Management of child maltreatment suspicions in general practice: a mixed methods study

Abstract

Background Maltreated children have many long-term consequences throughout their lives, but often maltreated children are not recognised in time by professionals. General practice could be central to the early recognition of child maltreatment due to the long-term relationship with families. Objective How do general practitioners (GPs) and practice nurses (PNs) deal with suspected maltreatment in children below 18 years of age, and which factors influence them to report cases to social authorities. Design and setting A mixed methods study set in general practice in Denmark. Method and subjects We combined data from a nationwide questionnaire with observations from five clinics and 20 interviews with GPs and PNs. We explored our data using the concept of uncertainty as a driver that shapes action and decision-making in general practice. Results Most GPs (94%) said they would discuss cases of suspected child maltreatment with social services, but in many cases they would prefer to discuss their suspicions with a colleague first (83%) – most likely where there are no clear-cut signs. The qualitative data added nuance to these findings by highlighting the difficulty of communicating across sectors, the importance of maintaining a connection with the child’s family, and practicing watchful waiting. Conclusion General practice has an opportunity to act early in cases of suspected child maltreatment if uncertainty is accepted as a critical part of the process of reaching a diagnosis. Communication across sectors is key, as is support for GPs with suspicions and for families in need of help. Key points GPs are often thought to underreport child maltreatment but despite low levels of reporting, this does not mean they ignore it. Building on the connection with the family, making follow appointments, and discussing suspicions with colleagues are typical of how GPs manage suspicions of child abuse. Accepting uncertainty as a condition of raising the alarm could help GPs to act quickly to support children at risk of abuse.

Extended prenatal and postnatal home visits in a vulnerable area in Sweden—a pilot study

“…An important success factor seems to be the collaboration between midwives, parent advisors, and child healthcare nurses [ 25 ]. The well-functioning family centre is an important meeting point that already before the start of the project included a maternal healthcare centre, the CHS, the social services, and an open preschool in one physical location [ 26 ].…”

Detecting and preventing child maltreatment in primary care and PHNs’ role—a cross-sectional study

“…Although our findings indicate a high level of availability and a strong commitment from PHNs, the Norwegian official reports contends that there are too few reports of child maltreatment and reported cases could have been detected earlier [ 34 , 35 ]. The thorough follow-up described by the PHNs may reflect concerns and uncertainty, which is considered a barrier in reporting child maltreatment [ 27 , 39 , 48 , 51 ]. A Danish study about management of child maltreatment suspicions in general practice found that GPs and practice nurses often felt left to themselves managing their suspicions, especially in cases without clear signs and emphasized the importance of scheduling new appointments as a strategy to track the child's progress and maintaining a relation to the child’s family [ 51 ].…”

“…The thorough follow-up described by the PHNs may reflect concerns and uncertainty, which is considered a barrier in reporting child maltreatment [27,39,48,51]. A Danish study about management of child maltreatment suspicions in general practice found that GPs and practice nurses often felt left to themselves managing their suspicions, especially in cases without clear signs and emphasized the importance of scheduling new appointments as a strategy to track the child's progress and maintaining a relation to the child's family [51]. The extensive follow-up may also indicate that PHNs are trying to address the child's needs in other ways than reporting.…”

‘There’s a will, but not a way’: Norwegian GPs’ experiences of collaboration with child welfare services – a grounded theory study

“…GPs are in a unique position to uncover and respond to child abuse [ 7 ] and Norwegian GPs consider themselves to be in a good position to discuss children’s situation in consultations with the parents, when a parent has a medical condition that might affect their caring ability [ 8 ]. Most studies focus on how GPs or primary care workers recognize vulnerability in children and their reporting practice to the CWS [ 9 – 11 ], and they show that GPs generally underidentify and have a lower reporting rate to the CWS than expected [ 12 – 14 ]. The barriers identified as preventing GPs from contacting CWS are among others structural obstacles such as time pressure and confidentiality, fear of affecting the patient-doctor relationship, negative prejudices against CWS and lack of knowledge about risk factors [ 10 , 15 , 16 ].…”

“…The barriers identified as preventing GPs from contacting CWS are among others structural obstacles such as time pressure and confidentiality, fear of affecting the patient-doctor relationship, negative prejudices against CWS and lack of knowledge about risk factors [ 10 , 15 , 16 ]. A need for better collaboration between general practice and CWS has been indicated several times [ 11 , 14 , 16 – 21 ] and there is a lack of intersectoral communication between the health care sector and child welfare sector [ 14 ]. We have not found research that focus directly on a collaborative process between GPs and CWS, although studies have been conducted on GPs’ collaboration with other agencies in the health care sector, such as nurses, pharmacists, mental health workers, physiotherapists and social workers working within the health care sector.…”