Facts and Recommendations regarding When Medical Institutions Report Potential Abuse to Child Guidance Centers: A Cross-Sectional Study

Round 1

Reviewer 1 Report

Appropriate for communication article, and interesting approach to link theoretical perspective with empirical data. And a few recommendation for easier reading. 

# 35. increased, rather than facilitated 

# 77. The survey was, according to the methodology statement, performed with Institution. But analysis was executed in person-base. This can be corrected. 

# 97. 2.3.3 Reason ...: selection of the items and validation or review process might have improved the credibility of the process. And citation for the 'literature' is required.  

Overall, implication of this survey may be stated someplace in the text, which seems to be the virtue of this study.

Author Response

■Response to comments by Reviewer 1

 Thank you for your valuable suggestions.

 

# 35. increased, rather than facilitated 

Thank you. Changed to “increased”.

 

# 77. The survey was, according to the methodology statement, performed with Institution. But analysis was executed in person-base. This can be corrected.

Thank you for your comments. The survey asked individuals most involved with cases of abuse in the facilities about the overall situation, not about their individual experiences. As a result, the analysis was conducted on a facility basis, not an individual basis. This point was clearly stated in the method.

 

Self-administered questionnaires were mailed to the chief pediatricians in pediatric specialist training facility hospitals designated by the Japanese Pediatric Society. At each facility, the pediatrician-in-chief was asked to select one person at that facility familiar with the response to child abuse (hereafter referred to as the “respondent”) and the respondent answered the questionnaire in terms of the situation at each facility, not in terms of their personal experiences.

 

# 97. 2.3.3 Reason ...: selection of the items and validation or review process might have improved the credibility of the process. And citation for the 'literature' is required.

 

Thank you for your comments. You are correct. We have cited the literature that we referred to in developing the questionnaire. The questions were first selected by the primary author with reference to previous studies, and their validity was determined through several review processes with the co-authors. This point has been added. The references have been renumbered (references 15-20 have been renumbered).

 

On the basis of prior literature, the first author (U.M.) selected 14 items as reasons for the notification response policy and assessed them on a four-point scale [13, 14, 15]. Their validity was determined through several rounds of review process together with the co-authors.

 

20.→15    Department of Health and Human Services. The Role if Professional Child Care Providers in Preventing and Responding to Child Abuse and Neglect. 2008. Available online at: https://www.childwelfare.gov/pubPDFs/childcare.pdf  (Accessed on May 31, 2022)

15→16. Besharov, D.J. Recognizing Child Abuse A Guide For The Concerned. FreePress, New York, 1990.

16→17. Powell, C. Safeguarding and Child Protection for Nurses, Midwives and Health Visitors. A Practical Guide. Open University Press, New York, US. 2011.

17→18. Kalichman, S.C. Mandated Reporting of Suspected Child Abuse. Ethics, Law, & Policy. 2nd ed.; Amer Psychological Assn, 1999, pp. 145–146.

18→19. London Safeguarding children board. London Child Protection Procedures and Practice Guidance. 2010.

19→20. Kobayashi, M. Jido-dodanjo kara mita Chiiki-iryo-network ni tsuite no Ankeito Chosa: Hi-gyakutaiji ni taio surutameno Byoin-nai oyobi Chiiki-iryo-system ni kansuru Kenkyu [Questionnaire Survey on Community Medical Network from the Viewpoint of Child Consultation Center: Study on Hospital and Community Medical System for Responding to Abused Children]. FY2004 Health, Labour and Welfare Science Research (Comprehensive Research Project for Children and Families) “Study on the Comprehensive Medical Treatment System for Abused Children (Principal Investigator: Toshiro Sugiyama),” FY2004 Research Report: 60-71, 2004.

 

Once again, thank you for reading our paper indetail. We hope this version is now acceptable for publication. We are also ready to further revize the manuscript.

Reviewer 2 Report

The study design is innovative, and the findings of the current study have practical implications for prevention of child abuse. My comments as follow:

1. Self-administered questionnaires were mailed to pediatric specialist training facility hospitals designated by the Japanese Pediatric Society, and those familiar with the response to child abuse at such facilities (hereafter referred to as “respondents”) were asked to respond. (Line 81 - 84)

Comment: How many “those familiar” were sampled in each hospital? What is the sampling method for “those familiar”? Convenience sampling or simple random sampling? The authors should explain these questions clearly.

 

2. Only those facilities with report experiences were counted (Table 4). A total of 176 facilities (63.3%) responded that they had experienced some difficulties as a result of notifying the family in conjunction with the report. Fifty-two facilities (18.7%) responded that they had experienced some difficulties when the CGC was reported, but the family was not notified. (Line 198 - 202)

Comment: The whole Table 4 is confusing. It is not an official frequency table. What is the total number for the 63.3%? Why don't the numbers of seven kind of problem add up to 176? The data may be all right, but the tables (Table 4 - 6) are hard to read. Please revise them.

 

3. A contrasting result between the notified and non-notified groups was found for the reason of the family’s right to know. (Line 299 - 307)

Comment: The whole paragraph seems like the results, rather than the discussion. There are many paragraphs or sentences listing results instead of discussing findings in the Discussion part. The authors should distinguish the difference between the Results and the Discussion, and provide actual discussion of the current study.

 

4. In the future, it will be necessary to clarify which cases are more likely to cause problems, and identify the factors affecting the families and children, as well as to investigate and study the method of notification. (Line 383 - 385)

 

Comment: This statement is not appropriate to show in the Conclusions. Apparently, it is not one of findings from the current study. On the other word, we can’t draw this conclusion it based on the results from this study. This statement is better to be a practical implication for future research in the Discussion part or the Limitations part.

Author Response

 

■Response to comments by Reviewer 2

Thank you for your valuable suggestions.

 

1. Self-administered questionnaires were mailed to pediatric specialist training facility hospitals designated by the Japanese Pediatric Society, and those familiar with the response to child abuse at such facilities (hereafter referred to as “respondents”) were asked to respond. (Line 81 - 84)

Comment: How many “those familiar” were sampled in each hospital? What is the sampling method for “those familiar”? Convenience sampling or simple random sampling? The authors should explain these questions clearly.

 

Thank you for your comments. As you indicated, the survey methodology was not clear. The survey method is as follows: A request form and questionnaire were mailed to the chief pediatricians of 518 pediatric specialist training hospitals designated by the Japanese Pediatric Society. The pediatrician-in-chief requested in writing that one person at the facility in question familiar with the response to child abuse respond to the survey. This was a concrete survey of each Japan-Pediatric-Society-designated pediatric specialist training facility hospital, and the selection of the respondent by the pediatrician-in-chief of the facility was convenience sampling. The description of the request method has been revised.

 

Self-administered questionnaires were mailed to the chief pediatricians in pediatric specialist training facility hospitals designated by the Japanese Pediatric Society. At each facility, the pediatrician-in-chief was asked to select one person at that facility familiar with the response to child abuse (hereafter referred to as the “respondent”) and the respondent answered the questionnaire in terms of the situation at each facility, not in terms of their personal experiences.

 

2. Only those facilities with report experiences were counted (Table 4). A total of 176 facilities (63.3%) responded that they had experienced some difficulties as a result of notifying the family in conjunction with the report. Fifty-two facilities (18.7%) responded that they had experienced some difficulties when the CGC was reported, but the family was not notified. (Line 198 - 202)

Comment: The whole Table 4 is confusing. It is not an official frequency table. What is the total number for the 63.3%? Why don't the numbers of seven kind of problem add up to 176? The data may be all right, but the tables (Table 4 - 6) are hard to read. Please revise them.

 

Thank you for pointing this out; the results in Table 4 are for the 278 facilities that responded that they had experienced notification. All of these facilities (278 facilities) were asked to indicate whether they had experienced problems when they did or did not notify their families. As you pointed out, the description in Table 4 was not clear, so we corrected it. The option "experienced some problems" was for cases in which respondents answered that they had experienced at least one of the seven problems (e.g., "Relationship with family members deteriorated"). Since this was a confusing description, we have added a footnote on the tabulation method. In addition, we asked respondents to answer the question breakdown in a format that allowed multiple responses. Therefore, the total number of question breakdowns exceeds 176. We have added a note to the table to indicate that there were multiple responses. In addition, Tables 5 and 6 has been revised to correct a point that was not clear.

 

Only those facilities with a reporting experience were counted (Table 4). Of the 278 facilities, 176 facilities (63.3%) responded that they had experienced some difficulties as a result of notifying the family in conjunction with the report. Fifty-two facilities (18.7%) responded that they had experienced some difficulties when they reported the matter to the CGC but did not notify the family. The percentage of respondents who experienced some problems was significantly higher when they notified the family than when they did not (p = 0.001). The most common problem experienced as a result of notification was “worsening of relationship with family” (at 143 facilities; 51.4%). Even in the case where the family was not notified, the most common problem experienced was “worsening of relationship with family” (at 25 facilities; 9%).

 

Table 4. Difficulty experienced with and without notification, n (%)

	In case of notification n (%)	In case of non-notification n (%)	p-value*
Overall	278 (100)	278 (100)
Experienced some kind of problem†	176 (63.3)	52 (18.7)	<.001
Content of Problems Experienced (multiple responses allowed)
Relationship with family deteriorated	143 (51.4)	25 (9.0)
Family requested early discharge or transfer	80 (28.8)	14 (5.0)
Family refused treatment for the child	39 (14.0)	9 (3.2)
Family was violent toward the staff or harmed the staff in some other way	38 (13.7)	8 (2.9)
The family removed or attempted to remove the child	38 (13.7)	6 (2.2)
The child suffered further abuse	10 (3.6)	19 (6.8)
The family filed a lawsuit	7 (2.5)	3 (1.1)

Note: Only the facilities that responded that they had reported the cases to the CGC or had notified the families were included in the sample (n = 278).

* McNemar test (p-value is based on the exact probability).

† When the option chosen was “experienced some kind of problem,” the respondents were defined as “experienced” if they answered that they had experienced at least one of the seven problems.

Table 5. Notification policy and difficulty experienced, n (%)

	Notification group	Case-by-case group Notification	p-value*	Non-notification group	Case-by-case group Non-notification	p-Value*
Overall	172 (100)	87 (100)		18 (100)	87 (100)
Experienced some kind of problem†	102 (59.3)	65 (74.7)	.015	2 (11.1)	30 (34.5)	.050
Content of Problems Experienced (multiple responses allowed)
Relationship with family deteriorated	79 (45.9)	56 (64.4)		0 (0)	13 (14.9)
Family requested early discharge or transfer	43 (25.0)	31 (35.6)		1 (5.6)	9 (10.3)
Family refused treatment for the child	15 (8.7)	18 (20.7)		0 (0)	4 (4.6)
Family was violent toward the staff or harmed the staff in some other way	22 (12.8)	13 (14.9)		0 (0)	4 (4.6)
The family removed or attempted to remove the child	17 (9.8)	18 (20.7)		0 (0)	4 (4.6)
The child suffered further abuse	6 (3.5)	2 (2.3)		1 (5.6)	10 (11.5)
The family filed a lawsuit	3 (1.7)	3 (3.5)		0 (0)	1 (1.2)

Note: Only the facilities that responded that they had reported the cases to the CGC or had notified the families were included in the sample.

* χ-square test (p-value is based on the exact probability).

† When the option chosen was “experienced some kind of problem,” the respondents were defined as “experienced” if they answered that they had experienced at least one of the seven problems.

 

 

Table 6. Difficulties arising and timing of notification

	Pre-report n (%)	Post-report n (%)	p-Value*
Overall	73 (100)	67 (100)
Experienced some kind of problem†	40 (54.8)	52 (77.6)	.005
Content of Problems Experienced (multiple responses allowed)
Relationship with family deteriorated	30 (41.1)	42 (62.7)
Family requested early discharge or transfer	16 (21.9)	20 (29.9)
Family refused treatment for the child	4 (5.5)	6 (9.0)
Family was violent toward the staff or harmed the staff in some other way	6 (8.2)	11 (16.4)
The family removed or attempted to remove the child	3 (4.1)	11 (16.4)
The child suffered further abuse	1 (1.4)	3 (4.5)
The family filed a lawsuit	1 (1.4)	1 (1.5)

Note: Only the notification group and the case-by-case group notifications were included in the sample of facilities that responded that they had reported the cases. To compare the results before and after the notification, we excluded those who answered that they chose to notify the family on a case-by-case basis.

* χ-square test (p-value is based on the exact probability).

^† When the option chosen was “experienced some kind of problem,” the respondents were defined as “experienced” if they answered that they had experienced at least one of the seven problems.

 

3. A contrasting result between the notified and non-notified groups was found for the reason of the family’s right to know. (Line 299 - 307)

Comment: The whole paragraph seems like the results, rather than the discussion. There are many paragraphs or sentences listing results instead of discussing findings in the Discussion part. The authors should distinguish the difference between the Results and the Discussion, and provide actual discussion of the current study.

 

Thank you for your comment.　As you indicated, we have not given this sufficient consideration. In the principal notification group, the family's right to know was emphasized. In Japan today, there is a mixture of individualism and family-centeredness. Therefore, it has been reported that the influence of family members is also significant in medical care (Ruhnke, G. W. et al. 2000. Ethical decision making and patient autonomy: A comparison of physicians and patients in Japan and the United States. Chest 118:1172-82.). It is presumed that family-centeredness will be higher, especially for minor patients. Perhaps the strong influence of traditional family-centered medicine in the facilities in the principal notification group emphasizes the family's right to know. We have added these points to the "Discussion" section.

 

A contrasting result between the notified and non-notified groups was found regarding the family’s right to know. In the notification group, 65.6% of the facilities cited the family’s right to know as the reason for their response, and in the principal non-notification group, 73.0% of the facilities responded that the medical institution had an obligation to notify the family. In Japan today, there is a mixture of individualism and family-centeredness. It has been reported that family influence is also significant in medical decision making [23]. It is presumed that family-centeredness will be higher, especially for minor patients. The facilities in the notification group may be more influenced by traditional family-centered medicine, which emphasizes the family's right to know.

 

 

4. In the future, it will be necessary to clarify which cases are more likely to cause problems, and identify the factors affecting the families and children, as well as to investigate and study the method of notification. (Line 383 - 385)

 

Comment: This statement is not appropriate to show in the Conclusions. Apparently, it is not one of findings from the current study. On the other word, we can’t draw this conclusion it based on the results from this study. This statement is better to be a practical implication for future research in the Discussion part or the Limitations part.

 

Thank you for your valuable comment. As you indicated, it was not appropriate to list this in Conclusion. We have moved the description of this section to Limitation.

 

(3) There are limitations inherent to the way in which the questions were asked about problems that actually occurred in the medical field. The survey was not about the number of problems that occurred but rather about whether or not respondents experienced problems. Therefore, there may be a gap between the number of problems and the actual cases. In the future, after analyzing and defining the details of the problems that occurred, it will be necessary to analyze the background of each case to determine how many of them actually occurred. Furthermore, it will be necessary to clarify which cases are more likely to cause problems and identify the factors affecting the families and children, as well as to investigate and study the method of notification.

 

Once again, thank you for reading our paper indetail. We hope this version is now acceptable for publication. We are also ready to further revize the manuscript.

Round 2

Reviewer 2 Report

I viewed the revised vision carefully, and I found the author replyed to the review's suggestions point to point, it's satisfactory.no other comments. I recommend this article for publication.