Our study demonstrated that training about CAN for pediatricians was associated with increased identification of victims of CAN.
The foundation of their competency in this role is established during their residency. Many authors have found areas of strength and weaknesses in current pediatric residency child abuse curricula [5, 6]. In the USA the recent creation of a Child Abuse Pediatrician subspecialty represents an opportunity to establish national standardized recommendations for child abuse training curricula and to identify several factors, including the presence of a written curriculum, that contribute to increased confidence among residents.
According to our study, available research demonstrates that different training strategies can improve knowledge and preparedness related to the recognition and response of CAN.
Starling et al. compared the training and knowledge in the United States among the 3 specialties most likely to encounter abused children: pediatrics, emergency medicine, and family medicine. Analyzing the survey received from 53 program directors and 462 residents they found that pediatric programs provide far more training and resources for child abuse education than emergency medicine and family medicine programs [5].
Narayan et al. analyzed with a survey the preparedness of residents to address CAN on graduation [7]. A 28-item survey was sent to chief residents of all 203 Accreditation Council for Graduate Medical Education–accredited pediatric residency programs in the United States from 2004 to 2005. The response rate was 71%. Respondents rated the levels of preparedness of graduating residents to address CAN as: very well (12%), well (54%), somewhat well (28%), or not well (6%). They demonstrated that the preparedness was significantly associated with hours of didactics, number of inpatient cases of CAN seen, number of sexual and physical abuse cases during mandatory rotation, and length of mandatory rotation [7]. They compared also their data with a similar study, by Dubowitz et al. conducted in 1988, and noted that not be a large difference between the perceived adequacy of training of residents over the two decades despite the impact of this problem on social and public health.
Hibbard et al. described the effect of a multidisciplinary project carried out in Indiana to educate medical, child protective and legal professional in the evaluation and care of children victims of child abuse [8]. The program was designed to accomplish 5 tasks: behavioural and physical indicator, interview, the use of dolls and drawing as interviewing aids, medical evaluation and legal responsibilities. The program was conducted with didactic presentation and discussions. They demonstrated an improved knowledge score at 2 weeks post-program and at 6 months [8].
In the literature, there is also a study by Showers et al. about the effect of self-instructional programs on physical and sexual abuse on emergency physicians [9]. The project was base on 2 self-instructional programs of about 6 h designed to study in the home or office. Topics in the didactic sections included incidence and consequences, legal aspects and documentation, risk and suspicion, types of abuse, interview techniques and treatment [9]. The project resulted in significant improvement in the knowledge.
These studies and experiences demonstrate that different tools can conduct to the same result and they are very useful to increase the best practice on this hot topic. In Italy actually there is no specific required training in CAN during graduation.
Our study suggests that the physicians should receive enough training to accurately identify and report abuse when it is suspected. Moreover, aside from identification, training can improve pediatricians’ ability to safely and sensitively respond to children exposed to maltreatment and their families, including improved communication in initial encounters, increased support to children and families in connecting with community services [10, 11]. First of all, is important to not underestimate symptoms such as abdominal pain and voiding disorders, in this cases it is fundamental to deal out organic causes for example taking drugs or rare diseases. So particularly, for abdominal pain and voiding disorders is important to rule out organic causes such as taking medication or other rare diseases [12].
Many programs should begin the process of implementing CAN training. In particular we believe that the CAN training not to be focused only on physical and sexual abuse but also on neglect or domestic violence. Neglect is the most common form of child abuse and the relationship between domestic violence and CAN has been well established [13,14,15,16,17,18].
Specific sessions on neglect and domestic violence training are mandatory in all didactic training programs on CAN.
There also is a need for a national CAN curriculum that can be adapted to any training site. Considering the incidence of CAN we think that the well-being of children depends on a well-trained and knowledgeable force of physicians who can identify and prevent CAN.
Characteristics of our sample may limit the generalization of the findings but our study is an example of efficacy of post-graduate training but to employ the medical practice on CAN, considering that child maltreatment is more prevalent than cancer and just as fatal, is necessary to have structured mandatory rotations for residencies. Furthermore the evolution of the concept of CAN leads to consider new types of maltreatment that in the future will certainly be taken into account with a new era of social paediatrics [19,20,21].
Domestic and interpersonal violence are public health problems so we think that it should warrant more attention during residency training on family violence as well as anatomy, molecular biology, genetic diseases or infective diseases.
