© 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_16
16. Training in Reporting of Child Maltreatment: Where We Are and Where We Need to Go
College of Education, Florida International University, Miami, FL, USA
Maureen C. Kenny
KeywordsChild maltreatmentProfessionalsTraining programsChild protectionDecision makingReporting
Child maltreatment is an international societal issue. The United Nations Convention on the Rights of the Child (United Nations General Assembly 1989) emphasized the need for countries worldwide to recognize the importance of children’s rights and to take action to promote these rights. Among these was the right to freedom from child abuse and neglect (Article 19). Unfortunately, despite this dictate, child maltreatment continues to be a pervasive issue in both developing and industrialized nations. Many countries have implemented extensive policies and legislation and responsive approaches, often known as child protection systems, with the goal of safeguarding children from maltreatment (Carter et al. 2006). While exact rates are impossible to report, between 500 million and 1.5 billion children are estimated to experience violence annually (UNICEF 2010). Even in those countries where there are strict laws against abuse and mandatory reporting of abuse, maltreatment occurs at alarming rates. For example, in the USA, 3.4 million referrals to child protection were estimated to include 6.2 million children (U.S. Department of Health & Human Services, Administration of Children and Families 2012), with victims hailing from all socioeconomic groups and ethnicities. From the referrals received, 61 % were screened in (indicating the allegation of child maltreatment met the state’s standards for acceptance and became a report), which resulted in two million reports. In National Child Abuse and Neglect Data System (NCANDS), a child is considered a victim of maltreatment if he or she receives a disposition of substantiated, indicated, or alternative response victim. For 2011, the national estimate of victims was 681,000. The national number of victims who received services was approximately 366,000, and the national number of non-victims who received services (in home or foster care) was approximately 747,000. Although it remains a complex social issue that has been addressed in many prevention models, increased focus on training and education of professionals is critical to provide early detection, identification, and referral to treatment.
The purpose of this chapter is to review the current literature on training professionals, reflect on the ongoing need for training, and propose training and education guidelines for mandated reporters. As Chen et al. (2013) state in regard to reporting child abuse, “education is required before achieving clinical competence” (p. 168) emphasizing that training is necessary to ensuring competence in identifying and reporting child abuse. The crucial need to protect children from abuse and neglect combined with their inherent vulnerability makes this an area of utmost importance in training professionals who will work with them.
It is important to note that the term child abuse will be used to cover the most commonly identified and researched forms of abuse and neglect (e.g., neglect, physical, sexual, and emotional abuse). While the author recognizes that countries vary in their definitions of abuse and neglect, and culture plays a role in defining such actions, for the purpose of brevity, it is assumed that the reader will apply the term accordingly in one’s own context and environment. In addition, many countries are addressing issues of training for professionals. Eissa and Almuneef (2010), for example, wrote about the expanding recognition of child abuse and neglect in Saudi Arabia, which has led to mandatory reporting and improved child abuse data collection strategies. Still, this chapter will draw heavily on the work in the USA and Australia as these countries have the most developed systems of reporting (Mathews and Kenny 2008) and have produced a large body of research on training efforts. This work may serve as information relevant to other countries that have also begun to adopt mandatory reporting.
Mandated Reporters and Reporter Training in the USA
In most States, mandated reporters include educators, medical personnel (primarily physicians and nurses), and mental health professionals (psychologists, counselors) (Mathews and Kenny 2008). While these professionals vary greatly in their professional activities, they share some commonalities including having direct contact with children, serving as confidants or role models to children, and in most countries require a minimum level of university education. They are also viewed as child advocates, safeguarding children and possessing concern for children’s welfare by virtue of their professional role, ethics, and activities. These professionals play an important role in the detection of maltreatment, enabling the provision of services to victims and their families, and the development and conduct of research in the area of maltreatment (Crettenden and Zerk 2012).
While many professional organizations in the USA deem child abuse to be a crucial issue for their members and many professionals are mandated reporters in all US states, there is currently no national standard governing the amount and content of child abuse training across the major professional groups – educators, physicians, and mental health professionals. Unfortunately, as Alvarez and colleagues (2010) state, “There has not been widespread dissemination of training programs to assist professionals in mandated reporting of suspected child maltreatment” (p. 211). This has meant that training programs differ across jurisdictions and across occupational groups even within jurisdictions, may not exist within some jurisdictions or for some professions within jurisdictions, may not be of high quality, may not be well administered, and thus leave professional groups untrained and victims vulnerable.
The Need for Training
Training is critical since the first professional who comes into contact with a victim is the one to direct the child’s access to the resources of the child protection team and ultimately the victim’s pathway to recovery (Hicks and Tite 1998). If professionals who are working with children and youth are appropriately trained, they may contribute to breaking the cycle of abuse (Swann 2000). Professionals will be in positions where they may have a legal and professional duty to report suspected abuse and neglect and will require training to develop the specialized knowledge and confidence needed to deal with this complex issue (Mathews 2011). As Lidchi (2007) states, “training needs to …transfer knowledge, improve research methods and develop practical skills” (p. 354). In addition to a need for training, there appears to be willingness for individuals to attend training as evidenced by the results of Orelove et al. (2000). They found that 92 % of educators and 96 % of investigators (including child protection workers and law enforcement) said they would attend specialized training if it were made available to them.
Proper, well-planned, and executed training is critical for professionals to assist in identification and reporting of child maltreatment. Given the high incidence, as well as the various and complex types of child maltreatment (e.g., sexual, physical, emotional, neglect), and often debilitating, long-term consequences for child victims, professionals need to be equipped to confront this social issue. Detection is frequently difficult due to the nature and context of some types of abuse as well as the secrecy surrounding them. Training allows for an exploration of the often complicated ethical, legal, and moral duties involved in the protection of children. The professional reporter plays a pivotal role in protecting seriously abused and neglected children, and they have the potential to make an impacting difference to the child’s and family’s life.
Widespread Variation in Training Efforts
While it is recognized that educators and early interventionists can play a pivotal role on child protection teams (Orelove et al. 2000), there is also an international consensus that most educators are ill equipped to perform their duties as mandated reporters. For example, although all of the educators and investigation workers in the Orelove et al. (2000) study in the USA were mandated reporters, less than a third reported being very knowledgeable about the process to report child abuse to child protection services (CPS). Seventy-nine percent of the educators said that their employers had a policy on reporting abuse, but only 25 % of them had received training on the policy within the past 3 years. According to Kenny (2004), almost two-thirds of the teachers surveyed in the USA reported having no training in child abuse during their preservice training, and very few teachers were aware of their school’s procedures for reporting abuse. In addition, teachers claimed inadequacy in their ability to detect and identify all types of child abuse even when they had training. This lack of training has been documented in other countries as well. Buckley and McGarry (2011) found that 61 % of their beginning teachers in Ireland reported their training in child protection while pursuing their degree to be inadequate. Similarly, McKee and Dillenburger (2009) found that undergraduate students in Ireland in initial teacher education, early childhood studies, and health and leisure studies had some basic awareness of child abuse and neglect (CAN) issues, but their knowledge base was inconsistent and did not reach the levels required for those who will work directly with children.
The findings from a study by Walsh et al. (2008) in Australia, although conducted on solely neglect and physical abuse, bear reporting here. They found that teachers with no formal child protection training were more likely to both detect and report child physical abuse and neglect than those with formal training. They hypothesize that training may, in fact, provide teachers with increased awareness of the complexities of child maltreatment, such that “the more teachers know, the more they may realise they do not know” (p. 991). This is consistent with the findings of Buckley and McGarry (2011) who found that many of those teachers who recall having no training (51 %) considered themselves confident, while the majority of those who had training (59 %) were not confident or certain about their ability to identify abuse. This lack of confidence may indicate the inadequacy of their training as well as a misperception of one’s abilities despite lack of education.
Many countries have begun to make programmatic efforts to provide training to teachers. In Queensland, Australia, teacher training includes a 3 h school-based interactive workshop using a standard package comprised of audiovisual segments, activities, question and answer clarification, and small group discussions on case scenarios (Walsh et al. 2008). Training is delivered by school leaders, generally principals and school/guidance counselors rather than child protection specialists.
In 2001, Hawkins and McCallum sought to evaluate the South Australian Education Department Mandated Notification Training (Hawkins and McCallum 2001). The training is a 1-day workshop designed to prepare educators and other mandated reporters to fulfill their reporting obligations. It includes an examination of one’s values, attitudes, and experiences, the importance of maintaining a child/young person’s focus and perspective when considering the possibility of child abuse and neglect, legal responsibilities, and recognition and notification of suspected child abuse and neglect. Using a control group, they found that, comparatively, participants in the workshop had increased confidence in their ability to recognize the indicators of abuse as well as increases in awareness of their reporting responsibilities, knowledge of what constitutes reasonable grounds, and of how to respond appropriately to a child’s disclosure of abuse.
The literature on educators demonstrates that while they often make many reports of child abuse, they may also lack proper training to carry out their duties. Training is sporadic and inconsistent at best. The extent to which teachers are trained in child abuse seems to vary significantly across countries.
Physicians, especially pediatricians, are often the first to come in contact with cases of suspected child abuse and neglect (Yehuda et al. 2010). However, it has been well documented that they may not receive adequate training in medical school (Johnson 1993). The majority of medical residents, pediatric program directors, and child protection program directors, in Canadian pediatric academic centers, rated their training in child maltreatment as “somewhat adequate, needs improvement” (Ward et al. 2004). Cavanagh et al. (2004) found that fewer medical staff (nurses and psychiatrists) had received training in asking about abuse than the nonmedical staff (therapists/psychologists). In addition, Kenny (2001b) found that slightly more than half (52 %) of the medical residents in her study reported having some education in child abuse in their training. Further, physicians may be ill informed about specifics related to abuse. For example, it was found that they tend to associate certain factors with child sexual abuse (such as religion, race, and family size), despite research demonstrating a lack of connection between these variables and a risk of experiencing child sexual abuse (Lentsch and Johnson 2000).
There is currently no specific mandated training in child abuse and neglect as a required subspecialty experience in pediatric residency education in the USA as per the Pediatric Residency Review Committee of the Accreditation Council for Graduate Medical Education (Narayan et al. 2006). For residency programs that offer didactic training in abuse issues, the majority (52 %) have been found to offer 3–6 h of training, and sessions were taught by physician experts (87 %) in child abuse and neglect. Overall, many pediatric residents leave residency with limited clinical training in child abuse and neglect, having been exposed to less than five cases of abuse. Narayan et al. (2006) found that 59 % of pediatric residency programs offer no mandatory rotation and 25 % offered no rotations at all in child abuse and neglect. However, 75 % did offer a mandatory, elective, or both rotations. Interestingly, elective rotations appeared to provide more comprehensive coverage of abuse and neglect.
In New York (USA), where there is a mandatory 4 h child abuse and maltreatment course for professionals (including physicians, mental health counselors, nurses, school service personnel, etc.) prior to licensure, Khan et al. (2005) surveyed physicians who had completed the course. On average, 90 % of the physicians answered the ten test items on child abuse correctly. Fifty to 85 % stated that the course made a significant difference in their knowledge and practice. However, results revealed that almost half of the surgeons and internists did not know how to initiate a report of abuse. The authors conclude that while the course may improve awareness, it may not increase reporting.
Palusci and McHugh (1995) utilized a child sexual abuse training for physicians (fellows, students, residents) that consisted of 3 h of didactic training and 6–12 h of patient care exposure and found that participants had a significant increase in their test scores on knowledge of various aspects of child sexual abuse (pre-post). The training utilized a multidisciplinary approach including video, direct patient care, supervision, interview, and medical examination. They believe that this approach had advantages over lectures and case discussions. This is consistent with Ward et al. (2004) who found that only 7 % of their medical residents reported didactic training as a strength, when being taught about child maltreatment.
The extent of training received by physicians seems to vary according to specialty. Starling et al. (2009) found that pediatric programs provide far greater training and resources in child maltreatment than emergency medicine and family medicine programs. In addition, pediatric programs were more likely to have a medical provider who specializes in child abuse, have physician faculty responsible for child abuse training, use a written curriculum for child abuse training, and offer an elective rotation in child abuse, than the emergency and family medicine programs. Residents who reported more training and patient experiences performed better on the knowledge quiz than those who did not have such experiences. This resulted in pediatric residents being more knowledgeable, more comfortable, and better trained in child abuse than their emergency and family medicine peers. While they performed better than their peers, their average score was still 73 %.
Donohue et al. (2002) utilized an abuse reporting skills checklist in a study in order to measure professionals’ ability to master these steps when making a child abuse report. The study employed a single subject (third-year medical student) who participated in six training sessions (45 min each) over a 4-week period. The first two sessions focused on education regarding the state reporting laws and rules. The remaining sessions taught skills relevant to initiating child abuse reports, handling upset during child abuse reports, role-play of making reports, and handling reports with clients. A controlled multiple baseline design across behaviors was used to evaluate skills acquisition. Results demonstrated that the participant improved her skills in the area of initiating abuse reports (from baseline to follow-up) and an improved ability to resolve upset by the caregiver to the abuse report. With regard to participant feedback, the participant strongly agreed that the program contributed to her professional development, knowledge in reporting child maltreatment, and confidence in reporting child maltreatment.
McCauley et al. (2003) trained physicians and other professionals by utilizing a 35 min video, Ask-Sympathize-Safety-Educate-Refer-Treat (ASSERT), and a pre- and posttest measuring both knowledge and attitudes. The video, which featured role-plays to demonstrate different approaches to difficult clinical encounters, such as suspected abuse, was created in conjunction with a multidisciplinary team. Physicians were found to have significantly improved knowledge and attitudes about abuse after the training and the video was rated highly. Compared to the other professionals (nurses and social workers), physicians were found to show improvement in knowledge related to the legal requirements to report abuse and neglect.
As Christian (2008) concludes, much of the literature on physician training in child abuse suggests that improving knowledge, while not easy, is simpler than influencing medical practice. She contends that clinical competence in medicine is based both in knowledge and experience. Thus, if the aim of medical education is to improve practice, rather than simply just improve knowledge, education must focus not only on knowledge but skill development. These skills would be in the area of identification of child abuse, addressing concerns with families, reporting suspected child abuse, managing consequences of abuse, advocating for families, and working with families affected by child maltreatment.
Mental Health Professionals
Mental health professionals are likely to see many cases of suspected abuse as they often work with families in crisis. Clinical and counseling psychologists reported that their graduate training programs and internships were deficient in training them to address abuse issues, but those who were trained more recently rated their training more positively than did earlier graduates (Pope and Feldman-Summers 1992). However, overall the ratings were still low. More recent graduates reported that their programs provided little coverage of abuse issues, but it was an improvement from previously trained psychologists. In Australia, Crettenden and Zerk (2012) found that most psychology programs exposed students to issues related to child abuse and neglect as part of or integrated into other units of study. This is consistent with Champion et al. (2003) who also found that doctoral programs in psychology included information on child maltreatment in several courses in their curriculum, most often in ethics courses. Crettenden and Zerk (2012) conclude that there needs to be some agreement on the minimum level of information on child maltreatment required for psychology students, both at the undergraduate and graduate levels.
Alvarez and colleagues (2010) utilized an in-person 3 h workshop for mental health professionals that included a PowerPoint presentation and video vignettes, dissemination of state and federal laws on child abuse reporting, common indicators of child abuse, and a review of misconceptions resulting in the failure to report suspected child maltreatment. After random assignment to the control or training group, it was found that participants who were assigned to the training group improved their knowledge of laws, were able to identify child maltreatment scenarios, and evidenced knowledge of skills required to make a report of child maltreatment compared to controls.
Cavanagh et al. (2004) report on a 1-day training program in New Zealand developed to train professionals (nurses, psychologists/therapists, psychiatrists) on physical and sexual abuse inquiry and response. This was developed in response to recommended best practices for trauma and sexual abuse. Evaluations completed on this training at the end of the day found that 94 % of participants found some benefit to the training, including increased confidence in ability to inquire about and respond to abuse. Aspects of the training that were rated favorably by participants included role-playing, written handouts, and research summaries. Many wanted more time for the training, including an extra day. Six weeks after the training, the majority of participants reported that the training changed their clinical practice. The training had a self-reported positive effect on confidence and self-perceived abilities both in asking about abuse and responding to disclosures. These authors recommend a combined skills and knowledge-based program.
Law enforcement plays an important role in identification and responding to child maltreatment. In some jurisdictions, police officers respond along with social services to reports of child abuse, while in other instances they may recognize child maltreatment when investigating other crimes. While police officers are not required to attend university, they typically are trained in police academies. Thus, training in child abuse generally takes place during academy training. In the USA, the Police Training Commission sets the minimum standards that must be achieved, and the topic of child abuse falls into those standards, under the criminal statute of endangering the welfare of children (Rick McGarry, personal communication, December 1, 2013). Frequently, child protection workers will be utilized during these trainings to emphasize policies and procedures. In addition, there may be in-service training classes provided by child protection workers for experienced officers and for officers and detectives assigned to police department patrol and juvenile bureaus. Currently in the USA, there is no mandatory retraining on child abuse during the tenure of an officer, and the focus of training in the academy is often on the criminal aspects of child abuse.