Introduction

Child abuse continues to be a leading pediatric publichealth problem. As experts in imaging of normal anddisease states in children, pediatric radiologists areresponsible for imaging-based diagnosis of child abuseand, when evident by radiologic means, the exclusionof non-abusive injury and disease states. Pediatricradiologists also serve a crucial role in the investiga-tive and legal proceedings in cases of alleged childabuse. The ability of a pediatric radiologist to respondproperly to suspected child abuse cases and handle

these appropriately is dependent on both educationand personal experience. However, there is not cur-rently a standardized program to insure uniformtraining of pediatric radiology fellows for theseresponsibilities. The Society for Pediatric Radiology(SPR) Committee on Child Abuse conducted a surveyin 2002 to evaluate the current state of pediatricradiology training regarding both the radiologic diag-nosis of child abuse and the role of the pediatricradiologist in the investigative and legal proceedingsrelating to child abuse. A summary of the results ofthe survey is presented.

Debra J. Pennington

Gael J. Lonergan

Kenneth L. Mendelson

How well do we prepare pediatric radiologistsregarding child abuse?Results of a survey of recently trained fellows

Received: 25 April 2003Revised: 22 August 2003Accepted: 26 August 2003Published online: 10 October 2003� Springer-Verlag 2003

Abstract Background: Pediatricradiologists serve an important rolein the radiologic diagnosis, investi-gation, and in legal proceedings incases of child abuse. The Society forPediatric Radiology should evaluateand insure the adequacy of trainingof pediatric radiologists for thisimportant role. Objective: TheSociety for Pediatric RadiologyCommittee on Child Abuse, 2002,conducted a 24-question survey toevaluate the scope and perceivedadequacy of training received bypediatric radiology fellows regard-ing the radiologic diagnosis of childabuse and the associated legal pro-cess. Materials and methods: Eigh-ty-four surveys were mailed toradiologists who had completed ayear in pediatric radiology fellow-ship training during the years 1999and 2000. There were 33 surveys

returned for an overall response of39%. Results: Respondents� per-ception of adequacy of training wasbest for the radiologic diagnosis ofchild abuse. The majority perceivedthey were not well trained in theinvestigative and legal processesregarding child abuse. The majoritywould welcome standardized train-ing. Conclusion: Current pediatricradiology training programs do notsufficiently prepare pediatric radiol-ogists for their role in the legalsystem regarding child abuse. Astandardized program to trainpediatric radiologists about theimaging diagnosis of child abuseand their role in the legal system isrecommended.

Keywords Education Æ FellowshipTraining Æ Child abuse

Pediatr Radiol (2004) 34: 59–65DOI 10.1007/s00247-003-1071-x ORIGINAL ARTICLE

D.J. Pennington (&) Æ G.J. LonerganAustin Radiological Association,6101 West Courtyard Drive,Bldg. 5, Austin, TX 78730, USAE-mail: penningtondmd@ausrad.comTel.: +1-512-7955100Fax: +1-512-3061954

K.L. MendelsonSouth Shore Hospital, Weymouth,Massachusetts, USA

Materials and methods

Eighty-four surveys were mailed to radiologists who had completeda year in pediatric radiology fellowship training during the years1999 and 2000. Survey responses were anonymous. There were 33surveys returned for an overall response of 39%. The 24-itemquestionnaire (Fig. 1) included 9 items evaluating objective infor-mation about the training program, including information aboutthe hospital and attending radiologists, as well as the numbers ofconferences and child-abuse cases reviewed per year. The remaining15 items were subjective statements about the perceived adequacyor presence of training or experience regarding child abuse duringthe fellowship, with the respondents giving a ranked response from1 (strongly agree) to 5 (strongly disagree).

Results

Training programs

Table 1 and Figs. 2, 3, and 4 summarize the results ofthe survey. The 33 respondents trained in universitypediatric radiology training programs, 32 training atfree-standing children�s hospitals, and one trained in apediatric radiology section at a university adult hospital.As survey responses were anonymous, the number ofprograms represented by the respondents is unknown.The majority of respondents (61%) had completed1 year of pediatric radiology fellowship training, and39% had completed 2 or more years.

The mean number of staff pediatric radiologists in atraining program was 11, with a range of 3–25. Themean number of pediatric neuroradiologists in a trainingprogram was 3.1, with a range of 0–5. Eighty-eightpercent (29/33) of respondents reported that pediatricneuroimaging studies were read by pediatric neuroradi-ologists; however, 3 respondents reported that generalneuroradiologists also contributed. Six percent (2/33) ofthe respondents reported that pediatric radiologists readneuroimaging studies, and another 6% (2/33) reportedthat general neuroradiologists or general neuroradiolo-gists with a special interest in pediatric neuroradiologyread neuroimaging studies.

The number of lectures and conferences on childabuse per year ranged from 0 to 26 per year, with amean of 5.7 and a mode of 2 per year. Eighty-fivepercent of respondents were aware that their programhad a written protocol for a skeletal survey for theevaluation of suspected child abuse. The meanestimated number of child-abuse cases reviewed in thelast year of fellowship was 36.1 for musculoskeletalimaging and 31.7 for neuroimaging; however, the modewas 10 and 0, respectively, and the median was 13 and20, respectively, with a range of 0–100 cases for both.Eighty-five percent of respondents reported that theirinstitution had a multidisciplinary child abuse ortrauma team, with 36% of the programs includingfellows on the team.

Adequacy of training

For the following subjective items on the questionnaire,the respondents were given positive statements, forexample, ‘‘I have received adequate training in themusculoskeletal manifestations of child abuse.’’Respondents were asked to give a ranked response of1–5 (1=strongly agree and 5=strongly disagree).

The fellows� perception of the adequacy of trainingwas best for the recognition and diagnosis of musculo-skeletal and neuroimaging findings of child abuse (mode1, median 2, range 1–5), and for the understanding of theimplications of skeletal findings (mode 2, median 2,range 1––5) (Fig. 2). Respondents also felt positiveabout the adequacy of training regarding the technicalaspects of a radiographic skeletal survey (mode 1,median 2, range 1––5), these factors including number ofimages, type of film, positioning of patient, and labelingof films.

Respondents perceived they were most poorly trainedregarding: child-protective services (mode 5, median 4,range 1–5); legal aspects of reporting child abuse (mode5, median 4, range 1–5); legal entities such as subpoena,affidavit, and deposition (mode 5, median 5, range 1–5);the pediatric radiologist�s role in the court system (mode4, median 4, range 1–5) or in the courtroom during trial(mode 5, median 4, range 1–5); and specifics of thecourtroom, such as the presenting of images as evidence(mode 5, median 5, range 1––5) (Fig. 3).

The majority of respondents would welcome a stan-dardized training program on the imaging evaluation ofchild abuse (mode 1, median 1, range 1–3). A majorityalso welcomed a standardized training program on thepediatric radiologist�s role and responsibilities, pertain-ing to child abuse, in the legal system (mode 1, median 1,range 1–5) (Fig. 4).

Discussion

Results of this survey indicate a great variability in thetraining experience of pediatric radiology fellowsregarding both the diagnosis of child abuse and thepediatric radiologist�s role in the legal system. Althoughthe average respondent ranking for training in theradiologic diagnosis of child abuse shows an overallconfidence in adequacy of training, the range ofresponses reveals that some pediatric radiologists per-ceive their training in the radiologic diagnosis of childabuse to be deficient. Although there was a trend towardthose respondents with lesser case experience reportingless confidence in their training, many who had reviewedmany cases and attended many lectures and conferences

Fig. 1 Fellowship training questionnaire

c

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on the subject also felt their training to be inadequate. Alarge majority of the respondents felt poorly trainedregarding the pediatric radiologist�s role in interactingwith child-protective services, investigative teams, andthe legal system.

The small number of completed surveys is a limita-tion of this study. Although a response rate of 39% isacceptable for a single mailing survey, the sample sizeis small. Thus, the results of the survey provide adescription of current fellowship training programs, ageneral indication of the perceived adequacy of training,

but do not allow rigorous statistical correlation of theparticulars of the training experience with the perceivedadequacy of the training.

Discomfort with issues relating to child abuse and aperception of inadequate training are not unique toradiology or to the practice of medicine. Barnard-Thompson and Leichner found that 75% of psychiatricresidents surveyed felt that instruction on child abuseduring their residency training was insufficient [1]. In astudy of emergency medicine physicians� response tochild abuse, Wright describes a number of obstacles to a

Table 1 Statistical summary of responses to questionnaire. (CAchild abuse, UFCH university-affiliated free-standing children�shospital, UAH university-affiliated pediatric section in adult hos-

pital, PNR pediatric neuroradiologist, GNR general neuroradiol-ogist, GNPI general neuroradiologist with special interest inpediatric neuroimaging,PR pediatric radiologist)

Questionnaire item Mode Range Median Mean Percentages

Location of training program 97% UFCH3% UAH

Length of training 1 1–2 1 1.39 61% 1 year39% 2 years

Number of fellows in fellow�s year of training 1 1–10 5 3.8Number of staff pediatric neuroradiologists 4 0–5 4 3Number of staff (non-neuroradiologist) pediatricradiologists

10 3–25 10 11

Pediatric neuroimaging studies read by: 79% PNR only9% PNR and GNR6% GNR or GNPI6% PR

Number of lectures/conferences on CA in 1 yearof training

2 0–26 3 5.7

Estimated number of CA skeletal cases reviewedin last year of fellowship

10 0–100 13 26.1

Estimated number of CA neuroimaging casesreviewed in last year of fellowship

0 0–100 20 31.7

Received adequate training in the musculoskeletalmanifestations of CA

1 1–5 2 1.9

Received adequate training in the neuroimagingmanifestations of CA

1 1–5 2 2.1

Received adequate training in the technical aspectsof a skeletal survey for CA

1 1–5 2 2.5

Has a good understanding of implications of skeletalinjury in children, as to which injuries or injury patternsare suspicious or specific for CA

2 1–5 2 1.9

Has a good understanding of a pediatric radiologist�srole in the court system

4 1–5 4 3.4

Would welcome a standardized training program onthe imaging evaluation of CA

1 1–3 1 1.5

Would welcome a standardized training program onthe pediatric radiologist�s role and responsibilities,pertaining to CA, in the legal system

1 1–5 1 1.4

Training program had a written skeletal surveyprotocol

1 1–5 1 1.6

Training program had a multidisciplinary CAor trauma team

1 1–5 1 1.3

Fellows Included as part of the CA team 5 1–5 4 3.2Has received training about Child Protective Services 5 1–5 4 3.8Has received training about legal aspects regardingreporting CA

5 1–5 4 3.4

Has been taught about: subpoena, affidavit, deposition 5 1–5 5 4.1Has been trained about pediatric radiologist�s rolein the courtroom

5 1–5 4 3.7

Has been trained about courtroom specifics such aspresenting evidence

5 1–5 5 4.1

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physician�s response to child abuse: lack of formaltraining on the topic, lack of experience handling cases,personal discomfort, and a feeling of being poorly pre-pared to interact with Child Protective Services and thepolice [2].

Standardized training would be expected to improveknowledge and confidence in the diagnosis of child

abuse and in one�s ability to respond appropriately andeffectively to legal obligations. However, a trainingprogram should be evaluated for effectiveness. A surveystudy by Hawkins and McCallum [3] demonstrated theeffectiveness of a standardized training program toprepare educators and other mandated reporters fortheir responsibilities in reporting child abuse and

Fig. 2 Response to questions evaluating technical aspects oftraining and the radiologic diagnosis of child abuse

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neglect. The participants reported increased confidencein their ability to recognize indicators of abuse, in theirunderstanding of what constitutes reasonable grounds

Fig. 3 Response to questions evaluating training regarding childprotective services and the legal system. (CPS child protectiveservices)

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for reporting, and in their knowledge of how to respondto a child who has disclosed abuse. Training also in-creased the participants� awareness of the seriousness ofabuse and their own reporting responsibilities.

Forensic pediatricians have become an importantasset to the pediatric and legal community for research,investigation, and legal consultation regarding childabuse. In order to standardize the education of forensicpediatricians, the American Academy of PediatricsSection on Child Abuse and Neglect and the ForensicPediatrics Physician Leadership Group collaborated to

develop a curriculum for medical fellowships in childabuse and neglect [4].

The results of this survey were presented to the SPRCommittee on Child Abuse. Although the survey is small,the committee believes the survey indicates a current lackof uniform training regarding the radiologic diagnosis ofchild abuse, as well as a lack of adequate trainingregarding the legal system. Without adequate training inboth the medical and non-medical aspects of child abuse,many pediatric radiologists will feel uncomfortable andmay avoid involvement with investigative and legal pro-cesses. The committee recommends that the SPR assist inthe creation of a standardized training program on childabuse for pediatric radiology fellows.

References

1. Barnard-Thompson K, Leichner P (1999)Psychiatric residents� views on theirtraining and experience regarding issuesrelated to child abuse. Can J Psychiatry44:769–774

2. Wright RJ, Wright RO, Farnan L, et al(1999) Response to child abuse in thepediatric emergency department: needfor continued education. Pediatr EmergCare 15:376–382

3. Hawkins R, McCallum C (2001) Man-datory notification training for suspectedchild abuse and neglect in South Aus-tralian Schools. Child Abuse Negl25:1603–1625

4. Starling SP, Sirotnak AP, Jenny C (2000)Child abuse and forensic pediatric medi-cine fellowship curriculum statement.Child Maltreat 5:58–62

Fig. 4 Response to questions evaluating whether standardizedtraining programs regarding child abuse would be welcomed

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