Barriers to and Consequences of Mandated Reporting of Child Abuse by Nurse Practitioners

ARTICLE

Barriers to and Consequences of Mandated Reporting of Child Abuse by Nurse Practitioners Pamela A. Herendeen, DNP, PNP-BC, Roger Blevins, CPNP, Elizabeth Anson, MS, & Joyce Smith, MS, PhD

ABSTRACT Introduction: The objective of this study was to examine the experiences of pediatric nurse practitioners (PNPs) in the identification and management of child abuse, determine the frequency of their reporting, and describe the effects, attitudes, and confidence in reporting child abuse. Methods: A survey based on the 2006 CARES survey was disseminated via e-mail through use of Survey Monkey to 5,764 PNP members of the National Association of Pediatric Nurse Practitioners. The data from this survey were then subjected to statistical analysis, and the resultant findings were compared and contrasted with other similar studies. Results: Data analysis revealed that smaller numbers of PNPs in the sample group failed to report suspected child abuse

than did their physician colleagues. PNPs and physicians encountered similar perceived barriers to reporting and used similar processes in dealing with them. Both physicians and PNPs with recent child abuse continuing education hours expressed greater confidence in child abuse management skills and were more likely to report suspected cases of abuse. Discussion: Much information was learned about PNP reporting practices regarding child abuse. The most significant facts that emerged from this study were that all health care providers require further child abuse education, both in their curriculum preparation and continuing education, to effectively diagnose and manage child abuse. J Pediatr Health Care. (2014) 28, e1-e7.

KEY WORDS Pamela A. Herendeen, Associate Dean for Education & Student Affairs and Associate Professor of Nursing, School of Nursing, University of Rochester, and Senior Nurse Practitioner, Golisano Children’s Hospital, Rochester, NY. Roger Blevins, Child Protection Team, Phoenix Children’s Hospital, Phoenix, AZ. Elizabeth Anson, Research Associate, School of Nursing, University of Rochester, Rochester, NY. Joyce Smith, Sr. Information Analyst, School of Nursing, University of Rochester, Rochester, NY. Conflicts of interest: None to report. Correspondence: Pamela A. Herendeen, DNP, MS, PNP-BC, BOX SON, University of Rochester SON, Rochester, NY 14642; e-mail: [email protected]. 0891-5245/$36.00 Copyright Q 2014 by the National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved. Published online August 9, 2013. http://dx.doi.org/10.1016/j.pedhc.2013.06.004

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Nurse practitioner, child abuse, mandated reporter

The incidence of child abuse has reached epidemic proportions. In 2010, more than 3 million children were referred to child protective services (CPS) for evaluation of possible abuse or neglect (Administration for Children and Families, U.S. Department of Health and Human Services [USDHHS], 2013). Of these cases, about 700,000 were substantiated, with 78% of the children experiencing neglect, 18% experiencing physical abuse, and 9% experiencing sexual abuse. An estimated 1,800 children were victims of fatalities (Administration for Children and Families, USDHHS, 2013). Pediatric nurse practitioners (PNPs) are legally mandated to report any injuries that they consider to be suspicious for child abuse or neglect. It is likely that at some point, a PNP will see a child in his or her practice whose condition raises the question of child abuse; dealing with this situation requires a particular set of skills January/February 2014

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(Hornor, 2011). Mandated reporting often presents a challenge to PNPs, particularly those with little training or experience in the field of child abuse. Several factors contribute to this challenge, not the least of which is history taking and evaluation. The history with these cases is often vague and imprecise (Hettler & Greenes, 2003). PNPs have been educated to obtain a thorough history from their patients, with the expectation that the information offered will assist in determining their diagnosis. In cases of suspected child abuse, the care provider may find the explanation of the presenting injury or situation to be less than forthcoming, perhaps even purposely misleading (Hettler & Greenes, 2003). These barriers to the reporting of child abuse may be encountered by even the most experienced PNP. Fraser, Mathews, Walsh, Chen, and Dunne (2009) reported that nurses with appropriate education and training demonstrate improved recognition and reporting of child abuse. In another study, Sege and colleagues (2011) indicate that child abuse experts and primary care providers are generally in agreement over reportable injuries; however, child abuse experts tended to report more often. Berkowitz (2008) found that education remains one significant modality that affects improved reporting. Mandated Enhanced education reporting often regarding child abuse presents that results in improved reporting a challenge to seems to be a theme. PNPs, particularly Jones and colleagues those with little (2008) discovered four major themes that aftraining or fected health care proexperience in the viders’ decisions to field of child abuse. report: injury circumstances and history, knowledge of and experiences with the family, consultation with colleagues, and previous experience with CPS. Goad (2008) notes that improved communication and collaboration may play an integral role in the final decision of whether to report. In 2006, Flaherty and colleagues reported results of a survey conducted with members of the American Academy of Pediatrics regarding factors associated with the identification and reporting of children suspected of being subjected to child physical and sexual abuse. Very little has been reported on this topic for PNPs; most studies that have been conducted have focused on physician reporting. We speculated that PNPs, who are well known for their strong advocacy for children, would be more inclined to report suspected child abuse and neglect than their physician colleagues. Permission was secured from Dr. Flaherty to use the survey she had sent to physicians and adapt the worde2

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ing so it would be appropriate for a PNP survey. The objective of the current study is to examine PNP experiences in identifying and managing child abuse cases and to compare results with those reported by physicians.

METHODS The survey was adapted, with permission, from a survey instrument that had been sent to members of the American Academy of Pediatrics (Flaherty et al., 2006). Because of practice differences between PNPs and pediatricians, additional choices were added to reflect the input of collaborating physicians in the decision-making algorithms of PNPs. The original self-administered paper and pencil survey was mounted on a commercial Internet survey hosting site (www.SurveyMonkey.com). An e-mail invitation to take the online survey was sent to 5,764 members of the National Association of Pediatric Nurse Practitioners (NAPNAP). Between August 2008 and January 2009, 643 respondents started or completed the survey, for a response rate of 11%. Response rates for Internet surveys vary widely, even when a specific professional association is targeted. Kung, Pannucci, Chamberlain, and Cederna (2012) reported a response rate of 5% from the membership of the American Society of Plastic Surgeons, all of whom were invited by e-mail to complete a short Web-based survey. Chipas and colleagues (2012) had a better response (26%) from student members of the American Association of Nurse Anesthetists. Therefore our response rate of 11% is reasonable for this type of survey. The responding PNPs were surveyed about their attitudes toward and experiences with their local governmental CPS, as well as their own attitudes and confidence regarding their ability to recognize and manage child abuse cases. Two fictional clinical vignettes were included in the survey; one was clearly a case of child abuse involving an infant, and another was an ambiguous vignette involving an older child. Respondents were asked to read the vignettes and indicate the probability that it was abuse on a 5-point scale, their recommendations for referral, and whether they would report the case to CPS. Data were downloaded from the hosting site with unique random numbers identifying each respondent. Initial data cleaning involved deleting incomplete responses. Data were further examined for eligibility of respondents to complete the survey, based on the criteria that the PNP must be working in primary care. Responses from 30 respondents were deleted because they reported working in specialty clinics or hospitals, and another nine were eliminated because they reported seeing zero patients per week, leaving a total number of 604 for analysis. Journal of Pediatric Health Care

Scale Development Scales for CPS experience, provider confidence, and provider attitudes were created based on methods described by Flaherty and colleagues (2006) and are detailed in the following sections. PNP CPS experience Five questions were used to assess PNPs’ experience with CPS. The five questions were: (a) the agency professionals are well trained, professional, and thorough; (b) the agency keeps me informed as to the progress and disposition of its investigations; (c) the children benefit from agency intervention; (d) the families benefit from agency intervention; and (e) my past experiences made me more willing to report my suspicions to the CPS agency in the future. A 5-point Likert scale with responses ranging from 1 (strongly disagree) to 5 (strongly agree) was used, with higher scores indicating more positive experiences with CPS. Factor analyses were performed using principal component analysis with varimax rotation and eigenvalue greater than 1 for criteria. One factor was extracted that accounted for 59.5% of the variance, with factor loading for all variables $ .65. The CPS scale demonstrated good reliability (Cronbach a = .82). PNP confidence and attitude Five questions were used to assess confidence and attitude related to child abuse: (a) I am confident in my ability to identify children at risk of injury from child abuse; (b) primary care providers help prevent the incidence of child abuse through anticipatory guidance; (c) primary care providers should screen for violence among adults within the home at regular health maintenance visits; (d) I am confident in my ability to manage patients who have been injured as a result of child abuse; and (e) I have received adequate professional training in the area of child abuse. A 5-point Likert scale with responses ranging from 1 (strongly disagree) to 5 (strongly agree) was used. Factor analyses were performed using principal component analysis with varimax rotation and eigenvalue greater than 1 for criteria. Two factors were extracted that accounted for 69.0% of the variance. Questions A, D, and E loaded on the first factor (confidence), with factor loading ranging from 0.83 to 0.85, and questions B and C loaded on the second factor (attitude), with factor loading of 0.79 and 0.81. The confidence subscale demonstrated adequate reliability (Cronbach a = 0.79), whereas the attitude subscale did not (Cronbach a = 0.48). Statistical Analysis Statistical analyses were performed using PASW Statistics 17.0 (SPSS, Chicago, IL) and SAS 9.2 (SAS Institute, Cary, NC). Associations between categorical variables were evaluated using v2 analysis. Continuous variables were analyzed using independent sample t-tests. Logiswww.jpedhc.org

tic regression models were used to assess the predictors of identifying the vignettes as abuse and whether the PNP would report the case to CPS. RESULTS Sample Description PNPs completing the survey had been in practice a mean of 13 years (SD, 9.5; range, 0 to 41). The median number of years in practice was 10. Although ethnicity was not determined by the survey, 24% of the respondents spoke Spanish in addition to English. Twentysix percent of those answering the question said they were considered a resource for evaluating suspected child abuse. Respondents stated that the number of patients seen per week ranged from 1 to 500, with a mean of 60 and a standard deviation of 46 patients. The median number of patients seen per week was 50. Prior Experience With Child Abuse Eighty-nine percent of the sample had seen a case of suspected child abuse in their career, and 11% indicated they had never seen a case of suspected child abuse. Among those who had ever seen a case of suspected child abuse, 248 (46%) had seen at least one case of suspected child abuse injury or death in the past year. There was a wide range in numbers of children in each age range seen by practitioners related to suspected child abuse injury or death in the past year (see Table 1). Overall, the median number of children seen for injury or death in the previous year was one for ages 0 to 1 year and 1 to 4 years and 0 for ages 5 years and older. Reporting Child Abuse to CPS One hundred five respondents (20%) reported that they had not reported every child with suspicious injuries to the authorities. The following reasons were given for not reporting: 64 said that the case was already referred to CPS; 52 referred the child to another professional; 15 worked with the family to solve the problem; 9 said their collaborating physician disagreed with their assessment; and 5 said that their collaborating physician agreed with the assessment but strongly advised them not to report it. Overall, 70% of the 105 PNPs who stated that they had not reported every child with suspicious injuries either referred the child to another professional

TABLE 1. Age groups of children seen with abuse injuries/death in the past year Age (years)

Mean

Median

Range

0-1 1-4 5-9 10-14 15+

5 5 6 4 2

1 1 0 0 0

0-250 0-250 0-500 0-300 0-250

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TABLE 2. Consequences of reporting to child protective services Consequence Type of outcome = positive for child Reported patient was protected from further abuse Reported patient was placed outside home and thrived Family received intervention and parenting improved Other positive child Type of outcome = negative for child A child suffered further abuse because the agency did not respond Other negative child Type of outcome = positive for practice Patient or family expressed appreciation that I had intervened Other positive practice Type of outcome = negative for practice Other patients heard about the report and left my practice I was sued for malpractice I lost reported family as patients I spent many hours in court and other legal proceedings Other negative practice

% 50 38 43 1 19 3 18

Respondents were asked about their overall experience with CPS, and more than half (51%) responded that they either strongly agreed or agreed that children benefited from CPS intervention, whereas slightly fewer (45%) believed that the families benefited. As shown in Table 3, 55% of the respondents either disagreed or strongly disagreed that CPS kept them adequately informed regarding the status and conclusions of the investigation. When asked about the CPS services in the respondent’s area, 66% believed that there were adequate CPS services in their area to assist victims of child abuse, but conversely, 21%% believed that the services were inadequate. The remaining 13% had no opinion or were neutral.

0.2 2 0 27 10 6

or knew that the case had already been reported; 35 PNPs (6.5%) either did not give an explanation or failed to report the suspicious injuries for other reasons. Consequences of Reporting to CPS Table 2 demonstrates the consequences of reporting cases to CPS. A majority (66%) of PNPs believed that the child or family had received some positive benefits from their intervention. The most common negative consequence reported was losing the family as patients (27%). Additionally, 19% reported that the child experienced further abuse because the agency did not act or did not act quickly enough. Overall, considering practice and child/family outcomes, 27% reported positive outcomes from all their experiences with child protection agencies, whereas 23% reported neither positive nor negative outcomes. Unfortunately, 9% reported only negative outcomes, and the remainder (41%) reported a mixture of positive and negative consequences.

PNP Confidence and Attitude PNPs’ confidence and attitude in managing child abuse cases was assessed, with PNPs expressing confidence in their ability to identify children at risk for child abuse (69% strongly agreed or agreed) and in their ability to manage patients injured as a result of child abuse (58% strongly agreed or agreed). PNPs clearly supported the role of the primary care provider in preventing child abuse; 87% strongly agreed or agreed that primary care providers can help prevent child abuse through anticipatory guidance, and 93% strongly agreed or agreed that primary care providers should screen for violence in the home at well-child visits. Slightly more than half of the respondents (53%) believed that they had received adequate professional training in child abuse; however, a surprising 21% either disagreed or strongly disagreed that they had received adequate training. Continuing Medical Education For the 5 years prior to the survey, the overall mean number of hours spent in contact hour activities related to child abuse was 13 (SD, 9), with a range of 0 to 550 (median, 5.0). Because the distribution of the number of contact hours was not normal, it was reduced to a dichotomous variable of any hours versus no hours. The presence or absence of contact hours in the previous 5year period was positively related to PNPs’ confidence

TABLE 3. Overall experiences with child protective services

CPS investigators are well trained, professional, and thorough (N = 529) CPS keeps me informed as to the progress and disposition of its investigations (N = 526) The children benefit from agency intervention (N = 527) The families benefit from agency intervention (N = 524) Past experiences have made me more willing to report my suspicions to the CPS agency in the future (N = 523)

Strongly agree/ agree, %

Neutral, %

Strongly disagree/ disagree, %

51 22

29 23

20 55

51 45 54

39 46 32

10 9 13

Based on a scale where strongly agree = 5; agree = 4; neutral = 3; strongly disagree = 2; and disagree = 1. CPS = child protective services.

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in identifying (p < .01) and managing (p < .01) child abuse cases. Vignettes Two following clinical vignettes were presented; one was clearly a case of child abuse, and the other involved an older child and was ambiguous. Vignette A J.J., a 14-year-old girl well known to your practice, comes in for follow-up of a broken wrist that was initially treated in the local emergency department. Upon reviewing her chart, you note that you were contacted by state child protective services 1½ years ago in relation to a charge of child abuse. The case was not substantiated by the agency. When J.J. comes to your office you ask her, in private, how the injury occurred; she states that she fell off her bicycle, but she is vague about where the bike accident happened and is annoyed with you for asking. Physical examination reveals a broken right wrist in a cast and bruises on her lower back. Vignette B S.J. is a 6-month-old infant who comes to your office because he has been crying whenever his mother changes his diaper. The mother, with a flat affect, tells you that ‘‘S’’ fell off the changing table onto a carpeted floor last night. Upon physical examination you note swelling and tenderness on the right thigh. A radiograph reveals a midshaft femur fracture. Respondents were asked to indicated whether they thought the vignette was a case of child abuse and whether they would report the case to CPS. Table 4 summarizes responses to the two vignettes. Respondents were more likely to consider the case involving the 6-month-old infant as child abuse than the case of the 14-year-old (82% vs. 26%). Among respondents who considered the 14-year-oldÕs injury to be ‘‘likely’’ or ‘‘very likely’’ caused by abuse, 6% (N = 9) said they would not report the case to CPS. Among those who considered the 14-year-oldÕs injury as ‘‘possibly’’ caused by abuse, 54% said they would report the case to CPS, but 46% said they would not report it.

TABLE 4. Responses to vignettes

‘‘Very likely’’ or ‘‘likely’’ that it was abuse ‘‘Unlikely’’ or ‘‘very unlikely’’ that it was abuse ‘‘Possible’’ that it was abuse Would report to child protective services

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Vignette A (14-year-old), %

Vignette B (6-month-old), %

26

82

4

2

70 63

16 92

Logistic regression was performed to determine to what degree PNP confidence, attitude, and CPS experience predicted responses to the ambiguous clinical vignette involving ‘‘J.J.,’’ the 14-year-old girl. Only provider confidence was a significant predictor of reporting the case to CPS (p < .05). Provider confidence was also the sole significant predictor of suspicion of abuse (p < .05). DISCUSSION The original objective of this study was to examine PNP practices in identifying and managing child abuse cases and to compare the results to those reported by Flaherty and colleagues, who surveyed physicians in their study. Many of the results were interestingly similar. Both PNPs (55%) and physicians (59%) strongly disagreed that CPS keeps them informed about the progression of the reported case. Physicians and PNPs also agreed regarding the concept that past experiences make them more willing to report suspicions to CPS, with 42% of physicians stating that they agree/strongly disagree and 54% of PNPs agreeing/strongly agreeing to this concept. Also similar was the response to practice and child/family outcomes, with 27% of PNPs reporting positive outcomes from their experiences with CPS agencies and 34% of physicians reporting positive outcomes. Overall, 105 PNP respondents (19.6%) indicated that they had not reported every child with suspicious injuries to CPS, and this was also the theme with their physician colleagues; 14.3% of those who failed to report stated that they worked with the family in an effort to address the problem. Both groups reported that they had seen child abuse during the past year. Fifty-two respondents (49.5%) dealt with their suspicions by making a referral to another professional, and 64 (61%) said that they knew the case was already referred to CPS. Similar to physicians, a significant number of PNPs reported losing their patient because of a child abuse report. This outcome may be inevitable in many cases, because the family may believe that an adversarial relationship exists with a health care provider after a report is made. At best, the family will find a new provider who will request medical records and discover the problems leading to a report within the records. At worst, the family may begin to use urgent care or multiple emergency departments or avoid health care providers altogether. The emergence of community coordinated electronic records may be beneficial in these situations. Thirty-five PNPs (6.5%) either did not give an explanation or failed to report the suspicious injuries for other reasons. We do not know to whom the 49.5% of nonreporting PNPs referred their suspicious patients; perhaps they referred them to a child abuse specialist in their community or a subspecialist to collaborate on the etiology of the injury. However, referring to others, even child abuse specialists, does not January/February 2014

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necessarily absolve these PNPs of their responsibility to report under most state statutes. The fact that 61% of those who did not report the abuse were seeing the child after a report had been made suggests that they perceived themselves as having enhanced child abuse diagnostic and management skills. The other possibility is that their community lacks adequate reIt is a concern that, sources to address similar to child abuse and the PNP believe this was physicians, 14.3% an area she or he could of nonreporting manage. It is a concern PNPs elected to try that, similar to physicians, 14.3% of nonrepto manage child orting PNPs elected to abuse issues in the try to manage child office. abuse issues in the office. This approach leaves the PNP vulnerable to civil liability and prosecution and may minimize the significant social issues involved in child abuse that often can be more effectively be managed through a multidisciplinary approach. Also consider the fact that some collaborating physicians have discouraged mandated reporting because they disagreed that the etiology of a given injury was most likely abusive. In these instances, it needs to be determined whose clinical acumen is most correct, because it is entirely possible that the PNP has had more experience or recent education than the collaborating physician. It also must be kept in mind that nearly 70% of the respondents in this study expressed confidence in identifying children at risk for abuse and nearly 60% expressed confidence in managing victims of maltreatment. Once again, more study regarding these questions is definitely needed. Of note, both physicians and PNPs identify recent child abuse education as a confidence-building factor that enabled them to report suspected abuse. This is a logical, to near predictable, finding that underlines the need for easily accessible child abuse continuing education for PNPs. Unfortunately, nearly 21% of respondents did not believe that they had adequate professional preparation in the field of child abuse. This finding may have implications for PNP program curriculum development and continuing education offerings. Notably, and in contrast to the pediatricians (Flaherty et al., 2006), no PNPs were sued for malpractice as a result of reporting a case of suspected child abuse to state authorities. Although it is heartening that no PNPs in this sample had been sued for malpractice, this finding may simply be related to the sample size and case characteristics; however, it also may be due to wording of the diagnosis in the record, presentation of the concerns to the family, or even a particularly strong therapeutic relationship with care providers. These possibilities warrant further investigation. e6

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Other themes that have emerged from this study are similar to those found in other studies. Although the majority of respondents had previously had positive experiences with their local CPS, others were more ambivalent on the subject, and the majority did not believe that they had been given adequate feedback regarding their case. Given the nationwide distribution of the subjects, some variability in child services provision should be expected. Because most CPS agencies must work with a fair degree of confidentiality, they are not usually inclined to share their progress on cases with reporters. In the specific instance of health care providers, it is necessary to share information, because they are already part of the management team. It may be necessary for PNPs to become more politically active in their states in an effort to alter that attitude. This study has several limitations; most notably, it only included PNPs, whereas a large number of family nurse practitioners also care for children. The survey was sent to all PNPs who were members of NAPNAP at that time, but thousands of practicing PNPs do not belong to NAPNAP, and thus the sample does not capture the majority of PNPs who are in practice. In addition, because the response rate was 11%, it did not include all the PNPs who are NAPNAP members. Much future research needs to be conducted, and many questions remain to be answered. Do PNPs who believe that their CPS systems are inadequate have a thorough understanding of how they work and what their limitations are, or do they have unreasonable expectations? PNPs need to fully understand that not reporting a child at risk for abuse is concerning for that child and siblings who may be at additional risk for abuse, but it also places the PNP at risk for professional liability (Hornor, 2011). Why do both physicians and PNPs have the impression that they can deal with child abuse alone in their offices given the .mechanisms for multifactorial nature improving access of abuse and the lack to child abuse of social services resources in most pricontinuing mary care offices? education for large What about communinumbers of cation and collaboration? The literature as practicing PNPs a whole supports the need to be belief that teamwork developed. provides the most effective care, which would be inclusive of a PNP and physician collaborating; therefore the concept that the physician is suggesting that the PNP not report a possible child abuse case is a cause for concern and deserves further investigation. Finally, it is clear that child abuse education need to be strengthened in all health care provider program curricula, and mechanisms for improving access to child Journal of Pediatric Health Care

abuse continuing education for large numbers of practicing PNPs need to be developed. REFERENCES Administration for Children and Families, U.S. Department of Health and Human Services. (2013). Child abuse and neglect statistics. Retrieved from http://www.childwelfare.gov/systemwide/ statistics/can.cfm. Berkowitz, C. (2008). Child abuse recognition and reporting: Supports and resources for changing the paradigm. Pediatrics, 122, S10-S12. Chipas, A., Cordrey, D., Floyd, D., Grubbs, L., Miller, S., & Tyre, B. (2012). Stress: Perceptionsmanifestationsand coping mechanisms of student registered nurse anesthetists, Perceptions, manifestations, and coping mechanisms of student registered nurse anesthetists. AANA Journal, 80(4), S49-S55. Flaherty, E., Sege, R., Price, L., Christofel, K., Norton, D., & OÕConner, K. (2006). Pediatrician characteristics associated with child abuse identification and reporting; results from a national survey of pediatricians. Child Maltreatment, 11(4), 361-369. Fraser, J., Mathews, B., Walsh, K., Chen, L., & Dunne, M. (2009). Factors influencing child abuse and neglect recognition and re-

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porting by nurses: A multivariate analysis. International Journal of Nursing Studies, 47, 146-153. Goad, J. (2008). Understanding roles and improving reporting and response relationships across professional boundaries. Pediatrics, 122, S6-S9. Hettler, J., & Greenes, D. (2003). Can the initial history predict whether a child with a head injury has been abused? Pediatrics, 111(3), 602-607. Hornor, G. (2011). Medical evaluation for child sexual abuse: What the PNP needs to know. Journal of Pediatric Health Care, 25(4), 250-256. Jones, R., Flaherty, E., Binns, H., Price, L., Slora, E., Abney, D., . Sege, R. (2008). CliniciansÕ description of factors influencing their reporting of suspected child abuse: Report of the child abuse reporting experience study research group. Pediatrics, 122, 259-266. Kung, T. A., Pannucci, C. J., Chamberlain, J. L., & Cederna, P. S. (2012). Migraine surgery practice patterns and attitudes. Plastic and Reconstructive Surgery, 129(3), 623-628. Sege, R., Flaherty, E., Jones, R., Price, L., Harris, D., Slora, E., . Wasserman, R. (2011). To report or not to report: Examination of the initial primary care management of suspicious childhood injuries. Academic Pediatrics, 11, 460-466.

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