A team of researchers from Boston University School of Medicine (BUSM) and Boston Medical Center (BMC), report that primary care providers (PCP) fail to report a substantial number of cases of child maltreatment. The study, which is scheduled to appear in the November-December issue of Academic Pediatrics, is the first to examine the validity of a PCP's decision to suspect child abuse as the etiology of an injury and their decision to report a suspicious injury to child protective services (CPS).
Identifying that a particular injury was caused by child abuse can be difficult. Typically, only the responsible person and child witness the injurious event, and the child may be preverbal or afraid to describe the abuse. The physical abuse of a child may be suspected after a careful history and physical examination, when the clinician determines the injury is not consistent with the history provided, or when the pattern of injuries is highly suspicious for maltreatment.
This study examined the validity of PCP assessment of suspicion that an injury was caused by child abuse and their decision to report suspected child abuse to CPS. By using a subsample of injuries drawn from the national Child Abuse Reporting and Experience Study, PCPs completed telephone interviews using a stratified sample (no suspicion of abuse; suspicious but not reported; and suspicious of abuse and reported) of 111 injury visits.
According to the researchers two techniques were used to validate the PCPs' initial decision: expert review and provider retrospective self-assessment. Five child abuse experts reviewed clinical vignettes created by using data prospectively collected by PCPs about the patient encounter. The PCPs' opinions 6 weeks and 6 months after the injury-related visits were elicited and analyzed.
Upon analysis of the data, the researchers found that PCPs and experts agreed about the suspicion of abuse in 81 percent of the cases of physical injury. PCPs did not report 21 percent of injuries that experts would have reported. Compared with expert reviewers, PCPs had a 68 percent sensitivity and 96 percent specificity in reporting child abuse.
Reporting suspected child physical abuse is a two-step process: assessment of the likelihood of child physical abuse and the decision to report. "Child abuse experts and PCPs are in general agreement concerning the assessment of suspected child physical abuse, yet this study demonstrates that primary care providers decide not to report a substantial proportion of child physical abuse cases," explained lead author Robert Sege, MD, FAAP, professor of pediatrics at BUSM, and director, Division of Ambulatory Pediatrics at BMC.
These results point to several opportunities for improvement in the training of physicians as well as the diagnosis and management of child physical abuse. "To become more certain of their suspicions, PCPs need better education about the recognition of injuries that are suspicious for child abuse, particularly bruises and fractures, and the role of state CPS agencies in investigating the child's circumstances," added Sege.
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