PUBLIC HEALTH BRIEFS
Child Abuse and Neglect: Physicians' Knowledge, Attitudes, and Experiences ALBERT CHANG, MD, MPH, ALLAN C. OGLESBY, MD, MPH, HELEN M. WALLACE, MD, MPH, HYMAN GOLDSTEIN, PHD, AND ALFRED C. HEXTER, MA
Introduction Although physicians play important key roles in the management of child abuse and neglect cases, most physicians are reluctant to get involved for the following reasons: lack of experience, inability to obtain the facts, emotional ties with the family, parent criticism or retaliation, reluctance to spend time in court, fear of lawsuit, etc.1 -6 Silver et al. studied the knowledge, attitude, and practice of pediatricians, general practitioners, and hospital house staff in Washington, D.C.,7 and Nagi more recently interviewed pediatricians and other physicians with special interest in the area of child abuse and neglect.8 Both studies confirmed the limited involvement of practicing physicians in this medical problem area. However, since very little is known on a nationwide basis of current knowledge, attitudes, and experience of physicians in the area of child abuse and neglect, a nationwide study was undertaken in 1974.
Methods Questionnaires were mailed to a sample of 3,000 pediatricians, radiologists, and "other" physicians to investigate their knowledge, attitudes and experience in the field of child abuse and neglect; and to identify the physician characteristics which were significantly associated with knowledge, attitudes, and experience in the field of child abuse and neglect.*
Results A total of 1,367 responses represented 55.7 per cent of the 2,453 physicians who received the questionnaire.** From the Maternal and Child Health Program and Family Health Program, University of California School of Public Health, Berkeley. Address reprint requests to Dr. Albert Chang, Lecturer and Director, Collaborative Research Project in Maternal and Child Health, University of California, School of Public Health, Berkeley, CA 94720. This paper, based on a presentation at the 103rd Annual Meeting of the American Public Health Association, Chicago, 1975, was submitted to the Journal February 17, 1976, revised, and accepted for publication August 20, 1976. *The study sample included 1,000 Board-certified pediatricians and 1,000 Board-certified radiologists listed in the Directory of Medical Specialists, 15th ed. (1972-73), and 1,000 "other" physicians (who were neither Board certified pediatricians nor radiologists) listed in the American Medical Directory, 25th ed. (1969). **Response rate for pediatricians, 69.6 per cent, for radiologists 49.3 per cent, for "other" physicians 46.6 per cent. Further detailed analyses of questionnaire returns are available on request to the senior author.
AJPH December, 1976, Vol. 66, No. 12
More than half (54.8 per cent) of the responding pediatricians reported that they had attended a course on child abuse and neglect some time in the recent past. Only 20.5 per cent of the radiologists and 17.3 per cent of the "other" physicians reported such attendance. Although the vast majority of the three types of physicians believed that physicians in their community "should" report cases of child abuse and neglect, only 71.2 per cent of the pediatricians, 57.7 per cent of the radiologists, and 46.2 per cent of the "other" physicians believed that these cases were "usually" reported (Table 1). All three types of physicians agreed that an appropriate agency and the courts have the right to remove the child from the parents, that there should be a law requiring reporting, and that physicians should be required to report. In addition, all three types of respondents indicated that there was an increase in awareness of child abuse in the communities. A minority of the respondents, however, believed that present services and methods of management were adequate or effective (Table 1). There were differences in the respondents' choice of agencies to which cases should be or usually are reported. Pediatricians most frequently named child protective services while "other" physicians cited the police most frequently. Radiologists indicated that they should report or usually report to "other" agencies, meaning referring physicians who had sought their consultation in establishing a
diagnosis. About half the pediatricians, a third of the radiologists and a fifth of the "other" physicians reported they had seen one or more abused children in 1973. The largest number of child abuse cases seen were infants and preschool children to five years of age. Pediatricians stated that 31 per cent of the cases seen were known to have been abused previously, and 11 per cent were known to have been abused subsequently. More than half of the cases seen were admitted to a hospital and more than a third were referred to a community agency. Parents of these children were primarily counseled or referred to an agency. Relatively small percentages of respondents of each type of physician were currently involved in community agencies and/or activities dealing with child abuse and neglect. Pediatricians were more likely to be so involved, and their involvement was mainly with hospitals, welfare departments, and child protective services. No major associations were found with the professional or sociodemographic characteristics of the respondent physicians and their knowledge, attitudes, and experience with child abuse and neglect. 1199
PUBLIC HEALTH BRIEFS TABLE 1-Physician Opinions, Attitudes, and Practice on Reporting and Disposition of Child Abuse and Neglect Cases, by Type of Physician
Question
Do you believe physicians in your communityshould report cases? Do you believe physicians of your specialty in your community usually report cases?
Should an agency have the right to remove a child from the parents?
Should a court have the right to remove a child from the parents? Should there be a law requiring reporting? Should physicians be required to report cases? Do you think community awareness of child abuse is:
Are community services for dealing with cases of child abuse and neglect:
Do you believe current methods of management of child abuse and neglect are:
Per Cent of Respondents "Other" RadiPediaPhysicians ologists tricians
Response
(N) Yes No Don't know (N) Yes No Don't know (N) Always Sometimes Never Don't know (N) Always
Sometimes Never Don't know (N) Yes No Don't know (N) Yes No Don't know (N) Increasing Remaining same Decreasing Don't know (N) Adequate Inadequate Don't know
(N) Effective Ineffective Don't know
(605) 98.0 0.2 1.8 (605) 71.2 6.3 22.5 (590) 34.9 55.8 6.0 3.4 (596) 57.0 41.4 0.5 1.0 (593) 91.7 3.5 4.8 (592) 92.4 3.2 4.4
10.3 9.8 (395) 45.8 47.6 0.3 6.3 (391) 81.6 5.9 12.5 (393) 81.2 5.6 13.2
(602)
(408)
(327) 92.4 3.3 4.3 (327) 46.2 30.8 23.1 (323) 24.5 60.7 7.1 7.7 (329) 43.2 53.2 0.3 3.3 (327) 86.5 4.9 8.9 (327) 86.5 4.9 8.6 (337)
73.3
44.1 0.7 28.9 26.2
52.2 0.6 23.7 23.4
(409)
(336)
24.4 14.2 61.4
31.8 20.9 47.3
(405)
(321)
14.6 17.0 68.4
18.7 20.2 61.0
0.7 19.1
6.9 (595) 44.9 36.3 18.8
(577) 33.3 33.1 33.7
(395) 83.3 9.9 6.8 (395) 57.7 9.9 32.4 (389) 22.9 57.1
(N) Number of respondents Note: Per cents were rounded independently and may not add to totals. Source: Maternal and Child Health Program, University of California School of Public Health, Berkeley
Discussion One important finding in this 1974 nationwide study of physicians' knowledge, attitudes, and practice on child abuse and neglect was a gap between stated attitudes and practice in regard to reporting cases. Almost all pediatricians, radiologists, and "other" physicians believed that physicians "should" report cases of child abuse and neglect. But fewer respondents in all three types of physicians believed that physicians "usually" report such cases, and some could not comment on the practice of reporting. Although the majority of physicians felt that there was an increasing trend in the awareness of child abuse and neglect in their communities, only a minority believed that existing services were adequate and that existing programs 1 200
were effective. This latter assessment agrees with findings of
DeFrancis who in 1972 noted that no state and no community had developed an adequate child protective service program and cited the need for additional cooperation from schools, social agencies, and courts.9 A more recent study by Nagi also found defects in the present management of child abuse by welfare departments and offered suggestions for improvement of services by welfare departments and caseworkers.8 Other needs noted in this study were concise and practical references and brochures delineating reporting requirements, additional training programs for physicians, reliable systems of detection and reporting, and clarification of roles and responsibilities of community agencies involved in child abuse and neglect cases. Hopefully, the innovative programs AJPH December, 1976, Vol. 66, No. 12
PUBLIC HEALTH BRIEFS
and activities made possible by recent federal legislation in the field of child abuse and neglect will begin to meet these needs.10
REFERENCES I. Helfer, R. E. Responsibility and Role of the Physician. In The Battered Child. R. E. Helfer and C. H. Kempe, Eds., University of Chicago Press, 1968. 2. Helfer, R. E. Why most physicians don't get involved in child abuse cases and what to do about it. Children Today 4:28-32, 1975. 3. Committee on Infant and Preschool Child, American Academy of Pediatrics. Maltreatment of children-The physically abused child. Pediatrics. 37:377-382, 1966. 4. Ebbin, A., et al. Battered child syndrome at the Los Angeles County General Hospital. Am. J. Dis. Child. 118:660-667, 1969. 5. Sanders, R. W. Resistance to dealing With parents of battered children. Pediatrics 50:853, 1972. 6. Mindlin, R. L. Child abuse and neglect: The role of the pediatrician and the academy. Pediatrics 54:393-395, 1974.
I
7. Silver, L. B., Barton, W., and Dublin, C. C. Child abuse lawsAre they enough? J.A.M.A. 199:101-104, 1%7. 8. Nagi, S. Z. Child abuse and neglect programs: A national overview. Children Today 4:13-17, May-June, 1975. 9. DeFrancis, V. The Status of Child Protective Services. In Helping the Battered Child and His Family. C. H. Kempe and R. E. Helfer, Eds. Lippincott, pp. 127-145, 1972. 10. Child Abuse Prevention and Treatment Act, P.L. 93-247, 93rd Congress, Jan. 31, 1974.
ACKNOWLEDGMENTS This study was supported by Grant No. MC-R-060208-03-0 from the Maternal and Child Health Service, Office of Clinical Services, U.S. Department of Health, Education, and Welfare, Rockville, MD. The authors would like to acknowledge Victor Eisner, MD, and Beverly Witchner for helpful comments and suggestions in preparing this report, and Dorothy Trujillo and Genevieve Coulson for secretarial assistance.
New Horizons in Epidemiology
I
E pidemiology is a burgeoning science .... The realization of this immense complexity in the balance between health and disease has stimulated efforts to meet the needfor broadening the horizons of epidemiology from a single-minded concentration on studying contagions. It is now concerned with all health and illness in population groups and with the factors-including health services-which affect them. Roy M. Acheson. The Need for Comparability in International Epidemiology, Milbank Memorial Fund Quarterly 43: 11, (part 2) April 1965.
AJPH December, 1976, Vol. 66, No. 12
1201
Child Abuse and Neglect: Physicians' Knowledge, Attitudes, and Experiences ALBERT CHANG, MD, MPH, ALLAN C. OGLESBY, MD, MPH, HELEN M. WALLACE, MD, MPH, HYMAN GOLDSTEIN, PHD, AND ALFRED C. HEXTER, MA
Introduction Although physicians play important key roles in the management of child abuse and neglect cases, most physicians are reluctant to get involved for the following reasons: lack of experience, inability to obtain the facts, emotional ties with the family, parent criticism or retaliation, reluctance to spend time in court, fear of lawsuit, etc.1 -6 Silver et al. studied the knowledge, attitude, and practice of pediatricians, general practitioners, and hospital house staff in Washington, D.C.,7 and Nagi more recently interviewed pediatricians and other physicians with special interest in the area of child abuse and neglect.8 Both studies confirmed the limited involvement of practicing physicians in this medical problem area. However, since very little is known on a nationwide basis of current knowledge, attitudes, and experience of physicians in the area of child abuse and neglect, a nationwide study was undertaken in 1974.
Methods Questionnaires were mailed to a sample of 3,000 pediatricians, radiologists, and "other" physicians to investigate their knowledge, attitudes and experience in the field of child abuse and neglect; and to identify the physician characteristics which were significantly associated with knowledge, attitudes, and experience in the field of child abuse and neglect.*
Results A total of 1,367 responses represented 55.7 per cent of the 2,453 physicians who received the questionnaire.** From the Maternal and Child Health Program and Family Health Program, University of California School of Public Health, Berkeley. Address reprint requests to Dr. Albert Chang, Lecturer and Director, Collaborative Research Project in Maternal and Child Health, University of California, School of Public Health, Berkeley, CA 94720. This paper, based on a presentation at the 103rd Annual Meeting of the American Public Health Association, Chicago, 1975, was submitted to the Journal February 17, 1976, revised, and accepted for publication August 20, 1976. *The study sample included 1,000 Board-certified pediatricians and 1,000 Board-certified radiologists listed in the Directory of Medical Specialists, 15th ed. (1972-73), and 1,000 "other" physicians (who were neither Board certified pediatricians nor radiologists) listed in the American Medical Directory, 25th ed. (1969). **Response rate for pediatricians, 69.6 per cent, for radiologists 49.3 per cent, for "other" physicians 46.6 per cent. Further detailed analyses of questionnaire returns are available on request to the senior author.
AJPH December, 1976, Vol. 66, No. 12
More than half (54.8 per cent) of the responding pediatricians reported that they had attended a course on child abuse and neglect some time in the recent past. Only 20.5 per cent of the radiologists and 17.3 per cent of the "other" physicians reported such attendance. Although the vast majority of the three types of physicians believed that physicians in their community "should" report cases of child abuse and neglect, only 71.2 per cent of the pediatricians, 57.7 per cent of the radiologists, and 46.2 per cent of the "other" physicians believed that these cases were "usually" reported (Table 1). All three types of physicians agreed that an appropriate agency and the courts have the right to remove the child from the parents, that there should be a law requiring reporting, and that physicians should be required to report. In addition, all three types of respondents indicated that there was an increase in awareness of child abuse in the communities. A minority of the respondents, however, believed that present services and methods of management were adequate or effective (Table 1). There were differences in the respondents' choice of agencies to which cases should be or usually are reported. Pediatricians most frequently named child protective services while "other" physicians cited the police most frequently. Radiologists indicated that they should report or usually report to "other" agencies, meaning referring physicians who had sought their consultation in establishing a
diagnosis. About half the pediatricians, a third of the radiologists and a fifth of the "other" physicians reported they had seen one or more abused children in 1973. The largest number of child abuse cases seen were infants and preschool children to five years of age. Pediatricians stated that 31 per cent of the cases seen were known to have been abused previously, and 11 per cent were known to have been abused subsequently. More than half of the cases seen were admitted to a hospital and more than a third were referred to a community agency. Parents of these children were primarily counseled or referred to an agency. Relatively small percentages of respondents of each type of physician were currently involved in community agencies and/or activities dealing with child abuse and neglect. Pediatricians were more likely to be so involved, and their involvement was mainly with hospitals, welfare departments, and child protective services. No major associations were found with the professional or sociodemographic characteristics of the respondent physicians and their knowledge, attitudes, and experience with child abuse and neglect. 1199
PUBLIC HEALTH BRIEFS TABLE 1-Physician Opinions, Attitudes, and Practice on Reporting and Disposition of Child Abuse and Neglect Cases, by Type of Physician
Question
Do you believe physicians in your communityshould report cases? Do you believe physicians of your specialty in your community usually report cases?
Should an agency have the right to remove a child from the parents?
Should a court have the right to remove a child from the parents? Should there be a law requiring reporting? Should physicians be required to report cases? Do you think community awareness of child abuse is:
Are community services for dealing with cases of child abuse and neglect:
Do you believe current methods of management of child abuse and neglect are:
Per Cent of Respondents "Other" RadiPediaPhysicians ologists tricians
Response
(N) Yes No Don't know (N) Yes No Don't know (N) Always Sometimes Never Don't know (N) Always
Sometimes Never Don't know (N) Yes No Don't know (N) Yes No Don't know (N) Increasing Remaining same Decreasing Don't know (N) Adequate Inadequate Don't know
(N) Effective Ineffective Don't know
(605) 98.0 0.2 1.8 (605) 71.2 6.3 22.5 (590) 34.9 55.8 6.0 3.4 (596) 57.0 41.4 0.5 1.0 (593) 91.7 3.5 4.8 (592) 92.4 3.2 4.4
10.3 9.8 (395) 45.8 47.6 0.3 6.3 (391) 81.6 5.9 12.5 (393) 81.2 5.6 13.2
(602)
(408)
(327) 92.4 3.3 4.3 (327) 46.2 30.8 23.1 (323) 24.5 60.7 7.1 7.7 (329) 43.2 53.2 0.3 3.3 (327) 86.5 4.9 8.9 (327) 86.5 4.9 8.6 (337)
73.3
44.1 0.7 28.9 26.2
52.2 0.6 23.7 23.4
(409)
(336)
24.4 14.2 61.4
31.8 20.9 47.3
(405)
(321)
14.6 17.0 68.4
18.7 20.2 61.0
0.7 19.1
6.9 (595) 44.9 36.3 18.8
(577) 33.3 33.1 33.7
(395) 83.3 9.9 6.8 (395) 57.7 9.9 32.4 (389) 22.9 57.1
(N) Number of respondents Note: Per cents were rounded independently and may not add to totals. Source: Maternal and Child Health Program, University of California School of Public Health, Berkeley
Discussion One important finding in this 1974 nationwide study of physicians' knowledge, attitudes, and practice on child abuse and neglect was a gap between stated attitudes and practice in regard to reporting cases. Almost all pediatricians, radiologists, and "other" physicians believed that physicians "should" report cases of child abuse and neglect. But fewer respondents in all three types of physicians believed that physicians "usually" report such cases, and some could not comment on the practice of reporting. Although the majority of physicians felt that there was an increasing trend in the awareness of child abuse and neglect in their communities, only a minority believed that existing services were adequate and that existing programs 1 200
were effective. This latter assessment agrees with findings of
DeFrancis who in 1972 noted that no state and no community had developed an adequate child protective service program and cited the need for additional cooperation from schools, social agencies, and courts.9 A more recent study by Nagi also found defects in the present management of child abuse by welfare departments and offered suggestions for improvement of services by welfare departments and caseworkers.8 Other needs noted in this study were concise and practical references and brochures delineating reporting requirements, additional training programs for physicians, reliable systems of detection and reporting, and clarification of roles and responsibilities of community agencies involved in child abuse and neglect cases. Hopefully, the innovative programs AJPH December, 1976, Vol. 66, No. 12
PUBLIC HEALTH BRIEFS
and activities made possible by recent federal legislation in the field of child abuse and neglect will begin to meet these needs.10
REFERENCES I. Helfer, R. E. Responsibility and Role of the Physician. In The Battered Child. R. E. Helfer and C. H. Kempe, Eds., University of Chicago Press, 1968. 2. Helfer, R. E. Why most physicians don't get involved in child abuse cases and what to do about it. Children Today 4:28-32, 1975. 3. Committee on Infant and Preschool Child, American Academy of Pediatrics. Maltreatment of children-The physically abused child. Pediatrics. 37:377-382, 1966. 4. Ebbin, A., et al. Battered child syndrome at the Los Angeles County General Hospital. Am. J. Dis. Child. 118:660-667, 1969. 5. Sanders, R. W. Resistance to dealing With parents of battered children. Pediatrics 50:853, 1972. 6. Mindlin, R. L. Child abuse and neglect: The role of the pediatrician and the academy. Pediatrics 54:393-395, 1974.
I
7. Silver, L. B., Barton, W., and Dublin, C. C. Child abuse lawsAre they enough? J.A.M.A. 199:101-104, 1%7. 8. Nagi, S. Z. Child abuse and neglect programs: A national overview. Children Today 4:13-17, May-June, 1975. 9. DeFrancis, V. The Status of Child Protective Services. In Helping the Battered Child and His Family. C. H. Kempe and R. E. Helfer, Eds. Lippincott, pp. 127-145, 1972. 10. Child Abuse Prevention and Treatment Act, P.L. 93-247, 93rd Congress, Jan. 31, 1974.
ACKNOWLEDGMENTS This study was supported by Grant No. MC-R-060208-03-0 from the Maternal and Child Health Service, Office of Clinical Services, U.S. Department of Health, Education, and Welfare, Rockville, MD. The authors would like to acknowledge Victor Eisner, MD, and Beverly Witchner for helpful comments and suggestions in preparing this report, and Dorothy Trujillo and Genevieve Coulson for secretarial assistance.
New Horizons in Epidemiology
I
E pidemiology is a burgeoning science .... The realization of this immense complexity in the balance between health and disease has stimulated efforts to meet the needfor broadening the horizons of epidemiology from a single-minded concentration on studying contagions. It is now concerned with all health and illness in population groups and with the factors-including health services-which affect them. Roy M. Acheson. The Need for Comparability in International Epidemiology, Milbank Memorial Fund Quarterly 43: 11, (part 2) April 1965.
AJPH December, 1976, Vol. 66, No. 12
1201
