Staff Responses When Parents Hit Children in a Hospital Setting.

OBJECTIVE: Physical punishment of children is a prevalent practice that is condemned by most medical professionals given its link with increased risk of child physical abuse and other adverse child outcomes. This study examined the prevalence of parent-to-child hitting in medical settings and the intervention behaviors of staff who witness it. METHOD: Staff at a children's medical center and a general medical center completed a voluntary, anonymous survey. We used descriptive statistics to examine differences in the experiences of physicians, nurses, and other medical staff. We used logistic regression to predict intervention behaviors among staff who witnessed parent-to-child hitting. RESULTS: Of the hospital staff who completed the survey (N = 2863), we found that 50% of physicians, 24% of nurses, 27% of other direct care staff, and 17% of nondirect care staff witnessed parent-to-child hitting at their medical center in the past year. A majority of physicians, nurses, and other direct care staff reported intervening sometimes or always. Nondirect care staff rarely intervened. Believing staff have the responsibility to intervene, and having comfortable strategies with which to intervene were strongly predictive of intervention behavior. Staff who did not intervene commonly reported that they did not know how to respond. CONCLUSION: Many medical center staff witness parent-to-child hitting. Although some of the staff reported that they intervened when they witnessed this behavior, the findings indicate that staff may need training to identify when and how they should respond.

Medical center staff attitudes about spanking.

Several medical professional organizations, including the American Academy of Pediatrics, recommend that parents avoid hitting children for disciplinary purposes (e.g., spanking) and that medical professionals advise parents to use alternative methods. The extent to which medical professionals continue to endorse spanking is unknown. This study is the first to examine attitudes about spanking among staff throughout medical settings, including non-direct care staff. A total of 2580 staff at a large general medical center and 733 staff at a children's hospital completed an online survey; respondents were roughly divided between staff who provide direct care to patients (e.g., physicians, nurses) and staff who do not (e.g., receptionists, lab technicians). Less than half (44% and 46%) of staff at each medical center agreed that spanking is harmful to children, although almost all (85% and 88%) acknowledged that spanking can lead to injury. Men, staff who report being religious, and staff who held non-direct care positions at the medical center reported stronger endorsement of spanking and perceived their co-workers to be more strongly in favor of spanking. Non-direct care staff were more supportive of spanking compared with direct care staff on every item assessed. All staff underestimated the extent to which their co-workers held negative views of spanking. If medical centers and other medical settings are to lead the charge in informing the community about the harms of spanking, comprehensive staff education about spanking is indicated.

Using simulation to identify sources of medical diagnostic error in child physical abuse.

Little is known regarding sources of diagnostic error at the provider level in cases of possible child physical abuse. This study examines medical diagnosis as part of medical management and not as part of legal investigation. Simulation offers the opportunity to evaluate diagnostic accuracy and identify error sources. We aimed to identify sources of medical diagnostic error in cases of possible abuse by assessing diagnostic accuracy, identifying gaps in evaluation, and characterizing information used by medical providers to reach their diagnoses. Eight femur fracture simulation cases, half of which were abuse and half accident, were created. Providers from a tertiary pediatric emergency department participated in a simulation exercise involving 1 of the 8 cases. Performance was evaluated using structured scoring tools and debriefing, and qualitative analysis characterized participants' rationales for their diagnoses. Overall, 39% of the 43 participants made an incorrect diagnosis regarding abuse. An incorrect diagnosis was over 8 times more likely to occur in accident than in abuse cases (OR=8.8; 95% CI 2 to 39). Only 58% of participants correctly identified the fracture morphology, 60% correctly identified the mechanics necessary to generate the morphology, and 30% of ordered all appropriate tests for occult injury. In misdiagnoses, participants frequently falsely believed the injury did not match the proposed mechanism and the history provided by the caregiver had changed. Education programs targeting the identified error sources may result in fewer diagnostic errors and improve outcomes. The findings also support the need for referral to child abuse experts in many cases.

Diagnostic agreement when comparing still and video imaging for the medical evaluation of child sexual abuse.

Still photo imaging is often used in medical evaluations of child sexual abuse (CSA) but video imaging may be superior. We aimed to compare still images to videos with respect to diagnostic agreement regarding hymenal deep notches and transections in post-pubertal females. Additionally, we evaluated the role of experience and expertise on agreement. We hypothesized that videos would result in improved diagnostic agreement of multiple evaluators as compared to still photos. This was a prospective quasi-experimental study using imaging modality as the quasi-independent variable. The dependent variable was diagnostic agreement of participants regarding presence/absence of findings indicating penetrative trauma on non-acute post-pubertal genital exams. Participants were medical personnel who regularly perform CSA exams. Diagnostic agreement was evaluated utilizing a retrospective selection of videos and still photos obtained directly from the videos. Videos and still photos were embedded into an on-line survey as sixteen cases. One-hundred sixteen participants completed the study. Participant diagnosis was more likely to agree with study center diagnosis when using video (p<0.01). Use of video resulted in statistically significant changes in diagnosis in four of eight cases. In two cases, the diagnosis of the majority of participants changed from no hymenal transection to transection present. No difference in agreement was found based on experience or expertise. Use of video vs. still images resulted in increased agreement with original examiner and changes in diagnostic impressions in review of CSA exams. Further study is warranted, as video imaging may have significant impacts on diagnosis.

Preliminary Development of a Performance Assessment Tool for Documentation of History Taking in Child Physical Abuse.

OBJECTIVES: This study aimed to develop a performance assessment tool for the history-taking components of the medical evaluation of physical abuse in young children by (1) determining the consensus-based injury history and social components for documentation, (2) identifying preliminary performance standards, (3) assessing current level-specific performance using the created tools, and (4) evaluating reliability and validity of the created tools. METHODS: The Physical Abuse Assessment Tool (PHAAT) was developed in 2 steps: (1) a modified Delphi survey was used to identify the injury history and social components for documentation in a medical evaluation for physical abuse, and (2) level-specific ("novice," "competent," "expert") practice standards (minimum passing scores) were created using the identified components via the Angoff method. To evaluate validity, reliability, and level-specific performance of the PHAAT, a chart review of 50 consecutive cases from each of the 3 levels was performed. RESULTS: Seventy-one child abuse pediatricians and 39 social workers participated in the modified Delphi survey, and 67 child abuse pediatricians and 27 social workers participated in the Angoff method. The resulting PHAAT included 2 checklists for use based on presence or absence of a history of an injurious event. One-way analysis of variance shows significant differences in performance based on team level (P < 0.001), indicating construct validity. Intrarater and interrater reliability evaluations showed strong (rs = 0.64-0.92) and moderate to strong (intraclass correlation coefficient = 0.81-0.98) correlations, respectively. CONCLUSIONS: Initial evaluation suggests the PHAAT may be a reliable and valid practice assessment tool for the medical evaluation of physical abuse.