Child abuse continues to be a problem that affects many children. In 2002, about 1.8 million children in the United States were reported to the child protective services (CPS) divisions of state human services divisions because of suspected abuse or neglect.1 In those cases, CPS determined that almost half of these children had been maltreated.1 About 20% of these children were victims of physical abuse, and between 1,000 and 2,000 children died because of their maltreatment.1'2
Young children are particularly vulnerable to abuse. An analysis of 2002 vital statistics showed that child abuse or homicide was the fourth leading cause of death for children ages 1 to 4.3 About 90% of child abuse deaths occur in this young age group.
Child abuse may go unrecognized. Ewigman found child maltreatment was drastically underreported and underrecognized as a cause of child fatality4 He performed a population-based study of all children younger than 5 who had died and found that only 47.9% of children with documented abuse histories were identified as abused on their death certificates.
About 60% of the deaths caused by child abuse are preventable.5 Children may suffer further abuse when child abuse is not recognized or reported. According to one study of children diagnosed with abusive head trauma, physicians had treated 31% of the children previously for signs and symptoms caused by their abuse but the diagnosis of abuse had been missed.6 Of those children whose head injuries had not been identified, 28% were re-injured before the cause of injury was determined, and 9% of those children died.
PHYSICIAN DECISION MAKING CONCERNING CHILD ABUSE
Warner and Hansen7 developed a multistep model that shows the factors affecting physician identification and reporting of suspected physical abuse. This model divides the decision process into four stages: assessment and evaluation, identification, reporting, and validation. The authors discuss the barriers that can occur at each stage of the process and that may prevent the identification and reporting of maltreatment. Although the authors have researched the existing data and provided good support for their model, this model has not yet been tested in a prospective study.
In this article, we combine the first two stages of the Warner-Hansen model and discuss the factors associated with physician recognition of child abuse. We then group the second two stages and describe barriers to physician reporting, including how validation of prior reports affects reporting.
BARRIERS TO PHYSICIAN RECOGNITION OF CHILD ABUSE
Several barriers may impede physician recognition of child abuse. Physicians simply may not be familiar with the typical physical syndromes associated with abuse, or they may have other psychological and subconscious biases that interfere with recognition of abuse.
Lack of Knowledge and Training
Physicians may not have the knowledge and skills to assess maltreatment adequately or to manage cases of suspected maltreatment.8 Although it is not always easy to determine that a particular injury is caused by abuse, many physicians have little training regarding child abuse, which limits their ability to recognize even the most obvious cases of child abuse. In our Chicago area study, 29% of the participants said they had received no continuing education about child abuse in the previous 5 years.9 The same study showed physicians who had some education about child abuse postresidency were much more likely to report all suspected abuse to CPS than those practitioners who had none.
Continuing education about child abuse is even more important today because the body of knowledge about child maltreatment is expanding rapidly. Research has contributed considerable new knowledge that can help practitioners differentiate intentional injuries from unintentional injuries.10
A good patient history is key to determining whether a child has been maltreated. When physicians fail to elicit complete and thorough histories, they may draw conclusions extrapolated from their own experience. We have observed that physicians often fail to ask caretakers for sufficient information to determine the cause of an injury. Several reviews of hospital emergency department and inpatient records show physicians failed to document information about how the injury occurred, where the injury occurred, the presence of any witnesses to the injury, the history of previous injuries, and a complete physical examination.11"13 In the cases reviewed, some physicians may have asked the appropriate questions and completed an appropriate evaluation, but their information-gathering effort could not be assessed because the information was not documented in the medical record.
It can be difficult for physicians and others to comprehend that a parent or caretaker would intentionally harm a child.14,15 Physicians sometimes think they can recognize and judge who is capable of abusing a child. For example, the physician may deny that a family may have abused a child because they appear caring and concerned.16,17 The idea that parents who are compliant and friendly in other aspects could harm a child causes dissonance for the physician. Sharing similar characteristics with a family, especially socioeconomic class, makes it even more difficult for the physician to label the caretaker as a "child abuser."18
Familiarity with the family may make the recognition of maltreatment even more difficult. Physicians have described how knowing a family well may interfere with their ability to recognize that a child has been maltreated.8 Other psychological factors also may prevent physicians from identifying and reporting maltreatment. Sanders19 discussed the discomfort that physicians feel when dealing with the parents of maltreated children. He suggests treating a maltreated child can stir up the physician's own ambivalent feelings about parenting. Sanders claims most parents have some negative and hostile feelings about their children, in addition to the positive feelings. These ambivalent feelings cause some physicians to avoid the family, while other physicians become angry and accusatory towards the maltreated child's family. Pollak and Levy20 described how anxiety caused by countertransference of fear, guilt, shame, and sympathy may prevent a physician from reporting suspected maltreatment.
Family Racial and Socioeconomic Factors
Several studies suggest race may influence the recognition of suspected maltreatment. Carole Jenny6 found physicians were more likely to miss abusive head trauma as a cause of a child's symptoms when the families were white and intact. In an analysis of data from the first National Incidence and Prevalence Study of Child Abuse and Neglect (NIS-I), the authors found that hospitals were more likely to identify child abuse when the child was black and from a lower socioeconomic group.18 Racial differences in the evaluation of children with injuries that might have been related to abuse were noted in a Philadelphia study21 Injured black children were up to seven times more likely to have the diagnosis of abuse considered compared with white children.
BARRIERS TO PHYSICIAN REPORTING OF SUSPECTED ABUSE
Even when physicians do suspect that a child has been maltreated, and even though all states mandate that physicians report suspected maltreatment, physicians do not report all suspected cases of physical abuse. In a survey of Chicago area pediatricians, 8% of the participating physicians admitted that, during the previous year, they had not reported children they suspected had been physically abused.9 In another study, 30% of pediatricians randomly selected from 15 states said they had failed to report suspected child abuse at some time in their career.22 The percentage of physicians who had not reported suspected maltreatment was probably higher in this study because the study asked about career, and not recent, experience.
When Australian pediatricians and general practitioners were surveyed in a similar study, 43% of the physicians said they had not reported cases of suspected abuse or neglect at some time in their whole career.23 These results may have differed from the other two studies because the study included general practitioners in addition to pediatricians and included both abuse and neglect reports.
Several factors can contribute to a physician not reporting suspected abuse.
Type of Maltreatment
Saulsbury24 surveyed Virginia physicians and found that most physicians reported suspected physical abuse (91%), but fewer physicians reported suspected physical neglect (58%), emotional abuse (45%), or medical neglect (43%). In a survey of Alabama pediatricians and family practitioners, these physicians reported 89% of cases of suspected child physical abuse and 94% of suspected child sexual abuse.25 Arizona physicians also were more likely to agree that some forms of maltreatment should be reported to CPS and other forms may not need to be reported.26 Most physicians agreed that drug use during pregnancy should be reported to CPS. In another study, respondents indicated that they were much more likely to report sexual abuse than either physical abuse or neglect.27
There may also be a threshold effect based on what physicians find to be acceptable parenting practices, such as the use of physical discipline. Morris et al. found that physicians who were more tolerant of physical discipline were less likely to suspect that a particular injury was caused by abuse.28
Physicians' areas of specialty may affect their decision to report certain types of maltreatment. In one study, general practitioners expressed a more cautious attitude about reporting than the pediatricians.23 However, pediatricians were less likely to agree that failure to thrive needed to be reported to CPS when compared with family practitioners or emergency physicians.26
Family Racial and Socioeconomic Factors
Although racial and socioeconomic factors appear to have some influence on reporting, an analysis of NIS-I data did not find black children were overreported to CPS.29 In fact, the analysis found white children were more likely to be reported to CPS if they were from a lower socioeconomic class, known by law enforcement, known by a medical agency, or female. According to a latter analysis, physicians reported 55% of white children they suspected were maltreated but only 50% of black children they suspected were maltreated. There also were racial differences in reporting depending on the type of maltreatment. White children who were emotionally maltreated were less likely to be reported, while white children who had been physically abused or sexually abused were more likely to be reported to CPS.30
Although Hampton et al.18 suggested child maltreatment is more likely to be identified and reported if the family is poor, Drake and Zuravin31 determined that families with poor socioeconomic status were not over-represented as reported to CPS for suspected physical abuse, nor was CPS more likely to substantiate that physical abuse had occurred in poor families compared with families from higher socioeconomic groups. They reviewed CPS-based data and non-CPS-based data to determine if there was a disparity in identifying, reporting, or CPS substantiation based on socioeconomic standing. The data was less clear regarding sexual abuse and neglect. A separate analysis of the first and second years of the NIS data did not show that the family's income influenced reporting.30
Lack of Knowledge and Training
Education about child abuse recognition not only affects physician identification, but also affects physician reporting behavior. King32 studied the effects of education on the lifetime reporting practices of physicians and other mandated reporters and found mandated reporters with more than 10 hours of training reported a significantly larger percentage of children whom they suspected had been abused than did those with fewer than 10 hours of training.
PHYSICIAN REASONS FOR NOT REPORTING SUSPECTED MALTREATMENT
Many practitioners say they do not report suspected maltreatment because they do not want to hurt their relationship with the family.9'24 In some cases, they believe that they can work with the family without outside intervention and that they can manage the maltreatment better than CPS.9·23·24 One option these practitioners may choose is to refer the family to a social worker for intervention or to a mental health professional for counseling.9-22
Some physicians do not report if they believe a child would be harmed by the report.32-34 Physicians express a concern that if they report a case to CPS that is unfounded, they will lose the family as patients, and the family then will not receive the needed medical and social service follow-up.28 Physicians also express concern that a report will otherwise interrupt the child's treatment or cause a child not to return for essential care.22,34
Previous Experience with CPS
Many physicians mistrust CPS because of negative experiences. Only a minority of physicians report they were kept informed about the status of an investigation.9,35 Other studies also have shown that this lack of CPS investigator feedback affects physician attitude and becomes a barrier to physician reporting.32·36
The Pediatric Practice Research Group (PPRG) study showed a majority of physicians believed children they had reported to CPS had not benefited from CPS intervention.9 Arizona physicians said that they were unsure that a report to CPS would lead to an improvement in the child's welfare.26 Many physicians express a concern that nothing will happen as a result of their report to CPS.24 Almost half of the physicians in the PPRG study (49%) indicated that their last experience with CPS made them less willing to report in the future.9
Because primary care physicians may see a small number of maltreated children, physicians may not be able to place a negative experience in the context of a range of experiences and responses by CPS. Any experience identifying or reporting suspected maltreatment may take on additional significance and distort their future actions. Some physicians describe a sentinel experience that continues to affect their decision making.8 Sometimes this sentinel experience has caused them to change an office routine (eg, now the physician completely undresses every child). For other physicians, an inadequate response from CPS has caused them to question the value of reporting to CPS. These physicians describe feeling exposed when CPS did not follow up on their concerns.
Although CPS response appears to affect physician reporting, factors other than the physician's previous experience with CPS may play a greater role in the physician's decision to report. In one study, a professional's belief that a report to CPS would benefit a child or family had less effect on the professional's decision to report than the severity of the maltreatment and the legal mandate to report.27 Other studies have also shown that the severity of the abuse affects physician reporting.22·27 Some physicians say they do not report if the abuse or neglect is not serious. Other physicians indicate that they did not report if they thought that the "situation had resolved itself."22
Misunderstanding of CPS Role
Many physicians misunderstand both the child abuse reporting laws and the role of CPS. State laws are purposely vague. Most state laws mandate that physicians report to CPS if they have reason to believe or reasonable cause to suspect that a child has been abused. According to one study, some physicians misinterpret these laws to mean that they are obligated to report abuse allegations made by someone else, even if they have no reason to suspect abuse.37
The legal system is designed to ensure that professionals in contact with children will report suspicion of abuse. The role of the state CPS is to investigate and determine whether or not the child was, in fact, abused. However, the most common reason given for not reporting was that physicians were reluctant to report before they were absolutely certain of the diagnosis.9·22'24 Many of the general practitioners in an Australian study indicated that reports should only be made if one is quite certain of abuse.23
Ewigman opines that child maltreatment is underreported because there is no universal definition of child maltreatment. He points out that the concept of child maltreatment is defined by social and political advocacy and that the definition fluctuates.4 Most state laws mandate that physicians report to child protective services if they "have reasonable cause to suspect," but reasonable cause is not defined.
On the other hand, physicians report that the legal mandate to report makes it easier for them to inform a family that they are reporting suspected maltreatment.8 Zellman found that the legal mandate to report most strongly correlated with the physician's decision to report suspected maltreatment.27
Many physicians expect that if they report suspected maltreatment to CPS that CPS will automatically remove that child from the home and place the child in foster care. In fact, most CPS agencies provide extensive family support, and are appropriately reluctant to remove children from their parents. Further research may better elucidate whether these expectations of dire consequences may cause the physician not to report their suspicions to CPS.
Other Barriers to Reporting
Office-based practitioners describe a need for other resources to assist them in making decisions about whether a child was maltreated, how to evaluate the child to make that determination, and whether they should report to CPS. They explain that immediate access to child abuse experts would assist them in determining their level of suspicion that a child was abused and how they could best keep this child safe while CPS investigates.8 Many physicians lack access to mental health and other community resources that could assist them in making decisions.
Physicians also describe system problems that sometimes impede the recognition of maltreatment. Following through on suspected child maltreatment takes precious office time and interrupts office flow. Physicians explain that a suspicion of maltreatment requires extra time to elicit a careful history, extra time to explain to the family the need to report to CPS, and extra time to notify CPS.8'14 Offices may not contain all of the imaging equipment and other diagnostic capabilities needed for physicians to determine their level of suspicion of maltreatment. Physicians are then faced with the dilemma of how to ensure the child's safety while they collect the information they need to determine the cause of the child's condition.
Healthcare plans can serve as an impediment to a quality child abuse medical assessment. Physicians have described how certain health care plans have prevented them from obtaining diagnostic studies or consultation from the institutions that would provide the quality evaluation needed to assist them in determining whether a child had been maltreated.8
Physicians also are concerned that, if they report suspected maltreatment, they will have to testify in court. Physicians fear testifying in court for a variety of reasons. Most physicians are not trained in the court system and have little or no experience providing testimony. The court is an adversarial system, where the physician's knowledge, skills, and treatment choices may be questioned. Physicians may be concerned about the time involved in providing this testimony15'24 In one study, 15% of the physicians listed "spending time in court or other legal proceedings" as one of the adverse consequences they had suffered as a result of reporting suspected abuse to CPS.9 During the previous year, 12 of 13 physicians said that they had spent a median of 5 hours (range: 1 to 22 hours) preparing to testify and providing testimony in court about children they had reported to CPS.
The need to testify can be costly for the physician, since physicians may be given little notice or choice about the date or time to testify and frequently are not reimbursed for their time away from their practice. Despite child abuse reporting laws that grant physicians immunity for reporting suspected maltreatment, physicians have been sued for malpractice because of their reports to CPS.38
When deciding whether or not to report suspected maltreatment, physicians often consider the potential costs of reporting while determining both risk and benefit to the patient.8,32 Mandated reporters who suspect that more harm than good will come from a report are less likely to report suspected maltreatment.32 Some physicians may deem the personal "cost" of reporting as outweighing the benefit of reporting, because of the increased time needed to evaluate the patient, arrange for the child's safety, and make a report to CPS.7-22
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.39 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.7 They suggested that CPS have special phone lines staffed by well-trained employees for mandated reporters to call.
Finkelhor and Zellman34 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 decisionmaking process and the barriers he or she faces when identifying and reporting child abuse.
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