PEDIATRICS Vol. 119 No. 1 January 2007, pp. e103-e108 (doi:10.1542/peds.2005-2121)
ARTICLE |
A National Assessment of Knowledge, Attitudes, and Confidence of Prehospital Providers in the Assessment and Management of Child Maltreatment
a Pediatric Emergency Medicine Section, Department of Pediatrics
b Department of Emergency Medicine, Maria Fareri Children's Hospital/New York Medical College, Valhalla, New York
c Center for Pediatric Emergency Medicine, Department of Pediatrics and Emergency Medicine, New York University School of Medicine/Bellevue Hospital Center, New York, New York
d Division of Pediatric Surgery, Department of Surgery, Columbia University College of Physicians and Surgeons/Harlem Hospital Center, New York, New York
e National Emergency Medical Services for Children Data Analysis and Research Center, Department of Pediatrics, University of Utah, Salt Lake City, Utah
f "For the Health of It" Consultation Services, New York, New York
g National Registry of Emergency Medical Technicians, Columbus, Ohio
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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OBJECTIVE. The goal was to assess the knowledge and confidence in recognition, management, documentation, and reporting of child maltreatment among a representative sample of emergency medical services personnel in the United States.
METHODS. A questionnaire was developed and pilot-tested, with the input of experts in emergency medical services and child maltreatment, to assess knowledge, attitudes, confidence, and training needs regarding assessment and treatment of child maltreatment. The questionnaire was distributed nationally to a random sample of prehospital providers by using a previously validated sampling plan.
RESULTS. Of 2863 surveys sent to prehospital providers, 1237 (43%) were returned. Most prehospital providers reported receiving 
1 hour of continuing medical education regarding child maltreatment. Most (78%) asked for additional educational opportunities, with only 3% stating that they required no additional training. Participants lacked knowledge regarding the developmental abilities of children, management of families in which child maltreatment is suspected, key elements of the history that should be noted, and the degree of suspicion necessary for reporting.
CONCLUSIONS. Prehospital providers expressed confidence in their abilities to recognize and to manage cases of child abuse and neglect; however, significant deficiencies were reported in several critical knowledge areas, including identification of child maltreatment, interviewing techniques, and appropriate documentation.
Key Words: child protection • child maltreatment • child abuse and neglect • emergency medical services
Abbreviations: EMS—emergency medical services • EMT—emergency medical technician • CME—continuing medical education
Violence against children, specifically in the area of child maltreatment, is a significant public health concern, with 3 million cases of child abuse reported each year in the United States. In 1996, child protection service agencies in the United States investigated >2 million reports, alleging maltreatment of >3 million children, and almost 1 million children were identified as victims of substantiated or indicated abuse or neglect. Between 1995 and 1997, 41% of fatalities related to child abuse involved children who had current or previous contact with local child protection service agencies.1 It is estimated that almost two thirds of substantiated or indicated reports were from professional sources (school, social services, law enforcement, and medical personnel).
Prehospital providers can have an impact on child maltreatment. Because emergency medical services (EMS) personnel are often the only health care providers allowed access to a family's home, they may have the only opportunity to assess the children's environment and family interactions, as well as their health status. A tremendous amount of information regarding many aspects of child maltreatment is available for health care providers (eg, physicians, nurses, physician assistants, and social work staff members), other professionals who interact with children (eg, teachers and counselors), and public safety personnel (eg, police officers). However, there is a lack of reference information and uniform national educational material addressing the role of EMS and other prehospital providers in child maltreatment.
Although prehospital providers have an important role in the recognition and treatment of child maltreatment, information on their ability to identify, to report, to intervene in, to document appropriately, and to prevent child maltreatment is lacking. In addition, there is little information regarding their education and attitudes with respect to this subject. We surveyed a national sample of prehospital providers, investigating their knowledge (recognition of signs and symptoms), education, attitudes, and role in identifying, managing, documenting, reporting, and preventing child abuse and neglect.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Study Design
The study used sampling methods developed and validated by the National Registry of Emergency Medical Technicians (EMTs). The National Registry created the sample from a random population of prehospital providers certified at the EMT-Basic or EMT-Paramedic level, to be representative of the national EMS practitioner population, for use both in a longitudinal study and in periodic surveys related to specific areas of interest regarding prehospital providers, such as the study on child maltreatment that we conducted. The details of this sample and its use for longitudinal and snapshot analyses were described previously.2 This study was approved by the institutional review board.
Sampling was stratified according to both EMT status (ie, EMT-Basic versus EMT-Paramedic) and duration of continuous registration at each level (<1 year [new] or >1 year [old]). The sample was further stratified according to race, to allow oversampling of minority subjects. Participants were categorized as "minority" if they identified themselves as Asian, black, Hispanic, or Native American and were categorized as white if they identified themselves as white or other or if they did not provide information on race. Sample size was intended to maximize the efficiency of the sample for comparing different types of EMTs, as well as for estimating population parameters. Sampling probabilities (ie, weights) within strata were adjusted to reflect nonresponse.
Questionnaire Development
A draft questionnaire was created and pilot-tested with a convenience sample of EMS providers in 5 states. Question types were cognitive, attitudinal, self-reported, confidence, and scenario based. To ensure consistency with prehospital provider training and inclusion of appropriate topics, the content of the survey was based on the items covered in the EMT-Basic National Standard Curriculum.3 Correct answers to the cognitive questions were based on national texts and policy statements regarding child maltreatment. The correct answers to the scenario-based questions were validated on the basis of unanimous agreement of the investigators and 5 identified experts in child maltreatment and child maltreatment education.
After pilot testing, the questionnaire was refined; the final instrument included 16 demographic questions (including training, EMS system, and exposure information), 5 questions regarding confidence (on a Likert scale), and 8 questions on cognitive knowledge (of which one half used single-choice answer testing and the other one half combination answer testing). To delineate key elements of the assessment of physical abuse, the respondents were given a list of items regarding bruising locations and types of burns and were asked to choose those suggesting abuse. Eight scenario-based questions were included, which presented a vignette and then asked the respondent to rate as suspicious of abuse, suspicious of neglect, not abuse/neglect, or more information needed. In an effort to define the source of the prehospital providers' deficiencies in knowledge, factors were evaluated that might be associated with improved performance on either the scenario-based or cognitive questions. These factors included years of experience, number of hours of training on child maltreatment during the initial certification course, number of hours of continuing medical education (CME) on child maltreatment in the past 12 months, and whether the prehospital provider was caring for a child. Finally, there were 5 opinion questions, which allowed for multiple answers and addressed desire for additional training, barriers to reporting, and resources for handling child maltreatment cases. The final instrument was also tested for time to complete; a range of 25 to 40 minutes was needed.
Data Collection
Each potential participant was mailed a questionnaire, a postage-paid return envelope, and a cover letter that outlined the goals of the project and provided assurance of confidentiality. Two mailings to nonresponders were conducted. The returned surveys were scanned with an optical reader, and the data were transferred into a database (Microsoft Access 2000; Microsoft, Redmond, WA).
Nonrespondent Survey
During the creation of the prehospital sample and the initial National Registry longitudinal study, an abbreviated version of the questionnaire, containing demographic, attitudinal, income, and educational items from the regular survey, was mailed to nonrespondents. Results from these returned abbreviated questionnaires suggested that there were no statistically significant differences in demographic or socioeconomic factors between nonrespondents and respondents in the current study.
Statistical Analyses
Initial analysis was performed by using descriptive statistics, and analysis of associations was performed with nonparametric tests of association, by using the 
coefficient for nominal data and Spearman's 
and Kendall's 
for ordinal data. Analyses were performed with SAS 8.0 (SAS Institute, Cary, NC) and SPSS 10 (SPSS Inc, Chicago, IL).
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Of 2863 eligible prehospital providers sent a survey, 1237 responded (43%). Most of the sample subjects were male (61.4%) and had obtained a high school diploma (49.5%) or college degree (associate or bachelor's degree) (44.8%). The majority had 1 to 4 years of experience (35.1%); a minority of respondents had >20 years (4.9%), with similar percentages having <1 year (19.9%), 5 to 10 years (19.8%), and 11 to 20 years (20.3%).
The majority of respondents reported receiving >12 hours of general CME during the past year, with >20% receiving >60 hours. In contrast, 44% reported receiving no CME on child protection, with 35.9% receiving only 1 to 2 hours (Fig 1). The number of hours of CME related to child maltreatment was associated with the total number of hours of CME (P < .01).
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In addition to reporting the actual hours of training received, respondents were asked to identify the areas in which they felt their knowledge regarding child maltreatment was deficient and they would like additional training. The majority (78%) asked for additional education on a broad list of child protection topics, with only 3% stating that they required no additional training (Table 1).
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Table 2 presents the results of the questions focusing on patient assessment and core concepts in child maltreatment, which included history, indicators of abuse, and documentation. These questions identified that there were significant deficiencies in many knowledge areas necessary for recognizing, managing, and reporting cases of child abuse. The area of greatest proficiency was in recognition of patterned bruises resulting from purposeful abuse. The areas of greatest deficiency were in knowledge of developmental abilities of children, management of families in which child maltreatment is suspected, elements of the history required for adequate documentation, and level of proof necessary for reporting.
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Additional analysis of the respondents' recognition of specific physical and historical indicators of possible child maltreatment was performed. For this analysis, the specific assessments chosen were of bruising locations and burn patterns. The results are presented in Table 3. Deficiencies were reported for both suspicious and nonsuspicious findings. Approximately one fourth (24.2%) of the respondents did not identify a hand-shaped bruise on the cheek as suspicious, and 13.7% thought that bruising on shins and elbows in a preschool-aged child was suspicious. With regard to the recognition of burn patterns, 35.4% failed to identify bilateral, symmetrical, stocking/glove patterns as suspicious, despite this being mentioned specifically in the EMT-Basic National Standard Curriculum. It is also of concern that 8.7% of the respondents failed to recognize a pattern burn as suspicious.
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In addition to the physical assessment of child maltreatment, analysis of respondents' knowledge of historical indicator assessment of possible abuse or neglect was performed (Table 3). Findings were that 15% of respondents thought that a parent and child giving similarly worded histories was suspicious; 10% did not identify parents/caretakers as changing the story as being suspicious.
We found that years of experience, initial hours of child maltreatment education, and CME were all associated with correct answers for both the scenario-based and cognitive questions (P < .01). Being a parent or caregiver for a child was not associated with correct answers on the cognitive questions (P = .483) but was associated with correct answers on the scenario-based questions (P < .05), although the effect was small (odds ratio: 1.145).
The last area evaluated was the prehospital providers' self-assessed confidence in identifying and managing child maltreatment. In several instances, their confidence level exceeded their knowledge, as assessed by the survey (Table 4). Their confidence was higher when treating cases of physical abuse than when treating cases of sexual abuse or neglect (89.9%, compared with 51.2% and 84.1%, respectively). Their confidence in their ability to manage families during calls in which child maltreatment is suspected was low (48.6%).
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Our study has 3 main findings. First, EMS providers receive minimal CME on child maltreatment, despite being mandated reporters in almost all states and desiring increased amounts of CME in this area. Second, EMS providers lack knowledge of child maltreatment, including key historical and physical indicators of abuse or neglect, level of proof needed for reporting, and knowledge of developmental abilities. Third, their confidence in several areas of child maltreatment exceeds their knowledge, and they have low self-expressed confidence in key elements of child maltreatment, such as handling the family.
EMS personnel are a large group (
600000 in the United States) of health care providers who are in a unique position to recognize child abuse and child neglect and to intervene in child maltreatment. EMTs are also in a position to identify and to describe mechanisms of injury, thereby providing important data to physicians, other health care providers, and child protection services personnel. In addition, EMS personnel can ensure transport to the hospital for care, social intervention, and support. The accuracy and completeness of ambulance call reports and the professionalism, persistence, and objectivity of EMS providers in reporting their findings to emergency department personnel may have an effect on identification of and successful intervention in the case.
The only article in the literature addressing specifically the knowledge, attitudes, and experience of prehospital providers was by King et al,4 who conducted a small study of EMS providers in Pennsylvania. The 48 providers who answered the questionnaire were able to identify the 4 categories of child abuse (physical, sexual, psychological, and neglect). More than one half (56%) said they were likely to encounter child abuse in the next year, 48% said they often or sometimes suspected abuse, and 78% had seen evidence of child abuse in the homes of patients. Only 31% understood their status as mandated reporters. Almost 60% had no training in the area of child abuse or child abuse reporting, despite this being a required topic in the Department of Transportation EMT-Basic National Standard Curriculum at that time.
The first step in the recognition of child maltreatment involves a thorough assessment, and this was an area in which the respondents expressed confidence in their abilities. Our study focused on additional analysis of child maltreatment assessment. Prehospital providers expressed confidence in their abilities to recognize and to manage cases of suspected child abuse and neglect; however, they demonstrated deficiencies in critical knowledge regarding identification of cases of child maltreatment, interviewing techniques, and appropriate documentation. Confidence levels were higher with respect to their abilities in recognizing physical abuse and in providing documentation and lower with respect to their abilities in recognizing and managing cases of neglect or sexual abuse. The low levels of confidence in recognizing neglect and sexual abuse are not surprising, because this is an area of concern for even highly trained child maltreatment experts. Although this was an expected finding, it is still concerning. The overall findings represent a significant national problem, because prehospital providers may be the only health care professionals who enter the child's home, and they have a unique opportunity to recognize child neglect. Their exposure to child maltreatment was shown by King et al,4 who found that more than one half (56%) of respondents said that they were likely to encounter child abuse in the next year, 48% said that they often or sometimes suspected abuse, and 78% had seen evidence of child abuse in the homes of patients. In our study, confidence levels for managing a family in which child maltreatment is suspected were low.
Despite increased emphasis on pediatrics in the current EMT-Basic National Standard curriculum and the expanded content on child maltreatment, the majority of providers in this study did not receive more than a few hours of education in this area and, on the basis of the results of the cognitive assessment, either the training was insufficient or retention levels were very low. This lack of knowledge was seen in areas considered key for recognition and reporting, such as developmental abilities and important elements of the history. The essential decision point regarding the level of proof necessary to determine whether to report child maltreatment was not known by almost one half of EMS providers, with the majority thinking that the level of proof is higher than actually necessary. This reflects a major potential source of under-reporting of child abuse and neglect.
Prehospital providers are required to participate in considerable CME time every year; however, very little of that time is devoted to child maltreatment. Interestingly, the areas in which prehospital providers demonstrated deficient knowledge and those in which the majority requested additional training were correlated strongly, which suggests that the prehospital providers were able to assess their abilities and knowledge levels accurately. Furthermore, we found that their involvement in CME correlated with improved performance on scenario-based and cognitive questions, which reinforces the importance and benefits of CME in this area.
Prehospital providers, who often observe scenes of child abuse and neglect, can fill an essential role in identifying and reporting neglect and abuse in the home, at school, and in other locations. In many states, EMS prehospital providers are mandated child maltreatment reporters (ie, required by state law to report suspected cases of abuse or neglect to a designated agency). However, the exact reporting mechanism (reporting to a mandated agency versus reporting to hospital personnel) may vary from state to state, and it is unclear from previous studies whether EMS personnel are aware of their status as mandated reporters or of proper reporting procedures in their regions.4 We found that only 31% of prehospital providers understood their status as mandated reporters. This reflects a lack of understanding by prehospital providers of their legally required role to recognize and to report suspicions of child abuse or neglect. This is compounded by the fact that nearly 50% of those surveyed did not know the level of proof required for reporting. Of those, the majority thought that a level higher than reasonable suspicion was necessary to make a report. The implication is that, of all prehospital providers who witness possible abuse or neglect, a large percentage would not make a report because of their incorrect assumptions regarding the level of proof necessary.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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This study identified areas of deficiency in prehospital provider education, knowledge, and confidence regarding child maltreatment. These deficiencies should be addressed in revisions of existing training programs. An educational program with text and slide material5 was developed on the basis of the results of this survey and the recommendations of a national panel on child maltreatment.6 Prehospital providers are an integral part of the public health system approach to child maltreatment and must be identified as mandated reporters in all states. As important as becoming mandated reporters, they must receive mandatory education on child maltreatment identification, treatment, and reporting. The assessment of the positive attitude toward the role of EMS personnel in child maltreatment recognition, reporting. and treatment suggests that, with proper education and inclusion in the public health system approach to child maltreatment, such personnel will be an important asset in the identification of and intervention for child maltreatment. Our study, which provides an initial assessment and approach to child maltreatment, also serves as a framework for how to proceed with assessment and improvement of prehospital provider education and roles in other areas of domestic violence.
Our study has several limitations. The 43% response rate in this study is low enough to raise the possibility of responder bias. Respondents to this survey might be more conscientious or motivated than their nonresponding colleagues, and their knowledge of child maltreatment and their attitudes toward the subject might represent overestimates. Surveys of an earlier, similar sample of EMTs revealed no statistically significant differences in demographic or socioeconomic factors between nonresponders and responders. Cross-sectional surveys can demonstrate association but cannot prove causation. Individuals who express confidence and seek extra training on child maltreatment may be more likely to have deficient knowledge in this area. Lastly, although scenario-based questions are a common educational tool for assessing performance, they may not represent performance in actual child maltreatment situations. Parental reaction, the influence of law enforcement, and a partner's opinion are examples of real-life factors that may alter performance in an actual call, compared with that described in a scenario.
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FOOTNOTES |
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Accepted Jul 31, 2006.
Address correspondence to David Markenson, MD, Pediatric Emergency Medicine, Maria Fareri Children's Hospital, Westchester Medical Center, Valhalla, NY 10595. E-mail: david_markenson{at}nymc.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
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REFERENCES |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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- Wang CT, Daro D. Current Trends in Child Abuse Reporting and Fatalities: The Results of the 1997 Annual Fifty State Survey. Chicago, IL: Center on Child Abuse Prevention Research, National Committee for Prevention of Child Abuse; 1997. Working Paper 808
- Brown WE Jr, Dickison PD, Misselbeck WJ, Levine R. Longitudinal Emergency Medical Technician Attribute and Demographic Study (LEADS): an interim report. Prehosp Emerg Care. 2002;6 :433 –439[Medline]
- Department of Transportation. EMT-Basic National Standard Curriculum. Washington, DC: Department of Transportation; 1993
- King B, Baker M, Ludwig SL. Reporting of child abuse by prehospital personnel. Prehosp Disaster Med. 1993;8 :67 –68[Medline]
- Markenson D, Tunik MG, Treiber M, Cooper A, Skomorowsky A, Foltin GL. Child Abuse and Neglect: A Prehospital Continuing Education and Teaching Resource. New York, NY: Center for Pediatric Emergency Medicine; 2003
- Markenson D, Foltin G, Matza-Haughton H, Cooper A, Treiber M. Knowledge and attitude assessment and education of prehospital personnel in child abuse and neglect: report of a national blue ribbon panel. Ann Emerg Med. 2002;40 :89 –101[CrossRef][Medline]
PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics
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