Reporting Child Abuse - A Need For Family Violence Education Among Physicians

Although child abuse is a well-documented social and public health problem in the United States, few medical schools and residency training programs include child abuse education and other family violence education in their curricula. The Committee on the Training Needs of Health Professionals to Respond to Family Violence of the Institute of Medicine examined the curricula on family violence for six groups of health professionals: physicians, physician assistants, nurses, psychologists, social workers, and dentists (Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence, Felicia Cohn, Marla E. Salmon, and John D. Stobo, eds., Washington, DC: National Academies Press, 2002).

The committee noted that as many as one out of four children and adults experience family violence during their lifetimes. Studies have shown that family violence is associated with many problems affecting health, including homelessness, alcohol and substance abuse, and delinquency. Although health professionals are usually the first people to interact with victims of family violence, their lack of education on family violence keeps them from identifying, treating, and helping their patients.

The committee found that most medical schools give instruction regarding at least one form of family violence.

TABLE 3.2

Requirements by accreditation institutions for family violence curriculum
Health care discipline	Accreditation institutions	Requirements related to family violence	Description
Note:
S = specific existing requirements.
NS = nonspecific requirements.
X = no identifiable requirements.
SOURCE: "Requirements by Accreditation Institutions Relating to Family Violence Curriculum," in Confronting Chronic Neglect: the Education and Training of Health Professionals on Family Violence, Felicia Cohn, Marla E. Salmon, and John D. Stobo, eds., National Academy Press, 2002
Medical schools	Liaison Commission on Medical Education (LCME)	S	"The curriculum should prepare students for their role in addressing the medical consequences of common societal problems, for example, providing instructions in the diagnosis, prevention, appropriate reporting and treatment of violence and abuse." Standards can be found on the LCME web site www.lcme.org.
	Accreditation Council for Graduate Medical Education (ACGME)	X	The institutional requirements of the ACGME are very practical in nature and do not outline any single curriculum requirements including any dealing with family violence.
	American Osteopathic Healthcare Association (AOHA)	NS	Institutions are required to include with the spectrum of "Emergency Procedures" some instruction regarding "abuse and neglect" of children. While these standards are not a requirement unto themselves, they do seem to be somewhat quantifiable.
Physician residencies	Residency Review Committees (RRC) of the ACGME	S	The residency review committees of the ACGME, which accredit programs rather than institutions, do have provisions for family violence in certain fields. Though the genetics area does not mention family violence, the areas of family practice and obstetrics indicate how to identify signs of family violence and the steps to take.
Dental schools	American Dental Association Commission on Dental Accreditation (ADA)	NS	There is no specific mention of family violence in the accreditation commission's standards. Such training is believed to fall under the purview of a provision for "ethical reasoning" and "professional responsibility."
Nursing schools	Commission on Collegiate Nursing Education Accreditation (CCNE)	X	CCNE guidelines are very generic and do not provide for any particular curriculum requirements. The guidelines allow schools to choose their own direction and philosophy and subsequently measures them against the standard they have chosen.
Nurse practitioners	National League for Nursing Accrediting Commission (NLNAC)	NS	"NLNAC does not include specific curriculum content areas within its standards and criteria. When specific curriculum content is designated it is usually from the State Boards of Nursing since NLNAC is voluntary." Standards can be accessed on the website at www.nlnac.org.
	National Association of Pediatric Nurse Associates & Practitioners, Inc. (NAPNAP)	NS	NAPNAP recognizes that there is "substantial scientific evidence that children who are abused physically, sexually, emotionally or who are neglected, are prevented from optimal development." NAPNAP has in place a thorough position statement on child abuse/neglect.
Psychology programs and internship sites	Committee on Accreditation of the American Psychological Association: accredits both school and internship sites (APA)	X	There is no mention of family violence in the APA accreditation guidelines. They take a broad stance on evaluating the goals that institutions set for themselves.
Social work programs	Council on Social Work Education (CSWE)	NS	CSWE has no specific requirements mandating that the issue of family violence be discussed on any level. There is an expectation that a program dealing with social work must at some point address the problem. Should an institution not do this, it would probably be cited.
Physician assistant	Commission on Accreditation of Allied Health Education (CAAHEP) Programs	X	There is no reference to family violence made in the CAAHEP standards or guidelines. Curriculum is the responsibility of the sponsoring institution with the exception of a few general study education requirements.
	Effective January 1, 2001, CAAHEP no longer will be the accreditor of physician assistant education programs. All current accreditations are being transferred from CAAHEP to the Accreditation Review Commission on Education of the Physician Assistant (ARC-PA) http://www.CAAHEP.org/caahep_pa.htm

In most cases, education revolves around reporting requirements, patient interviewing skills, screening tools, health conditions related to violence, and service referrals for victims. The teaching sessions vary, ranging from a very brief discussion to several lectures or case discussions. Although about 95% of schools teach material related to child maltreatment, usually during pediatric rotation, the committee found that the curriculum is inadequate. Table 3.2 illustrates the minimal requirements for accreditation, a process that determines whether a medical school or program meets certain established standards. Accreditation is needed for eligibility to participate in federal student loan programs.

Medical residents specializing in fields in which they are most likely to interact with maltreatment victims are required to receive training in family violence. These include pediatricians, internists, obstetricians/gynecologists, geriatricians (specialists who treat the elderly), psychiatrists, and emergency-medicine doctors. The training consists of lectures and case discussions, and the training duration varies from program to program. As for continuing medical education on family violence, the committee found very little information, including lectures and programs on the Internet, for which health professionals can earn credits.

The committee also noted that not much is being done to evaluate the effects of family violence training. So far, evaluations that had been performed concerned short-term effects of the training, such as how the training had increased the health professionals' knowledge of family violence. The committee suggested that more in-depth evaluation of the training programs should measure the effects of training on health professionals' behavior and victims' health.

Primary Care Residency Program in Child Maltreatment

Suzanne P. Starling and Stephen Boos noted that, since 1962, when Dr. C. Henry Kempe wrote of the "battered child syndrome," a term that encompasses all aspects of child abuse, research on the subject has grown. Physicians' knowledge about child abuse, however, has not followed suit ("Core Content for Residency Training in Child Abuse and Neglect," Child Maltreatment, vol. 8, no. 4, November 2003). According to the authors, while there are physician specialists in child maltreatment, their numbers are limited. Therefore, primary care physicians are called upon to perform their functions, including monitoring family health, diagnosing abuse, consulting with government agencies, testifying in court, and participating in abuse prevention programs and in multidisciplinary teams that evaluate and manage child maltreatment. Drs. Starling and Boos suggested offering a core curriculum in residency programs that would enable primary care physicians (including pediatricians, family doctors, and emergency-medicine doctors) to recognize, evaluate, and manage cases of child abuse and neglect.