Mandatory reporting between legal requirements and personal interpretations: Community healthcare professionals' reporting of child maltreatment

Child physical abuse: changes over ten years in the perceptions of Finnish dental professionals

OBJECTIVE

This study aimed to assess perceptions and actions taken by Finnish dental professionals in suspected cases of child physical abuse (CPA) and to describe changes over 10 years.

MATERIAL AND METHODS

Data collected from two child abuse and neglect (CAN) surveys among Finnish dental professionals, working in public health care, covering suspicions of CPA and actions taken as well as training on CPA issues, were compared. The chi-squared (χ2) test was used to analyze associations.

RESULTS

In total, 625 (2008) and 1,025 (2019) questionnaires were completed. Respondents reported that they suspected CPA more frequently in 2008 than in 2019 (21.0% vs. 8.7%, p < 0.001). Out of all respondents, 1.1% had reported their concern to the police in 2019. Worries about the report's negative consequences to the child at home (44.5% vs. 56.4%, p < 0.001) and to the informer (30.2% vs. 36.3%, p = 0.016) increased between the surveys. The proportion of respondents with previous training on CPA issues increased between the surveys (5.9% vs. 36.4%, p < 0.001).

CONCLUSIONS

Recognition of CPA was low and decreased over the years. Furthermore, mandatory reporting to the police was low. Additional education on issues related to CPA is needed.

Detecting child sexual abuse in child and adolescent psychiatry: a survey study of healthcare professionals' assessment practice

BACKGROUND

Research shows that only around half of all survivors of child sexual abuse (CSA) disclose the abuse during childhood and adolescence. This is worrying, as CSA is related to substantial suffering later in life. The proportion of children and adolescents who have been exposed to CSA is significantly higher in Child and Adolescent Psychiatry (CAP) than in the general population. Healthcare professionals report that uncovering CSA is a complex and challenging task. However, we know little about how they proceed when uncovering CSA. More knowledge of healthcare personnel's experience is therefore necessary to facilitate and increase CSA disclosure. The study aims to explore how CAP healthcare professionals in Norway proceed when assessing and detecting CSA, how they experience this work, and what hinders or facilitates their efforts.

METHODS

The study employed a mixed method approach. Data was collected through an anonymous online survey, generating both quantitative and qualitative data. The sample consisted of 111 healthcare professionals in CAP, of whom 84% were women, with a mean age of 40.7 years (range 24-72; sd = 10.8). Mean years of CAP clinical experience were 8.3 years (range 0-41; sd = 7.5). The quantitative data was analysed using descriptive statistics, correlations, and independent sample t-tests, while the qualitative data was analysed using a team-based qualitative content analysis.

RESULTS

The results showed that detection of CSA was viewed as an important, but complex task in CAP, and the existing procedures were deemed to be insufficient. The therapists mostly felt confident about how to proceed when they suspected or detected CSA, yet they seldom detected CSA. In their initial assessment they applied standardised procedures, but if their suspicion of possible CSA persisted, they seemed to rely more on clinical judgement. Specific challenges and facilitators for CSA detection were identified, both in the individual and in the organisation.

CONCLUSIONS

The study highlights the challenges and complexities healthcare professionals and the CAP system face when assessing CSA, which may account for the low detection rate. The results show that healthcare professionals believe room for clinical autonomy and targeted competence development may improve CSA detection. Additionally, the findings suggest a need for CAP to define roles and responsibilities within and between agencies.

Suspicion of child maltreatment: Knowledge and experiences with mandatory reports to social services among general practitioners in Denmark in 2019-20

BACKGROUND

Child maltreatment has many consequences through the lifespan. The general practitioners (GPs) are in longitudinal contact with the family and can play an important role in identifying children in danger and reporting to the social services.

OBJECTIVE

To explore how GPs manage suspicions of child maltreatment and to investigate potential demographic and geographic differences in reporting practices among Danish GPs.

PARTICIPANTS AND SETTING

All registered GPs in Denmark retrieved from Medcom, a state-financed non-profit organization.

METHODS

We mailed a questionnaire to all registered GPs with demographics, experiences, knowledge, and attitudes in the context of child maltreatment.

RESULTS

We received 1252 completed questionnaires (response rate: 38 %). Most of the participants had suspected child maltreatment during their professional life (90 %) and had made a mandatory report (85 %). More than half had received feedback after the report (56 %) and said that their report led to action (56 %). Most GPs reported feeling confident in dealing with child maltreatment (79 %) and being willing to get involved in case of suspicion (8.9 on a 0-10 scale). We observed no geographical differences in reporting neither across the Danish regions nor among rural and urban practices, but GPs working in single practices made fewer reports to the social services.

CONCLUSIONS

Participant GPs in this study are aware of their role in child protection, have experiences with mandatory reports, and are willing to get involved. Possible areas for attention include collaboration and support between different settings, especially between GP practice, hospitals, justice sector, and social services.

Processes of Multiprofessional Child Protection Decision Making in Hospital Settings: Systematic Narrative Review

The aim of this systematic narrative literature review is to explore empirical evidence as to how a multiprofessional approach to child protection decision making is implemented in hospitals settings. Child protection cases where there is a suspicious serious injury suspected sexual abuse or serious neglect are often investigated in hospital, involving a number of relevant professions. Five electronic bibliographic databases were used for the search. To be included in the review studies had to be published in a peer-reviewed journal, report on empirical research, be available full text in English, and have used an identifiable research design. The search was restricted to 10 years, from January 1, 2010, to December 31, 2019, and retrieved 6,934 studies. The review includes 26 studies undertaken in 10 countries. In all the hospital-based settings studied, child protection decision-making tasks were assigned to a designated multiprofessional team. However, there was remarkable diversity in models of team structure, regulation of workflow, structured procedures, and standardized tools through which practice was carried out. Research focused on evaluating the teams' effectiveness in fulfilling their duties which were, first and foremost, the identification of possible child maltreatment. The analysis identifies various systemic approaches and quality improvement methods to promote effective team-based decision-making processes in hospitals. The interactional aspect of collaborative team-based practice was generally missing from the published research. This article discusses next steps for the development of practice, policy, and research to enhance useful multiprofessional child protection team working in hospitals.

Child abuse knowledge and attitudes among dental and oral health therapists in Aotearoa New Zealand: a cross-sectional study

BACKGROUND

Child abuse and neglect are significant social and health issues in New Zealand. As the government provides free oral care to children and adolescents, oral health practitioners are positioned to respond to child protection concerns. However, research on the knowledge and attitudes of oral health practitioners is limited. This study aimed to understand the knowledge and attitudes of New Zealand dental and oral health therapists in detecting and reporting child abuse and neglect.

METHODS

In this descriptive exploratory cross-sectional study, we invited registered New Zealand dental and oral health therapists treating children and adolescents to the anonymous online survey.

RESULTS

Among the 92 dental and oral health therapists, 72% agreed that they could recognise the signs and symptoms of child abuse and neglect. Yet, only 48% agreed they were familiar with the reporting process. During their professional careers, 62% had at least 1 suspected case; and only 21% had ever reported their concerns. Fear of false reporting (70%) was the most significant barrier.

CONCLUSIONS

Participants understood child abuse and neglect as significant social issues; however, the knowledge and attitudes to respond were limited. Efforts to enhance the knowledge and attitudes will be necessary to promote child safety and wellbeing.

Survey on Reporting of Child Abuse by Pediatricians: Intrapersonal Inconsistencies Influence Reporting Behavior More than Legislation

Background: Internationally, various laws govern reporting of child abuse to child protection services by medical professionals. Whether mandatory reporting laws are in place or not, medical professionals need internal thresholds for suspicion of abuse to even consider a report ("reasonable suspicion" in US law, "gewichtige Anhaltspunkte" in German law). Objective: To compare internal thresholds for suspicion of abuse among US and German pediatricians, i.e., from two countries with and without mandatory reporting laws. Participants and Setting: In Germany, 1581 pediatricians participated in a nationwide survey among child health professionals. In the US, a survey was mailed to all Pennsylvania pediatricians, and 1249 participated. Methods: Both samples were asked how high in their rank order of differential diagnoses child abuse would have to be when confronted with a child's injuries to qualify for reasonable suspicion/gewichtige Anhaltspunkte (differential diagnosis scale, DDS). In a second step, both had to mark a 10-point likelihood scale (0-100%) corresponding to reasonable suspicion/gewichtige Anhaltspunkte (estimated probability scale, EPS). Results: While for almost two-thirds of German pediatricians (62.4%), child abuse had to be among the top three differential diagnoses for gewichtige Anhaltspunkte, over half of the US respondents (48.1%) had a lower threshold for reasonable suspicion. On the estimated probability scale, over 65% in both samples indicated that the probability of abuse had to exceed 50% for reasonable suspicion/gewichtige Anhaltspunkte. There was great variability between the two countries. Conclusions: There are similar uncertainties in assessing cases of suspected child abuse in different legal systems. There is a need for debates on thresholds among medical professionals in both countries.

Judgements of physicians, nurses, and social workers regarding suspected Child maltreatment in community health care services

This study investigated how physicians, nurses, and social workers in community health care services make judgements about possible child maltreatment in ambiguous situations. We examined the influences of social biases (i.e., perceptions linking ethnicity, gender, and family socioeconomic status to child maltreatment) and belonging to distinctive occupational groups (i.e., physicians, nurses, and social workers) on professionals' assessment of suspected child maltreatment, intention to consult with others, and reporting. We used an experimental survey design including vignettes presenting a child's history inspired by real-life clinical cases. Data were collected from 397 health care professionals-170 physicians, 179 nurses, and 48 social workers-employed at community health care clinics in northern Israel. Findings show that the child's gender and family socioeconomic status had significant effects on assessment of possible child maltreatment. Also, professionals' occupational group had significant effects on assessment of child maltreatment and intention to pursue consultation. Another key finding was the significant effects of judgements about child maltreatment assessment, consultation, and reporting on one another. The study reinforces efforts to improve health care professionals' management of suspected child maltreatment that include the development of clinical decision support systems that use routinely collected electronic medical record data.

Recognizing medical child abuse in children presenting with chronic pain

Medical child abuse (MCA), previously referred to as Munchausen by proxy, can present as chronic pain. We report the presentation of five children seeking treatment for chronic pain who we identified as victims of MCA. The index case had essentially not eaten for the 6 years of her life due to alleged allergies to all foods, developed severe pain, used a wheelchair for ambulation beyond a few blocks, and was alleged to have dysautonomia requiring oxygen monitoring at night. Other cases posed as arthritis that resulted in foot amputation and total body pain, fibromyalgia with alleged mutation negative Stickler syndrome who had symptoms only in her mother's presence, severe incapacitating intermittent pains along with abdominal pain that resulted in appendectomy, cholecystectomy, and pancreatectomy, and alleged disabling hypermobile Ehlers-Danlos in a non-hypermobile child for which the mother sought a power wheelchair. The unusual pattern to the pain, the presence of multiple additional, atypical symptoms and diagnoses, and a generally well appearing child are characteristic. The perpetrator is typically over-invested in the symptoms, derives tangible and intangible secondary gain from the child's alleged illnesses, and is able to present the child in such a fashion to enlist the physician to aid in perpetuating the abuse. These children are highly over-medicalized and suffer significant morbidity. Multiple barriers exist to identifying and reporting these children to Child Protective Services, which need to be recognized and overcome in order to protect these vulnerable children.

Reporting suspicion of child maltreatment - a 5 yr follow-up of public dental health care workers in Norway

OBJECTIVE

This study examined stability and change of Norwegian dental health care workers' mandated reporting of suspected child maltreatment from 2014 to 2019 as well as the influence on reporting practices from regional, sociodemographic- and attitudinal factors. It was hypothesised that those factors associate independently with reporting practices across the survey period.

METHODS

In 2014 a census of 1542 dental health care workers employed in the public dental health care service (PDHS) were invited to participate in an electronic survey and 1200 (response 77.8%) consented to participation. Corresponding figures in 2019 were 1791 and 1270 (response 70.9%). Of the 1200 participants in 2014, 591 participated in 2019 (follow up 49.3%).

RESULTS

A total of 58% and 25.7% of the dental health care workers confirmed ever reporting and avoidance of reporting in both survey years whereas 24.6% and 17.2% changed the status of ever- and avoiding reporting across time. The likelihood of being a stable reporter was greatest in experienced participants, those living in eastern parts of Norway and confirming professional obligations to report. At the population level, 59.6% and 79.5% confirmed ever reporting of suspected maltreatment in 2014 and 2019. Corresponding figures for confirmed avoidance of reporting were 33.9% and 37.9%.

CONCLUSION

Reporting of suspected child maltreatment is maintained at a relatively high level and varies by socio-demographic and attitudinal concerns.

Organizational factors affecting nurses' tendency to report child abuse and neglect

OBJECTIVE

To examine the factors that affect the tendency of nurses working in mother and child health clinics (MCHC) to report child abuse to the authorities.

DESIGN

Cross-sectional survey.

SAMPLE

Three hundred and forty-one female nurses working in MCHC across Israel.

MEASUREMENTS

(1) Social and organizational variables; (2) the tendency to report child abuse and neglect; (3) attitudes toward reporting child abuse and neglect.

RESULTS

On average, the participants perceived that they have good collaboration with other staff members and with welfare services. They showed a favorable attitude toward reporting child abuse, but less than half (44.8%) would report child abuse suspicion to the authorities. None of the organizational variables (MCHC type, collaboration among staff, collaboration with welfare services) were correlated with the tendency to report child abuse and neglect, yet all three variables were significantly correlated with attitudes toward reporting child abuse. Nurses' attitudes toward reporting were mediated by the organizational variables.

CONCLUSIONS

The effect of the organizational factors on the actual tendency to report child abuse is mediated by nurses' attitude toward reporting. Organizational constraints probably encourage MCHC nurses to be cautious before reporting child abuse and neglect to the authorities, restricting adherence to the law, which requires direct reporting.

Understanding factors associated with barefoot social workers' decision making in assessing and reporting child physical abuse in China

BACKGROUND

Mandatory reporting is new in China, and barefoot social workers are responsible for detecting and reporting child maltreatment.

OBJECTIVE

Guided by the decision-making ecology, this study examined factors associated with barefoot social workers' decision making in assessing and reporting child physical abuse in China.

PARTICIPANTS AND SETTINGS

Cross-sectional data were collected from barefoot social workers (N = 1489) in a metropolitan city in Southern China.

METHODS

Descriptive, bivariate, and binary logistic regression analyses were conducted. Dependent variables were barefoot social workers' assessments of and intention to report child physical abuse in two cases.

RESULTS

For a less severe physical abuse case, case severity (OR = 2.78, p < .001), receiving a social worker license (OR = 1.64, p = .03), and having a reporting history (OR = 23.55, p = .03) were associated with higher odds of assessments, whereas being younger (OR = 0.97, p = .04) was associated with lower odds. For a more severe physical abuse case, case severity (OR = 3.64, p < .001) and child welfare training (OR = 2.27, p = .03) were associated with higher odds of assessments. Across two cases, case severity (Case 1: OR = 1.44, p < .001; Case 2: OR = 1.34, p < .001), assessment of whether it is abuse (Case 1: OR = 11.48, p < .001; Case 2: OR = 15.98, p < .001), impacts of reporting on the family (Case 1: OR = 1.21, p < .001; Case 2: OR = 1.25, p < .001), and perceived behavior control (Case 1: OR = 1.06, p = .01; Case 2: OR = 1.10, p = .01) were associated with higher odds of reporting. Impacts of reporting on the child (OR = 1.27, p < .001) were associated with higher odds of reporting the less severe case. Attitudes regarding punishment of offenders or victims of child abuse (OR = 1.09, p = .01) and subjective norms of reporting (OR = 1.09, p = .01) were associated with higher odds of reporting the more severe case.

CONCLUSIONS

This study identified factors associated with barefoot social workers' decision making in assessing and reporting child physical abuse in China. Results of this study indicate the importance of providing training to barefoot social workers on recognizing, detecting, and reporting child physical abuse. It is also important to encourage them to receive continued social work training and obtain a social work license, which may increase their confidence in decision making. Furthermore, increasing the effectiveness of mandatory reporting is needed.

Assessing, Consulting, Reporting Heuristics in Professional Decision-Making Regarding Suspected Child Maltreatment in Community Healthcare Services

This study investigated child protection decision-making practices of healthcare-professionals in community-health-services. We examined the effect of heuristics in professional judgments regarding suspected maltreatment, as affected by the child's ethnicity, gender, and family socioeconomic-status, as well as the healthcare-worker's workload-stress, and personal and professional background. Furthermore, we examined how these variables influence judgments regarding suspected maltreatment and intentions to consult and report child-maltreatment. We used an experimental survey design including vignettes manipulating the child's characteristics. Data was collected from 412 professionals employed at various community-health-service-clinics of the largest health-management organization in northern Israel. Findings show that all subjective factors have a significant effect on suspected child-maltreatment assessment, which appears as a significant predictor of later decisions regarding consultation and reporting. This study lends support to prior research indicating that healthcare-professionals' decisions may incorporate biases, and suggests how the effects of these biases' are mediated through a sequence of decisions. Recommendations focus on providing regular consultation opportunities for practitioners.

An Ecological Model for High-Risk Professional Decision-Making in Mental Health: International Perspectives

Mental health professionals are frequently presented with situations in which they must assess the risk that a client will cause harm to themselves or others. Troublingly, however, predictions of risk are remarkably inaccurate even when made by those who are highly skilled and highly trained. Consequently, many jurisdictions have moved to impose standardized decision-making tools aimed at improving outcomes. Using a decision-making ecology framework, this conceptual paper presents research on professional decision-making in situations of risk, using qualitative, survey, and experimental designs conducted in three countries. Results reveal that while risk assessment tools focus on client factors that contribute to the risk of harm to self or others, the nature of professional decision-making is far more complex. That is, the manner in which professionals interpret and describe features of the client and their situation, is influenced by the worker's own personal and professional experiences, and the organizational and societal context in which they are located. Although part of the rationale of standardized approaches is to reduce complexity, our collective work demonstrates that the power of personal and social processes to shape decision-making often overwhelm the intention to simplify and standardize. Implications for policy and practice are discussed.

Reasonable suspicion in reporting child maltreatment: a survey among German healthcare professionals

BACKGROUND

With regular contacts to the general child population, healthcare professionals could play an important role in the detection of child maltreatment. However, a majority of child maltreatment cases go unnoticed by the healthcare system. Child protection legislations usually offer terms like "reasonable suspicion" to corner a threshold that warrants reporting to child protection services (CPS) is defined as. The indistinct legal terminology leads to marked differences in the interpretation of this threshold. Therefore, we aimed to systematically assess the understanding of reasonable suspicion and subsequent handling of cases in the German context.

METHODS

A cross-sectional online survey was conducted among 2485 physicians and psychotherapists working with children and adolescents. Field access was gained by German professional associations. Via case vignettes, predictors of thresholds for reporting were assessed.

RESULTS

The probability of a report to CPS increased positively with the degree of suspicion for maltreatment. However, even if participants were certain that child maltreatment occurred, 20% did not chose to report to CPS. Training in child protection lowered the professionals' threshold for reasonable suspicion; experience with child protection cases and good knowledge of the legal framework increased the likelihood to report an alleged situation of child maltreatment to CPS.

CONCLUSION

Our data show that a significant proportion of health care professionals are uncertain about estimating reasonable suspicion and on how to proceed when there are strong indications for child maltreatment Therefore, data point towards the relevance of training in child protection among healthcare professionals in order to improve detection and adequate handling of cases of child maltreatment.

Decision-Making and Relationship Competence When Reporting Suspected Physical Abuse and Child Neglect: An Objective Structured Clinical Evaluation

Mandatory reporting of suspected child abuse and neglect highlights the challenges between the ethical and legal obligations of social workers and the need to maintain the therapeutic relationship with the client. The ability to bridge this tension is paramount to ensure continued psychosocial treatment and the well-being of children. This paper discusses a study to determine the decision-making factors of social work students and practitioners when facing a suspicion of child abuse and neglect, how they justify their decision to report or not report to child protection services, and the current and future relationship repair strategies used with simulated clients during an objective structured clinical evaluation (OSCE). Nineteen BSW, MSW, and experienced practitioners (N = 19) underwent an OSCE with one of two child maltreatment vignettes, physical abuse or neglect. Fisher's exact test was used to examine participants' historical and current reporting behaviors. Independent samples T-tests, Cohen's D, and qualitative content analysis was used to examine participants' decision making and relationship repair strategies when faced with suspected child abuse and neglect. Results showed that six participants discussed the duty to report during the OSCE while 13 participants did not. Participants' who discussed and did not discuss the duty to report during the OSCE articulated clear reasons for their decision and identified relationship repair strategies in working with the client. A sub-group of participants who identified the child maltreatment but did not discuss the duty to report, provided more tentative and complex reasons for their inaction and next steps in working with the client. All participants demonstrated a degree of competence and critical reflection in the OSCE, with integration for future learning. These findings are discussed and implications for future practice are offered.

Characteristics of child welfare investigations reported by healthcare professionals in Ontario: secondary analysis of a regional database

OBJECTIVES

This study examines the characteristics and outcomes of child welfare investigations reported by hospital-based and community-based healthcare professionals.

METHODS

A sample of 7590 child maltreatment-related investigations from the Ontario Incidence Study of Reported Child Abuse and Neglect-2018, a cross-sectional study, was analysed. Bivariate analyses compared characteristics of hospital and community healthcare-reported investigations. Chi-square automatic interaction detector analyses were used to predict the most influential factors in the decision to provide a family with services following a child welfare investigation from each referral source.

RESULTS

Community healthcare-reported investigations were more likely to have a primary concern of physical abuse while hospital-reported investigations were more likely to be focused on assessing risk of future maltreatment. Hospital-reported investigations were more likely to involve noted primary caregiver (eg, mental health issues, alcohol/drug abuse, victim of intimate partner violence (IPV)) and household risk factors. The most significant predictor of service provision following an investigation was having a caregiver who was identified as a victim of IPV in hospital-reported investigations (χ²=30.237, df=1, adj. p<0.001) and having a caregiver for whom few social supports was noted in community healthcare-reported investigations (χ²=18.892, df=1, adj. p<0.001).

CONCLUSION

Healthcare professionals likely interact with children who are at high risk for maltreatment. This study's findings highlight the important role that healthcare professionals play in child maltreatment identification, which may differ across hospital-based and community-based settings and has implications for future collaborations between the healthcare and child welfare systems.