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More Than a Feeling?: Physician Self-Confidence and Response to a Standard Child Abuse Vignette

M Trowbridge 1, E Flaherty 2, L Price 1, K OConnor 3 and R Sege 1. 1Pediatric and Adolescent Health Research Center, Floating Hospital for Children at Tufts-NEMC, Boston, MA; 2, Childrens Memorial Hospital at Northwestern University, Chicago, IL and 3Division of Health Policy Research, AAP, Elk Grove, IL.

Background: Child abuse detection and management is a complex and difficult process in primary care. Although pediatricians vary in their identification and management of suspected child abuse, little is known about their decision-making process.

Objective: Identify physician factors that affect (a) assessment of likelihood of abuse in a standard child abuse vignette and (b) the decision to report suspicious cases to child protective services(CPS).

Design/Methods: AAP Periodic Survey #55 was sent to a random sample of 1,603 active United States AAP fellows from Oct 2002 to May 2003 (response=851, 53%). The survey included 5-point Likert scale items that measured attitudes and experiences surrounding management of child abuse as well as a purposefully ambiguous clinical vignette with a patient suspicious for abuse. Respondents were asked to rate the likelihood of the vignettes injury resulting from abuse (1-5) and whether they would report to CPS (y/n). For analysis, only physicians who had completed residency and currently provided direct patient care were included (n=668). Utilizing factor analysis, three scales (self-confidence in management of child abuse, perceived value of CPS, and attitude regarding role of pediatricians in abuse prevention) were created from the survey responses. Decision-making was evaluated using these scales as well as assessment of local CPS services, years since residency, child abuse CME in last 5 years (y/n), and sub-specialist vs general pediatrics. Association with vignette responses was tested using logistic regression and proportional odds modeling.

Results: A range of vignette responses were recorded (Table). Higher self-confidence in management of child abuse was associated with 1) higher perceived likelihood of abuse in the vignette (p=.004) and 2) higher likelihood of reporting case to CPS(p=.005). No other tested variables demonstrated significant univariate or multivariate association with vignette responses.

Responses to Standard Child Abuse Vignette
Likelihood Injury in Vignette Caused by Abuse
Report to CPS:​ ​Very Likely/
​Possible Unlikely/
Very Unlikely
210 (94%) 197 (61%) 2 (5%)
​13 (6%) ​125 (39%) 35 (95%)

Conclusions: There is substantial variability in level of suspicion for abuse that leads to reporting. Self-confidence in management of child abuse is a predictor of pediatricians likelihood to suspect and report abuse.

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