Response to child abuse in the pediatric emergency department: need for continued education.

BACKGROUND: Child abuse is a leading pediatric public health problem. Pediatric emergency physicians are on the front line to identify and respond to child abuse. The physician's response to suspected child abuse cases is influenced by educational content and experience.

OBJECTIVE: To determine pediatric emergency medicine Fellows' level of preparedness to respond to suspected child abuse, and to assess obstacles and attitudinal barriers to effective response.

STUDY DESIGN: Self-reported written survey.

METHODS: A 30-item anonymous questionnaire was mailed to 162 pediatric emergency medicine Fellows in the United States and Canada in 1995. A response rate of 77.2% (n = 125) was achieved.

RESULTS: Prior to fellowship, 97.6 % of the responding Fellows reported having had some pre-fellowship instruction, including formal courses, conferences, and direct patient contact, on child abuse during medical school and residency. Whereas the majority (61.4%) received > or =10 hours of child abuse response instruction before fellowship, most (70.1 %) reported <10 hours of child abuse response instruction during their fellowship; 17.1 % reported they had no child abuse response training during their fellowship. Prior experience was also determined by reported involvement with managing child abuse cases during their medical training to date. Before fellowship, the median level of child abuse case involvement was 15 (mode 20) compared with a median of 10 cases (mode 10) reported during fellowship training. More than one third (48/125) noted the lack of organized lectures or conferences on child abuse available during fellowship training. While the majority (107/125) reported the opportunity to do a rotation in child protection/ abuse during fellowship training; the rotation was required for only 32.7% (35/107); among Fellows who reported an elective rotation in child abuse (72/107), one half (36/72) reported that they were unlikely to participate. Factors most frequently selected as perceived obstacles to responding to child abuse included lack of formal training on the topic (33.6%), lack of experience handling these cases (37.6%), personal discomfort (41.6%), and perceived lack of response by local protective services (42.4%) and police (25.6%). Sixty percent (75/125) had a protocol in the pediatric emergency department to facilitate response to child abuse. Many felt ill-prepared to interact with Child Protective Services (52.8%) and police (42.4 %). Prior experience managing child abuse cases and educational content during fellowship training were independently predictive of frequency of identifying cases of child abuse during fellowship.

CONCLUSIONS: Significant training gaps in postgraduate medical education on response to child abuse for the pediatric emergency subspecialist are identified, as well as perceived obstacles to effective response, which may have implications for designing future curricula.