C.A.R.E. Survey Results

In matters crucial to detecting and addressing child abuse and neglect, Kentucky physicians and social workers hold conflicting views of each other’s role and performance.

            Recent surveys confirm the scale of this divide and suggest possible ways to bridge it.

            The surveys, conducted last year as part of the Child Abuse Recognition Education (C.A.R.E.) program, reveal gaps in trust and teamwork between physicians who suspect child abuse or neglect and social workers who must determine whether children need protection.

Physicians and state child protection workers were surveyed separately. Findings include:

 

• Kentucky physicians who see children as patients generally think they know child abuse or neglect when they see it. Child protection workers, in the main, disagree.

 

• When physicians report that a child has been abused or neglected, they want to learn what happens to that child, but most physicians say social workers do not tell them.

 

• Most social workers say physicians understand how the state works with the families of abused children. Only about half the physicians surveyed said they understood the state’s role.

 

• Most physicians say abuse or neglect occurs among children in their practices, but few workers say physicians play an important role in reporting child maltreatment.

 

• Fewer than half the physicians surveyed said they had good experiences working with the state child protection system. Fewer than half the workers surveyed said physicians respected their views.

 

Dr. Allen Brenzel, medical and mental health consultant to the Kentucky Department for Community Based Services, said survey findings also contain some good news. Miscommunication between physicians and child protection workers may abound, he said, but both sides "obviously care a lot about this issue, and both seem to want to do something about it."

DCBS and Prevent Child Abuse Kentucky (PCAK) sponsored the surveys as part of C.A.R.E., an effort to prevent child maltreatment through physician training and collaboration between DCBS and physicians. C.A.R.E. also promotes the use of physician protocols to identify abuse and neglect.

If successful, C.A.R.E. will lead to better understanding within each professional group – physicians and social workers – of the other's role in child protection.

C.A.R.E.’s centerpiece is the development and support of a statewide network of medical professionals who participate in peer-to-peer trainings. A core group of physicians started work on the training plan in August 2005, pilot sites were chosen in January 2006 and trainings began in May 2006.

By March 2007, C.A.R.E. training sessions involving 613 physicians, nurses and social workers had been held at 18 sites statewide. C.A.R.E.'s steering group intends to continue the trainings as long as they prove productive.

Brenzel, who helped design the C.A.R.E. curriculum, said the surveys confirm a statewide need to supplement the cursory training in the recognition of child abuse and neglect that physicians usually receive in medical school. He believes the need for that is clear: Reviews of some child deaths in Kentucky show "that there have been missed opportunities" for physicians to identify child abuse before a fatal incident, he said.

C.A.R.E. trainings take place on varying scales suited to the setting and available time. That can range from a half-hour session over lunch break in a physician’s office to elaborate presentations at a hospital or medical meeting.

Brenzel, who helps conduct some C.A.R.E. trainings, said local DCBS staff routinely take part. He said that adds value in at least two ways: Social workers can explain how physicians' reports of suspected abuse or neglect are handled; and the face-to-face contact with social workers may give physicians "an increased comfort level" in making such reports.

Ideally, Brenzel said, C.A.R.E. will also help make child protection workers more forthcoming with physicians who report. Physicians need to be told of agency actions that may affect the welfare of children in their care, he said.

Jill Seyfred, the PCAK executive director, said future trainings will likely incorporate some of the contrasts between physicians’ views and those of social workers. Those should prove valuable teaching aids, she said, "because of the participants' interest in learning and understanding what those gaps might be."

Brenzel said he hopes C.A.R.E. can help rid physicians of the belief that they should report only if they are certain abuse or neglect has occurred.

 “We would like them to have the confidence that, by identifying families with risk factors for maltreatment, … this could be a positive intervention for the family, ensuring that the families get some help.”

 

The Child Abuse Recognition Education (C.A.R.E.) physician survey was drawn up by private physicians and staff members of the Department for Community Based Services (DCBS) and Prevent Child Abuse Kentucky. They based their work on the C.A.R.E. curriculum and a Pennsylvania study of community-based education of physician in the detection of child abuse and neglect.

A separate work group of DCBS management and field staff developed the survey for workers.

Both surveys dealt with the reporting of suspected child abuse and neglect by physicians and the interaction between social workers and reporting physicians. Specific topics included: physicians’ ability to recognize child maltreatment; procedures and forms they use to document it; barriers they encounter to reporting it; and DCBS workers' willingness to share information with physicians about cases under investigation.

            Survey forms were mailed to Kentucky physicians licensed in family practice, pediatrics, emergency medicine, pediatric emergency medicine, critical care and pediatric critical care – all fields that are likely to bring physicians into contact with abused or neglected children. Of 2,339 surveys sent to valid addresses, 807 responses were received, for a response rate of 34.5 percent.

            DCBS workers were surveyed electronically, and 570 of 1,815 front-line social workers and supervisors responded, for a response rate of 31.4 percent.

The surveys revealed differences between the perceptions and priorities of the two groups and points on which each group held negative views of the other. These findings include:

• Ninety percent of physicians were confident they could recognize child physical abuse. (Physicians’ confidence in their ability to recognize was 83 percent for neglect, 56 percent for emotional abuse and 69 percent for sexual abuse). Only 20 percent of social workers agreed physicians knew the signs and symptoms of physical abuse. (Worker confidence in physicians’ ability to recognize was 43 percent for neglect and 33 percent for sexual abuse).
• Seventy-four percent of workers agreed physicians understand DCBS’ role in working with families around abuse and neglect, and 80 percent of workers agreed physicians understand how the decision to investigate is made. Only 48 percent of physicians said they knew how social services handles reports of abuse or neglect.
• Seventy-eight percent of physicians agreed that abuse or neglect occurs among children in their practices. Only 10 percent of workers agreed that physicians play an important role in reporting child abuse or neglect, and only 5 percent of workers considered it very important to include physicians on multidisciplinary teams.
• Eighty-eight percent of physicians wanted to be told what happens to a child after they report abuse or neglect, but only 17 percent said DCBS kept them informed. Only 32 percent of workers said they would inform a physician who is the reporting source that an investigation of child abuse or neglect had been accepted.
• Asked to select significant barriers to the reporting of suspected abuse, physicians were most likely to select uncertainty that reporting would help the child (chosen by 26 percent) and fear that reporting would make matters worth for the child (chosen by 22 percent).
• Eighty-five percent of workers identified court appearance as a significant barrier to reporting by physicians.
• Only 10 percent of physicians identified the risk of medical malpractice as a barrier to reporting, while 46 percent of workers thought it was a barrier.
• Only 43 percent of the physicians said they had had a good experience working with DCBS, and only 24 percent of them agreed families get the help they need when abuse or neglect is reported.
• Only 41 percent of workers agreed that physicians respected their views and opinions, and 33 percent said physicians were hard to work with because they were arrogant.

 

In the space for comments on the physicians' survey, one physician wrote: "I will report all suspected cases of abuse but I am frequently disappointed by how cases are handled and how many children remain in unsafe homes."

A worker wrote: "I believe most physicians are willing to report but are not as well versed on what meets criteria and what we can and cannot do. Physicians could do a better job of recognizing patterns that indicate abuse and neglect. Sometimes they only report when the worst scenario plays out but should have reported sooner based on the cumulative patterns."

Another worker reported "very good relationships” with local medical providers, adding: “They are very forthcoming and dialogue is very open during investigations."

The full report on the C.A.R.E. surveys of physicians and child protection workers is posted on the Cabinet for Health and Family Services website at http://chfs.ky.gov/dcbs/diqi/.