Primary care clinicians do not report about one 1 in 4 cases of suspected
physical child abuse, because they either distrust local child protective
services or think they can intervene more effectively by other means,
according to studies published in the August and September
Of the 15,003 child-injury visits included in the study, 1,683 raised
suspicion of physical abuse, yet the clinicians reported to child-protection
authorities only 73 percent of the children they thought were"
likely" or "very likely" to have been abused; only 24
percent reported those they thought had "possibly" been abused.
The rest were not reported (see table below).
"Clearly, factors other than levels of suspicion play a role in
clinicians' decision to report," wrote Emalee Flaherty, M.D., and
colleagues of the Child Abuse Reporting Study (CARES). The patient's medical
and family history and physical examination findings, injury characteristics,
and the clinician's previous reporting experience also affected their
"The 27 percent of clinicians who did not report is a very
conservative number, and in fact a larger percentage of clinicians may not
have reported very suspicious injuries," said Flaherty in an interview
with Psychiatric News.
The 327 clinicians (88 percent were physicians, and most of those were
pediatricians) whose data were included in the CARES study were members of the
American Academy of Pediatrics Pediatric Research in Office Settings Network
or the National Medical Association Pediatric Research Network. Data were
collected from October 2002 to April 2005.
The U.S. Agency for Healthcare Research and Quality, the Maternal and Child
Health Bureau, and the American Academy of Pediatrics funded the studies.
A second, related study based on interviews with a subsample of clinicians
delved into their reasoning about decisions to report suspected child abuse.
Those who did not report often cited worries that child protective services
(CPS) agencies would not investigate a report or would not supply ongoing
information on a case, wrote Risé Jones, Ph.D., and her colleagues
(including Flaherty). Those who reported were more likely to consult with
other professionals in making their decision.
"The pediatricians were pretty brave to take on this issue,"
said Sandra Kaplan, M.D., a professor of psychiatry at New York University
School of Medicine and director of the Division of Trauma Psychiatry at North
Shore-Long Island Jewish Health System, in an interview. She commended the
American Academy of Pediatrics for addressing the problem of underreporting
child abuse and suggesting steps to overcome it.
Clinicians were more likely to report if the injury was inconsistent with
the patient's history or if the patient was referred because of suspected
They were also more likely to report suspected abuse to CPS if they had
ever lost patients after reporting or if they had not previously reported all
suspected child abuse.
That may seem contradictory, but perhaps more experienced clinicians feel
more confident about reporting or not reporting and may manage some suspected
abuse on their own, suggested the authors.
Some doctors fear they will lose patients if they report child abuse. But,
said Flaherty, "Most families stay with their doctor even after he or
she reports suspected child abuse. For one thing, the perpetrator may not be a
member of the immediate family."
There were no racial differences in reporting rates of patients without
private health insurance. However, among privately insured children, injuries
to black children were reported at a higher
"We think this is not because the black children were over-reported,
but because the injuries to the non-black children were underreported,"
"We don't know why this should be," she said. "The
pattern has shown up in other studies, and we will be looking more closely at
our data to try to understand it."
Severe injuries were more likely to be reported. That may seem obvious, but
the researchers noted that clinicians may be reluctant to report less-serious
injuries because they found that CPS was less likely to confirm them. However,
limiting reporting to severe injuries may lessen the chances of receiving
services by children who are repeatedly abused with "minor"
injuries, which may also lead to long-lasting emotional and developmental
harm, they said.
In detailed follow-up interviews of 75 clinicians, Jones and colleagues
identified influences on the decision to report.
"As in most medical decisions, clinicians weigh the likely costs and
benefits of reporting a case and apply the lessons learned from previous
experience," they wrote.
Most clinicians who reported injuries said they had little familiarity with
the family, while clinicians with a high suspicion of child abuse who did not
report injuries frequently said that familiarity with the family led them to
their decision. Others said that knowledge of family stressors or prior red
flags about the family increased the chance of reporting.
Seeking outside advice appeared to help tip the balance toward reporting.
About 82 percent of those who reported discussed their suspicions with
colleagues first, while just 18 percent of those not reporting did so.
Those who did not report said they assumed responsibility for patient
follow-up, referred patients to other medical or social services, or would
look for further injury in a return visit before reporting.
The disconnection between the medical and the child-protection worlds
serves to hinder full reporting, said consultant John Goad, M.A., a former
director of child protective services in Illinois, in an online supplement to
the research articles. On one hand, many doctors distrust CPS and believe such
agencies will not protect the child. They have seen CPS apparently fail to
pursue reported cases and fail to provide feedback to physicians. Doctors
grumble about the need to take an uncompensated day from work if they need to
testify in court.
For their part, CPS workers may complain that doctors don't provide enough
information to conduct a proper investigation or that physicians want to
encroach on their turf. CPS agencies, like most government social-service
agencies, are under-staffed and underfunded.
Several approaches may improve the reporting system and its outcomes.
Better education for clinicians about child abuse on every level would be a
"There have to be changes in medical education," said Kaplan."
Child abuse is taught, briefly, in the preclinical years, but it should
be addressed in the clinical years of medical education and residency because
experience is needed to develop competency."
Studies of the effectiveness of continuing medical education programs about
child abuse are few and have produced equivocal results.
Developing team approaches to identifying injuries reportable as child
abuse might improve understanding of what each professional group can do and
lead to better cooperation and better results for the children.
"Rather than a response that combines the expertise of all involved,
there are multiple, parallel, but often uncoordinated efforts," said
Goad. Establishing interdisciplinary child-protection committees at the
medical-center or community levels would help break down barriers, said
several of the authors.
Flaherty now works with a group in Chicago comprising CPS workers,
law-enforcement personnel, and medical practitioners from three city hospitals
to sort out difficult cases of potential child abuse. The team approach can
also provide expert consultation for primary care physicians, an advantage,
given that doctors who consult are also more likely to report.
"I see the benefits, but I also see that it's not easy to get it to
work," she said. Simply scheduling group members to meet in the same
room at the same time can be difficult. Ultimately, the life and safety of the
child are the touchstones for action.
"You don't have to be certain that a child was abused, just see a
'reasonable likelihood' of abuse," said Flaherty. "If you wait
until you are certain and have eliminated all other possibilities, it may be
too late for the child. You have to keep the child safe while investigating
"From Suspicion of Physical Child Abuse to Reporting: Primary
Care Clinician Decision-Making" is posted at<http://pediatrics.aappublications.org/cgi/content/full/peds.2007-2311v1>.
Other articles in the series are posted at<http://pediatrics.aappublications.org/papbyrecent.shtml>.▪