How prepared are medical students for the identification and management of child abuse?

Introduction

One in five adults in England and Wales experience at least one form of child abuse before the age of 16. Child abuse can come in many different forms, although typically it is categorised as emotional abuse, physical abuse, sexual abuse or neglect [1].

The General Medical Council (GMC) places a duty on doctors to protect children from child abuse. As medical professionals, doctors are expected to promote the health and wellbeing of young people and part of this is to act on any concerns that they have about their safety [2]. Therefore, medical students must be prepared for this responsibility.

Child abuse is a difficult subject to teach in for many reasons. It is emotive, sensitive, hard to define and near impossible to use typical medical teaching and assessment methods such as observed structured clinical examination (OSCE).

As I neared the end of my time at medical school, I wondered whether I had been adequately prepared to assume the responsibly of protecting children from abuse. Therefore, the aim of my elective project was to assess whether final year medical students are sufficiently equipped to identify and manage cases of child abuse. This was considering the knowledge and skill required as well as understanding the core ethical principles.

Methods

To achieve my aim, I undertook theoretical research using a three-step approach.

Firstly, I travelled to the New York Centre for Children, USA where I received high level teaching from an expert in the field. I aimed to optimise my understanding on the subject and to understand the key principles and skills required for the identification and management of child abuse cases.

Secondly, I conducted a review of the literature, in order to explore others’ findings about the preparedness of medical students.

Finally, I reflected upon my experience of medical school along with my new knowledge in order to assess whether medical students in the UK are adequately prepared to identify and manage cases of child abuse.

My experience

Unfortunately, due to the breakout of the covid-19 pandemic, I could only complete two of the four weeks with the New York Centre for Children. However, during this time I gathered a significant amount of information and took away resources that enabled me to complete the learning remotely.

The teaching that I received covered all aspects of child abuse cases: signs, risk factors, examination techniques, examination findings, interview techniques, support services, legal processes, ethical principles and long-term effects. The experience took place in various locations including a hospital, courthouse and charity centre.

I felt that most areas of the course had been touched upon during my time medical school, but I felt that I deepened my knowledge and increased my confidence in all areas. The information that was new to me was around examination and interview techniques. Before the course I had thought that this was specialist knowledge, but I learnt how achievable it would be to include the principles in every examination that I do and how important this could be for those children affected. What was also new to me was gaining the perspective from members of the multidisciplinary team involved in child abuse cases and experiencing the legal process that follows a report of abuse. This learning aided my understanding of the role that I will play in protecting children.

The course leader was passionate about ensuring that all doctors practice ‘trauma informed medicine’ meaning that they can confidently rule in or out child abuse for every young patient that they see and examine. I felt that increasing my understanding of the subject in this full and rounded way will enable me to practice in this way going forward.

A review of the literature

My initial search produced 44 articles. Abstract screening identified 12 that were relevant for review. Articles were predominantly from the USA but included studies reporting on medical students from around the world.

Overall, research suggested that most medical students are introduced to the subject of child abuse during their education. One study included medical students from 82 schools across 31 different countries. It found that 75% of schools covered the signs of child abuse, 69% of schools covered the risk factors, 59% covered preventative measures and 60% covered referral services [7].

The literature did suggest that teaching was inconsistent across the types of abuse. One review of 350 medical students in Turkey found that students were much more aware about neglect than they were about emotional abuse [3].

In general, research suggested that there is room for improvement. A study based in Saudi Arabia found that medical students were less confident in reporting cases of child abuse and neglect than more senior colleagues [6]. Another based in the USA found that students undertaking a specialist course showed a significant increase in their ability to effectively treat and advocate for maltreated children when compared to those learning on the normal curriculum [4].

One study reported factors that significantly affected students’ ability on the subject including gender, and belief about whether medical school had prepared them well [6].

It was important to note, evidenced by the few studies found, that the literature was very limited in this field.

Conclusions

In conclusion, both my experience and the literature suggest that medical students who undertake specialist courses on the subject of child abuse are better prepared to assume the responsibility of identifying and managing cases of abuse as a doctor.

More work should be done to determine the feasibility of integrating this extra material into medical school curricula in order to ensure that all students are adequately prepared.

Acknowledgements

I would like to thank the University of Exeter for the elective experience that they offered. I would like to thank the New York Centre for Children for the teaching that I received, and I would like to thank the Institute of Medical Ethics for the Medical Elective Bursary that enabled my travel to the USA.

Dr Molly Dineen MSc BMBS

 

References

1. Office for National Statistics. Child abuse extent and nature, England and Wales: year ending March 2019. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/articles/childabuseextentandnatureenglandandwales/yearendingmarch2019 [Accesssed 14/12/2020].
2. General Medical Council. Protecting children and young people: The responsibilities of all doctors. Available at: https://www.gmc-uk.org/-/media/documents/protecting-children-and-young-people—english-20200114_pdf-48978248.pdf?la=en&hash=662E8DA032529B8CCAF1B927AB09A60D00231877. [Accessed 14/12/2020].
3. Altan H, Budakoğlu Iİ, Şahin-Dağlı F, Oral R. Measuring awareness about child abuse and neglect: Validity and reliability of a newly developed tool-child abuse and neglect awareness scale. Turk J Pediatr. 2018;60(4):392–9.
4. Pelletier HL, Knox M. Incorporating Child Maltreatment Training into Medical School Curricula. J Child Adolesc Trauma. 2017;10(3):267.
5. Donohue B, Carpin K, Alvarez KM, Ellwood A, Jones RW. A standardized method of diplomatically and effectively reporting child abuse to state authorities: A controlled evaluation. Behav Modif. 2002;26(5):684–99.
6. Alnasser Y, Albijadi A, Abdullah W, Aldabeeb D, Alomair A, Alsaddiqi S, et al. Child maltreatment between knowledge, attitude and beliefs among Saudi pediatricians, pediatric residency trainees and medical students. Ann Med Surg. 2017;16:7–13.
7. Villaveces A, Kammeyer JA, Bencevic H. Injury prevention education in medical schools: An international survey of medical students. Inj Prev. 2005;11(6):343–7.