The first three authors are affiliated with Safra Children's Hospital, Sheba Medical Center, and Ms. Glasser is with Mental Health Epidemiology and Psychosocial Aspects of Illness Unit, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, Tel Hashomer, 52621 Israel (e-mail: saraleeg@gertner.health.gov.il).

Recognizing the pivotal role of hospitals in identifying and diagnosing child abuse and neglect, the Israeli Ministry of Health has mandated each hospital to establish a child protection team (CPT) to be responsible for assessing cases of suspected child abuse or neglect. The CPT at Safra Children's Hospital, Sheba Medical Center, comprises a social worker, child psychiatrist, pediatrician, and nurse. This multidisciplinary approach brings a complementary, varied set of skills and is essential for viewing each case in a holistic context to best determine whether the child is maltreated. The team's psychiatrist (E.B.) contributes valuable insight into the impact of abuse and neglect at the various developmental stages of childhood, observes child behavior and parent-child interaction, and assesses the difficult-to-delineate borders of insult, such as emotional abuse and neglect.

In cases of suspected child abuse or neglect, the child is hospitalized, regardless of medical condition. Although hospitalization itself could be a negative experience for the child, Safra makes every effort to minimize the possible trauma of hospitalization. This period is necessary to allow the CPT to collect medical and psychosocial data from clinical examinations, observations, and interviews with parents and community-based services to determine whether there is reasonable basis for suspicion. If so, the case is reported to a child protection officer (court-authorized social worker), the police, or both. The Safra CPT has reviewed over 1,500 cases since its establishment in 1991, approximately two-thirds of which have been referred to the authorities.

Despite the active involvement of the CPT in investigating suspicions, their work depends on the acuity and sensitivity of the staff members in direct contact with the patients. Staff primarily identifies the suspicion, on the basis of physical, behavioral, and emotional indicators. Thus all staff members must be attuned to possible indications of suspected child abuse or neglect. Because child abuse and neglect have received little attention in medical, nursing, and paramedical educational programs, the necessary acumen is often a function of professional experience and personal inclination and initiative. The problem is exacerbated by heavy workloads, understaffing, and relatively rapid staff turnover, because Safra serves as a university teaching hospital.

To improve staff members' skills, the Safra CPT established a program of weekly roundtable sessions, to which all hospital workers and students-in-training are invited. During 2002 (when participation was systematically recorded) there were 86 participants, many attending several sessions, including 61 nursing staff, 13 physicians, and 12 social workers. Cases under deliberation are presented for discussion—in addition to those resolved during the past week—to examine the elements of the decision-making processes. Cases are presented regarding physical and psychosocial aspects, and there is integrative analysis of all findings.

The social worker (team leader) presents an overview of the case, emphasizing the initial reason for suspicion. The physician addresses medical findings, the nurse reports on behaviors observed in the department, and the social worker or psychiatrist presents behavioral and emotional findings after interviews with the child and parents. Pertinent issues arising from cases are expanded for educational purposes. Thus in the medical sphere, a case of spiral fracture of the femur of a nine-month-old infant would lead to a discussion about highly suspicious injuries. On the procedural front, for example, in cases of suicidal teenagers, the relevant legal aspects involved in reporting would be elaborated. The discussion that ensues is an open and honest exchange, whereby the CPT seriously considers the staff's feedback. In addition to the educational and clinical aspects, given the ambiguous nature of many cases, the discussions serve the CPT itself as an informal auditing mechanism.

In 2004 a hospital staff survey was conducted of knowledge and attitudes toward suspected child abuse or neglect. This was a convenience sample; therefore the results may be biased toward those who attended the sessions. Forty roundtable participants and 45 nonparticipants were surveyed. Participants were more likely to express the opinion that family violence requires attention within the hospital setting (not just by welfare or police authorities) and to consider the department or CPT nurse responsible for clarifying the circumstances that led to the suspicion. Most respondents were aware of hospital policy regarding such cases and expressed willingness to act when suspicions arise. Very few expressed fear of personal safety or legal entanglement. The roundtable sessions act as a vehicle for developing the skills, knowledge, and attitudes required for promoting effective intervention.