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Current Educational Activities in the Health Professions

This chapter reviews the current educational activities for health professionals on family violence, focusing on what, how, and when health professionals are taught to assess, evaluate, and treat patients experiencing family violence. The committee obtained information on educational programs that have been published in the professional literature and supplemented these published descriptions by soliciting input from educational institutions, health care provider settings, health professional organizations, family violence advocacy groups, researchers, public policy makers, and individual health care providers. The results of this search provide an illustrative sample that was useful in informing the committee’s work (see Appendix E). The following descriptions are based on the committee’s review of this illustrative sample.

PHYSICIAN EDUCATION

Medical School

A majority of medical schools report the existence of educational content on at least one form of family violence (Liaison Committee on Medical Education Annual Medical School Questionnaire, 1999-2000, questions 39a, 39b). Most often, education appears to focus on reporting requirements, patient/victim interviewing skills, screening tools, health conditions associated with violence, and services to which victims can be referred. The amount of training varies widely from very brief (e.g., a discussion of topics to cover during a patient interview)



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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence 3 Current Educational Activities in the Health Professions This chapter reviews the current educational activities for health professionals on family violence, focusing on what, how, and when health professionals are taught to assess, evaluate, and treat patients experiencing family violence. The committee obtained information on educational programs that have been published in the professional literature and supplemented these published descriptions by soliciting input from educational institutions, health care provider settings, health professional organizations, family violence advocacy groups, researchers, public policy makers, and individual health care providers. The results of this search provide an illustrative sample that was useful in informing the committee’s work (see Appendix E). The following descriptions are based on the committee’s review of this illustrative sample. PHYSICIAN EDUCATION Medical School A majority of medical schools report the existence of educational content on at least one form of family violence (Liaison Committee on Medical Education Annual Medical School Questionnaire, 1999-2000, questions 39a, 39b). Most often, education appears to focus on reporting requirements, patient/victim interviewing skills, screening tools, health conditions associated with violence, and services to which victims can be referred. The amount of training varies widely from very brief (e.g., a discussion of topics to cover during a patient interview)

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence to more extensive (e.g., a series of lectures or case discussions during a clinical rotation). About 95 percent of medical schools report curricular inclusion of material related to child abuse and neglect (Alpert et al., 1998). The curricula generally include content on the identification, reporting, and management of child abuse and neglect and are typically introduced during the pediatric rotation in medical school (Alexander, 1990; Bar-on, 1998). Teaching strategies are both didactic and interactive. With regard to intimate partner violence, medical schools report an increase in education (AAMC, 2000). Content usually focuses on screening, history taking, and available community resources for victims. Sexual assault appears to receive more attention than other forms of maltreatment. Teaching appears to occur most often in the form of lectures, frequently involving presentations by victims, case discussions, and role-playing exercises. The content is usually integrated into courses on history taking and communication or is offered during emergency medicine and obstetrics-gynecology rotations. With the exception of the few schools that now offer problem-based intimate partner violence cases or clinical electives, most instruction on intimate partner violence and elder abuse still occurs in the preclinical years and is predominantly content focused, lecture based, isolated, and not integrated into the overall educational schema with clinical correlations and cross-disciplinary education (Alpert et al., 1998). Elder maltreatment appears to be least often included in medical school curricula. When it is, content tends to focus on institutional abuse and abuse between older intimate partners rather than other forms of maltreatment in a family setting. The most common teaching method is case discussion, most likely to occur during patient interviewing courses or during emergency department rotations. Schools with a geriatrics rotation appear most likely to address elder abuse. Residency Training Family violence training during residency appears most common among programs whose residents are considered mostly likely to encounter victims: pediatrics, obstetrics-gynecology, emergency medicine, internal medicine (primary care), geriatrics, and psychiatry. The Residency Review Committees of the Accreditation Council for Graduate Medical Education require education on family violence in a number of residency and subspecialty residency programs. Programs in pediatrics, adolescent medicine, pediatric emergency medicine, and forensic psychiatry specifically are required to include training in child abuse or neglect. Obstetrics and gynecology residencies must include training on intimate partner violence. Family practice geriatric medicine and geriatric psychiatry residencies must include training on elder maltreatment. Family practice, internal medicine, and emergency medicine residencies must contain training

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence on all forms of family violence. The time allocated for training about family violence appears to vary greatly from program to program, and content appears to focus on identification and treatment. The methods include primarily lectures and case discussions. Pediatric residency programs report a mean of 8 hours of training on child maltreatment during the first and third years of training and a mean of seven hours during the second year (Dubowitz, 1988). The standardized experiences for pediatric emergency fellowship training include a curriculum developed by the American Board of Pediatrics, the American Academy of Pediatrics, and the American College of Emergency Physicians. Despite this program, fellowship directors in emergency medicine reported a need for an increase in training on child abuse (Biehler et al., 1996; Wright et al., 1999). A number of residency and fellowship programs report intimate partner violence content. In a study of primary care internal medicine residency program directors on women’s health issues, 40 percent stated they include structured teaching on intimate partner violence in their training programs, and 20 percent believed their residents had mastered the subject (Staropoli et al., 1997). In a similar study of family practice residencies, 80 percent reported that intimate partner violence was included in their curricula (Rovi and Mouton, 1999). Teaching methodology consisted predominantly of lectures and case vignettes. Compared with a previous study, the inclusion of intimate partner violence content in family medicine residency curricula has increased (Hendrick-Matthews, 1991; Rovi and Mouton, 1999). Among psychiatry residents, 28 percent reported receiving any training about intimate partner violence during any phase of their medical education (Currier et al., 1996). Emergency medicine programs report increased attention to intimate partner violence and a focus on identifying potential victims and preventing further abuse (Abbott et al., 1995; Dearwater et al., 1998; Goldberg, 1984; McLeer and Anwar, 1989). Elder maltreatment training varies from program to program but is less frequently included in training programs. Information on residency program training about elder abuse is minimal. Emergency medicine and geriatrics programs appear most often to include content on elder maltreatment. However, in a survey of practicing emergency medicine physicians, only 25 percent could recall any education on elder abuse during residency (Jones et al., 1997). Continuing Medical Education Little information is available about the level and amount of continuing medical education on family violence, beyond what the legal requirements dictate (discussed in Chapter 4). A number of lectures appear to be offered around the country each year and web-based programs exist, for which credit is available. The effects of continuing medical education on physician practice are discussed in depth in Chapter 6.

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence PHYSICIAN ASSISTANTS Physician assistants (PAs) are licensed health care providers who practice medicine under the supervision of physicians. Little information about the specific training for physician assistants is available. The American Academy of Physician Assistants and the Association of Physician Assistant Programs recognize family violence as a public health epidemic in the United States and encourage PA programs to include violence prevention, assessment, and intervention in program curricula. Physician asssistants sometimes participate with medical students in medical school coursework, some of which contains content on family violence. One example of curricula at Nova Southeastern University, Florida, includes three hours of lecture and case presentations on diagnosis, treatment, counseling, prevention, and legal requirements for all types of family violence. DENTISTRY Data are scarce about dental education on family violence, regardless of specialty. The available data show that dentists are becoming aware that they encounter victims of family violence but often do not recognize the signs of abuse and are uncertain about how to intervene (Chiodo et al., 1994). A study in Oregon showed that dentists who graduated from dental school after 1980 were more apt to have received family violence education than their colleagues who graduated earlier (Chiodo et al., 1994). In one study comparing the formal education available to physicians, nurses, psychologists, and dentists, the dentists reported the least amount of formal education on all areas of family violence— this was most notable in education on elder abuse (Tilden et al., 1994). A survey of the 64 accredited dental schools in North America, however, indicated that 96 percent of preprofessional dental students are taught to recognize and report child maltreatment. The majority of schools taught about child maltreatment through the pediatric dentistry rotation, with most providing one or two hours for teaching this subject (Jesse, 1995). In another survey, 43 of 55 predoctoral pediatric dental programs reported including the subject of child maltreatment in their curricula (Posnick and Donly, 1990). Prevent Abuse and Neglect through Dental Awareness (PANDA), a pioneer program in Missouri, is a coalition of social service and health agencies, professional dental organizations, and dental schools that develops education and training programs for dental health practitioners. PANDA programs have been established in other states as well (Ramos-Gomez et al., 1998; Hazelrigg, 1995). A similar group, the Dental Coalition to Combat Child Abuse and Neglect, was formed in Massachusetts to educate dental professionals about how to detect and report cases of child maltreatment. The coalition conducted an intensive statewide program that included educational materials on child maltreatment, intensive media coverage, oral slide presentations at state society meetings, and

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence publicity about their work in the local dental journal. Participation in the statewide education program, however, was low (Needleman et al., 1995). NURSING Nursing education does include attention to family violence, particularly child abuse and neglect and intimate partner violence. In one major study, responses from 298 schools (48 percent of the total; 85 percent baccalaureate degree or higher) indicated that all of the responding schools of nursing had at least some family violence-related content in their curricula, but only 53 percent of the schools felt that content was adequately addressed (Woodtli and Breslin, 1996). In spite of reports of content in baccalaureate schools of nursing, a regional random sample survey of 1,571 practicing clinicians in six disciplines including nursing demonstrated that more than one-third of these practicing clinicians reported no educational content in family violence (Tilden et al., 1994). Content on child abuse and neglect was systematically integrated into almost all nursing curricula and texts in the late 1960s and 1970s, primarily as a result of national legislation and publicity on the subject. The Woodtli and Breslin (1996) study indicates that child abuse and neglect were addressed by 90 percent of the schools and that child abuse had the greatest number of separate classroom hours devoted to it, with 56 percent of schools indicating 3 or more hours on the topic. Attention to intimate partner violence in the literature on nursing research and practice appears to be increasing, accompanied by professional association and curriculum development. Curriculum content on intimate partner violence has increased with official nursing organization attention to the issue (e.g., American Nurses Association [ANA], 1995; American Association of Colleges of Nursing [AACN], 1999; American College of Nurse Midwives [ACNM], 1997; Association of Women’s Health, Obstetric, and Neonatal Nurses [AWHONN], 2000; Emergency Nurses Association [ENA], 1998; Paluzzi and Quimby, 1998). A total of 91 percent of schools reported addressing intimate partner violence (Woodtli and Breslin, 1996). One-third of the programs reported specifically planned and professionally guided learning experiences in clinical settings (primarily domestic violence shelters) that particularly focused on aspects of family violence.1 The area of elder abuse has received the least attention and is represented 1   Some preliminary or indirect descriptive-level evidence from attitude surveys and course evaluations suggests that guided clinical experience focusing on families experiencing violence and settings in which violence occurs is most effective in teaching clinical nursing skills on violence against women (Barnett et al., 1992; Campbell and Humphreys, 1993; King, 1988).

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence least well in nursing curricula. Currently, there are no curricular requirements for the topic. A total of 82 percent of responding schools reported having any elder abuse content, and 66 percent of responding schools spent only 1-2 classroom hours on the subject (Woodtli and Breslin, 1996). The AACN, in conjunction with the John A. Hartford Institute for Geriatric Nursing Practice, has done much in recent years to address the paucity of geriatric curricula. The Geriatric Education Center Program, funded by the Bureau of Health Professions, is one vehicle for continuing education programs for nurses who need classes on elder abuse and neglect. Almost all major textbooks in undergraduate baccalaureate nursing programs do have content on at least one form of family violence. However, family violence content is noticeably lacking in the physical assessment textbooks commonly used at both baccalaureate and advanced-practice levels, except for child abuse and neglect. Nursing texts at both the associate degree and advanced-practice levels also have less content on family violence, except again for child abuse and neglect in pediatric nursing. The other advanced-practice exception is nurse midwifery, which has systematically addressed the issue of violence against women through programs and texts (Paluzzi and Quimby, 1998). PSYCHOLOGY Although the American Psychological Association’s (APA) Presidential Task Force on Violence and the Family (1996) recommended that training occur on issues of family violence, implementation of such recommendations is not a simple matter. For example, a review of 24 recently published introductory psychology textbooks, used primarily in undergraduate education, revealed great disparities in covering child sexual abuse (Letourneau et al., 1999). Furthermore, unlike many health professionals-to-be, doctoral students in psychology do not participate in a standard curriculum (for the relevant accreditation guidelines, see www.apa.org/ed/gp2000.html). There are also no standard texts (even as a matter of conventional practice) for most graduate psychology courses and no standards for addressing family violence. Although licensing boards often require that candidates have completed course work in broad areas of psychology (e.g., biological bases of behavior), they do not prescribe the content of the courses (e.g., the biological bases requirement could be met through a survey course or a seminar on basic neuropsychology, physiological psychology, behavior genetics, or neuropsychological assessment). Indeed, the initial survey course in statistics is the only commonality that can be expected in the curricula experienced by doctoral students in clinical, counseling, and school psychology. Moreover, it is often possible to obtain a PhD in psychology without meeting the requirements (which vary substantially across states in any event) for admission to licensing exams for psychologists wishing to engage in clinical or counseling practice. Most training about child maltreatment takes place in workshops and con-

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence tinuing education (Kalichman and Brosig, 1993). Fewer than 20 percent of psychologists in Colorado and Pennsylvania reported having had education about such issues in graduate school (Kalichman and Brosig, 1993). Most clinical psychologists in a national sample rated their graduate education about child maltreatment as poor, and ratings of internship training about the problem were not much better (Pope and Feldman-Summers, 1992). Approximately 90 percent of clinical, counseling, and school psychology programs reported that they do not have courses specifically on the topic (Howe et al., 1992). These findings, drawn from surveys conducted about a decade ago, may be somewhat outdated, given the increased interest in the problem of child maltreatment among psychologists and the attention that the problem has been given by the APA in recent years. At a minimum, however, the data indicate serious gaps in the education of psychologists graduating a decade or more ago and raise questions about the systematization of educational efforts now occurring.2 Recognizing these issues, the APA Working Group on Implications for Education and Training of Child Abuse and Neglect (Haugaard et al., 1995) developed several recommendations for training (including, for example, experiential training in all APA-accredited internships in clinical, counseling, and school psychology about services for abused and neglected children). The working group also generated materials to meet the needs for curricular resources that it had identified. Besides initiating some workshops for continuing education and other training activities, the working group prepared booklets for college and university teachers of graduate (Haugaard, 1996a) and undergraduate (Haugaard, 1996b) psychology students, relying on course syllabi and reading lists garnered from the field. The booklet on graduate education presents suggestions of topics and reading lists for three situations: (a) integration of examples relating to child abuse and neglect into conventional courses (e.g., inclusion of discussion of the origins of abusive behavior in a course on personality); (b) focus of a lecture or two on child abuse and neglect in a conventional course (e.g., discussion of prevention of child maltreatment in a course on community psychology); and (c) entire courses on child maltreatment or a type of maltreatment (e.g., sexual abuse). The booklet is organized with reading lists and other materials (e.g., lists of commercially available videotapes) for (a) a graduate course on child abuse and neglect and (b) specialized training for clinical, counseling, and school psychologists. 2   The degree to which psychologists have been involved in family violence appears to have varied dramatically across forms of family violence. For example, searches in August 2000 of the PsycINFO data base of behavioral science journals published since 1990 revealed the following results. Using the terms child abuse or child maltreatment, 5,228 hits occurred. For intimate partner violence or domestic violence or spouse abuse, 802 citations were identified. The term elder abuse elicited 133 articles. Adding psychologists as a qualifying term—for example, child abuse or child maltreatment and psychologists—reduced the number of hits to 186, 24, and 0, respectively.

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence The outline for the graduate course includes one section devoted to the “Recognition and Referral of Abused and Neglected Children and Adults.” The three books that are suggested readings for that session all focus on mandated reporting (Besharov, 1990; Kalichman, 1993; Monteleone, 1994). The outline on specialized training for professional psychologists includes a section on “Identifying Abuse and Neglect Victims,” and the suggested readings (i.e., Melton and Limber, 1989; Morgan and Edwards, 1995; Myers, 1992) all relate to the need for care in evidence gathering and opinion formation. Approximately three-fifths of mental health practitioners report having had training about intimate partner violence, a substantially smaller proportion than now claim to have been trained about child sexual abuse (Campbell et al., 1999; Tilden et al., 1994). As with child maltreatment, such training, when it occurs, usually consists of continuing education workshops. A task force convened by the presidents of five APA divisions is, at this writing, near completion of curricula on intimate partner violence. The curricula are being designed for education of undergraduate and graduate students and mental health professionals. With special attention to experiences of gay and ethnic-minority couples, the curricula will present topics for study from the perspectives of victims, perpetrators, and others, including children who witness intimate partner violence, and will include lists of relevant readings, music, and videos. No specialized guidelines or training programs for psychologists on responses to elder abuse appear to exist. The general lack of attention is illustrated by a booklet published in 1997 by an APA working group on What Psychologists Should Know About Working with Older Adults. The discussion of elder abuse is limited to two paragraphs in the chapter on “Psychological Problems of Aging.” The only concrete advice given is to question the cause of physical injuries to an older client and to be aware of state reporting laws. The remainder of the passage focuses on the epidemiology of elder abuse and the circumstances under which it is most likely to occur. However, the problem has not been ignored by organized psychology. In 1999, the APA Public Interest Directorate published a booklet informing both the general public and professionals serving older adults about Elder Abuse and Neglect: In Search of Solutions (available at www.apa.org/pi/aging/practitioners/homepage.html). This booklet provides an extensive overview of the nature of elder abuse, psychosocial and cultural factors in its occurrence, steps for laypersons to take when elder abuse is suspected, and resources for help and further information. SOCIAL WORK A preliminary review of the 407 Council on Social Work Education accredited bachelor of social work (BSW) programs and 136 accredited master’s of

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence social work (MSW) programs in the United States indicates that little systematic education is being offered on family violence in schools of social work.3 To date, of the 258 BSW programs with information obtainable from web sites, 15 have courses on child abuse, 3 have courses on intimate partner violence, none have a course on elder maltreatment, and 18 have a course covering all aspects of family violence. One school offers a course on elder mistreatment that is available to both BSW and MSW students. Of the 74 MSW programs with course information online, 8 schools offer course(s) on child abuse and neglect, 5 schools on intimate partner violence, 1 on elder mistreatment, and 17 on all aspects of family violence. Of the deans and directors who responded to the inquiry about family violence education, several noted that information is included in their general courses on treatment methods or human behavior in the social environment, the course on problems in the human environment (the equivalent of a psychopathology course in many MSW programs), or in courses on welfare policies and programs. However, none of the responding deans and directors suggested that the amount of time spent on the issues of family violence in all its forms was anything more than minimal. The initial information from deans and directors also clearly suggests that a number of schools are actively involved in continuing education efforts in the area of family violence. At least two schools indicated that they are affiliated with centers that study family violence or one of its component elements, i.e., child abuse and neglect, intimate partner violence, or elder abuse. These centers by report tend to be actively involved in continuing education, with at least three of the schools indicating that they have produced conferences and workshops in all areas of family violence. CONCLUSIONS This review of the current state of training suggests the following conclusions: A number of curricula on family violence for health professionals do exist and the number appears to be increasing. 3   These initial data were developed from the committee’s review of social work program web sites containing information about curricula. The committee sought information concerning any course listings that indicated the course was about family violence, violence in general, domestic violence, intimate partner violence, child abuse, child sexual abuse, or elder mistreatment. In addition, information was solicited directly from deans and program directors about educational content on family violence at either the BSW or MSW levels. Only 12 deans or program directors responded to the committee’s written inquiry. Work remains to be done to gather information not available on the Internet and to check the accuracy of the web-based information.

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Confronting Chronic Neglect: The Education and Training of Health Professionals on Family Violence Studies indicate that health professionals and students often perceive curricula on family violence as inadequate (e.g., content is insufficient to address the issue) or ineffective (e.g., students cannot recall training). In formal curricula on family violence, content is incomplete, instruction time is generally minimal, content and teaching methods vary, and the issue is not well integrated throughout the educational experience.