Clinicians’ Description of Factors Influencing Their Reporting of Suspected Child Abuse: Report of the Child Abuse Reporting Experience Study Research Group
OBJECTIVES. Primary care clinicians participating in the Child Abuse Reporting Experience Study did not report all suspected physical child abuse to child protective services. This evaluation of study data seeks (1) to identify factors clinicians weighed when deciding whether to report injuries they suspected might have been caused by child abuse; (2) to describe clinicians’ management strategies for children with injuries from suspected child abuse that were not reported; and (3) to describe how clinicians explained not reporting high-suspicion injuries.
METHODS. From the 434 pediatric primary care clinicians who participated in the Child Abuse Reporting Experience Study and who indicated they had provided care for a child with an injury they perceived as suspicious, a subsample of 75 of 81 clinicians completed a telephone interview. Interviewees included 36 clinicians who suspected child abuse but did not report the injury to child protective services (12 with high suspicion and 24 with some suspicion) and 39 who reported the suspicious injury. Interviews were analyzed for major themes and subthemes, including decision-making regarding reporting of suspected physical child abuse to child protective services and alternative management strategies.
RESULTS. Four major themes emerged regarding the clinicians’ reporting decisions, that is, familiarity with the family, reference to elements of the case history, use of available resources, and perception of expected outcomes of reporting to child protective services. When they did not report, clinicians planned alternative management strategies, including active or informal case follow-up management. When interviewed, some clinicians modified their original opinion that an injury was likely or very likely caused by abuse, to explain why they did not report to child protective services.
CONCLUSIONS. Decisions about reporting to child protective services are guided by injury circumstances and history, knowledge of and experiences with the family, consultation with others, and previous experiences with child protective services.
The Child Abuse Reporting and Experience Study (CARES) examined primary care clinicians’ decision-making processes about whether injured children were victims of physical child abuse (CA). Among the 15 003 injured children evaluated by CARES clinicians, 90% were assessed as having an injury “very unlikely for abuse.”1 Although some degree of suspicion was reported for the remaining injured children, even at the highest levels of suspicion (ie, likely or very likely caused by physical CA) only 73% of injuries were reported to child protective services (CPS).
When making a decision to report a suspicious injury to CPS, clinicians considered a number of patient-related factors,1 including the level of suspicion; injury history, type, and severity; whether the patient was referred to the clinician because of a suspected abusive injury; child's race; family and child risk factors for CA; and familiarity with the child's family.1 Also, clinicians were more likely to report suspicious injuries if they had not reported all suspicious injuries in their careers and if they had lost families as patients because they had reported the families to CPS.
Although analyses of CARES quantitative data1 confirmed earlier retrospective survey outcomes,2–5 they did not capture the array of reasons influencing suspicion or decisions to report suspected CA to CPS, from the clinician perspective. Therefore, CARES also collected more-detailed qualitative data, regarding specific injury cases, from a subsample of clinicians. This report examines (1) factors clinicians weighed when making a decision about whether to report a suspicious case to CPS, (2) alternative management strategies they used in lieu of reporting, and (3) and how they explained not reporting injuries they judged were likely or very likely to have been caused by physical abuse.
The 434 clinicians who participated in CARES1 were eligible to participate in this substudy. Clinicians were sampled in strata based on responses to questions on submitted injury encounter cards1 about their level of suspicion that an injury was caused by physical CA and whether they reported the injury to CPS. An informative sampling scheme was designed to create a set of ∼100 clinician interviews with approximately equal numbers of clinicians (1) who reported suspected CA to CPS, (2) who indicated some level of suspicion that an injury was caused by CA but who did not report the injury, and (3) who indicated that they were not suspicious that an injury was caused by CA. The “no-suspicion” cases were matched according to age and gender with the reported cases but were not included in this report. For this report, the injuries for which the clinicians indicated some level of suspicion but did not report were divided into 2 strata, that is, high level of suspicion but not reported (likely or very likely) or some suspicion but not reported (possible or unlikely). These 2 strata and the stratum in which the index injury was reported to CPS are shown in Table 1.
The sampling scheme was designed to interview clinicians about only 1 child's visit; however, 1 clinician was interviewed twice. Of the 81 clinicians who indicated some level of suspicion for CA and were selected for interview, 93% completed the interview process. CARES was approved by the American Academy of Pediatrics institutional review board, 4 institutional review boards representing the study investigators, and 17 additional local institutional review boards affiliated with clinician participants.
Qualitative data about decision-making were collected through a written survey ∼3 weeks after the patient's visit and a telephone interview ∼6 weeks after the visit. The written survey data were used to guide the subsequent telephone interview. Telephone interviews were conducted between January 2003 and January 2005.
Baseline data were collected as described previously.1 Data concerning participating clinicians were collected with the Practitioner Characteristic Survey, which asked several questions about office and community resources available to the clinician. Case data, including information used to assign sampling strata, were obtained from injury encounter cards, which assessed the level of suspicion that the injury had been caused by CA (5-point Likert scale with 1 = very unlikely, 2 = unlikely, 3 = possible, 4 = likely, and 5 = very likely), whether the clinician had reported the injury to CPS (yes or no), and whether the clinician had referred the patient or consulted with anyone about the patient. Clinicians who reported suspected CA completed a report follow-up form, which asked whether the clinician had consulted with others regarding the decision to report the injury and what the clinician anticipated would happen as a result of the report to CPS.
The written survey requested information on medical tests, consultations, and referrals; the clinician's perceptions about the injury case; the clinician's relationship to the patient and the family; other communications that supported the final determination regarding whether the injury was caused by CA; and any subsequent information the clinician received about the case and the source of that information. The survey questions were specific to each sample stratum (reported, high suspicion/not reported, or some suspicion/not reported). For example, clinicians who reported suspected abuse were asked what influenced their decision to report and whether they told the family they planned to report. Clinicians with high suspicion or some suspicion who had not reported were asked whether they made plans for any additional care or services for the child in lieu of reporting. They were also asked to describe the outcomes of any special recommendations they made.
Trained interviewers from an independent survey research laboratory conducted the telephone interviews, using a structured format. To protect privacy, interviews were not audio-taped and clinicians were asked to avoid using patient identifiers. Interviewers entered data directly into a computerized database, omitting any identifying responses that were released inadvertently.
Data were analyzed for frequencies by using SAS 9.1 (SAS Institute, Cary, NC).
Telephone interview data were analyzed with ethnographic techniques by Dr Jones, a qualitative analyst.6–8 A code dictionary was developed by following 3 preidentified key phases in CA decision-making, that is, (1) assessment and evaluation of the child; (2) identification and diagnosis of the cause of the injury; and (3) care of children with an injury having any level of suspicion for physical abuse, including decisions about reporting or alternative management.9 The interview data were coded by using this guide and were categorized in line with these phases. Major themes and subthemes were identified within each sample stratum related to suspicion and management. To understand how these themes influenced decision-making and management, we examined differences in theme emphasis and frequency across sample strata. Construct validity of predetermined and emergent themes was established through review by the CARES steering committee. Intercoder reliability was established through adjudication by the CARES steering committee.7,8
Factors Influencing Decisions to Report or Not to Report to CPS
Several themes that described clinicians’ decision-making regarding whether to report suspected abuse to CPS emerged. These themes were grouped into 4 main categories, which focused on clinicians’ (1) familiarity with the patient or family, including any previous involvement of the family with CPS; (2) reference to elements of the case history; (3) use of available resources; and (4) perceptions of anticipated outcomes of CPS intervention.
Familiarity With Patient or Family
Many clinicians discussed their familiarity/unfamiliarity with a family in describing their decision-making processes about the injuries they evaluated. These references are categorized and compared in Table 2.
Relationship With Family
The majority of clinicians (27 of 39 clinicians) who reported an injury mentioned they had little familiarity with the family or did not comment on their familiarity with the family in describing their consideration of a case. In a few cases, clinicians who reported injured children to CPS based these reports in part on their knowledge of the family. They described family stresses (eg, ongoing divorce proceedings) or previous concerns about the family that influenced them to report the current injury.
In contrast, most clinicians (10 of 12 clinicians) interviewed about high suspicion/not reported injuries described their familiarity with the family and/or the family's previous attention to health supervision visits. They cited their familiarity with the family as their reason for not reporting. Familiarity did not emerge as a major theme for the some suspicion/not reported cases.
Knowledge About Previous CPS Involvement
Of the 39 clinicians who reported to CPS, 11 (28%) mentioned previous suspicions (9 with suspicions of abuse and 2 with questionable/unclear previous history) and 6 mentioned previous CPS involvement. In contrast, few of the clinicians discussing high suspicion/not reported injuries described knowing that the family and/or child had previous interactions with CPS, and less than one third of those clinicians discussed any previous suspicious history. In 3 of 12 cases, the clinician specifically stated that there was no history of previous suspicious injuries. In cases of some suspicion/not reported injuries, 2 of 24 clinicians reported that the family had previous or ongoing involvement with CPS.
Six case-specific elements were used by clinicians to describe their decision-making process, including (1) history provided was not consistent with the injury (“… don't see how [the child would] get injury like that from a coffee table”); (2) lack of explanation given for the injury (“if I see an unexplained skull fracture in a 1-year-old, that is child abuse until proven otherwise”); (3) injury pattern (“there was an outline of fingers in the bruise”); (4) previous injuries (“repeated little injuries that no one is able to explain”); (5) exclusion of other medical diagnoses (“I conducted these tests … and I had no other explanation for this [bruise]”); and (6) delay in seeking care (“the family did not seek any medical care until 4 weeks after [the injury]”).
Of clinicians who reported cases, most (23 of 39 clinicians; 59%) cited ≥2 case elements in their decision-making. In contrast, clinicians discussing high suspicion/not reported cases mentioned only 1 (n = 7) or no (n = 6) case-specific elements when discussing factors related to their decision-making. Clinicians with some suspicion about an unreported injury also tended to weigh ≥2 case elements.
Some clinicians discussing some suspicion/not reported cases mentioned the timing of medical care in their interviews. When parents promptly sought care for a child's injury, the clinicians indicated that this prompt response decreased their suspicion that the injury was caused by CA.
Use of Available Resources
Except for the 3 clinicians who did not respond to this question, all clinicians in this subsample reported some access to consulting colleagues in their practice and/or specialists outside their practice. Although 82% of the clinicians who reported injuries used a resource, only 18% of the clinicians who had high suspicion but did not report used another resource. One clinician who did not report an injury indicated to have high suspicion discussed consulting with both a social worker and another physician in the practice and receiving reassurance about not reporting. Another clinician who did not report a case with some suspicion was reassured after consulting another clinician who was more familiar with the family. Several clinicians who treated fractures described discussing the injuries with an orthopedic surgeon. In some of those cases, the clinicians received reassurance that the injury was likely accidental; in other cases, the orthopedic surgeon agreed with the decision to report.
Radiographic findings seemed to play a role in some decisions; several clinicians were reassured and decided not to report when no fracture was found. Two clinicians referred children with high suspicion injuries to emergency or urgent care settings and said that those children were reported to CPS after radiographs were taken.
Anticipated Outcome of CPS Intervention
In reaching patient management decisions, clinicians routinely consider the likely outcomes of alternative strategies. In this study, some clinicians reported that they decided not to report because they anticipated negative child or family consequences of a report (Table 3). Conversely, the majority of clinicians who reported the 39 cases of suspected CA indicated on the report follow-up form that the child (n = 21) and/or family (n = 15) would benefit from their report to CPS. Although clinicians could indicate >1 outcome, a minority of clinicians (16 of 39 clinicians) who reported suspected abuse indicated that they anticipated a negative outcome (“nothing will change,” n = 12; “child will be hurt,” n = 2; “family will be hurt,” n = 3).
Alternative Management Plans
Many clinicians who were suspicious and decided not to report suspicious injuries used an alternative management strategy (Table 4). Clinicians who provided active case follow-up management either assumed primary responsibility for follow-up management or assigned this responsibility to another professional. Informal case follow-up management relied on the clinician's relationship with the family and a heightened awareness to watch for other injuries.
Clinician Explanation of Decision Not to Report High-Suspicion Injuries
When some clinicians were interviewed 6 weeks after the index visit, they minimized or negated their initial opinion that the injury was likely or very likely caused by abuse (high suspicion but not reported). For example, they stated, “this doesn't seem like an abuse problem” or “no other reason to suspect abuse” or “not so much suspicion as a possibility.”
Clinicians sometimes referred to factors that served to temper their initial perspective. For example, familiarity with the family either was used to change an original decision or was added to a perspective to explain a decision. For example, “if I had been an ER doctor I would have contacted social services—knowing the family is why I didn't make a formal report … [I] reached my decision based on knowing the family well.” In some cases, they referred to case specifics or lack of case specifics when explaining their decision to not report, for example, “… no other previous suspicious episode—main concern was that a couple of days elapsed—no other evidence to suggest that this was anything more” or “I made a decision to not report because the injury was not very suspicious.” Sometimes the clinician's expectations of the CPS response seemed to outweigh the “troubling” case-specific elements, for example, “the bruises were in an area where he would not be landing if he did trip and fall. I just couldn't attribute them to the story that he presented with … I knew it would get screened out [by CPS].”
Some clinicians indicated that their alternative management would be superior to CPS intervention as their reason for not reporting. For example, a clinician stated, “I felt that the level of support services the clinic would offer could have been more than what CPS could do.”
Key Aspects of Decision-Making Process
This qualitative study reports the decision-making processes that clinicians use when they suspect that their patient might have been physically abused, which illuminates the quantitative analysis of CARES data.1 CARES showed that practitioners do not always report injuries that they suspect are likely caused by abuse. In describing their own decision, clinicians cited 4 key aspects of the decision-making process, that is, (1) the clinician's familiarity with the family, (2) elements of the case history, (3) the use of available resources, and (4) the clinician's experience-based expectations of the CPS response. Decision-making processes related to reporting were complex, and clinicians weighed many factors when deciding whether to report a suspicious injury. Some themes are particularly important.
Relationships With Families in Primary Care
The clinicians frequently cited their familiarity with the family as their reason for not reporting and even as a reason for amending their initial suspicion of abuse. Provider knowledge of the family's circumstance may play a dual role regarding the reporting decision; a good relationship makes the provider reluctant to report, whereas knowledge of family risks may increase the likelihood of reporting.
Use of Consultants
We hypothesized that reporting suspected abuse would make clinicians uncomfortable and they would seek expert advice to support their decisions. In previous studies, clinicians indicated that they had not reported all suspected CA because they were “not certain” that the child had been abused.2,3,5,10 Two findings of our study suggest that clinicians may struggle more with a decision to report than with a decision to not report suspicious injuries. First, clinicians who reported suspicious injuries often cited specific elements of the case that justified their decision to report, compared with clinicians who did not report. Second, clinicians often consulted with other professionals before reporting. This finding suggests that clinicians seek additional support to reinforce their decision to report suspected abuse to CPS.
In contrast, those who chose not to report often mentioned concerns related to the child protection system. Many expressed concern that their own ability to continue to monitor the child would be compromised if the child was reported. Those who decided not to report might have been more confident in their own judgment or simply less willing to discuss their decisions with others because of the legal obligation to report.
Doubts About Benefits of Reporting
Participating clinicians considered projected child-level outcomes, including their own estimations of how CPS would respond, in reaching their decisions. For some clinicians, anticipated negative patient outcomes of reporting seemed to outweigh the legal mandate to report injuries from suspected CA to CPS.11 These findings are consistent with those from a survey of mandated reporters that found that the respondents were more concerned about the outcome of a report and whether the child and family would benefit. Those respondents indicated that their principal reasons for reporting suspected abuse to CPS were to stop maltreatment and to help the family and that those factors were more salient than the legal mandate to report.12 In particular, primary care clinicians avoided reporting cases that they thought CPS would dismiss without investigation, viewing the risk of reporting as most salient. The expectation of negative outcomes was guided by clinician experience with responses to previous cases, which in effect set a level of suspicion at which to report.
Most primary care clinicians have personal experiences with a relatively small number of cases and may receive little substantive feedback after reporting, which makes it difficult for them to predict how CPS would respond to a particular case. Additional study is needed to determine whether reporting might be improved through more reliable and detailed feedback from CPS.
Explaining Unreported Cases
During the telephone interview, clinicians sometimes opined that a child's injury was not caused by CA, thus contradicting the suspicions they recorded on the injury encounter card. This apparent contradiction may reflect the clinician's cognitive dissonance13–15 (ie, processes that may occur when 2 conflicting cognitions/beliefs are held). Such a conflict may arise when clinicians suspect that an injury was caused by CA and they know that they are mandated reporters but they choose not to report. The clinician may take steps to reduce this internal conflict by negating or modifying one of the cognitions or by adding a new one. Therefore, cognitive dissonance, created by the initial suspicion coupled with the decision not to report, might have motivated a change in the initial belief about whether the episode was highly suspicious for CA. There was evidence of this phenomenon in our telephone interviews, including both rethinking of the likelihood of abuse and the addition of another belief, namely, that adequate protective measures were in place through their own monitoring of the situation.
This report includes only cases in which the clinician suspected abuse. The telephone interviews relied in part on the clinicians’ recollections of their decision-making several weeks after the index visit, and their recollections might have been inaccurate. Although the number of telephone interviews was limited, the number of interviews conducted was sufficient for the use of qualitative analytic tools to describe the central themes underlying clinician decision-making. Although percentages were presented to illustrate the spectrum of responses, quantitative analysis of this sample was not possible.
The decision regarding whether to report a suspicious injury to CPS is a complex judgment for primary care clinicians. Their decisions are based not only on clinical factors but also on the clinician's previous interactions with the family and CPS, available resources, and perceptions of what constitutes appropriate case management. The data suggest that clinicians sometimes find themselves in the position of bearing a legal requirement to report suspicious cases that, on the basis of previous experience, they expect CPS will neither investigate nor manage to benefit the child or the family. As in most medical decisions, clinicians weigh the likely costs and benefits of reporting a case and apply lessons learned from previous experience. Clinicians assessing the risks and benefits of reporting suspicious cases may rationally conclude that the best course of action lies in not reporting. Many clinicians developed alternatives to reporting, the effectiveness of which is not known. Future analyses, based on interviews conducted 6 months after the index visit, will examine the results of these efforts.
This study, together with the accompanying article reporting on the practices of the full CARES sample,1 suggests that the interface between primary care clinicians and CPS agencies requires renewed attention, in terms of both research and programming. This study suggests that future clinician education efforts may need to include helping clinicians assess risks and benefits of reporting to CPS. More research is needed to determine whether improved feedback from CPS would result in more-accurate clinician reporting of suspected CA.
This study was funded by the Agency for Healthcare Research and Quality (grant R01 HS010746), the Maternal and Child Health Bureau (grant R40 MC 00107), and the American Academy of Pediatrics.
This is a report from the Pediatric Research in Office Settings network and the National Medical Association Pediatric Research Network. The participating pediatric practices that agreed to be listed (45% of the participating practices either did not respond to a query about listing or asked not to be listed) are shown according to American Academy of Pediatrics chapter, as follows: Alabama: Physicians to Children (Montgomery); Alaska: Anchorage Pediatric Group (Anchorage); Arizona: Mesa Pediatrics Professional Associates (Tempe), Orange Grove Pediatrics (Tucson); California-1: Rowe, Maisel, Heath and Harvey (Greenbrae), Shasta Community Health Center (Redding), Pediatric & Adolescent Medical Associates of the Pacific Coast (Salinas); California-2: practice of Bharati Ghosh, MD, FAAP (Montclair), University of California, Los Angeles, West Los Angeles Office (Los Angeles), Inland Empire (Riverside); California-4: Southern Orange County Pediatric Associates (Rancho Santa Margarita), Edinger Medical Group (Fountain Valley); Colorado: Cherry Creek Pediatrics (Denver), Rocky Mountain Youth Clinics (Thornton); Florida: Giangreco, Scarano & Taylor Pediatrics (Bradenton), Atlantic Coast Pediatrics (Merritt Island); Georgia: The Pediatric Center (Stone Mountain); Hawaii: Children's Medical Association (Aiea), practice of Christine S. Hara, MD (Honolulu), Island Pediatrics (Hilo); Illinois: Fairview Pediatrics (Grayslake), Kidz Health (Chicago); Indiana: Jeffersonville Pediatrics (Jeffersonville); Kansas: Ashley Clinic (Chanute); Kentucky: Pediatric & Adolescent Medicine (Lexington), practice of Carl E. Smith, MD, FAAP (Harlan); Massachusetts: Baystate Pediatric Group (Springfield), Jonathan A. Benjamin, MD, and Roger W. Spingarn, MD, LLC (Newton Center), Northampton Area Pediatrics (Northampton), Pediatric Associates of Norwood & Franklin (Franklin), Holyoke Pediatric Associates (Holyoke), Tri-River Family Health Center (Uxbridge); Maryland: Shady Side Medical Associates (Shady Side), Children's Medical Group (Cumberland), Potomac Pediatrics (Rockville), practice of Steven E. Caplan, MD (Baltimore); Maine: Maine Coast Pediatrics (Ellsworth), Kennebec Pediatrics (Augusta), InterMed Pediatrics (Portland); Michigan: Kidz 1st Pediatrics (Rochester Hills), Orchard Pediatrics (West Bloomfield), Children's Health Care of Port Huron, PC (East China), Children's Hospital of Michigan (Detroit); Minnesota: Brainerd Medical Center (Brainerd); Missouri: Priority Care Pediatrics (Kansas City); North Carolina: Elizabeth Pediatrics (Charlotte), Eastover Pediatrics (Charlotte); North Dakota: Medical Arts Clinic-TMC (Minot), MeritCare Medical Group-Pediatrics (Fargo); New Hampshire: Dartmouth-Hitchcock Clinic (Keene); New Jersey: Chestnut Ridge Pediatric Associates (Woodcliff Lake), Delaware Valley Pediatric Associates (Lawrenceville); New Mexico: Albuquerque Pediatric Associates (Albuquerque), University of New Mexico Hospital (Albuquerque); New York-1: Lewis Pediatrics (Rochester), Elmwood Pediatric Group (Rochester), Outer East Side Health Clinic (Buffalo), State University of New York Upstate Medical University (Syracuse); New York-3: St Barnabas Hospital (Bronx); Ohio: Oxford Pediatrics & Adolescents (Oxford), Children's Choice Pediatrics (Stow), Pediatric Associates of Lancaster (Lancaster), practice of John DiTraglia, MD (Portsmouth), South Dayton Pediatrics (Dayton); Oklahoma: Norman Pediatric Associates (Norman), practice of Patrice A. Aston, DO (Oklahoma City), Shawnee Medical Center Clinic (Shawnee); Pennsylvania: Reading Pediatrics (Wyomissing); Rhode Island: Rainbow Pediatrics (Providence), practice of Marvin Wasser, MD (Cranston); South Carolina: Barnwell Pediatrics (Barnwell), Palmetto Pediatrics & Adolescent Clinic (Columbia); Tennessee: Plateau Pediatrics (Crossville); Texas: practice of Sarah L. Helfand, MD (Dallas), Winnsboro Pediatrics (Winnsboro), Building Block Pediatrics (Pleasanton); Utah: University Health Care (Salt Lake City), Mountain View Pediatrics (Sandy), Utah Valley Pediatrics (American Fork); Virginia: Pediatrics of Arlington (Arlington), Alexandria Lake Ridge Pediatrics (Alexandria); Vermont: St Johnsbury Pediatrics (St Johnsbury), Hagan & Rinehart Pediatricians (South Burlington), Pediatric Medicine (South Burlington); Washington: Harbor Pediatrics (Gig Harbor); Wisconsin: Gundersen Lutheran Pediatrics (La Crosse), Beloit Clinic (Beloit); Wyoming: Jackson Pediatrics (Jackson). National Medical Association Pediatric Research Network practices (listed here by state) are as follows: Florida: Arlene E. Haywood, MD (Plantation); Maryland: Cambridge Pediatrics (Waldorf). The listing of participants’ names does not imply their endorsement of the data and conclusions.
- Accepted November 27, 2007.
- Address correspondence to Emalee G. Flaherty, MD, Children's Memorial Hospital, 2300 Children's Plaza, Box 16, Chicago, IL 60614. E-mail:
The authors have indicated they have no financial relationships relevant to this article to disclose.
What's Known on This Subject
Primary care clinicians evaluate childhood injuries they suspect were caused by child abuse. They do not report all suspicious injuries to child protective services, even injuries they indicate were likely or very likely caused by child abuse.
What This Study Adds
This study adds detailed information about factors that influence clinicians to report suspected child abuse to child protective services, alternative management strategies they may use, and how they explain decisions not to report very suspicious injuries.
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- Copyright © 2008 by the American Academy of Pediatrics