**4. Conclusions**

130 Child Abuse and Neglect – A Multidimensional Approach

to CPS) had been adopted by the team.

that all the necessary steps had been taken, and indeed the suggested procedure (reporting

Group B began the study without a history of reporting to CPS, but just before their training (while Group A had started to receive training), Group B made a report of a suspected case of sexual abuse. One may speculate if this reporting behavior was prompted by familiarity with the topic provided by the instruments. The reported case involved a 9 month-child, female, who was taken to Family Health Unit by her aunt because the baby had a rash in the genital area. Two professionals examined the child separately and found that the genital region did not have a rash, but was indeed, edematous and red, signaling possible sexual abuse. The girl's aunt told both professionals that she suspected sexual abuse by the child's stepfather. CPS was, then, called and a letter by the physician indicating possible sexual abuse was forwarded as well. When the first author examined this case at CPS, there was also a letter from the child's mother among the documentation, registering a complaint against the

According to staff reports, the child was sent for an exam at the city's Legal Medical Institute, but supposedly the expert had written that that "*because there is no hymen rupture one cannot claim that there was sexual abuse"*. The family moved away from the neighborhood, and no longer visited that particular health unit. During the first training meeting with Group B, the case was narrated, and assessed by the team as an example of failure from the protection network. The general opinion was that even when the professional fulfilled his/her role, there were no guarantees that the case would have a proper resolution, point

This case illustrates the difficulties and shortcomings of the Protection Network and how difficult it is to prosecute child sexual abuse cases in the city [36]. The case also illustrates the need for ongoing training of all agencies involved, including experts from the Forensic Institute, who conduct medical examinations of children who may have been sexually

After training, one more report record was observed by Group B, which may indicate that the intervention helped to overcome the initial negative experience. There is however another complication concerning notifications to CPS by Group B. At the fifth meeting in which a CPS staff made a presentation to the group, health participants reported five cases during this visit (two cases involving adolescents with drug involvement, a case of suspected neglect and two cases of physical violence). CPS staff wrote down names and addresses of the five children, explaining that he would refer them to other staff members of CPS. Nevertheless, no such records existed when the first author examined CPS data, but one cannot say that the reporting steps were not taken because the cases could have been

"old" in the sense of previously reported, and therefore inaccessible in their data base.

staff reported having had previously with sexual abuse cases.

Despite the low number of reporting done by the groups after the training, the fact that they existed may be considered an important step and positive result, given the very low contact

physician, as she felt that the reporting was aimed at harming her family.

that was often discussed throughout the course.

abused.

The goal of this study was to to increase awareness of Family Health Program professionals for preventing child abuse, by evaluating a training course to identify and report abuse. The choice of these professionals was based on the literature that indicates that training the team as a whole is more efficient than just training professionals individually [22].

Results indicated that there were positive changes of opinion and attitudes facing the topic of child abuse. From a quantitative point of view, results were not as robust as expected. Perhaps the instruments used in the study were not sensitive enough to observe changes, which would require investment in the construction of questionnaires with proper psychometric data, tested in large scale. Additionally, the reduced sample may have hampered the detection of quantitative improvements. From a qualitative viewpoint, on the basis of consumer satisfaction, the results were very encouraging. Additionally, there seems to have been initiated a systematic engagement with Child Protection Services, which did not exist before.

The prompt acceptability by staff, with which the teams agreed to take part of this training, reflects an interested and motivated attitude to learn about child abuse. However, because we provided training to a team in operation, many challenges had to be overcome as, for example, the insertion of a researcher in the teams and the floating of professionals during meetings for various reasons, hindering attendance. Initial questionnaire data confirmed that there was a lack of familiarity with the topic and, this way, basic concepts such as the fact that humiliating a child corresponds to psychological violence, had to be discussed with the teams.

One aspect that may have contributed to participants' positive course evaluation were the visits from CPS staff and the forensic psychologist, which helped to provide a realistic picture of the work involved, diminishing negative impressions. Some of the comments professionals made after such visits were: "*now I understand how Child Protection Services work, it was very enlightening*" (PA1), and "*It was enough to get a sense of how difficult it is to work there*" (PA6).

Authors [22] indicate that one should work with the team as a whole in order to reduce the disparity of knowledge of health professionals from the same institution. We could see that this was indeed possible and that it strengthened the bonds amongst teams.

Increasing Awareness of Brazilian Family Health Team Professionals on Reporting Child Abuse: A Case Study 133

training program recommendation on the ecological context of child abuse to understand risk and protective factors [22] was well suited to the context of the Family Health Program, which aims to meet individuals and family needs fully and continuously, developing

In conclusion, the training of health professionals to identify and report to competent authorities cases of child abuse, may be instrumental to Brazil's Family Health Program. It would be important to incorporate this approach, once tested in large scale, as public policy aimed at training professionals to improve the general care of the population, and especially

*LAPREV (The Laboratory of Violence Analysis and Prevention), São Carlos, São Paulo, Brazil* 

*LAPREV (The Laboratory of Violence Analysis and Prevention).São Carlos, São Paulo, Brazil* 

This paper is part of the M.A. thesis conducted by the first author with a fellowship from FAPESP (Federation of Research Support from the State of São Paulo), supervised by the

[1] Minayo, MCS. The inclusion of violence in the health agenda: historical trajectory. Cien

[2] Krug EG, Linda LD, Mercy JA, Zwi AB, Lozan R. World report on violence and health.

[3] Brazil, Congress. [Statute of Child and Adolescent]*.* São Paulo, Editora Escala; 1990.

[4] Pires ALD, Miyazaki MCOS. [Children and adolescents maltreatment: a literature review for health professionals]. Arq de Cienc Saude. 2005 Jan-Mar; 12 (1): 42 – 9.

[5] Pascolat G, Santos CFL, Campos ECR, Valdez LCO, Busato D, Marinho DH. [Physical abuse: the profile of aggressor and child victim]. J Pediatr (Rio J). 2001 Feb; 77(1): 35-40.

[6] Gonçalves H, Ferreira AL. [Health professionals' reporting of family violence against children and adolescents]. Cad Saude Publica. 2002 Jan/Feb; 18 (1): 315-19. Portuguese.

actions to promote and restore health [38].

*Federal University of São Carlos, Department of Psychology,* 

*Federal University of São Carlos, Department of Psychology,* 

Saude Colet. 2006 April/June;11(2): 1250-67.

Geneva, World Health Organization; 2002.

to prevent violence.

**Author details** 

Thais H. Bannwar

Lúcia C.A. Williams

second author.

**6. References** 

Portuguese.

Portuguese.

Portuguese.

**5. Acknowledgement** 

Another point observed was the influence of health professionals own personal history of abuse as in the example of one team staff who said that: "*the last meeting (*about different types of violence*) made me reflect on the way I was raised, always with slaps and screams and that this was not necessary*" (PA12). Another participant disclosed to the team that when she was young, the aunt who raised her used to bang her head against the wall, if the child did not do house chores properly, and in addition, her cousins had attempted to rape her. It was agreed that these disclosures reflected confidence in the group as a team, and should remain confidential. A third participant disclosed privately to the researcher that she had been sexually abused as a child by and uncle, and a fourth professional told the researcher privately about what it was like to grow in a home with domestic violence, and how much she strived to provide a different environment to her children.

Yoshihama and Mills [37] examined the personal history of professionals and their influence on the professional responses to allegations of family violence. They found that about half of professionals (n = 303) reported having suffered physical and/or sexual violence by an intimate partner; one-third of respondents reported physical abuse in their childhood, and 22% had suffered sexual abuse as a child. Professionals who had an abuse history identified more with abused cases encountered, and offered greater support to victims, making more protective decisions. This aspect was not explored in the present questionnaires, but participants' accounts in each group with a history of corporal punishment, sexual and psychological violence indicate that there were indeed previous abuse histories. In future research it would be interesting to investigate this variable and match them to their respective opinions about the role of health professionals.

The emphasis given to the need of a training program rather than a single lecture [22] seems to be valid. The training in the present study lasted five months, enabling reflection among participants and a change of verbalizations, beliefs and attitudes about child abuse, which would have been difficult to observe in a shorter period of time. In addition, the inclusion of the training course in the work routine encouraged discussion of several potential or real child abuse cases.

Lane and Dubowitz [27] stated that clinical experience is essential for the development of skills and comfort level regarding assessments of child abuse Thus, a brief training may not be suitable to create the knowledge needed to assess and treat children suspected of abuse. Additionally, Lane and Dubowitz [27] verified the need for expert assistance, which is also relevant to this study, as after the training, the team pointed out that an interdisciplinary group would be ideal in terms of assessment of child sexual abuse and neglect cases.

Another possibility of course expansion would be to include in-depth encounters for each type of violence, as was proposal by the second author [25] after giving a specific training course on sexual sexual abuse, as each violence modality leads to specific demands. The Increasing Awareness of Brazilian Family Health Team Professionals on Reporting Child Abuse: A Case Study 133

training program recommendation on the ecological context of child abuse to understand risk and protective factors [22] was well suited to the context of the Family Health Program, which aims to meet individuals and family needs fully and continuously, developing actions to promote and restore health [38].

In conclusion, the training of health professionals to identify and report to competent authorities cases of child abuse, may be instrumental to Brazil's Family Health Program. It would be important to incorporate this approach, once tested in large scale, as public policy aimed at training professionals to improve the general care of the population, and especially to prevent violence.
