Practical Issues and Challenges for Physicians Reporting Suspected Child Maltreatment
© Springer Science+Business Media Dordrecht 2015Ben Mathews and Donald C. Bross (eds.)Mandatory Reporting Laws and the Identification of Severe Child Abuse and NeglectChild MaltreatmentContemporary Issues in Research and Policy410.1007/978-94-017-9685-9_15
15. Practical Issues and Challenges for Physicians Reporting Suspected Child Maltreatment
Ann & Robert H. Lurie Children’s Hospital of Chicago, 225 E. Chicago Ave, 16, Chicago, IL, USA
KeywordsChild maltreatmentChild protectionDecision makingReportingPhysiciansPolicyMandatory reportingPediatric care and child abuseMedical care and child abuse
Child maltreatment, including physical abuse, sexual abuse, emotional abuse, and neglect, affects an estimated 10–35 % of children each year (Gilbert et al. 2009). These numbers are based on individuals’ self-reports and parents’ reports of maltreatment (Finkelhor and Dziuba-Leatherman 1994). Unfortunately, even in jurisdictions with mandatory reporting laws, only a minority of these children are brought to the attention of Child Protective Services or other state agencies who can provide intervention and services. In one study, only 5 % of children who had been physically abused and 8 % of children who had been sexually abused reported that they had contact with Child Protective Services (CPS) (MacMillan et al. 2003). Without intervention, many of these children will continue to suffer severe harm.
Child maltreatment has significant consequences. It is estimated that about 30,000 children around the world die each year because of child maltreatment, not including fatalities caused by malnutrition (World Health Organization 2010). All forms of severe child abuse, whether physical, sexual, or emotional, and neglect also produce significant short-term and long-term morbidity and disability. These adverse childhood events are associated with poor health in childhood, adult disease, shortened life expectancy, lower educational achievement, increased risk of behavior problems, depression, and other mental health problems (Chartier et al. 2007; Felitti et al. 1998; Flaherty et al. 2006b, 2009; Jonson-Reid et al. 2012; Leeb et al. 2011). To prevent these outcomes, it is important to identify children who have been maltreated, provide treatment, and protect them from further harm.
The UN Convention on the Rights of the Child requires that all signatory nations have integrated systems that coordinate the response to child maltreatment (Svevo-Cianci et al. 2010). Some countries have enacted legislation that mandates designated professionals to report suspected child abuse, while other countries make it voluntary for professionals to report (Mathews and Kenny 2008). The United States was the first country to enact mandated reporting legislation; it is one of several countries that have statutes mandating the report of suspected child maltreatment to Child Protective Services (CPS), law enforcement, or both (Oswald 2013). All 50 states in the United States have laws that mandate that physicians must report to the state Child Protective Services or law enforcement if they have reasonable suspicion or reasonable cause to suspect that a child may have been abused or neglected. The exact language of these laws varies from state to state, but all have kept the mandate intentionally vague to allow room for discretionary judgment (Mathews and Kenny 2008). Physicians are mandated reporters in all states, and a substantial number of states require that all persons who suspect child maltreatment must make a report. Although laws may vary from country to country, many of the issues and challenges surrounding child maltreatment reporting appear to be similar.
Physicians are an important source of CPS reports. Pediatricians and family physicians are often the first to identify child maltreatment in children at all ages. They are particularly well positioned to identify child maltreatment in infancy, because they evaluate the infant multiple times during the first year of life. These frequent examinations may be critical to the outcome of these children, because young children are more vulnerable to suffer serious injuries that can lead to permanent disabilities and even death. In addition, physicians are in a unique position to identify families where there may be a significant risk of future abuse, because they are often aware of family stressors such as unemployment and may know of other family dysfunctions such as drug abuse, alcoholism, and interpersonal violence.
Underreporting of Suspected Child Maltreatment: Physicians and Other Reporter Groups
Even when laws mandate reporting, physicians admit that they do not always report suspected child abuse (Borres et al. 2007; Flaherty et al. 2000; Offer-Shechter et al. 2000; Van Haeringen et al. 1998). In a number of surveys of physician practice in the United States, physicians have said that they report most, but not all, suspected abuse and neglect. Injury severity and the risk for serious harm appear to positively influence reporting behavior (Benbenishty and Schmid 2013), as physicians are more likely to report more serious injuries (Flaherty et al. 2008a; Morris et al. 1985; Zellman 1992). A survey of Chicago primary care clinicians found that 95 % said they had reported all physical abuse (Flaherty et al. 2000). In a similar survey conducted nationally, 3 % of physicians said they had not reported all injuries they suspected were caused by child abuse (Flaherty et al. 2006a).
In a survey of Virginia physicians, 91 % said they reported all physical abuse and 92 % responded that they reported all sexual abuse, while far fewer reported all physical neglect, emotional abuse, and medical neglect that they suspected (58 %, 45 %, and 43 %, respectively) (Saulsbury and Campbell 1985). It is not clear why physicians are less likely to report neglect, both physical and medical, and emotional abuse, but physicians in this study did say they were reluctant to report if they were not certain that it was abuse or neglect. They also indicated that they were less likely to report if they thought they could solve the problem without outside intervention. Another possible explanation for less frequently reporting these types of maltreatment is that they did not perceive them as harmful to the child as physical abuse and sexual abuse.
The Child Abuse Reporting Experience Study (CARES) was a national study that examined prospectively physicians’ reporting practices (Flaherty et al. 2008a, b). Four hundred and thirty-four primary care practitioners collected data about 15,003 child injury visits. The practitioners indicated their level of suspicion that an injury was caused by child abuse using a five-point Likert scale (very unlikely, unlikely, possible, likely, very likely) and also indicated whether they reported a suspicion of physical abuse to CPS. CARES found that physicians did not report suspected child abuse far more commonly than they indicated in retrospective surveys. In summary, the physicians in the CARES study did not report 27 % of the children they suspected had injuries likely or very likely caused by child abuse. They also did not report 75 % of the injuries they assessed to be possibly caused by abuse. The term reasonable suspicion is intentionally vague, and one could argue that considering that an injury was possibly caused by abuse is not reasonable suspicion and so should not activate the reporting duty. However, considering an injury likely or very likely caused by abuse should be reasonable cause to suspect that child abuse has occurred, and in principle these situations should have been reported.
Other Mandated Reporter Groups
Other groups of mandated reporters also admit that they do not report all suspected child maltreatment to CPS. About 25–50 % of clinical psychologists, social workers, child care providers, elementary principals, and secondary principals said that they had failed to report all child abuse they suspected (Zellman 1990). The participants also reviewed an equal mix of vignettes describing cases of possible neglect, possible physical abuse, and possible sexual abuse. They rated the sexual abuse vignettes as most serious, and they indicated they were most likely to report sexual abuse than physical abuse and neglect. Asked how they had typically responded if they suspected child maltreatment, dentists, dental hygienist, nurses, and psychologists responded that they would most commonly consult with another professional, chart and observe, or discuss with the family rather than report to CPS, while physicians most frequently said they would report their suspicion to CPS (Tilden et al. 1994). In a survey of Taiwan nurses, 21 % responded that they had failed to report suspected child abuse (Feng and Levine 2005). An Australian study of nurses found an identical rate of failure to report (Mathews et al. 2009). Teachers also admit that they have failed to report all children that they suspected had been maltreated, including failure to report suspected child sexual abuse (Kenny 2001; Mathews et al. 2009).
Reasons Physicians Do Not Report Child Maltreatment
A number of studies have examined why mandated reporters do not report suspected child maltreatment, and many of these studies have explored physicians’ experience. The most common reason physicians give for not having reported a suspicion of maltreatment is that they were not “certain” that the child was abused (Badger 1989; Flaherty et al. 2000; Offer-Shechter et al. 2000; Saulsbury and Campbell 1985). They fail to report despite the language of the laws which does not require certainty. In a particularly notable example, physicians admitted that they do not report caregiver-fabricated illness (Munchausen-by-proxy; Medical Child Abuse) in a child unless they are virtually certain of the diagnosis (McClure et al. 1996). These physicians estimated that, to report, they would need to feel the probability their diagnosis was correct as being greater than 90 %.
Perceived Disruption to the Family
Sometimes, mandated reporters express concern that a report to Child Protective Services will disrupt the family (Jones et al. 2008). However, for some categories of case in particular, this attitude fails to consider that the investigation triggered by a report may lead to information that allows Child Protective Services to determine with certainty that a child has or has not been abused. When discussing why they did not report suspicious injuries, physicians frequently mention their concern about harming the family, but they appear to omit any consideration of the potential harm to the child. Their failure to report may leave an abused child unprotected and vulnerable to further injury and even death (King et al. 2006; Oral et al. 2008; Ravichandiran et al. 2010; Jenny et al. 1999).
Inadequate Education and Training
The lack of certainty referred to above may be influenced by a lack of knowledge about child maltreatment and reporting duties. Physicians, like all mandated reporters, require excellent training to equip them with the knowledge, attitudes, and skills to be able to comply with their reporting duties. The reporting laws are complex, and the nature of the various forms of child abuse and neglect are also complex and can be very difficult to detect, even for doctors who can conduct physical examinations. Yet, physicians often receive little education about child maltreatment (Woolf et al. 1988). Physicians who have received education about child abuse expressed more confidence in their ability to identify and manage child abuse (Badger 1989; Flaherty et al. 2006a). Likewise, physicians with high confidence in their abilities were more likely to suspect and report child abuse in vignettes (Flaherty et al. 2006a). More education about abuse also correlates with appropriate thresholds for when suspected abuse must be reported (Crowell and Levi 2012).
Pediatric training programs provide more child abuse education than emergency medicine and family medicine programs (Starling et al. 2009). Pediatric residents in programs with an interdisciplinary child abuse assessment team and programs that used a written curriculum and had mandatory training scored significantly better on a test of child abuse knowledge (Starling et al. 2009). The majority of pediatric training programs do not require mandatory clinical rotations in child maltreatment (Narayan et al. 2006; Ward et al. 2004). Although some programs offer electives, some training programs offer no rotation in child maltreatment (Narayan et al. 2006). Residents who completed a mandatory rotation indicated they were better prepared to identify and evaluate child maltreatment than those without this mandatory training. As would be expected, residents’ self-rating of competency correlated with the amount of training they received and the number of cases of child maltreatment they assessed (Ward et al. 2004).
Similarly, medical professionals have also indicated that they did not report suspected maltreatment, because they lacked knowledge about reporting laws and did not understand the reporting mechanism or process (Ashoor et al. 2012; Feng and Levine 2005; Gunn et al. 2005; Offer-Shechter et al. 2000). Particularly in countries without laws mandating reporting, physicians may be uncertain how to make a report to the proper authorities (Al-Moosa et al. 2003).
Familiarity with the Family
Several studies have found that physicians are less likely to report families that they know well and more likely to report families they do not know well (Flaherty et al. 2008a; Jones et al. 2008; Morris et al. 1985). In deciding whether to report a suspicious injury, clinicians were influenced by the length of their relationship with the family, by a family’s attentiveness to other health needs, and by their familiarity with other children in the family. In some cases their familiarity with a family made them more likely to report a suspicion that the child had been abused. In those cases, because of their long relationship with a family, they were aware of family stresses, previous reports to CPS, or had previous concerns about parenting skills.
Physicians may sometimes have so much confidence in their knowledge of the family that they become angry with others who report suspected maltreatment to CPS. Child abuse pediatricians describe how primary care physicians have told them that they have “no business” reporting the family, because they are a “nice” family (Flaherty et al. 2012). Pollak suggested that countertransference may play a role in the physician’s strong feelings and their subsequent failure to report suspected child maltreatment (Pollak and Levy 1989). This countertransference includes sympathy for the family and fear that the family will become angry with them.
Socioeconomic and Racial/Ethnic Biases
Socioeconomic and racial/ethnic biases may consciously or unconsciously affect the physician’s identification and report of child maltreatment. African American children are more likely to be reported to CPS and substantiated as victims of maltreatment, but it is unclear whether they are more likely to be abused (Putnam-Hornstein et al. 2013). It is clear, however, that the possibility of abuse is more likely to be considered if the child is African American (Lane et al. 2002; Rangel et al. 2009; Wood et al. 2010). In the CARES study, the practitioners were more likely to report African American children with private insurance than non-African American children with insurance. The reporting rate was no different between racial groups without insurance. Insurance status served as a proxy for socioeconomic status (Flaherty et al. 2008a). These results suggest that Caucasian patients were underreported. Other studies also suggest that physicians may underreport Caucasian patients rather than overreport African American patients (Hampton and Newberger 1985). In Carole Jenny’s study, the children with abusive head trauma whose diagnosis was initially missed were more likely to be Caucasian (Jenny et al. 1999). Other studies have found that social class influenced the identification and reporting of child abuse, but that race did not (Lane and Dubowitz 2007; Laskey et al. 2012).
Perceptions About Efficacy of CPS
Physicians may decide not to report child maltreatment, because they think that they can do a better job of managing and handling a family’s dysfunctions than CPS. They may believe that reporting to CPS accomplishes little (Al-Moosa et al. 2003; McDonald and Reece 1979). Previous experience with CPS may influence whether a physician decides to report suspected abuse or neglect (Flaherty et al. 2000; Gunn et al. 2005; Zellman 1990). In one study examining physician experience reporting child abuse, the majority of physicians indicated that the children they had reported previously had not benefitted from CPS intervention. Almost half of these physicians said that this experience would make them less likely to report child abuse in the future. The majority of physicians complained that CPS did not keep them informed about the progress of the investigation (Flaherty et al. 2000; Socolar and Reives 2002; Vulliamy and Sullivan 2000). In the CARES study, physicians frequently anticipated the outcome of CPS intervention when deciding whether to report a suspicious injury to CPS (Jones et al. 2008). If they felt that the child and family would benefit from the intervention, they reported, and conversely, they did not report if they felt that CPS would not provide effective intervention (Finkelhor and Zellman 1991).
Fears Involving the Family
Physicians also express concern that a family and maybe other families in the community will leave the practice if they make a report to CPS (Jones et al. 2008; McDonald and Reece 1979; Vulliamy and Sullivan 2000). Some physicians fear that if the family leaves the practice because they report to CPS, they will no longer be able to provide help and necessary intervention and that the child may “get lost” to follow up (Jones et al. 2008). It is significant that in the CARES study, this fear was not justified as families did not leave the practice after they were reported (Jones et al. 2008). Some physicians do not report because they want to avoid conflict with the family or fear angering a patient (Ashoor et al. 2012; Jones et al. 2008). Some said they “feared precipitating a crisis which could result in harm to the child” (Gunn et al. 2005).
Concern About Involvement in Legal Proceedings
Some physicians express concern that they will have to testify in legal proceeding if they report suspected child maltreatment (Badger 1989). Some said that they are “afraid to go to court” (Vulliamy and Sullivan 2000). Others express concern about the time that testifying takes away from their medical practice. They also said they fear a lawsuit if they report (Gunn et al. 2005; Vulliamy and Sullivan 2000), despite legislative protections in all jurisdictions clearly protecting reporters from liability (Mathews and Kenny 2008