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OBJECTIVE: To describe the programs for medical diagnosis of child abuse and neglect in three states and efforts to establish state-wide programs in two states. To describe common themes and issues that emerged related to the establishment and maintenance of these programs. METHODS: Five states were selected as case studies to represent a range of experience and type of function embodied in programs that address medical diagnosis of child abuse and neglect. Individuals knowledgeable about the programs or efforts to establish state-wide programs in their home states described these in detail. Inductive analysis was used to identify themes and issues that emerged across the states studied. FINDINGS: Themes emerged in three general areas: funding, services, and training. Findings related to funding were: 1) State funding was vital for initiation of statewide programs; 2) Alliances with other groups with parallel interests were successfully used to garner support for child abuse programs; 3) Services needed to be adequately reimbursed to be sustained; 4) Political climate often affected funding. With regard to services we found: 1) There was no optimal way to organize services, but rather many ways that worked well; 2) It was critical to address local service needs; 3) Provision of standardized quality services was essential. With regard to training: 1) Professional training was an integral part of all statewide programs; 2) New technologies, including televideo, have been explored and implemented to assist in training in statewide programs. CONCLUSIONS: Each state has taken a unique approach to programs for the medical diagnosis of child abuse and neglect. However, there are commonalities, particularly among the states that have been successful in establishing and maintaining comprehensive services and/or training.

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PURPOSE: To collect data on institutional policies regarding tenure, promotions, and benefits for part-time faculty at U.S. medical schools and determine the extent to which part-time work is a feasible or attractive option for academic physicians. METHOD: In July 1996, the authors sent a 29-item questionnaire regarding tenure, promotions, and benefit policies for part-time faculty to respondents identified by the deans' offices of medical schools in the United States and Puerto Rico. Responses were analyzed using descriptive statistics and chi-square analyses. RESULTS: Respondents from 104 of 126 medical schools (83%) completed the questionnaire; 58 responded that their schools had written policies about tenure, promotion, or benefits for part-time faculty. Tenure. Of the 95 medical schools with tenure systems, 25 allowed part-time faculty to get tenure and 76 allowed for extending the time to tenure. Allowable reasons to slow the tenure clock included medical leave (65), maternity leave (65), paternity leave (54), other leave of absence (59). Only 23 allowed part-time status as a reason to slow the tenure clock. Policies written by the dean's office and from schools in the midwest or west were more favorable to part-time faculty's being allowed to get tenure. Promotions. The majority of respondents reported that it was possible for part-time faculty to serve as clinical assistant, assistant, associate, and full professors. Benefits. The majority of schools offered retirement benefits and health, dental, disability, and life insurance to part-time faculty, although in many cases part-time faculty had to buy additional coverage to match that of full-time faculty. CONCLUSIONS: Most medical schools do not have policies that foster tenure for part-time faculty, although many allow for promotion and offer a variety of benefits to part-time faculty.

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OBJECTIVES: To describe maternal discipline of children in at-risk families and to determine factors associated with disciplinary practices. DESIGN: Cross-sectional survey. SETTING: At-risk families in North Carolina followed up in a longitudinal study of child maltreatment. PARTICIPANTS: Maternal caregivers of 7- to 9-year-old children with factors at birth that placed them at risk. MEASUREMENTS AND RESULTS: A total of 186 maternal caregivers were interviewed. A measure, based on coding parental responses, was used to assess disciplinary practices for 5 different misbehaviors. Limit setting was the most commonly used disciplinary practice for 4 of 5 misbehaviors, with 63% of mothers reporting that this method generally worked best. Spanking was more likely used as a secondary response for each misbehavior, when the primary one had not succeeded. Conversely, teaching or verbal assertion was always less likely as a secondary response. Teaching or verbal assertion was used more commonly for lying than for any other misbehavior, limit setting for disobeying, spanking for stealing, and spanking with an object for being disrespectful. Regression modeling for the 4 most common disciplinary practices showed (P<.05) that black race, lack of Aid to Families With Dependent Children receipt, more-educated mothers, and female sex of child were associated with higher use of teaching or verbal assertion; a biological father in the home was associated with less use of limit setting; and black race and report for child maltreatment were associated with more use of mild spanking. CONCLUSIONS: In this sample, limit setting was the most common disciplinary technique. Disciplinary practices used varied depending on the type of misbehavior and other contextual factors, including child, parent, and family characteristics.

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OBJECTIVE: To determine if written feedback improves the chart documentation and knowledge of physicians doing evaluations for child sexual abuse and to learn what other factors are associated with better documentation and knowledge. DESIGN: Randomized, controlled trial. SETTING: A statewide network of physicians performing child abuse evaluations. PARTICIPANTS: All physicians who performed evaluations for sexual abuse during 1991 to 1992. One hundred forty-seven physicians were randomized to control (n = 75) and intervention (n = 72) groups, 122 (83%) remained at follow-up, and 87 of the 122 (71%) had done evaluations for child sexual abuse. INTERVENTIONS: Tailored written feedback based on chart reviews and relevant articles were sent to a randomly selected one-half of the physicians during a 3-month period. MAIN OUTCOME MEASURES: The quality of documentation and physician knowledge before and after the intervention. RESULTS: Documentation by chart review of up to five randomly chosen records per physician (preintervention, n = 552; postintervention, n = 259) by reviewers blinded to intervention status and physician knowledge was assessed by survey (78% completion). Change in documentation and knowledge for physicians in the intervention group was not statistically significant compared with the control group. The risk ratio for a mean overall history rating of excellent/good was 0.89 (0.63, 1.25) and for a mean overall physical examination rating of excellent/good was 1.03 (0.73, 1.45). Both groups improved significantly during the time period. The largest improvements in the time period were in documenting the history of where abuse occurred, in the physical examination position, hymenal description, penile findings, and knowing that chlamydia infection should be assessed by culture. A structured medical record, female physicians, and credits in continuing medical education were associated with better documentation. CONCLUSIONS: Tailored feedback to the physician with directed educational materials did not seem to improve most aspects of documentation and knowledge of child sexual abuse, although notable improvement was seen during the time period studied. This study suggests that chart audits may not be the best use of resources for trying to improve physician behavior; credits in continuing medical education and use of structured records may be more likely to be beneficial.

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OBJECTIVE: Social capital describes the benefits that are derived from personal social relationships (within families and communities) and social affiliations. This investigation examined the extent to which social capital is associated with positive developmental and behavioral outcomes in high-risk preschool children. DESIGN: A cross-sectional case-control analysis of young children "doing well" and "not doing well" at baseline in four coordinated longitudinal studies. PARTICIPANTS: A total of 667 2- to 5-year-old children (mean age, 4.4 years) and their maternal caregivers who are participating in the Longitudinal Studies of Child Abuse and Neglect Consortium. At recruitment, all children were characterized by unfavorable social or economic circumstances that contributed to the identification of the children as high risk. MEASURES: Social capital was defined as benefits that accrue from social relationships within communities and families. A social capital index was created by assigning one point to each of the following indicators: 1) two parents or parent-figures in the home; 2) social support of the maternal caregiver; 3) no more than two children in the family; 4) neighborhood support; and 5) regular church attendance. Outcomes were measured with the Child Behavior Checklist, a widely used measure of behavioral/emotional problems, and with the Battelle Developmental Inventory Screening Test, a standardized test that identifies developmental deficits. Children were classified as doing well if their scores on these instruments indicated neither behavioral nor developmental problems. RESULTS: Only 13% of the children were classified as doing well. The individual indicators that best discriminated between levels of child functioning were the most direct measures of social capital-church affiliation, perception of personal social support, and support within the neighborhood. The social capital index was strongly associated with child well-being, more so than any single indicator. The presence of any social capital indicator increased the odds of doing well by 29%; adding any two increased the odds of doing well by 66%. CONCLUSIONS: Our findings suggest that social capital may have an impact on children's well-being as early as the preschool years. In these years it seems to be the parents' social capital that confers benefits on their offspring, just as children benefit from their parents' financial and human capital. Social capital may be most crucial for families who have fewer financial and educational resources. Our findings suggest that those interested in the healthy development of children, particularly children most at risk for poor developmental outcomes, must search for new and creative ways of supporting interpersonal relationships and strengthening the communities in which families carry out the daily activities of their lives.

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OBJECTIVE: To evaluate the attitudes of academic child abuse professionals toward spanking, the effect of context and mode of administration on their attitudes toward spanking appropriateness, and what they teach residents about spanking. DESIGN: A survey. PARTICIPANTS: Convenience sample of 114 members of the Ambulatory Pediatric Association's Special Interest Group on Child Abuse and Neglect. MAIN OUTCOME MEASURES: Respondents were asked if spanking was an appropriate disciplinary option for children 2, 5, and 8 years of age who refused to go to bed, ran into the streets without looking, or hit a playmate. Respondents also rated the appropriateness of spanking in 6 additional scenarios where the setting in which spanking occurred was varied. Respondent's teaching practices relative to spanking observed during a clinic visit were also elicited. RESULTS: The response rate was 70%; 39% thought spanking was appropriate sometimes. The context and mode of spanking affected the acceptance of spanking. All respondents thought that some response was appropriate when spanking was observed during a continuity clinic visit. However, only 29% of respondents taught residents how to handle such situations. CONCLUSIONS: Most academic child abuse professionals believe that spanking is inappropriate and their beliefs are influenced by the context in which spanking occurs. Little is taught about how to manage spanking observed in a clinical setting.

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This study was undertaken to describe the knowledge about child sexual abuse, and factors that affect the knowledge of a statewide sample of physicians. A survey of physicians (n = 113) participating in a statewide program for child abuse evaluations was made in Summer 1993, with 78% participation. Knowledge scores were derived from the survey based on comparison to the responses of a panel of five experts. Several areas of inadequate knowledge were found including assessment of chlamydia infection, Tanner staging, and documentation of historical and physical exam findings. Factors associated with better knowledge scores were physician participation in continuing medical education and specialization in pediatrics. In addition, variations in presentation of the data affected physician judgement. We conclude that knowledge of physicians about child sexual abuse shows some deficiencies, is generally better among pediatricians, and may be improved by continuing medical education.

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This report describes maternal discipline of infants and toddlers, focusing on how the context of the misbehavior affects maternal beliefs and practices. Mothers of 1- to 4-year-old children were interviewed using a 20-minute, structured questionnaire at two practice sites: (1) an inner-city teaching hospital pediatric clinic (n = 104) and (2) a private pediatrician's office in a nearby suburban neighborhood (n = 100). Measures were constructed to assess beliefs and practices about three kinds of discipline (teaching, spanking, and removing) and about two approaches to discipline (positive or negative). We found that mothers believe significantly (p < .001) more strongly in all three kinds of discipline for dangerous misbehavior compared with annoying ones. Belief in teaching, spanking, and negative approach increase with age; belief in removing decreases (p < .001); and belief in positive approach remains stable. Belief in spanking starts earlier than belief in teaching, and belief in negative tone increases with age. Mothers seem to have better formulated beliefs about spanking and negative and positive approach to discipline than about teaching or removing. Eighty-five percent believe time-out is at times appropriate for 2 year old, but only 67% had practiced it in the past week. Belief and practice of time-out varied by the age of the child and practice site. Explaining, distracting, and praising were practiced frequently, whereas bribing was less common. Less than half (44%) reported that they had ever discussed discipline with their child's physician, although 85% thought that their physician could give good advice. There is evidence that mothers change their minds about the appropriateness of time-out as their child gets older, but beliefs about other kinds of discipline remain relatively constant. We conclude that the type of misbehavior and the age of the child affect a mother's beliefs about discipline. These findings suggest a role for pediatricians in exploring and broadening parents' concepts of discipline.

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OBJECTIVES: To assess the quality of documentation by physicians in their evaluations for sexual abuse of children and to define factors that affect documentation. DESIGN: Cross-sectional survey and blinded chart review. SETTING: A statewide program for child abuse evaluations. PARTICIPANTS: Physicians (n = 145) who performed evaluations during fiscal year 1992-1993 were surveyed. Up to five randomly chosen medical records (n = 548), obtained from each eligible physician, were reviewed. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: A survey of physicians who participated in the statewide program was made in summer 1993, with 78% participation. Knowledge scores were derived from the survey based on a comparison with the responses of a panel of five experts. Charts that were obtained from eligible physicians were assessed by two blinded reviewers. Documentation of the history and physical examination was evaluated as good or excellent by 30% and 23% of the physicians, respectively. Factors that were positively associated with better documentation of the history included a more structured format for the record, continuing medical education courses on sexual abuse of children, female gender, and a history of disclosure (P < .005 for all). Factors that were related to good documentation of the physical examination included structured records, continuing medical education courses, female gender, and knowledge scores. Factors that were not related to knowledge or documentation included the number of evaluations performed, practice group size or location, age of the physician, and a physician's reading of journal articles about sexual abuse of children. CONCLUSION: Quality of evaluations for sexual abuse of children may be improved by the use of structured records and participation in continuing medical education courses with regard to sexual abuse of children.

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OBJECTIVE: To describe maternal beliefs and practices of spanking infants and toddlers and the relations between factors affecting these beliefs and practices. DESIGN: Cross-sectional survey. SETTING: Site 1 was an inner-city teaching hospital pediatric clinic. Site 2 was a private pediatrician's office in a nearby suburban neighborhood. PARTICIPANTS: Mothers of children less than 4 years old in the waiting area. Site 1: n = 104; site 2: n = 100. SELECTION: Systematic sample of convenience. METHODS: Mothers were interviewed using a 20-minute structured questionnaire. Measures were constructed to assess beliefs (Cronbach's alpha = .90) and practices about spanking and approach to discipline (alpha > .71). RESULTS: Belief in spanking correlated significantly (P < .001) with belief in negative approach (r = .52) and with the practice (r = .46) and severity (r = .34) of spanking. Nineteen percent of the mothers believed that there are times when it is appropriate to spank a child less than 1 year old, and 74% believed this about children 1 to 3 years old. Forty-two percent reported that they had spanked their own child in the past week. Mothers believed more strongly in spanking for dangerous misbehaviors than for annoying ones (P < .001). Belief in spanking and negative approach were stronger for older toddlers (P < .001). Belief in and frequency of spanking were more common at the inner-city site (P < .001). CONCLUSIONS: The belief in and practice of spanking are prevalent in disciplining very young children. The context of the spanking affects beliefs and practices. The finding that belief and practice of spanking are highly correlated suggests that belief rather than impulse largely explains spanking of children less than 4 years old. The high correlation between spanking and negative approach toward discipline raises questions about whether negative consequences of spanking are the result of spanking per se, the negative approach toward the child, or both.

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