This is the first analysis assessing systematically the understanding of “reasonable suspicion” and the application of the legal framework in specific child protection cases in healthcare professionals in Germany—and one of few similar analyses worldwide.
The overwhelming majority of respondents saw at least average probability for child maltreatment in the case vignettes. A percentage of 23 to 36% (depending on the profession) of participants however had no or low suspicion for child maltreatment. This finding suggests high heterogeneity and uncertainty in the assessment of particular cases—a fact well established in the empirical literature for all professionals in child protection [15, 16]. Empirically validated key risk factors for child maltreatment have been used in both case vignettes, which in turn suggests insufficient knowledge on the risk factors of child maltreatment. In consequence, child protection training increased the likelihood of perceiving the situation in the vignette as reasonable suspicion for child maltreatment.
Literature underlines insufficient knowledge of child maltreatment in healthcare professionals in Germany: in a previous study assessing reporting behavior of pediatricians and child and adolescent psychiatrists in the German capital Berlin, the majority of participants described to have difficulties in detecting child maltreatment [17]. Uncertainty regarding potential maltreatment is known to be a major risk factor for inconsistent reporting to CPS by healthcare professionals. [18, 19].
In line with these findings, even if participants reported suspicion for maltreatment, only 80% chose to report to CPS. Even though 80 % seem to be a high percentage in a system without mandatory reporting, it has to be considered that known barriers for reporting, such as familiarity with the family [20], fear of negative consequences of a report for oneself, the patient or the family [19] and uncomfortability with addressing the issue of maltreatment with the family [21] may be a minor obstacle in a theoretical case vignette compared to real life.
Previous research suggests that another common reason for omitted reports to CPS might be a lack of feedback on the possible course of action when maltreatment is suspected. [18, 19]. In addition, many might shy away from reporting if they perceive CPS intervention as incompetent or insufficient—even if the legal norm warrants a report. But also lack of knowledge and experience seem to impact reporting. In our data, self-perceived good knowledge of the legal framework and work experience with cases of suspected maltreatment were positive predictors for reports to CPS.
Our data show that training in child protection is a predictor for the degree of perceived suspicion for child maltreatment in the vignette, but not for reporting the case to CPS. This is surprising and points towards a divergence of evaluation of the case (threshold for suspicion) and handling of the case (threshold for reporting). Consequently, child protection training should put more focus on the legal framework and subsequent implications for handling of the case beside recognition of child maltreatment.
Interestingly, work experience as proxy measured by participants’ age was not a predictor for higher level of suspicions or reporting to CPS. A cautious interpretation might be that one only sees what one is looking for, even as a healthcare professional: Many years of experience without cases of suspected maltreatment (whether not present or not detected) might add to a confirmation bias and making detection of and appropriate decisions harder, not easier.
The central limitation of the present study is that the participants cannot be considered as representative for their profession. Although almost all relevant German professional associations have supported the survey, the response rate of its members fluctuated and amounted to 3.9% overall participation. However, it should be noted that this response rate is based on the total number of members of the associations even though not all members received this call (as not all had agreed to receive emails by their association). Consequently, a higher actual response rate can be assumed. The gender ratio of the participants was almost exactly the same as that of the respective population, although on average they were younger (see Additional file 1). Another limitation is that questions on knowledge about child protection and the case vignettes were designed or adapted by the authors themselves - due to the lack of such instruments, psychometrically validated methods could not be used here. There are other factors besides personal suspicion of maltreatment and reasonable suspicion that are discussed to influence reporting. These include faith in the CPS, personal connection to the family, and decision-maker’s education [8]. While we have controlled for education, personal connection to the family cannot play a role in our case vignettes. As the latter usually keeps professionals from reporting, our results may even overestimate reporting rates.