Sample Review
Professional Issues

From suspicion of physical child abuse to reporting: Primary care clinician decision-making. Emalee G Flaherty, Robert D Sege, John Griffith et al. Pediatrics 2008; 122:611-619. (from Chicago, IL and Boston, MA)

Clinicians’ descriptions of factors influencing their reporting of suspected child abuse: Report of the Child Abuse Reporting Experience Study Research Group. Rise Jones, Emalee G Flaherty, Helen J Binns et al. Pediatrics 2008;122:259-266. ( from Chicago, IL)

Review from Winter 2009 issue

These two studies come from the American Academy of Pediatrics’ Pediatric Research in Office Settings (PROS) and the National Medical Association Research  (NMAPedsNet) Networks. The first is a prospective observation of primary care clinicians, designed to investigate the following questions:

  1. How frequently do pediatric medical clinicians report suspected child abuse?
  2. At what level of suspicion do clinicians report?
  3. What factors influence reporting to Child Protective Services (CPS)?

The second study reports on interviews with clinicians from the first study who had cared for suspicious injuries.

Data were collected about injuries, children, families and clinicians. Clinicians were asked to rate injuries for likelihood of physical abuse. Results showed that of 1,683 injuries documented by 327 clinicians from 144 practices in 41 states, 95 (6%) were reported to CPS. Notably, 27% of the injuries that were rated “likely” or “very likely “ due to abuse were NOT reported.

The following factors increased the likelihood of a report being made: injury inconsistent with history, direct referral due to question of child abuse, serious injuries, injuries other than lacerations, more that one family risk factor, and lack of familiarity with the family. Insured black families compared with insured white families were reported more often but the study showed no difference in reporting for uninsured families. Clinicians who had not reported all injuries and ones who had lost families as patients because of previous reports were also more likely to report.

Several expected findings with respect to reporting or non-reporting related to the physicians’ previous relationship with the family, a family’s perceived involvement with CPS, and the nature of the injury. In questionable cases, the opinion of medical or social work consultants influenced reporting. At times, physicians waffled on their original opinion of abuse likelihood. Previous experience with the likelihood of CPS intervention was balanced against the likelihood that a family would leave a practice.

Reviewed by Gregory Parkinson, M.D.

Reviewer’s Note:  
This is an excellent, large, multi-center study. It quantifies the issue of physician non-reporting of probable abuse and then goes beyond the numbers with personal interviews to help figure out why. It concludes that renewed efforts at provider education are required. It also documents the persistence of some racial prejudice. Whether or not a provider’s knowledge of a family really improves the accuracy of the diagnosis of child abuse is a question it leaves unanswered.

Perhaps most importantly, it exposes the lack of faith that clinicians have in current CPS services. With every case of potential abuse, the clinician is forced to think about whether or not a report will be acted upon – if not, a change of practice for the family will result, which will put the family back “under the radar” and possibly expose the child(ren) to more harm.