and the quality of the home was measured by the Home Observation Measure of the Environment 18 months after recruitment.

ANALYSES

Repeated-measures multivariate analyses of covariance were used to examine changes in children's growth and development and parent-child interaction. Analyses of covariance were used to examine the quality of the home. Independent variables were intervention status and age at recruitment (1.0 to 12.0 vs 12.1 to 24.9 months). Maternal education was a covariate in all analyses. When changes in developmental status and parent-child interaction were examined, weight for height and height for age at recruitment were included as covariates.

RESULTS

Children's weight for age, weight for height, and height for age improved significantly during the 12-month study period, regardless of intervention status. Children in the HI group had better receptive language over time and more child-oriented home environments than children in the clinic-only group. The impact of intervention status on cognitive development varied as a function of children's ages at recruitment, with younger children showing beneficial effects of home intervention. There were no changes in motor development associated with intervention status. During the study period, children gained skills in interactive competence during feeding, and their parents became more controlling during feeding, but differences were not associated with intervention status.

CONCLUSIONS

Findings support a cautious optimism regarding home intervention during the first year of life provided by trained lay home visitors. Early home intervention can promote a nurturant home environment effectively and can reduce the developmental delays often experienced by low income, urban infants with NOFTT: Subsequent investigations of home intervention should consider alternative options for toddlers with NOFTT:

Family violence. A child-centered, family-focused approach

Child maltreatment and spousal abuse are complex problems without simple solutions. Pediatricians can play a critical role in the early detection of abuse, carry out an initial assessment, and make appropriate referrals. By taking a family-focused perspective, and considering the social-emotional and economic context in which all family members live, the pediatrician will be more sensitive and alert to both the stressors and strengths within each family. Child maltreatment and spousal abuse affect children directly and indirectly in a variety of domains, including social-interactional, emotional status, self-image, behavior, and learning. A better understanding of these issues will enhance the comprehensiveness of the pediatrician's efforts and provide a better outcome for children and their families.

Parenting style and developmental status among children with nonorganic failure to thrive

Examined differences in several developmental indices of competence among 102 low-income, inner-city, predominantly African American children with non-organic failure to thrive (NOFTT) and a comparison group of 67 children with adequate growth matched on age, gender, race, and socioeconomic status. Parents were categorized into one of three groups (nurturant, authoritarian, and neglecting) based on observations during feeding. Parents of children with NOFTT were less nurturant and more neglecting than parents of comparison children. Associations between parenting style and children's social-cognitive development were similar across groups. Children of nurturant parents consistently demonstrated better social-cognitive development. Results support the importance of considering heterogeneity among high-risk families and the need to examine the relationships linking parenting style and child development.

School behavior of children in kinship care

This paper is based on the first comprehensive study of the health and educational status of children in kinship care, an increasingly frequent arrangement where children are placed in the care of relatives, mostly following neglect or abuse. Questionnaires were completed by teachers of 75% of the 374 school-age children in kinship care in one city, and additional information was obtained from caseworkers, caregivers, and school records. Compared to classroom peers, children in kinship care had poor study habits and attention and concentration skills. Other common problems included overactive, aggressive, and attention-seeking behavior. Most children had average or better relationships with teachers and peers. Multivariate analyses yielded several predictors that explained a modest amount of the variation in the children's school behavior. There was poor to moderate concordance in the assessments of teachers, caregivers, and caseworkers concerning various school related behaviors. Schools, caseworkers, and pediatricians should pay special attention to children in kinship care and ensure that this high-risk group of children receives necessary services.

School performance of children in kinship care

This study represents the first comprehensive assessment of the school performance of children placed in the care of a relative, an arrangement termed kinship care. The educational programs, academic achievement, and cognitive and language skills of the children were assessed with a teacher questionnaire and standardized tests. Compared to their peers, high rates of grade retention and participation in special and remedial education, as well as significant academic achievement, cognitive, and language deficits were found. Most teachers, however, reported that educational services were appropriate and several interventions had proven successful. Analyses of predictor variables showed that placement at a later age and fewer children in the home were associated with higher academic achievement. Results are reviewed in the context of other foster care studies, and recommendations are made regarding future research and educational needs of children in kinship care.

Medical neglect: what can physicians do?

Neglect is the most prevalent form of child maltreatment. Although the morbidity and mortality associated with it are significant, child neglect has attracted relatively little attention from professionals, the media, and the public. This article focuses on unmet, basic needs of children, particularly with regard to health care. In addition to defining neglect, the article discusses incidence, etiology, various forms of medical neglect, and principles for evaluation and management.

Sexual abuse: developmental differences in children's behavior and self-perception

Developmental differences in behavior and self-perception were examined in a group of 44 preschool and school-age children referred for evaluation of sexual abuse and 41 comparison children with no history of sexual abuse, matched on age and gender, and from a similar socioeconomic background. Children suspected of having been sexually abused were rated by their parents as having more internalizing and externalizing problems than comparison children. When children rated their self-competence and social acceptance, there were no group differences between children based on their abuse status; however, there was significant within-group variation among the children suspected of having been sexually abused. Preschool children had elevated scores of perceived competence and social acceptance, and school-age children had depressed scores. There were no age differences among the children in the comparison group. The results suggest that among children suspected of abuse, not only does their self-perception vary by their developmental level, but preschool children may respond with elevated perceptions of themselves. Focusing on individual differences in children's response to suspicions of sexual abuse enables us to identify risk and protective factors that contribute to the psychological outcomes of child sexual abuse.

A follow-up study of behavior problems associated with child sexual abuse

The objectives of this study were to examine: (a) behavior in children evaluated for sexual abuse, (b) the stability of their behavior over 4 months, and (c) the relationship between aspects of the abuse and the children's behavior. The Child Behavior Checklist (CBCL) was completed by parents of 93 prepubertal children evaluated for sexual abuse and 80 nonabused children matched on age, gender, and race. A follow-up CBCL was completed after 4 months by 45% of parents of abused children. Sexually abused children had significantly more behavior problems than comparison children, including depression, aggression, sleep and somatic complaints, hyperactivity, and sexual problems. At follow-up, only those children who initially had externalizing behavior in the clinical range improved significantly. During the initial evaluation, behavior problems were associated with the child's disclosure of abuse and during follow-up, behavior problems were associated with abnormal physical findings. However, behavior problems were not related to characteristics of the abuse or perpetrator, likelihood of abuse, or therapeutic services. The persistence of behavior problems suggests that children suspected of having been sexually abused should receive an assessment of their psychological status and careful follow-up.

The diagnosis of child sexual abuse

OBJECTIVE

To examine how the history, psychological evaluation, medical examination, and child's response to the examination contributed to a diagnosis of child sexual abuse by an interdisciplinary team.

DESIGN

Patient series.

SETTING

Subspecialty clinic for evaluating prepubertal children alleged to have been sexually abused.

PARTICIPANTS

One hundred thirty-two children alleged to have been sexually abused and their parents or guardian, evaluated consecutively in a subspecialty clinic between September 1989 and June 1990.

MEASUREMENTS/MAIN RESULTS

A social worker interviewed the parents, a psychologist interviewed the child, and a pediatrician obtained a medical history and examined the child. Parents completed a Child Behavior Check list and the child's response to the physical examination was noted. Both a disclosure by the child and abnormal physical findings were significantly and independently associated with the team's diagnosis of sexual abuse, whereas the presence of sexualized behavior, somatic problems, and the child's response to the examination did not make an additional contribution to the diagnosis.

CONCLUSIONS

The findings support the need for a skilled psychological interview and a medical examination of a child alleged to have been sexually abused to make the diagnosis of sexual abuse. An interdisciplinary team appears to be a valuable approach for evaluating these children and their families.

The pediatrician's documentation of child maltreatment

Pediatricians are increasingly involved in the assessment of suspected child maltreatment. These assessments are a crucial component of the overall evaluation of the patient and provide the basis for interventions to protect the child. An accurate documentation of the pediatrician's assessment is important to convey the information to professionals in the public agencies involved, including the legal system. However, there may be uncertainty among pediatricians concerning what should be documented in the medical record in cases of child maltreatment. The objectives of this article are to provide a detailed but generic description of the information that should be gathered during the evaluation of children who show signs of any form of child abuse and neglect and to provide clear guidelines for the proper written documentation of child maltreatment.

The physical health of children in kinship care

OBJECTIVE

The objectives of this study were to assess the current and chronic health problems and the adequacy of primary health care of children placed with a relative (kinship care) by a public agency.

RESEARCH DESIGN

Population survey.

SETTING

Children in kinship care in Baltimore, Md.

PARTICIPANTS

Four hundred seven (78%) of 524 children in kinship care in 1989.

INTERVENTIONS

None.

MEASUREMENTS/MAIN RESULTS

Information on the child's health status and care was obtained via a review of medical records; questionnaires sent to primary care physicians, parents, care givers, and caseworkers; and clinical assessment of the child by a nurse, pediatrician, and child psychologist. The children were found to have health problems similar to those in foster and poor children, but more problems than American children in general. Frequent diagnoses included impaired visual acuity and hearing, obesity, dental caries, and asthma; often, these problems had not been identified or treated. Gaps in the medical records precluded firm conclusions concerning the children's primary care, but suggest an inadequate system for ensuring their health care.

CONCLUSIONS

There is a need for improving the system of health care for children in kinship care. There is also a need for additional research on this high-risk group of children.

Failure-to-thrive: lessons from animal models and developing countries

To better understand the complex associations between undernutrition and poverty in determining behavioral outcome for infants with failure-to-thrive (FTT), we have reviewed findings from research in undernutrition among animal models and among children in developing countries, where rates of infant undernutrition are extremely high. The associations among undernutrition, poverty, and family functioning persist in both animal and human research, whether manipulated in laboratory settings or observed in natural settings. Although environmental support and stimulation appear to ameliorate many of the negative consequences associated with undernutrition, infants with a history of nutritional deprivation are at increased risk for behavioral and emotional problems. Recommendations for prevention and intervention follow an ecological framework and include adequate access to food, knowledge of nutritional requirements and feeding approaches, support for parents and families, and a nurturant environment for infants.

Pediatrician's role in preventing child maltreatment

Pediatricians have the opportunity to play an important role in preventing child maltreatment. Major issues that influence pediatric practice in this area are discussed in this article. General ideas and specific strategies are presented to help guide the pediatrician's prevention efforts.

Prevention of child maltreatment: what is known

There has been increasing awareness of the need to prevent child maltreatment. In this review, prevention programs that have been evaluated are critically assessed. This is based on computer searches of the relevant literature spanning the last decade and final reports regarding prevention programs to state and federal agencies. Although many programs have been implemented, relatively few have been evaluated, and of those that have been, many have serious methodologic flaws. Interventions that do appear promising include home visiting, lay counseling, group and family therapy, and education about sexual abuse. In addition, comprehensive programs that address the multiple contributory factors of child maltreatment appear to be a valuable approach. Suggestions are made as to how the practicing pediatrician might play a preventive role. Finally, there is a need for good evaluation research of prevention programs.

The changing American family

The increase in single-parent families, step-families, maternal employment, and young children in substitute care are among several important changes in the American family in recent decades. Although it is not clear that these changes necessarily lead to negative outcomes in children, it is apparent that a variety of potential risks and challenges confront many families today. Pediatricians can play a valuable role by helping families to adjust and cope with certain difficulties, such as divorce. However, in other areas such as child care, changes in public policies and programs are needed to better support families to optimally nurture their children.

Child abuse programs and pediatric residency training

Child maltreatment has become an increasingly important concern for pediatricians. The purpose of this study was to assess, via mailed questionnaires, the training and resources of pediatric residents in the area of child maltreatment. Responses were received from 72% of all US programs. The median amount of training was eight hours during the first and third years of training and seven hours during the second year; approximately half of this was clinical supervision in the care of maltreated children. Eighty-one percent of programs had an interdisciplinary team for suspected cases of child maltreatment. Only 17 of 167 programs reported a separate budget for their team. Although two thirds of programs were rated as adequate or better, 79% of respondents wanted to strengthen their teaching efforts. There appears to be a limited commitment by residency programs to enhance the competency of pediatricians in the area of child maltreatment. There is a need for improved training and resources.

What residents know about child abuse. Implications of a survey of knowledge and attitudes

Residency training programs are the appropriate milieu in which physicians should receive specialized training in the diagnosis and management of child abuse. The purposes of the present study were to assess and compare residents' knowledge of child abuse and their attitudes toward the propriety of different forms of childhood discipline. We surveyed 192 residents from seven different training programs with questionnaires probing their knowledge of child abuse and their attitudes toward childhood disciplinary measures; 161 (84%) of the questionnaires were satisfactorily completed by residents in pediatrics (n = 87), family medicine (n = 51), and surgery (n = 23). Both pediatric residents and family medicine residents outperformed surgery residents in one subscale and the total score on the test. Scores were not related to year of training or attitudes toward childhood discipline but were correlated with self-reports of previous child abuse teaching. Residents' performance on a childhood disciplinary measure demonstrated wide latitude in their rating of the acceptability of 23 different modes of childhood discipline. Our findings indicate a need for a more systematic approach to residents' education in childhood intentional injuries and some value clarification of their attitudes toward various forms of childhood discipline.