Availability and perceived competence of pediatricians to serve as child protection team medical consultants: a survey of practicing pediatricians.

Objectives: The effectiveness of multidisciplinary child protection teams has been demonstrated. This study is an attempt to assess the level of this commitment and the perceived competence of primary care pediatricians to provide this service.

Methods: A questionnaire survey was mailed to primary care pediatricians practicing in the state of Alabama.

Results: Among respondents who did not consider themselves competent to conduct sexual abuse or physical abuse examinations, 27% and 19%, respectively, were called on to conduct such examinations. Approximately half of respondents expressed a willingness to serve as consultants under a time commitment obligation of less than 2 hours per week or 1 day per month, and under a reimbursement provision of $200 per examination or less. Respondents recognized a need for, and expressed a desire for, more training in this area.

Conclusions: Primary care pediatricians are willing to serve as multidisciplinary child protection team medical consultants if provided appropriate training and support.

Key Words: child abuse, continuing medical education, physical abuse, residency education, sexual abuse

**********

Fifty years after the sentinel publications of Caffey (1) and Kempe et al, (2) child maltreatment continues to be a serious and pervasive problem confronting children, families, pediatricians, and society. The approximately 896,000 victims of maltreatment and 1,400 deaths attributable to child abuse and neglect in the year 2002 are comparable in magnitude to asthma, the most common chronic disease of childhood. (3,4) Clearly, resources must be directed toward the prevention, recognition, and treatment of child abuse.

The effectiveness of multidisciplinary child protection teams (CPTs) in providing essential services to victims of child maltreatment and their families has been well documented. The multidisciplinary team has generally been defined as encompassing the services, expertise, and consultative input of mental health professionals, social workers, attorneys, law enforcement, and pediatricians, with each member having additional training and experience in the care of abused children. (5-10) The need for physicians with both the expertise in child maltreatment and the willingness to provide consultation to CPTs has been made evident. (9) Higher physician knowledge scores and greater perceived competence regarding child sexual abuse have been associated with specialization in pediatrics. (11,12) Historically, pediatricians have considered community services for dealing with child abuse to be inadequate, and social workers have noted the limited availability of medical consultants. (13,14) Although some states have established systems of CPTs incorporating the multidisciplinary model, others have been slow to do so. (7,15,16)

The State of Alabama has a population of 4.5 million persons and proportions of rural and child residents similar to most states. (17,18) Alabama has several community-based CPTs, but does not have a statewide system of multidisciplinary teams. Secure statewide funding for such teams, including physician reimbursement, is not yet available. A survey assessing the physician resources for establishment of such a system of child advocacy and protection in the state of Alabama is, therefore, timely and appropriate.

The primary aim of this research was to survey practicing pediatricians in Alabama to determine their perceived competence and willingness to participate in multidisciplinary CPTs as well as the terms under which they are willing to serve. The study tested the hypothesis that primary care pediatricians are interested in obtaining and maintaining expertise in the evaluation of victims of child abuse and, in addition, that they are willing to participate as medical consultants for child protection teams should sufficient support for their training and for the establishment and continuation of such teams become available.

Materials and Methods

Subjects

The study used a database of primary office addresses for pediatricians practicing in the state of Alabama comprised of listings maintained by The Children's Hospital of Alabama. Excluded were current pediatric residents, fellows, and subspecialty pediatricians. On October 1, 2001, surveys were mailed to each of these pediatricians accompanied by a cover letter from the principal investigator requesting completion of the survey for the purpose of assessing resources in the state of Alabama for the creation of multidisciplinary CPTs.

On November 1, 2001, a second, identical survey was mailed to pediatricians from whom a response had not been received. An effort was made to correct the addresses of nonrespondents and of surveys returned without forwarding addresses by accessing the "Member Directory-Member Only" section of the American Academy of Pediatrics web site (www.aap.org). Surveys returned with notification of the subject's retirement from pediatric practice, death, or indicating subspecialty status were excluded from the study.

The study was approved by the Institutional Review Board of the University of Alabama at Birmingham. Informed consent was obtained by means of a cover letter accompanying the survey. All mailings and survey responses were managed confidentially.

Survey instrument

The survey consisted of 26 questions. Demographic items included age, sex, zip code, years in practice, board certification status, and practice setting (solo/group, self-employment or government employment, office/hospital/medical center). The remainder of the survey addressed training, current involvement, and perceived competence in the evaluation of children in whom physical or sexual abuse is a concern, the perceived need for state legislation for the funding of CPTs, the conditions under which the subject would be willing to participate as a consultant, and the willingness of the subject to supervise physician extenders, use telemedicine technology, participate in peer review, and attend biannual statewide continuing medical education seminars. Survey questions for which a respondent did not make a legible response were categorized as "no response," and those for which a respondent wrote in "no" were designated as such in the database. Practice location was considered urban if the primary office address zip code was within a county having a population of greater than 50,000 persons in accordance with year 2000 census data and the definition of "urbanized area" of the US Census Bureau. Rural county practice location was defined as a county having a population of less than 50,000 persons. (18-20)

Statistical analysis

All survey data were entered into a statistical database and analysis software package (True Epistat 5.3, Richardson, TX, 1994) by two investigators. A goal of the study was to achieve 98% or greater accuracy of data entry. Data entry accuracy was assessed by determining the concordance rate between survey data entered into the database and a 20% random sample of surveys reviewed for concordance by a third investigator. An agreement statistic using a Z score was used to test the hypothesis that the observed concordance between the survey records and the random sample exceeded 98%. The Z test score was calculated as follows:

Z = [P.sub.observed] - 0.98/[square root of ((0.02)(0.98)/[.sub.n])]

where [P.sub.observed] is the proportion of concordant survey and random sample data pairs and n is the number of pairs evaluated. Data were analyzed by using contingency table analysis based on the [chi square] statistic, with odds ratios and 95% confidence intervals determined where appropriate. A Z test for determining differences in proportions with resulting 95% confidence intervals of the differences detected was also used.

Results

Of 447 pediatricians in our database, 13 respondents did not meet inclusion criteria (eg, physician retirement from practice [n = 9], death [n = 1], subspecialty practice [n = 3]), and 68 surveys were undeliverable after two mailings, resulting in 366 surveys considered to be deliverable to primary care pediatricians in practice. Of these, 206 were returned, yielding a response rate of 56%. Data entry accuracy was performed on 1,134 data pairs (n) and yielded a concordance of 99% for these pairs (Z = 3.99; P < 0.001).

Demographics 

Respondent demographics are summarized in Table 1. Forty percent of respondents were female. The mean age was 40.6 years for female, 50.1 years for male, and 46.2 years for all respondents. Fifty-one percent had been in practice more than 15 years, and 97.5% were board-eligible or board-certified. The proportion of rural respondents was 10%. Solo practitioners comprised 16.5% of respondents, 83.5% listed their primary practice setting as an office, and 76% were self-employed.

Training and competence

The amount of time devoted to training in child abuse during residency training varied widely, and 47% of respondents considered their residency training in child abuse to have been sufficient (Table 2). A strong statistical association existed between the perceived adequacy of residency training in child abuse and perceived current competence in conducting sexual abuse and physical abuse examinations. A greater proportion of physicians who felt competent in conducting sexual abuse examinations also considered their residency training adequate versus those who did not feel competent in conducting such examinations (63% versus 34%; P < 0.001; 95% C[I.sub.diff], 15-43%). Similarly, a greater proportion who felt competent in conducting physical abuse examinations also considered their residency training to have been adequate versus those who did not feel competent (52% versus 19%; P = 0.001; 95% C[I.sub.diff], 14-52%).

Of 200 respondents who answered the questions pertaining to perceived competence, 107 (52%) considered themselves not competent in conducting sexual abuse examinations. Among these 107 respondents, 29 (27%) were currently conducting such examinations. A greater proportion of those who considered themselves competent were involved in the administration of these examinations versus those who did not consider themselves competent (89% versus 27%; P < 0.001; 95% C[I.sub.diff], 48-76%).

Of these 200 respondents, 32 (16%) considered themselves not competent in conducting physical abuse examinations, and 6 (19%) of these respondents were currently conducting such examinations. Again, a greater proportion of those who did versus those who did not consider themselves competent were involved in the administration of these examinations (88% versus 19%; P < 0.001; 95% C[I.sub.diff], 53-85%).

Child protection team needs and participation

Several questions addressed the respondents' perceptions of the prevalence of child abuse and the need for multidisciplinary CPTs. Respondents reported their experience in recognition and reporting of suspected abuse. They also reported on whom they call to refer a case. The majority of respondents acknowledged the need for CPTs (80%) and favored state legislation for the creation and funding of such teams (81%).

When asked what level of time commitment respondents would be willing to serve as a CPT consultant, 41 (20%) of respondents wrote in "no." However, 118 (57%) expressed a willingness to act as a CPT consultant at least 1 day per month. A similar question pertained to the level of reimbursement per examination at which the respondent would participate. Thirty-six (17%) wrote in "no" for this question and 69 (33%) gave no response.

In response to questions pertaining to other aspects of CPT participation, 40% expressed a willingness to supervise physician extenders and 53% to participate in peer review. Sixty-nine percent and 47%, respectively, noted an interest in attending statewide child abuse training seminars and in using telemedicine technology to review cases with other physicians.

Discussion

A statistical association was noted between perceived adequacy of residency training and perceived competence. However, 53.5 and 15.5% considered themselves not competent in conducting sexual and physical abuse examinations, respectively, and 27 and 19% of these respective groups were nonetheless currently conducting such examinations. These results were unexpected to the study team and further illustrate the need for training and continuing medical education for pediatricians involved in the care of these children. Although it is encouraging that 97% of respondents know how to report or refer cases, this discordance between perceived lack of competence and involvement in the conduct of examinations is a concern.

Participation as a consultant is predicated on multiple considerations, including but not limited to time commitment and reimbursement. (21) Survey recipients were not asked directly whether they would be willing to serve as CPT consultants. However, the investigators did not anticipate two responses to the questions pertaining to time commitment and reimbursement that a number of respondents made but which were not choices on the survey. Forty-one (20%) and 36 (17%) of respondents replied "no" on the survey form to these questions, respectively, indicating that they would not participate as consultants under any condition. Moreover, a large proportion of respondents made no reply to the questions pertaining to time commitment (23%) and reimbursement (34%). Although it is difficult to estimate the amount of time that serving as a CPT consultant might entail, the options for reimbursement per examination were within ranges previously published. (5,22) One might interpret these nonresponses as indicating the respondents would not participate as consultants under the conditions of time and reimbursement offered, or under any time or reimbursement scheme. Alternately, these respondents may have believed that they were not qualified to participate as consultants or that they were not provided sufficient information to answer the question. Should these nonresponses and the "no" responses reflect an overall unwillingness to function as CPT consultants on the part of these respondents, it is of concern for several reasons. Foremost is the constraint placed on the medical and child protection communities in providing a necessary service to children and families. The continuing decline in rural practice location among pediatricians and residency graduates will result in more limited access to these services in rural areas, where 26% of the US child population reside. (23) Another explanation for these nonresponses may be that they reflect a concern among some respondents that an expressed willingness to participate as a consultant might result in their being called on to do so, although survey recipients were assured their identity would be anonymous. Alternatively, respondents may not have understood the question, or may have been confused by the time commitment and reimbursement options offered, as these options were not all mutually exclusive. Nonetheless, fully 57% and 50%, respectively, indicated a willingness to serve as medical consultants under the time and reimbursement provisions offered.

The response rate to this survey is comparable to the 51 to 60% response rate of other survey studies involving primary care pediatricians. (13,24-26) Survey respondents varied widely in age and years in practice. Respondents comprised proportions of both rural (10%) and practicing female pediatricians (40%) comparable to the 8.1% and 46%, respectively, reported nationally. (23,27) However, among survey respondents there were greater proportions of both office-based (83.5%) and self-employed (76%) pediatricians than reported nationally, 69 and 50%, respectively. (27)

The wide range of ages and years in practice of our survey respondents reflects a broad representation of pediatricians from several eras of child abuse training in pediatric residency programs. This would seem to account, at least in part, for the wide range of responses to questions pertaining to numbers of hours of child abuse training during residency and whether residency training was sufficient.

The only published national survey of physicians appraising their attitudes on the adequacy of community services for maltreated children, conducted in 1974, noted that only 45% of respondents considered these services to be adequate. (13) The present study asked a similar question, whether the respondent perceived the need for a multidisciplinary CPT in their area. It is noteworthy that 80% perceived such a need and that 81% favored state legislation for the creation and funding of such teams.

There is uncertainty as to the extent to which pediatric residency programs should incorporate training to enable all pediatricians to identify and manage child abuse. (28) Of note is the concern that residency programs have displayed less than adequate commitment to training pediatricians in this area, and there has been a call for training that is both sufficient and standardized. (10,29-31) That 69% of respondents would attend seminars on child abuse sponsored by a children's hospital is testament to pediatricians' recognition of a need for training in this area, and is consistent with a study in which 86% of urban pediatricians requested more training in the evaluation and management of sexual abuse. (32) It is encouraging that a statistically significant association exists among our respondents between perceived competence and adequacy of residency training, suggesting that a perception of adequate emphasis on training in this area during residency equates to at least perceived competence in practice.

A strength of this study was the ability of respondents to reply anonymously. In addition, the demographics of our survey population appear to reflect those of pediatricians in the United States as a whole, and the results of this survey may be useful for pediatricians and legislators in states contemplating the formation of multidisciplinary CPTs and other responses to child maltreatment.

A limitation of this study is its geographic specificity, and it is an open question whether the results are generalizable to physicians providing, or available to provide, medical consultation to CPTs in other states or regions. The study did not survey family practitioners and general practitioners, physicians who often provide services to children and who may be a resource as consultants to child protection teams. Family and general practitioners constitute 25% of rural physicians and provide primary care to many children. (33) Family practitioners perform medical evaluations of abused children in some states. (21) The survey also included only pediatricians in one southeastern state, and a broader survey of pediatricians from different regions, countries, or the United States as a whole may be warranted. It is also likely that our database did not include all pediatricians in Alabama and that some of those without forwarding addresses did nonetheless practice in the state.

Another potential limitation was response bias, although the survey response rate of 56% is comparable with that of similar survey studies of pediatricians. (13,24-26) A more significant limitation is reporting bias; those pediatricians with more interest in or stronger opinions regarding child protection may have responded to the survey. In addition, the survey is limited to respondents' perceived competence, which may not reflect actual competence in the conduct of these examinations. Respondents were also not queried regarding perceived competence in evaluating neglect and emotional abuse, both significant threats to the welfare of children.

The study is also limited by the number of survey questions left unanswered. In particular, nonresponses on the two questions pertaining to willingness to function as a CPT consultant at different levels of time commitment and reimbursement presented us with the question of whether this was, in fact, an indication of overall reluctance to become involved with a CPT regardless of time commitment or reimbursement, or whether this could be explained otherwise as discussed. Finally, the survey instrument did not provide a definition of "multidisciplinary CPT" but left this definition to the respondent, as resources in their community may dictate the specific composition and definition of such a team.

Conclusion

Future studies may appropriately further address issues specific to training, such as the various options for teaching curricula and media, as well as specific funding and reimbursement issues relevant to the recruitment of competent physicians for these evaluations. More generalized information may be realized by survey studies of pediatricians and other physicians from other regions involved in the medical evaluation of children in whom abuse is a concern.

The need for and success of medical expertise, referral centers, and CPTs in the evaluation and care of abused children have been widely advocated. (6,7,9,30) The goals for training physicians, and specifically pediatricians, in this regard have become better elucidated. (16,28,29) The results of this study are relevant to the dual objectives of availability and competence and may be of use to community and legislative bodies contemplating the establishment of multidisciplinary child protection teams.

Table 1. Demographic characteristics of respondents (a)

                          No. (%)
Variable                  (n = 206)

Age
  25-34.9                  31 (15)
  35-44.9                  58 (28)
  45-54.9                  67 (33)
  55-64.9                  25 (12)
  65-74.9                  11 (5)
  75-84.9                   4 (2)
  NR                       10 (5)
Sex
  Female                   83 (40)
  Male                    118 (57)
  NR                        5 (3)
Years in practice
  <5                       30 (15)
  5-15                     67 (33)
  >15                     106 (51)
  NR                        3 (1)
Board eligible/certified
  Yes                     201 (97.5)
  No                        4 (2)
  NR                        1 (0.5)
Location
  Rural                    21 (10)
  Urban                   178 (86.5)
  NR                        7 (3.5)
Practice type
  Group                   167 (81)
  Solo                     34 (16.5)
  NR                        5 (2.5)
Practice setting
  Office                  172 (83.5)
  Hospital                 15 (7)
  Medical center           12 (6)
  NR                        7 (3.5)
Employment status
  Government               28 (14)
  Self                    157 (76)
  NR                       21 (10)

(a) NR, no response.

Table 2. Training and perceived competence of respondents (a)

                                                         No. (%)
Question                                                 (n = 206)

Hours of child abuse training during residency
  0                                                       19 (9)
  1-4                                                     46 (22)
  5-9                                                     52 (25)
  10-14                                                   28 (14)
  [greater than or equal to]15                            45 (22)
  NR                                                      16 (8)
Was your residency training in child abuse sufficient?
  Yes                                                     96 (47)
  No                                                     105 (51)
  NR                                                       5 (2)
Do you consider yourself competent at this time to
    conduct child sexual abuse examinations?
  Yes                                                     93 (45)
  No                                                     107 (52)
  NR                                                       6 (3)
Do you currently conduct medical examinations for child
    sexual abuse?
  Yes                                                    115 (56)
  No                                                      89 (43)
  NR                                                       2 (1)
Do you consider yourself competent at this time to
    conduct medical examinations for physical abuse?
  Yes                                                    169 (82)
  No                                                      32 (16)
  NR                                                       5 (2)
Do you currently conduct medical examinations for
    physical abuse?
  Yes                                                    157 (76)
  No                                                      46 (22)
  NR                                                       3 (2)

(a) NR, no response.

Acknowledgment 

The authors gratefully acknowledge the skill and assistance of Faye Davis, Office Assistant, in accomplishing the mailings involved in this study.

Accepted November 13, 2004.

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RELATED ARTICLE: Key Points

* This study demonstrates that although many pediatricians are reluctant to serve as child protection team consultants, a significant number are willing to do so.

* The study research reveals that a number of pediatricians who do not currently consider themselves competent are nonetheless called on to conduct examinations for child abuse, and that clinicians who perceive their residency training in this area to have been sufficient tend to perceive themselves as competent.

* This study finds a perceived need and desire of primary care pediatricians, in both rural and urban settings, to obtain more training in the area of child abuse.

Donald H. Arnold, MD, David M. Spiro, MD, MPH, Michele Holloway Nichols, MD, and William D. King, RPH, MPH, DrPh

From the Division of Emergency Medicine, Department of Pediatrics and Southeast Child Safety Institute, The Children's Hospital of Alabama, University of Alabama at Birmingham, Birmingham, AL, and the Section of Emergency Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT.

Reprint requests to Dr. Donald H. Arnold, Department of Emergency Medicine, Vanderbilt University Medical Center, 703 Oxford House, Nashville, TN 37232-4700. E-mail: [e-mail]

The authors of this manuscript have no commercial or proprietary interest in any of the concepts or interests addressed and/or mentioned in this work.