Difficulties to identify and report cases of abuse against children and adolescents from the viewpoint of pediatricians

Difficulties to identify and report cases of abuse against children and adolescents from the viewpoint of pediatricians Dificuldades enfrentadas para identificar e notificar casos de maus-tratos contra crianças e/ou adolescentes sob a óptica de médicos pediatras Las dificultades enfrentadas para identificar y notificar casos de malos tratos a niños y/o adolescentes bajo la mirada de médicos pediatras


Introduction
Violence is a serious public health problem in Brazil. It is the leading cause of death among children and adolescents aged 5 years or older (1) . The involvement of health professionals in this matter has been studied because of the complex aspects of abuse against children and adolescents and the close relationship between violence and public health. There is special interest in this topic because the competent authority must be informed of any suspected or confirmed case of abuse. If health professionals fail to do that the penalty is a fine of three to 20 reference salaries, as specified in the Statute of the Children and Adolescents (ECA) in Article 245 (2) .
The definition of abuse provided by the World Health Organization (3) is as follows: "All forms of physical and/or emotional ill-treatment, sexual abuse, neglect or negligent treatment or commercial or other exploitation, resulting in actual or potential harm to the child's health, survival, development or dignity in the context of a relationship of responsibility, trust or power." The relationship between violence and public health is not restricted to the increasing number of ill-treated children and adolescents who seek health care at public health facilities and private clinics. This is a short-, medium-, and long-term relationship as a consequence of maltreatment. The analysis of health professionals' identification and reporting of maltreatment of children and adolescents considers the following categories of maltreatment: neglect and abandonment, physical abuse (including the shaken baby syndrome), sexual abuse, psychological abuse, and the Munchausen syndrome by proxy (1,(3)(4)(5) .
In Brazil, maltreatment of children and adolescents has been considered a health problem since the 1960s. The implementation of the ECA in 1990 guaranteed special rights and full protection to children. The Statute also provides that health professionals must report any suspected and/or confirmed cases of abuse. In 1998, the Brazilian Ministry of Health developed the "National Policy for Reduction of Morbidity and Mortality for Accidents and Violence." This policy included coordinated actions on the matter. In 2001, with the publication of the "National Policy for Reduction of Morbidity and Mortality for Accidents and Violence in Childhood and Adolescence," health professionals working at public health care facilities were required to report any suspected and confirmed cases of maltreatment (6) . Such report means informing the competent authorities that the event occurred or may have occurred in the case of suspicion. Such information is used to plan public actions aimed at eliminating violence in Brazil, since when there is notification, data such as victim, perpetrator, location of occurrence, type of occurrence, etc. are disclosed. The difference between report and denunciation is that the latter consists of providing the police with information about a crime. Despite child maltreatment report is mandatory in Brazil, violence is underreported in the country. It is estimated that for every reported case there are two other cases that remain unknown (7) .
The difficulties faced by health professionals to identify and report maltreatment have been addressed in some studies (8)(9)(10)(11)(12) . Such investigations have demonstrated that in general health professionals rule out the organic hypothesis using tests, and then they investigate the "external causes". In these studies, health professionals have oscillated between belief and disbelief in the possibility of solving the cases. These professionals who provide health care to children and their families showed fear and emotional insecurity, mainly in terms of problems related to the fact that abuse is generally not addressed during their professional training and reproduction of cultural patterns, avoiding involvement in issues that are considered to be family matters. There are also reports of fear of legal involvement (10) , lack of basic information enabling the identification of violence (12) , a topic that has not been dealt with in undergraduate curricula. Peculiarities of each case are influenced by the professionals' personal characteristics and by the structures of the health care facilities, mostly insufficient (8,9,11) , with lack of infrastructure, work overload for the officers of the Child Protective Service and even absence of this councils in some Brazilian municipalities (9,12) .
Thus, the objective of the present study was to analyze the difficulties in identifying and reporting abuse against children and adolescents in the public health system in a midsized municipality of the state of São Paulo from the viewpoint of pediatricians.

Method
This is a qualitative study involving eight pediatricians from a charity hospital in a midsized municipality of the state of São Paulo, who worked as independent professionals in their offices and were also employees of the hospital. The participants included four men and four women whose mean age was 48 years old and mean work experience was 22 years. The completion of the questionnaire was conducted at the participants' medical office.
The instrument for data collection was a questionnaire with two vignettes describing a situation of suspected maltreatment of children, including two questions in each vignette about the process of identifying the suspicion and the difficulties in taking action regarding the case. A second part included three specific questions about the difficulties in identifying and reporting abuse. The situations suggested to the participants were as follows: 1. Part 1 -Situation 1: Carly, two years old, is brought by her mother to the emergency room and is seen by the health professional Joan. The child cries incessantly.

Results
The answers about the measures taken by the participants in Situation 1 were divided into three subcategories considering the existence of suspicion: Yes, mentioned by 12.5%; no, by 12.5%; and Doubt, by 75% of participants. We found that there is a frequent belief that health professionals must check and confirm based on evidence if the abuse indeed occurred.
Faced with the certainty or uncertainty of suspected abuse (among the 87.5% who answered "Yes" or "Doubt"), the participants reported appropriate and inappropriate procedures ( Table 1). It is worth noting that one participant pointed out that he/she would take more than one measure in case of suspicion or certainty of abuse, and such measures may be appropriate or inappropriate. Thus, Table 1 shows the percentages per procedure mentioned by each participant. We found that the pediatricians often reported both appropriate and inappropriate procedures, that is, at the same time that the competent authorities are notified, the professional tries to talk to the parents in an investigative manner. This is a high-risk behavior because of professional exposure.
The difficulties in taking measures regarding the case (QIISI) are presented in Table 2. The need to present evidence or to confirm maltreatment is in agreement with the meaning of "to suspect" for medical professionals. The Child Protective Service is responsible for protecting children and professionals at the same time, avoiding professional exposure, and the police are responsible for investigating the case. However, the medical culture leads doctors to treat the phenomenon of abuse as if it was a disease, a diagnosis to be confirmed by tests, limiting it to the biological aspects when it is a social problem instead (13) .
In Situation 2 (QISII), which is a case of sexual abuse, suspicion involves different aspects. Certainty of suspicion is  The project was approved by the Research Ethics Committee of UFSCar. The research project included 30 pediatricians, that is, all pediatricians of a charity hospital of the municipality in 2007 and 2008. All the 30 professionals (pediatricians) were invited to participate in the study. They received an envelope containing the written consent form, the questionnaire, and a cover letter with contact information so that they could get in touch with the researchers to clarify any doubts. Upon delivery of the material, the participants were instructed that the date to return the material properly completed would be informed in advance by telephone. The pediatricians returned eight completed questionnaires and two blank questionnaires. The remainder refused to participate. Figure 1 shows the reasons for refusal.
Interestingly, 14% of the refusals were related to a personal reason (lack of time or interest), which may be linked to the difficulty in dealing with the topic investigated by the present study. This was also observed in the response "never had a case like this" (14%) provided by pediatricians who had homeopathy as a second specialty. Therefore, the total number of participants who answered the questionnaire, eight physicians, accounted for almost 30% (27%) of all the pediatricians of the hospital.
Data analysis was based on the categories established in questions. The answers to question 1 of situation 1 (QISI) and situation 2 (QISII), describing what procedures would be adopted in that situation, were divided into "Appropriate" and "Inappropriate." "Appropriate Procedures" are those which led to reporting, request for aid to deal with the case, or any suspicion of abuse, because these measures protect children and/ or adolescents. "Inappropriate Procedures" are related to the absence of such measures. It is important to emphasize that this classification is not aimed at evaluating the technical procedure, but checking when there should be a report or denunciation. In the answers to question 2, in both situations (QIISI and QIISII), the category being analyzed was the difficulties faced by health professionals.
Regarding the second part of the questionnaire, Question 1 (Q1) investigated the difficulty in reporting the suspected abuse to the competent authorities, Question 2 (Q2) analyzed the contact with the topic during training, and Question 3 (Q3) approached the possible consequences of the measures taken in cases of suspected abuse. For all questions, recurrent answers were identified and grouped into subcategories. predominant (75%) and there is not lack of suspicion, with 25% of participants reporting doubts. The answers regarding the health professionals' procedures in Situation 2 (QISII) are somewhat similar to the answers provided in Situation 1. The participants believed that there should be a previous condition for denunciation, which is the confirmation of suspicion, as presented in Table 3. This table shows the percentages of each action suggested by the participants (who may have suggested more than one procedure among appropriate and inappropriate procedures). Among the difficulties faced in this situation, confrontation with the family in different ways was the problem most often mentioned. This situation was considered more delicate and fear is evident in two ways: child's fear to tell what happened and the professional who does not report the case

P1
"To make a hasty decision believing that there is maltreatment and in fact the family does not have food and the children fight a lot and there may be accidents"

P2
"If the suspicion of abuse was confirmed I do not know who to turn to -first I would report to the Child Protective Service and then it would be necessary to perform a forensic examination"

P3
"The biggest difficulty is to know whether the first impression is correct. The child is dirty because he/ she was playing and her mother rushed to the emergency room? The child is thin because his/her family constitution is thin? The mother blames the 6-year-old child because she is nervous?" P4 "None"

P5
"Conclusive evidence that the child is being subjected to maltreatment and how to investigate and prove the fact" P6 "If it's really a case of maltreatment, at least I would have to confront the family with a report to the Child Protective Service"

P7
"Regarding the fact of being "skinny" and "wearing dirty clothes", unfortunately this is very common because of the socioeconomic conditions of a large portion of the Brazilian population with low income" P8 "-Little experience in similar cases -I am a general pediatrician -Difficulties in dealing with the mother who is probably directly responsible for the dislocation -How will the Child Protective Service act?" because of fear. Legal consequences are also mentioned more often than in the previous situation and the fear of misinterpreting the situation is present. However, aspects of medical routine are suggested, such as difficulties in the clinical examination and undefined time for the patient's care. Table 4 shows the difficulties faced when reporting and denouncing a suspicion of abuse to the competent authorities (Question Q1).
An interesting aspect is seen in the question about the approach of the topic during training. Only one participant reported he took a theoretical course in a Department of Legal Medicine and another participant reported cases he/she saw during his/her training, that is, he/she apparently expanded the concept during the residence period,

37.5
To report to the Child Protective Service To report to social workers Appropriate To talk to the mother Inappropriate

25
To refer to a psychologist To require evaluation of a specialist Appropriate To hospitalize the child To request laboratory tests Inappropriate

12.5
To report to the hospital management

To perform anamnesis Appropriate
To conduct clinical evaluation To prescribe medication Inappropriate Table 1 -Categories of procedures and percentage of answers of QISI

P1
"They do not provide feedback on the reported event, or sometimes treat the family (father and mother) badly and the parents might not be responsible for the abuse (uncles, neighbors, friends)" -Lack of information in relation to the procedures that must be respected in these cases"

P3
"It's a long-term process. It often seems clear that there is abuse and the child remains with his/her family until the situation is investigated" P4 "None"

P5
"I haven't experienced such situations recently. I believe I would have no difficulties in reporting and denouncing abuse to the hospital management, the Child Protective Service or the juvenile court" P6 "I never had such problems, but I have information from colleagues that they are protected by the management of the hospital of a town in the state of São Paulo. I have information on how the public agencies treat these problems"

P7
"I have no difficulties at the facilities where I work. I talk to the head nurse of the department who takes the appropriate action (calling, reporting, "unreadable excerpt"). I prepare the reports or statements required by the hospital" P8 "-I never had to report such events. Thus, the greatest difficulty is my lack of experience: how to report? There must be a hotline to report child abuse, but I'm not aware of it. I believe it is possible to report to the competent authorities. Are there specific forms and instruction on how to deliver these forms? Can it be handed out to the child and youth court judge?  learning about the topic during clinical practice. Most participants (75%) reported they had contact with "none" or "very few" cases.
In the question about the consequences that the participant believes may occur before the actions in cases of suspected abuse (Q3), we found that the fears of "accusing an innocent individual," "causing further trauma or discomfort for the family and/or child," and "being sued" are present in 37.5% of the answers, "physical threat" is present in 25%, and "omission" in 12.5%.

Discussion
The difficulties described by the participants of the present study are similar to those found in other national and international studies (8)(9)(10)(11)(12)14) , especially with regard to the oscillation between belief and disbelief in the possibility of solving the cases. In addition, the participants reported they feared to be legally involved (10) and there was also lack of basic information enabling them to identify violence (12) . The evaluation of the particular characteristics of the cases presented in the instruments was influenced by the professionals' personal factors and the structure of the health care facilities, which was insufficient in most cases.
Gomes et al (9) stated that the identification and appropriate reporting of cases of maltreatment may be influenced by emotional aspects that impair a better performance, among these aspects are the professionals' difficulties to deal with problems related to taboos and escaping behavior when facing stressful situations. However, the important factors that have an influence on the decision-making process are: the explanation given by those who took the child to the health care facility, the type of injury, and the child's age (15) .
The level of knowledge on the subject and the reasons for making the decision of not reporting coincide with some difficulties described in the present study, such as: willingness to wait until there is more conclusive evidence, confidence in family dynamics, difficulty in identifying emotional abuse or neglect, and perception of disadvantages of reporting, such as lack of change and possible harmful effects -involvement in legal matters or being threatened by the family (14) .
Also, the professionals' lack of training to deal with victims of violence (often identified in their statements and in the questions they made) might be caused by their lack of knowledge on how to proceed in such cases. In Brazil, the shortage of regulations setting technical procedures, the absence of legal mechanisms to protect those responsible for reporting the abuse, the failure to identify violence in health care facilities, and the lack of respect for professional secrecy are considered barriers for reporting (11) .
Reporting cases of violence is extremely important because it is a tool to fight violence since it enables the implementation of intervention actions at several levels. When a private event becomes public, we realize that such events are more common than people might think, but that is not a reason to consider them trivial or normal (16) . The poor training received by health professionals in general about the meaning and the importance of reporting abuse against children results in confusion between the terms report and denunciation. Reporting should be synonymous with ensuring that children and adolescents and their families will receive support from institutions and competent professionals (17) . The role of the professional, as stated in the Article 245 of the ECA (2) , is to communicate, that is, to report suspected or confirmed cases of abuse to the competent authority.
After identifying "automatic" and hierarchized procedures, we found that social workers and psychologist are considered responsible for the approaching that goes beyond the biomedical model. This model of medical education can be regarded as a barrier to the identification of cases of maltreatment. According to Camargo Jr. (13) , the medical rationality provides that diagnostic categories assume a typical set of signs and symptoms that define them, which is also known and described as the "clinical picture" of the disease. The problem is that this relationship includes the data possibly observed, which does not mean that a patient will present all or even the most relevant symptoms. Therefore, when the health professional has to treat a patient who is a suspected victim of abuse, this logic seems not to work because signs and symptoms can be confused with other differential diagnoses. Also according to Camargo Jr. (13) , the pursuit of the "ultimate cause" of the diseases is basic in medicine, i.e., the "essence" of the disease lies in its cause; therefore, if the cause is removed then the disease is resolved: "disease and injury are intimately linked: one does not exist without the other. This theoretical assembly is fundamental for the construction of the interventionist medical model, since the identification between disease and injury reduces to the biological aspect the whole process of illness, excluding other ("psychological", "social") components that may be involved in this determination." Some limitations of this study should be taken into account, especially the limited number of participants in relation to the total number of pediatricians of the hospital. The participation of only 27% of the pediatricians who work at the hospital is low. Some hypotheses for this low rate of participation are: work overload, the fact that the instrument was handed out to the doctors' secretaries, lack of interest and training in the subject, underestimation of the study importance, ignorance of the benefits in participating in the study. However, the difficulties described by the participants are similar to those reported in the literature, which may suggest that similar results would be found even if there were more participants. Nevertheless, for future studies it would be important to create conditions for greater participation of pediatricians.

Thais Helena Bannwart et al
In order to reduce the difficulties described by the participants and by other studies conducted in this area regarding children victims of violence, health professionals should be trained about abuse and studies evaluating the effectiveness of training should be conducted (6,(14)(15)(16)(18)(19)(20) . In addition, the inclusion of this topic in undergraduate curricula is crucial (15) . It is also important that health professionals are familiar with epidemiological data on childhood maltreatment, because it can help them to make a decision while assessing the information collected, in addition to training them in the establishment of differential diagnoses (14,15,19) .
Ferreira (18) points out some challenges for pediatricians when following up cases of abuse. These challenges can be included in a training project, such as: strategies to engage without causing more violence; focusing on the families and not just on children and mothers; assess, in the health care routine, risk and protective factors related to children and families, strengthening the protection factors and working to minimize or eliminate the risk factors. In addition, it is vital to educate about the conceptual distinction regarding reporting and denunciation in order to prevent an avoidance behavior of health professionals as for the most appropriate reporting procedure in cases of suspected or confirmed child maltreatment.
Thus, the training of medical professionals or any health professionals should aim to invest in promoting actions to sensitize to the rights and needs of children and adolescents in order to increase the professionals' capacity to identify situations of abuse, recognizing them as such, and expand their commitment to report abuse, strengthening the linkage between these actions at all levels, agencies and institutions responsible for fulfilling the rights of children and adolescents.