Awareness and knowledge of child abuse amongst

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Key words: Child abuse, awareness, physicians, survey,. Austria. Introduction ... were, to a large extent, based on annual criminal statistics, which in 2008 .... Fisher's exact test where appropriate; multiple answers in Table 3 ... age was 48.6 years (SD = 7.3). Participants' ..... cantly performed better in a knowledge quiz. As.
original article

Wien Klin Wochenschr (2011) DOI 10.1007/s00508-011-1579-2 © Springer-Verlag 2011 Printed in Austria

Wiener klinische Wochenschrift The Central European Journal of Medicine

Awareness and knowledge of child abuse amongst physicians – a descriptive study by a sample of rural Austria Christoph Kraus1, Elisabeth Jandl-Jager2 1 2

Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria Department of Psychoanalysis and Psychotherapy, Medical University of Vienna, Vienna, Austria

Received August 10, 2010, accepted after revision April 5, 2011, published online May 4, 2011

Wahrnehmung von Kindesmisshandlung bei Ärzten – anhand einer Studie im medizinischen System Österreichs Zusammenfassung. Diese Studie mit eigens ausgewählten Ärzten hat zum Ziel, das Wissen über und die Wahrnehmung von Kindesmisshandlung im medizinischen System Österreichs zu erheben. Zwei Drittel aller Teilnehmer bestätigten Kontakt mit misshandelten Kindern im Laufe ihres Berufslebens, wohingegen 87.3 % keine vorhergehende Ausbildung diesbezüglich angeben. Kinderärzte nahmen misshandelte Kinder signifikant häufiger wahr (p = 0,021) und besaßen signifikant mehr themenrelevante Ausbildung (p = 0,012). Die vorliegenden Ergebnisse lassen darauf schließen, dass Ärzte in ländlichen Regionen Österreichs zwar ein Grundwissen über das Erkennen und die Behandlung von Kindesmisshandlung haben, jedoch weitere Ausbildung und Spezialisierung benötigen um Diagnoseprozesse zu erleichtern, Meldungsraten zu erhöhen, Zusammenarbeit mit anderen Spezialisten zu verbessern und Ängste im Umgang mit misshandelten Kindern zu verringern. Österreich ist ein reiches Land mit einem ausgezeichneten Gesundheitssystem und konkurrenzfähigen Forschungsstrukturen, in der Forschung zu Kindesmisshandlung müssen jedoch noch Rückstände zu gegenwärtigen internationalen Entwicklungen aufgeholt werden. Summary. This study with a selected sample of physicians was conducted to assess their awareness and knowledge of child abuse. Two thirds (66.7%) of all participants confirmed contact with obviously abused children in the course of their professional life, whereas 87.3% did not report any prior education or training in that field. In relation Correspondence: Christoph Kraus, MD, Department of Psychiatry and Psychotherapy, Medical University of Vienna, Waehringer Guertel 18–20, 1090 Vienna, Austria, E-mail: [email protected] wkw 2011 © Springer-Verlag

to general practitioners, pediatricians had significantly more contacts with abused children (p = 0.021) and more prior education (p = 0.012). Results indicate that physicians in rural regions of Austria possess basic knowledge. Better training and further specialization is needed to facilitate diagnosing, enhance reporting, strengthen cooperation with experts and reduce fears when handling abuse victims. Austria is a rich country with excellent health care and competitive research structures. However, child abuse research in Austria still has to fill gaps in order to keep up with international developments. Key words: Child abuse, awareness, physicians, survey, Austria.

Introduction Lack of child abuse research in Austria

The publication of medical guidelines describing the diagnosis and handling of abused children draws a clear picture of deficits in Austrian child abuse research. The American Medical Association published and distributed the first guideline in 1992. Out of all German-speaking countries (Switzerland in 2000, Germany in 2000) Austria was the last country to publish guidelines of that kind in 2008. Measured by total health expenditures per gross domestic product, Austria ranks top five in OECD listed countries and is known for a highly developed health care system. In that regard, research about child abuse in Austria is unsatisfactory and has to fill gaps to keep up with international developments. Notably, in November 2009, the American Board of Pediatrics implemented a new subspecialty called “child abuse pediatrics”. Moreover, publication statistics shows that child abuse research in German speaking countries has to make up ground in comparison to other countries. Herrmann points out that during the last 20 years five articles about sexual abuse and almost 20 about physical abuse were Awareness and knowledge of child abuse amongst physicians

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published in the official journal of the German Pediatric Association. During the same period the American journal “Pediatrics” by the American Academy of Pediatrics lists up to 200 articles in this field [1]. National data on child abuse in Austria exists, but is rare and not up to date. A national child abuse agency has not yet been founded; research therefore depends on ambitious experts, private organizations and governmental institutions, which all act independently from each other. Additionally, the in-depth governmental report on violence against children by the Austrian Institute for Family Studies postulates a large number of unknown cases in Austria [2]. In fact, epidemiological research in all Germanspeaking countries delivers unsatisfactory data, which makes comparability difficult. National prevalence data were, to a large extent, based on annual criminal statistics, which in 2008 shows rates of 0.527/1000 for physically assaulted children less than 10 years old, 0.085/1000 for neglected children less than 18 years old and 0.273/1000 for sexually abused children under 14 years old (figures were provided by the Austrian Federal Criminal Police Office as of 2008). Criminal statistics poses an insufficient source for various reasons. The report by the Institute for Family Studies summarizes experts stating that crime statistics tends to underreport the overall number. According to them, the rate of reporting is indirectly proportional to social closeness of the perpetrator, lower social classes are more likely to be targeted by police and young age groups are underrepresented, because their testimonies are deemphasized by poorly trained personnel [2]. More reliable data on prevalence provide a sample of American adults (n = 1442) in which approximately 32.3% (n = 152) of females and 14.2% (n = 66) of males reported childhood sexual abuse; 22.2% (n = 103) and 19.5% (n = 92) of males and females, reported childhood physical abuse, which leads to an overall rate of 37% of all investigated subjects (n = 345), who were either confronted with physical or sexual abuse. Approximately 21% of those were exposed to both physical and sexual abuse [3]. The authors did not find any comparable Austrian research or data on local risk factors, awareness or prevention. However, a calculation by the Austrian Institute for Conflict Research found that consequential costs of domestic violence in total account for 78.4 million euro per year [4]. To sum up, it can be stated that in relation to research fields examining health issues with equal prevalence rates, such as child oncology, child abuse research plays a too insignificant role in Austria.

Physical abuse

Definitions of abuse types for further Austrian research

Investigated population

Interindividual and intercultural understandings of what is violence and what is not, lead to confusion [5]. Wide definitions could include a too large section of society, whereas narrow definitions make a too small description of the phenomenon [6]. For the sake of clarity and for a collection of definitions for further Austrian research, we list understanding of violence forms, which are compatible with Austrian moral, societal and legal demands.

Presumably, physicians in regions that are well serviced in regard to health care have better knowledge, since they are closer to specialized centers, receive more education by specialists and are part of tighter networks, hence know more about child abuse. Consequently, we investigated a region, in which health care density, actuality, and networking with other professions were potentially low. On that score we selected a sample of physicians in one of Austria’s most medical understaffed rural areas. In that region the number of gynecologists, pediatricians and general practitio-

Awareness and knowledge of child abuse amongst physicians

Physical abuse is every non-accidental infliction of harm to children by others [7]. Psychological abuse

Any enduring, recurring inadequate attitude from the parent or caregiver toward the child, which harms its creative potential and mental abilities, can be seen as psychological abuse [8]. Parental behavior, which is inadequate for the child’s development, can cause psychological harm for instance: overprotection, excessive demands or criminalizing, traumatizing and depriving access to education or similar needs [9]. Sexual abuse

Sexual abuse is the exploitation of children for the sexual satisfaction of adults [10]. Sexual abuse overlaps with other forms of abuse, because a sexual aggressive act may cause harm to the body as well as damage to the psychological integrity. Neglect

A child has the right to receive and the parents have the duty to provide: food, clothes, shelter, safety, care and education. If one of these basic needs is not fulfilled a child is neglected [7].

Objectives The idea for the study originated from observations in psychotherapy at the Medical University of Vienna. A large number of patients, who reported child abuse experiences, said that although they had frequent contacts with physicians, their fate was not disclosed then. Our aim was to investigate the role of physicians in child abuse cases. Physicians in various fields are often the only occupational group in contact with children before they enter kindergarten or day care. In this period of life, physicians play a key role in identifying children at high risk. To assess knowledge about child abuse, we measured knowledge about epidemiology, risk factors and diagnostics as well as cooperation in a sample of physicians in a medical understaffed region. Thus we expected to clarify the role of physicians in an area with potentially low knowledge, up-to-dateness and interprofessional cooperation.

Methods

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Table 1. Number of medical doctors per inhabitants Speciality

Investigated region

Second weakest region

Austria

Gynecology*

0.113

0.185

0.187

Pediatrics*

0.092

0.128

0.136

General medicine*

0.124

0.108

0.153

All medical doctors**

271

1,282

38,313

*N/thousand inhabitants; **N total; Source Austrian Medical Association and Federal Institute for Statistics, as at 2007.

ners per 1000 inhabitants was either the lowest or among the three lowest in Austria (Table 1). Together with a return envelope and an accompanying letter, a structured questionnaire was sent to all general practitioners, pediatricians and gynecologists in that region located in the eastern part of Austria. The local federal medical association granted permission and provided addresses of physicians. These specialists were chosen because of their role as local first responders in child abuse cases [11]. To enlarge the number of return, all physicians were asked by telephone three weeks later if they had filled out and sent back the envelope.

Survey tool

found and used for adjusting questions and answers to evidencebased standards. Two questions demanded numbering depending on importance; two questions were Likert-scale like. In total the questionnaire contained 29 items, structured as follows: 1. Sociodemographic questions: sex, age, children, year of specialty training completion, child abuse training and self-assessed level of information. 2. Epidemiology: prevalence number of physical abuse, prior contact with abused children. 3. Diagnostics: symptoms, risk factors, sexually transmitted diseases, education style, forensic securing of evidence, formulation of reports. 4. Patient management: interprofessional cooperation, documentation, reasons for not speaking out in the case of a suspicion, contact details of other professionals in child welfare, information brochures and secrecy obligation. 5. Personal attitude toward corporal punishment. To enhance questionnaire processing, easy questions were alternated with more complicated ones. Questionnaires were piloted with a number of general practitioners and experts on child abuse at the Medical University Vienna. Readability and content were improved afterward. A version of the questionnaire is available from the authors on request.

Statistics

The survey was conducted with a self-developed questionnaire containing 29 items, which was sent by mail to 158 physicians. Sending a postal questionnaire was meant to avoid the excuse that a candidate had no time for an interview; also reaching physicians in remote regions was easier. The survey started in June 2007 and ended in May 2008. To fulfill evidence-based standards, key information for question construction was taken out of international guidelines [12–17]. Additionally, literature was obtained in a database research in “Medline”, “Cochrane Library” and “Google Scholar” with a combination of the following key words: “maltreatment”, “child abuse”, “neglect”, “sexual abuse”, “emotional abuse”, “psychological abuse”, “violence – children”, “guidelines – child abuse”, “abuse – recognition”, “abuse – awareness”, “battered child syndrome” and “shaken baby syndrome”. Local university libraries were searched for topically related books. In total ca. 200 original articles, handbooks or presentations were

All returned questionnaires could be used for statistical processing, data referring to personal details were kept safe and questionnaires were anonymized before processing. Answers were used as far as possible or deleted. For statistical analysis SPSS version 15.0 for Windows (SPSS Inc., Chicago) was used. Frequencies were obtained with SPSS, where multiple answers were possible cumulative percentages may exceed 100%. Tables and figures were designed with Microsoft Excel 2008 for Macintosh. Ratios in subgroups were compared using Chi-square test (χ2) or Fisher’s exact test where appropriate; multiple answers in Table 3 were corrected with Bonferroni–Holm adjustment. The level of significance was set at 5%, therefore, a p-value ≤ 0.05 was considered significant. The institutional review board of the Medical University of Vienna approved the project plan including the questionnaire.

Results Table 2. Participants in the mail survey. Personal and professional characteristics (N = 63) Variable

Participants

All

GPa

PDa

GYNa

Received envelopes

N

158

129

13

16

Returned envelopes

N

63

44*

10*

9

Rates of return

%

39.9

34.1*

76.9*

56.3

Age

mean min max SD

48.6 32 69 7.3

48.3 32 69 7.6

49.4 43 59 5.5

49.1 41 68 8.3

Sex

N

m f

33 30

21 23

6 4

6 3

Children

N

yes no

56 6

38 5

9 1

9 –

Years in practice

mean

16.3

17.2

16.5

15.3

*Difference significant (p = 0.005; Fischer’s exact test, α = 0.05). aGP general practitioners, PD pediatricians, GYN gynecologists. wkw 2011 © Springer-Verlag

Of all 63 respondents, 30 were female, 33 male, the mean age was 48.6 years (SD = 7.3). Participants’ further demographic and personal descriptions are presented in Table 2. Overall rates of response were 39.9%, at the highest for pediatricians (76.9%) and the lowest for general practitioners (34.1%), which turned out to be significant in Fisher’s exact test (p = 0.005). Mean ages in all professions ranged between 48.3 and 49.4 years. Only general practitioners were gender balanced; pediatricians and gynecologists were predominantly male. Due to data privacy, no distinction between clinical and resident working physicians is presented. Individuals would become identifiable, as the number of clinically working personal is small in that area. There is no quantitative data on non-responding physicians except from mail addresses and statements given during follow up telephone calls. Awareness and knowledge of child abuse amongst physicians

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Table 3. Overview of all dichotomous answers Variable

GP/PDa

pc

GP/GYNa

pc

PD/GYNa

pc

Prior contact with abused children

N

yes no

25b/10 17b/0

0.021

25b/7 17b/2

NS

10/7 0/2

NS

Performed forensic securing of evidence

N

yes no

0/2 44/8

0.031

0/5 44/4

0.05, Fisher’s exact test). Recognition of symptoms and announcement of suspicion

Figure 1 shows details of physicians’ view of symptom importance. A majority of the participants identified “recurring hematoma” (47.6%, n = 30) and “unexplainable fractures” (57.1%, n = 36) as leading symptoms of child abuse out of six provided symptoms, which were all typical of abuse. “Growth retardation”, was crossed by 6.3% (n = 4) as important evidence. Additionally, pediatricians in relation to general practitioners (p = 0.038, Fisher’s exact test) and gynecologists asked parents more often about their education style (p < 0.001, Fisher’s exact test, significant after Bonferroni–Holm correction, Table 3). Participants were asked which two sexually transmitted diseases play the most important role after sexual abuse. The majority of all respondents (65.1%, n = 41) considered gonorrhea as the most important. Frequencies for others were: human-papillomavirus virus infections (49.2%, n = 31), herpes simplex type II, syphilis and trichomonades (each one 34.9 %, n = 22). Out of those 22 physicians, who crossed syphilis, everyone also crossed gonorrhea. More© Springer-Verlag 2011 wkw

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Table 4. Importance of risk factors Risk factor

Percentage of respondents (N = 63 )

Results from literature

1

OR

2

3

4

5

95% CI

Reference

1.29–7.45

[18]

(1 = most important, 5 = unimportant) Unwanted child

19

Abuse in parental history Financial distress

58.7 12.7

Organic developmental disorder Parental conflict

22.2 19 20.6

20.6 12.7 30.2

25.4 1.6 28.6

9.5

6.3

12.7

19

17.5

33.3

30.2

17.5

12.7

3.1a

7.9

a

3.6

n.a.

[19]

9.95

3.10–32.12

[20]

7.9

3.02

1.64–5.57

[18]

52.4

11.79

1.01–126.17

[18]

1.6

1.7

1.06–2.71

[18]

a

**Relative risk; Sexual only; n.a. not available. (For bold numbers see results and discussion sections.)

over, answer frequencies among specialties showed that all three groups considered gonorrhea as the most important sexually transmitted disease in sexually abused children. Subgroup analysis yielded that compared to general practitioners (χ2 = 5.453, p = 0.02) and gynecologists (χ2 = 6.3, p = 0.012) pediatricians more often chose human papillomavirus infection. Furthermore, in relation to general practitioners gynecologists were more likely to associate an infection with trichomonas vaginalis with sexual abuse (χ2 = 9.021, p = 0.011). After having a suspicion that a child might be abused, “fear of false accusation” is the most important reason (73%, n = 46) for not pursuing the issue further, followed by “knowing the parents personally” (34.9%, n = 22, see Fig. 1). An “unimportant” reason for not acting was “not enough time” (60.3%, n = 38) and “fear, patients could change their physician” (58.7%, n = 37). Cooperation with other professions

Responding physicians collaborated most frequently with federal youth agencies (65%, n = 41) and with the police (19%, n = 12), 27% did not have contacts with any professional organization. Collaboration was defined as any previous contact with other professionals in child welfare or child abuse specialists on the job during the physicians’ professional experience. In detail, 10 out of 10 pediatricians had previous contacts with federal youth agencies, significantly more than general practitioners or gynecologists (Fisher’s exact test, p = 0.015). Additionally, gynecologists had the highest rates of no contacts (44%, n = 4). General practitioners and pediatricians, as Table 3 shows, more often provide relevant material. As far as providing access to professional support is concerned, all professional groups, provided little. Pediatricians, however, make an exception; 5 out of 10 pediatricians provide access to professional support in child abuse issues, although not significantly more than other groups [18–20]. Asked whom physicians would call in an emergency 46% (n = 29) ticked that they would look up names and addresses of child abuse specialists in a telephone book, 31.7% (n = 20) had contact details available at their workplace and 17.5% (n = 11) could list name and address, 4.8% (n = 3) did not answer. If participants had to write a notification to other professions, they chose a rather compliwkw 2011 © Springer-Verlag

cated formulation. Instead of a universally understandable formulation like “many bruises” (34.9%, n = 22) a higher percentage (38%, n = 24) chose “multiple hematoma, painful on palpation” out of three pre-formulated answers. Of those who have already collaborated with youth welfare, the rate of those who chose the more complicated answer was higher (43.9%, n = 18). Level of education and personal attitudes

A vast majority 87.3% (n = 55) did not report education about abuse prior to the survey. Pediatricians made an exception; 4 out of 10 had prior education, which was significantly different to education levels amongst general practitioners (p = 0.012, Fisher’s exact test). Asked for an appraisal of their level of information, nobody declared himself “not well educated”, 30.1% ticked “not sufficiently educated”, 25.3% ticked “sufficiently educated”, a third (33.3%) claimed to be “well educated” and 9.5% meant he or she was “very well educated”. About half of all respondents 49.2% rejected corporal punishment (n = 31) under all circumstances, 38.1% (n = 24) stated that they would rather oppose corporal punishment, 11.5% (n = 7) would rather agree and one respondent fully accepted corporal punishment.

Discussion Summary of results and conclusions

In this group of physicians in one of Austria’s most medically understaffed regions, standards on child abuse based on guidelines and recent literature were investigated by a specially designed questionnaire. Results were processed quantitatively and groups were tested for differences. It is important to note that generalization is not justifiable, as this sample emerged out of a medical and psychosocial understaffed region. In view of this, conclusions should be drawn with regard to possible excessive demands and deficits in up-to-dateness amongst investigated physicians. However, our intention is that presented data draw the attention of professionals to child abuse research and serve as an initial spark for broader investigations in Austria. Our rate of return amounts to 39.9%, which is within the range of other methodically similar studies [21–23]. Apart from addresses, there is no quantitative data on the 60.1% Awareness and knowledge of child abuse amongst physicians

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Fig. 1. Importance ratings. Bubble sizes represent % of respondents; multiple answers possible. 1 = unimportant, 6 = very important

(n = 95) who did not return a questionnaire. Reasons for not participating can only be derived from telephone calls, which were conducted 14 days after sending questionnaires to remind physicians to take part in the survey. Lack of time, indifferent attitudes toward child abuse, and general refusal to fulfill studies were common statements given over the telephone. Surprisingly, the percentage of physicians (66.7%) who had contact with abused children during their professional career corresponds with international figures [24–27]. Our obtained rate of contacts depicts that cognition of abused children amongst Austrian physicians, even in a medically understaffed region, equal rates in other countries. Alternatively, as to our best knowledge no reliable epidemiologic data are available for the investigated area, this finding could be explained through high child abuse rates and, compared to better-educated physicians in other countries, lower recognition rates. A vast majority, 87.3% (n = 55), did not report education about abuse prior to the survey. Pediatricians were an exception (p = .012); 4 out of 10 had prior education. Asked for an appraisal of their level of information, out of all asked physicians, nobody declared himself “not well educated”, which we interpret as deficiency to admit ignorance in a highly knowledge dependable profession. Participants in our sample, except for some outliers, reject corporal punishment. Obviously physicians take their time in evaluating a potential abuse victim, as our findings show “not enough time” is no obstacle in reporting, according to our findings. However, this might be confounded by the fact that extra time was also needed for questionnaire handling and only

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those physicians with plenty of time sent back a questionnaire. Contrary to previous findings [28], “fear, patients could change their physician” was not an obstacle, which could be explained through the low density of physicians. It is striking that pediatricians were most eager to return questionnaires (100%) and general practitioners were least likely to do so (34.1%, p = 0.005), as demonstrated in Table 2. This is consistent with previous research [11, 29–32]. Moreover, as Table 3 shows, pediatricians reported the highest rate of contacts with abused children (100%), whereas general practitioners reported the lowest rate (56.8%, p = 0.005). To sum up, pediatricians in our sample had more contacts with abused children than general practitioners (p = 0.021), compared to gynecologists and general practitioners had a higher rate of prior education (p = 0.012), reported more contacts to other professional groups (p = 0.015) such as federal youth welfare or police, provided more often access to child abuse specialists (Table 3) and talked more often about education styles with parents (Table 3). Therefore, we conclude that as far as child abuse is concerned pediatricians in our sample are better educated, are more aware of abused patients, and loom large in child welfare networks. This finding is well established by previous literature. As Socolar previously found in a sample of 113 physicians who performed medical examinations on sexual abused children, linear regression analysis showed that specialization in pediatrics per se brought better knowledge about child abuse, opposed to family medicine or obstetrics/ gynecology (bcoeff = 1.09; t = 2.6; p > t = 0.01 [33]. Pediatric and family medicine residents as well outperformed sur© Springer-Verlag 2011 wkw

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gery residents in a knowledge test [32]. In another study, according to Badger, pediatricians are, due to their specialty, most frequently confronted with children and, therefore, the greater number of detected abused children is an artifact of a higher number of contacts with children [34]. Correspondingly, Starling et al. [29] investigated knowledge about child abuse with a self designed 24-itemknowledge test in a sample of 462 pediatricians, family medicine residents and emergency medicine physicians who were part of residency programs. According to them, training was highest among pediatricians and lowest at family medicine residents. Moreover, residents who participated in a larger child abuse-training program significantly performed better in a knowledge quiz. As pediatricians in our study were also more eager to cooperate, either because of motivational aspects or simply because of more time for completing a questionnaire, for future work we propose focusing on pediatricians. A reasonable approach would be the implementation of a diploma in child abuse pediatrics by the Austrian Medical Association, as they are already available for other specializations like psychosomatic medicine. Moreover, this first step would create essential experts for preventive measures like parenting programs, school-based or hospitalbased educational programs, which Macmillan and colleagues recently reviewed [35]. To further assess actual knowledge about child abuse, we provided risk factors, which were all valid risk factors for abuse taken out from literature sources. The strongest results were obtained for “violence in parental history” as the most important risk factor (58.7%) and “organic developmental disorder” as the least important risk factor (52.4% – see bold numbers in Table 4). Results show in addition that other provided risk factors were considered as medium important. Lisak found that the rate of victimized parents who pass violence on to their children was 38%, on the other hand, 70% of all perpetrators were abused in their childhood [36]. In that regard, others refer to a lack of study quality, however support a dysfunction transmission process in parenting [37]. In consideration of evidence that abuse in parental history is a very important risk factor [20], we hypothesize that physicians overestimate an inner family circle of violence and neglect other important risk factors like financial hardship. Additionally, we assume that physicians are not aware of resilient children [38, 39], as resilience is not part of the medical education. As far as children with organic developmental disorders are concerned, referring to Kvam, most studies propose a double or triple risk increase for sexual abuse [40]; Sobsey et al. cite studies suggesting handicapped children have increased risks for abuse in general ranging from 1.7 to 10 times [41]. Attributing “organic developmental disorder” as an unimportant risk factor, as the results show in Table 4, is therefore not reasonable. That finding indicates a lack of awareness of abuse of disabled children among investigated physicians. Abuse of handicapped children as well as abuse of the elderly is still a powerful taboo in Austrian society, apparently as well among physicians, so that this result is not astonishing.

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As far as symptoms are concerned, physicians in our sample know “hard signs” of child abuse, like hematoma and fractures (see Fig. 1). The most frequent sexually transmitted disease, gonorrhea [42], was also identified. Additionally, sub group analysis showed that gynecologists chose significantly more often “trichomonas vaginalis” (p = 0.011) and pediatricians “human papilloma virus” (p < 0.001). Obviously, only child abuse specialists treat sexually transmitted diseases in child abuse. Human papillomavirus (HPV), for instance, was considered more important (49.2%), although it is not [7]. We, therefore, propose that answer frequencies to that question should be regarded as minor important; it is stunning, however, that gonorrhea was correctly identified. A “soft” sign such as growth retardation, on the other hand, is less frequently recognized (Fig. 1). It does not directly point to abuse and requests more detailed knowledge. Furthermore, our results yield that diagnosing is affiliated with unease, as 72% of all respondents consider fear of wrongful accusation the greatest obstacle in reporting, which accords with previous findings [34]. We also found that in slightly more than one third of physicians in our sample (34.9%), a personal relationship with patients interferes with their decision to report. In our view, that finding has several implications for rural areas with small social structures, as is frequently the case in Austria. Gilbert et al. point out that knowledge of the family negatively affects reporting. Furthermore, according to Gilbert, a burden for pediatricians and primary-care physicians in recognizing is that although about 10% of children they see during one year might be exposed to maltreatment, only a few show injuries or physical symptoms [43]. Thus, physicians have to be aware of emotional and psychological symptoms. Based on their personal relationship, abusing parents have a better chance to persuade doctors that everything is fine with the affected child. Physicians might also be reluctant to report because they want to solve a case with the family by themselves, especially in rural settings, where violence against children is traditionally more accepted and child protection services are less known or considered as stigmatizing. Finally physicians personally related to an affected family might not want to expose their friends, either because of embarrassment or due to potential legal consequences for the perpetrator. On the other side, physicians might as well use their personal relationship for closer observation, education, early intervention or prolonged assessment. All in all, personal relationships, in our view, complicate processes of abuse clarification. Child abuse prevalence data are still unreliable for a broad number of reasons, which should not be further elaborated here. According to the U.S. Department of Health and Human Services [2], which collects nationwide case reports every year, prevalence rate for sexual abuse amounts to 0.806/1000 children. In comparison, the prevalence rates of sexual abuse in Austria are estimated at 0.19/1000 children [44], which approximate the number of criminal statistics in the investigated region (0.189/1000, as of 2009). Other official numbers are not available for the investigated region.

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A number of studies document a discrepancy between official numbers and data from epidemiological research [45–47]. Shaffer et al. argue that differences in study designs (prospective, retrospective or combined designs) are responsible for broad ranges [5]. The report on violence from the Austrian Institute for Family Studies emphasizes the unreliability of official numbers because of the estimated big dark field in Austria [2]. Nevertheless, we took a rate in a study by Briere and Elliott as a reference point, which suggests a prevalence rate of 37% for all forms of abuse, 23,3% for sexual abuse and 21% for physical abuse amongst a random, retrospective sample of 1442 American adults [3]. Additionally, to adjust to a nearly similar sociocultural region, we picked a study by Pfeiffer et al., which found a prevalence rate of 41% for all forms of abuse in families only among a sample of 16,100 German school children in 9th and 10th grade [48]. To meet unreliability of prevalence rates, we suggest that the answer to prevalence rates by physicians in our questionnaire should rather be interpreted as appreciation of the problem than evidencebased knowledge. Our findings show that a majority (65.1%) estimates overall abuse prevalence for physical abuse under 41%, most of the answers were given in the category 11–20%, the maximal number of respondents spread between 11 and 41% (n = 35), which agrees with findings from Briere and Elliott. However, these numbers reflect estimates and do not imply naturalistic prevalence, which could be a target of further evaluation as there are no current prevalence data in Austria. It is clearly the case that physicians only account for a small proportion of child abuse reports. Data from the U.S.A. and Austria correspond in this area. Medical personnel made out 8.5% of all reporters contributing to the National Child Abuse and Neglect Data System (n = 3,220,901) of the Children’s Bureau in the Administration of Children, Youth and Families part of the U.S. Department of Health and Human Services. Data from Vienna, since there is no nationwide reporting system in Austria, show that doctors account for 5% (n = 10,400) of all reports to the federal youth agency. Not only are the rates low, there is also growing evidence that physicians underrecognize and under-report child abuse victims [25, 43, 49, 50]. Zellmann proposed five important factors in decisionmaking. Thus, judgments are influenced by the seriousness of the incident, whether the incident should be labeled abuse or neglect, whether the law would require a report and whether the child and, separately, the rest of the family would benefit [51]. In an in-depth review, which is part of a series about child abuse, Gilbert et al. highlight that factors positively affecting clinical reporting include consultation with colleagues and other professionals. They emphasize factors that negatively affect reporting: knowledge of the family, expected negative outcomes of reporting to child-protection services, lack of confidence that reporting would improve patient outcomes, the hope that working with the family would resolve the issue would be preferable and concern that reporting would damage the clinician’s relationship with the family [52]. We propose that these factors should be taken into account for any fur-

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ther educational concepts. Regional boards on a regular basis consisting of child abuse professionals, representatives of local organizations, child welfare institutions and resident physicians would be an applicable model to strengthen child welfare in Austria’s rural regions. As a result, networks between child welfare professionals and other professionals involved in child abuse cases would be tightened and knowledge as well as up-to-dateness among all participants would be heightened. Especially pediatricians with special education like the aforementioned child abuse diploma would be valuable to regional boards. We could demonstrate that physicians sustain networks in child protection mainly with federal youth welfare and police. Almost one third of the respondents did not have contact with any other profession in child protection issues, which goes along with the number of those who did not recognize abuse cases during their professional life (Table 3). Pediatricians, compared to general practitioners or gynecologists, had a higher rate of contacts with youth welfare and the police. In our view those existing networks should be updated with further training and education. Most of the respondents (46%) would have to look up contact details in local telephone directories, which indicates, that amongst those physicians networks are not kept not on a regular basis. From 2008 on a newly published Austrian guideline [53] recommends that residents first assess the child’s level of danger, when necessary by supplementary home visits, which can be delegated to youth welfare upon request. Physicians are then explicitly prompted to evaluate if the child’s risk profile permits outpatient care or, in case of acute danger, requested to refer to a pediatric clinic with youth advocacy. Our data yield that in 2007/2008, before the distribution of the guideline, 9.5% of all physicians had previous contacts with hospital-based youth advocacies. In other words, of those physicians who had contact with abused children 57.2% never referred to clinical youth advocacies, but rather contacted federal youth welfare or the police. However, it is not clear, whether severity did not demand referral or if services were unknown to those physicians. Therefore, we propose an in-depth evaluation of the Austrian guideline. The presented results, especially data about cooperation could serve well as reference, because our data were recorded before the distribution of the Austrian guideline. Finally, considering presented evidence, we wish that treatment of child abuse victims and research projects in Austria will be equally funded as organic diseases with the same prevalence rates. Limitations

This study illuminates awareness and knowledge concerning child abuse in a sample of Austrian physicians. We have to report limitations concerning study design and outcome measures, which are likely to modify presented results. First, a broad non-responder analysis would be desirable to draw attention to reasons why 60.1% did not take part in the survey. As no quantitative data are known on non-responders, it is not clear whether and how results would differ with the inclusion of the non-responding © Springer-Verlag 2011 wkw

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group. Second, using a self-developed questionnaire exhibits risks of deficiency in validity, which was accepted, as no standardized questionnaire was available. Third, although desired in the beginning, limited resources made a larger cross-sectional design unfeasible, sample size therefore had to be kept small compared to similar studies [21]. However, we found one similar study, which also lacks a non-responder analysis and investigated smaller sample size [54]. Small sample size and no data on non-responder lead in fact to an impairment of study quality, nevertheless, our data of a selected sample serve well as a first-time exploration in Austria.

14. 15.

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Acknowledgment The authors thank Andreas Hahn, Georg S. Kranz, Markus Savli, Anna Höflich, Pia Baldinger, Jan Losak, Alexander Holik and Rupert Lanzenberger for support.

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Conflict of interest There is no conflict of interest to be reported.

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