Child Abuse

Mandatory Reporting – required to report concerns about a child who may have experienced significant physical or sexual abuse

Child Abuse

1. Neglect
2. Sexual abuse
3. Physical abuse
4. Psychological abuse

Circumstances suggesting physical NAI

• Delay in seeking medical treatment for significant injury 
• Explanation of injury cause changes over time without apparent reason 
• Explanation of injury cause differs between caregivers without apparent reason 
• Explanation offered is inconsistent with child’s developmental capabilities 
• Possible impairments to caregivers’ capacity to supervise and protect the child

Clear

• injuries sustained as the result of a deliberate action by another person
• Proof of intention to cause harm is not required.

Debatable

• adult’s failure to provide adequate supervision, failure to provide a safe environment or failure to discourage engagement in dangerous activities.

Red Flag History in Child Injury Assessment

• Unexplained Injury: No adequate explanation for the injury presented by the caregiver.
• History Changes Over Time: Different or evolving accounts of how the injury occurred.
• Developmental Inconsistency: The injury is inconsistent with the child’s developmental abilities.
• Unexplained or Unwitnessed Falls: Lack of corroborating evidence or witness accounts of an incident.
• Delayed Presentation: Caregivers seek medical attention long after the injury has occurred.
• Parental Disinterest: Apparent lack of concern or emotional response from the caregivers.

The “4 Bs” of Non-Accidental Injury (NAI) Risk

B: Bruises

• Age Consideration: Bruises are uncommon in pre-mobile children and should raise suspicion if present.
• Location Concerns: Bruises on protected body parts (e.g., behind the ears, neck, trunk, and buttocks) are concerning for potential NAI.
• Atypical Bruising Patterns: Bruising away from bony prominences or shaped to match objects or ligatures should prompt further evaluation

B: Burns

• Unusual Locations: Burns on areas such as the back of the hands or genitals may suggest an inflicted injury.
• Immersion Burns: Characterized by the absence of splash marks, with linear or uniform edges, often indicating forced immersion.
• Specific Burn Shapes: Circular or regular-shaped burns (e.g., from lighters or cigarettes) may suggest inflicted trauma.

B: Bone

Rib Fractures

• Highly Specific Indicator: Rib fractures are common and highly specific for abuse in children under 2 years of age.
• Multiple Posterior Rib Fractures: These are particularly indicative of non-accidental injury.

Classic Metaphyseal Lesions

• Bucket Handle or Corner Fractures: These are virtually pathognomonic for child abuse, indicating torsional force on a limb.

Rare Fractures with High Specificity

• Acromion, Sternum, and Spinous Process Fractures: These fractures are so rare in accidental trauma that their presence suggests a high specificity for abuse.
• Femur Fractures in Non-Ambulatory Children: Suspicious and should raise concerns.
• Avulsion Fractures of Thoracic and Lumbar Vertebrae: Indicative of significant force and potential non-accidental causes.

B: Head Trauma and Brain Injuries

• Shaken Baby Syndrome: This term is best avoided as shaking is only one mechanism of potential head injury.
• Clinical Signs: May include altered consciousness, unexplained neurological findings, nausea, vomiting, and potentially no visible signs of trauma.
• Acute Subdural Hematomas:
  • Often bilateral.
  • Approximately 60% of cases in children are related to non-accidental injury.
  • Typically involve parieto-occipital regions and are caused by the tearing of bridging veins due to acceleration-deceleration forces.
• Retinal Hemorrhages:
  • Present in 80% of non-accidental head injury cases but recent debate has arisen regarding their specificity.
  • Often caused by a sudden increase in intracranial pressure (ICP).
  • Rarely present in accidental head trauma.

Mandatory Reporting and Legislative Context

• Legislation Variability: Mandatory reporting laws for child abuse vary between states and territories.
• Forms of Abuse: Physical, sexual, emotional/psychological, financial, neglect (including basic care, medical, and educational), and exposure to domestic violence.
• Special Cases: Example includes a 14-15-year-old victim in a sexual act with a partner/offender more than 2 years older (specific to NT).

General Practitioner (GP) Management of Suspected Child Abuse

• Immediate Steps:
  • Assess the safety of the child, any siblings, and other caregivers.
  • Consider admission for protection when necessary.
  • Manage and assess injuries thoroughly.
  • Carefully explore the explanations provided for the injuries.
  • Mandatory reporting of suspected non-accidental injury (NAI) to child protection services.
  • Collaborate with child protection agencies, paediatrics, forensics, and medicolegal services.
  • Long-term follow-up and support for the child and family.

Medicolegal Considerations in Child Abuse Notification

• Potential Issues:
  • Breaching doctor-patient confidentiality.
  • Potential breakdown of the doctor-patient relationship.
  • The patient and family will be aware of the GP’s report.
  • Risk of incorrect reporting.
  • Possible escalation of family difficulties.
• Responses to Concerns:
  • The law protects the identity and anonymity of reporters.
  • Legal protection is offered against criticism, reprisal, and liability.
  • Broad reporting is mandated to protect children, recognizing occasional over-reporting of non-abuse cases.

Clinical Priorities

• Suspect and Diagnose NAI: Be vigilant in identifying and diagnosing potential abuse.
• Immediate Safety: Assess and prioritize the child’s immediate safety.
• Medical Care: Provide necessary acute medical treatment.
• Safe Disposition:
  • Ensure safe outcomes
  • whether through admission, paediatric care, or safe discharge.
• Mandatory Reporting: Notify child protection services upon reasonable suspicion.
• Ongoing Support: Provide continuous monitoring and support to the family.

Approach to Suspected Abuse Liaison Officer (ALO) and History Gathering

• Initial Steps: Use an interpreter if needed.
• Thorough History: Corroborate history across multiple family members. Check for consistency in the narrative, delayed presentations, and any minimization of responses by caregivers.
• Collateral Information: Where appropriate, consider seeking input from teachers and police while maintaining confidentiality.
• Consider Differential Diagnoses: For example, consider conditions like thrombocytopenia or von Willebrand disease when bruising is present.
• Past History: Document any previous injuries, failure to thrive, or multiple hospital admissions.
• Social History and Risk Factors: Assess family dynamics, socio-economic status, child care practices, and signs of neglect.
• Immediate Care and Documentation: Prioritize medical care and meticulously document all findings.

Handling Family Conversations and Safety Measures

• Clear Communication: Express concerns clearly to the family, including explanations of why injuries are inconsistent with reported mechanisms.
• Mandatory Reporting Transparency: Inform the family that a report is being made and why, emphasizing that it does not automatically lead to child removal.
• Ensuring Child Safety: If there is an attempt to leave, contact the police.
• Broader Safety Considerations: Ensure safety for other children and assess for domestic violence.
• Involvement of Social Services: Engage social work support.
• Indigenous Considerations: Recognize the historical trauma and potential sensitivities, involving an ALO where appropriate.
• Confidentiality: Particularly in smaller communities, confidentiality is critical; consult with paediatric specialists and consider regional care options as necessary.

https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/abuse-and-violence/children-and-young-people/child-abuse-and-neglect

Key Messages

• Child abuse prevalence: It is common, with most cases perpetrated by someone within the family or a person known to the child.
• Vulnerability of young children: Children under one year of age are particularly susceptible to physical abuse and poor attachment to parents.
• Health impact: Child abuse is a major health issue causing both immediate and long-term health problems that often persist into adult life.
• Professional responsibility: Health practitioners have a duty to be aware of services to prevent child abuse and to detect and refer at-risk families to appropriate services.
• Legal obligations: Health practitioners need to be aware of mandatory reporting requirements for child abuse suspicions according to state or territory laws.
• Supportive care: Health practitioners can provide essential support to families affected by adverse circumstances through trauma-informed care and connecting them to services as needed.

Recommendations

• Identify at-risk families: Health practitioners should identify families at risk, especially where domestic violence is present, and refer them to parent training and nurse home visitation programs.
  • Evidence level: Strong recommendation with moderate certainty of evidence.
• Address harmful substance use: Reduce alcohol consumption in adults caring for children using evidence-based methods such as alcohol screening and brief interventions.
  • Evidence level: Practice point based on expert consensus.

Clinical Context

Definitions and Terminology

• Child abuse and neglect: Acts or omissions by a caregiver that result in harm or potential harm to a child.
• Types of child abuse and neglect:
  1. Physical abuse: Intentional use of force (e.g., hitting, shaking, burning) causing physical injury.
  2. Emotional abuse: Harmful behaviours (e.g., belittling, isolating) impacting a child’s psychological development.
  3. Sexual abuse: Any sexual act or contact with a child, including penetration and inappropriate touching.
  4. Neglect: Failure to provide basic needs (e.g., nutrition, safety, medical care).
  5. Exposure to domestic violence: Children witnessing or being victims of domestic violence are considered abused.

Adverse Childhood Experiences (ACEs)

• Definition: Stressful or traumatic events experienced before age 18, including abuse, neglect, and other adverse experiences like parental substance abuse or divorce.
• Prevalence: 40-60% of adults have experienced at least one ACE, with 25% experiencing three or more.
• Impact: ACEs are linked to poorer physical and mental health, increased substance abuse, and other negative outcomes.

Effects of Child Abuse and Neglect

• Developmental impact: Detrimental effects on cognitive, emotional, behavioral, and social development in children.
• Long-term health outcomes: Increased risk of physical conditions (e.g., obesity, heart disease) and mental health issues (e.g., depression, suicide) in adult survivors.

Prevalence

• Global statistics: Nearly three in four children aged two to four years experience physical punishment or psychological violence from caregivers. One in five women and one in 13 men report childhood sexual abuse.
• Australian context: Approximately 2.5 million adults experienced childhood abuse, with 26,400 children having substantiated child protection notifications in 2017-18. Emotional abuse is the most common form of substantiated abuse.

Risk Factors for Child Abuse and Neglect

• Babies:
  • Increased risk factors: Hazardous drug/alcohol use during pregnancy, family violence, mental health issues, poor attachment, lack of social support, unstable housing, parental history of abuse.
  • Identification opportunities: Supporting families during the antenatal period can help identify special needs and plan for care.
• Children:
  • Risk factors: Increased mobility leading to accidental trauma, substance abuse, and mental illness in caregivers reducing supervision capacity.
  • Supervision: Inadequate supervision can lead to physical harm and emotional neglect impacting development and relationships.

Role of GPs

• Unique position: GPs often have ongoing relationships with families, making them well-placed to identify and respond to child abuse and neglect.
• Intervention levels:
  1. Primary prevention: Recognize and reduce risk factors to prevent abuse.
  2. Secondary prevention: Identify harm and respond to prevent further harm.
  3. Tertiary prevention: Support the long-term wellbeing of the child and family.

In Practice

• Stepped approach to recognition and response:
  1. Recognize vulnerability and risk: Be aware of changing family dynamics and stresses.
  2. Assess harm: Determine the extent and nature of the harm.
  3. Provide initial response and intervention: Offer immediate support and connect to services.
  4. Seek additional advice: Consult with specialists or child protection services as needed.
  5. Notify child protection services: Report to appropriate authorities as required by law.
  6. Ongoing care: Provide continuous support to address long-term impacts.
• Engaging support services: Connect families to social, welfare, financial, legal, or mental health support within the community to address vulnerabilities.

Additional Considerations

• Risk factors: Pay attention to children with medical needs, risky social or family contexts, lack of social support, and caregivers with mental health or substance abuse issues.
• Interdisciplinary collaboration: Work across education, social, and health sectors for a multidisciplinary response to child abuse and neglect.

For further education and resources, refer to the VEGA Project training module and literature on ACEs and child abuse impacts.

Assessing Harm: Key Points

Asking Children About Possible Harm

• Training Module: Access the free training module “Recognising and responding safely to child maltreatment” on the VEGA Project website for comprehensive guidance.
• Further Inquiry: Move from considering to suspecting child abuse by further inquiring about signs or symptoms.
• Information Sources: Do not rely solely on information from the caregiver.
• Inquiry Limits: Only inquire enough to determine a reason to suspect abuse.
• Role Limitation: Confirming or investigating abuse is the role of child protection services, not healthcare providers.
• Mandatory Reporting: Suspecting child abuse mandates a report to child protection services according to state or territory laws.

Preparation Before Asking a Child

• Training and Support: Ensure you have training and support for safely responding to a child’s disclosure.
• Private Safe Space: Create a private, safe consultation space and allocate adequate time.
• Referral Approach: Have an established clinic approach for referrals to external services, including support or child protection services.
• Professional Interpreters: Use professional interpreters if needed, not family, friends, or other staff.

Key Strategies for Inquiry

1. Separate the Child from the Caregiver:
   • Ensure privacy and that the conversation cannot be overheard.
   • See the child alone depending on their developmental stage, generally from about eight years of age.
   • Communicate to the caregiver that seeing the child alone is standard practice without implying suspicion of abuse.
2. Discuss Limits of Confidentiality:
   • Inform the child that confidentiality is maintained except if safety is at risk.
   • Ensure the child understands the term “safety.”
3. Conduct a Phased Inquiry:
   • Start with the presenting concern, inquire about the child’s wellbeing, and then about safety at home.
   • Stop asking once there is enough information to suspect abuse and report to child protection services.
4. Understand How Children Tell:
   • Recognize children may minimize, feel shame, or fear consequences, and may have communication difficulties.
   • Children might not disclose even if asked but may communicate abuse indirectly or spontaneously over time.

Example Questions

Physical/Emotional Abuse/Neglect:

• “How do the people in your family get along?”
• “Has anyone made you feel afraid? Can you tell me about that?”
• “What happens when you get into trouble or don’t listen to your [caregiver]?”
• “I notice you have a bruise on your [body part]. Tell me about that. How did it happen?”
• “Do people in your family ever make you feel bad about yourself? Tell me what that looks like; does anything else happen? What’s the worst thing that happens?”
• “Who takes care of you?”

Sexual Abuse:

• “My job is to keep children safe. Some kids have worries about their bodies. Do you have any worries about yours?”
• “Parts of our bodies are sometimes called private parts. Do you know where your private parts are? What do you call yours?”
• “Has any child or adult touched or hurt your private parts? Has anyone made you touch or look at their private parts?”
• “Sometimes teenagers are asked to do sexual behaviors they don’t really want to. Has that ever happened to you?”

Third Person Technique:

• “Sometimes children are good at keeping secrets. What type of secrets do you think children are good at keeping?”
• “Sometimes I see children I worry about. I saw someone else who was sore like you, what do you think happened to them?”
• “Some children can get scared at home, what do you think makes them scared?”
• “Sometimes kids worry about a lot of things, like when they have a fight with their friend, or when someone was mean to them. Kids also worry about things in their home, maybe about mum and dad fighting or when their mum or dad was mean to them. Sometimes kids are scared and don’t know what to do. Do you sometimes worry about things like that?”
• “Does anything happen that makes it hurt for you to wee?”

Questions to Ask Older Children:

• “Growing up can be a really tough time. Sometimes parents and kids don’t see eye to eye on the same things and that can be really difficult. How are things going with your parents?”
• “Do you ever compare how your parents treat you with how your friend gets treated by their parents? How do they compare?”
• “What happens when people disagree with each other in your house?”
• “What happens when things go wrong at your house?”
• “What happens when your parents or carers are angry with you?”
• “Who makes the rules? What happens if you break the rules?”
• “How good are the good days? What makes them so good?”
• “How bad are the bad days? What makes them so bad?”

Documenting and Reporting

• Documentation: Use verbatim quotes when possible, document observations, actions taken, and outcomes.
• Notifying Child Protection Services: GPs and nurses must report child abuse and neglect if significant harm is suspected. Awareness of mandatory reporting laws is crucial as they vary by state and territory.

Providing an Initial Response and Intervention

• Response Considerations: Be aware of the child’s and caregiver’s potential emotions (fear, guilt, shame, helplessness).
• LIVES Acronym:
  1. Listen: Show empathy and attention.
  2. Inquire: Ask about needs and concerns respectfully.
  3. Validate: Acknowledge the severity of their experience.
  4. Enhance Safety: Discuss safety planning.
  5. Support: Determine necessary resources and referrals.

WHO Safety Planning Guide:

Safe Communication: Ask about phone and social media access, and code words for help. Safe Place to Go: Identify a safe location or relative/friend’s place. Transport: Plan how to get to the safe place. Items to Take: Prepare a bag with essentials in a safe place. Support Nearby: Identify a neighbor or parent of a friend who can help

• Safe Communication: “Who has access to your phone and social media? Do you have a code word to let people know you need help?”
• Safe Place to Go: “If you had to leave home in a hurry, or if you needed to spend a few days away, where would you go? Is there a friend or relative’s place you feel safe at?”
• Transport: “How will you get there? Can your protective caregiver take you? Can you be picked up from a safe location?”
• Items to Take: “Can someone help you put a bag together in a safe place with clothes, a toothbrush and the things that make you feel safe at home (e.g., soft toys or books)?”
• Support of Someone Close By: “Is there a neighbor or a parent of a close friend who can help you when things get really scary at home?”

Initial Interventions

• Physical Abuse: Conduct an X-ray and/or skeletal survey, refer to emergency in severe cases.
• Sexual Abuse: Refer directly to the region’s forensic unit (e.g., Victorian Forensic Paediatric Medical Service).
• Neglect: In severe cases at high-risk ages (e.g., babies), refer to emergency.

Evidence-Based Recommendations for Preventing Child Abuse

For Children Under Five:

• Attachment-Based Interventions: Improve parenting nurturing, understanding of child’s behavior, and positive responses to child’s cues.
• Home Visiting Programs: High level of evidence for programs like community child health nurse home visiting program, Right@home, and Parents as Teachers.

For Children Aged 12 or Under:

• Parenting Programs: High evidence for Triple-P program, Incredible Years, SafeCare, Circle of Security Parenting Intervention, Tuning in to Kids, and Parents Under Pressure.
• School-Based Programs: High level of evidence for programs preventing sexual abuse and bullying.

Notifying Child Protection Services

• Mandatory Reporting: Report if the child has suffered or may suffer significant harm due to abuse or neglect, based on state or territory laws.
• Monitoring and Reporting: Awareness that initial signs may not warrant a report but further information might clarify the situation and necessitate a report.

Making the Report

• Initiating the Report: Call your centralised Child Protection helpline or local Child Protection Division Intake Service. Some states, like Western Australia and New South Wales, offer an online reporting option.
• Independent Reports: Even if another team member or agency has already made a report, it is important to make your own independent report. This adds weight of evidence and may provide additional information.

After Making the Report

• Potential Loss of Patients: Be aware that the family may decide to leave your care, though maintaining the relationship is possible and beneficial.
• Ongoing Roles and Responsibilities:
  • Monitor Behavior: Continue monitoring the child’s behavior for signs of ongoing harm through follow-up appointments.
  • Assess and Respond: Continue assessing and responding to the child’s physical and mental health needs.
  • Coordinate Care: Help families access appropriate services and supports, including culturally specific services.
  • Liaise with Professionals: Work with other professionals and child protection workers regarding the child’s wellbeing.
  • Provide Reports: Offer written reports for case planning meetings or court proceedings related to the child’s wellbeing.

Supporting the Child and Family

• Child’s Emotional Needs: The child may feel distressed, guilty, ashamed, confused, or frightened, and will need support throughout the protective intervention.
• Professional Support: Offer ongoing support by:
  • Liaising with Child Protection Workers: Ensure appropriate support is given to the child.
  • Supporting the Family: Provide support where appropriate.
  • Managing Behavioral Changes: Deal sympathetically and effectively with changes in the child’s behavior due to intervention.

Ongoing Care

• Continuous Support: Provide support to manage the long-term effects of harm related to child abuse and neglect.
• Engage Support Services: Connect the child and family with appropriate support services (social, welfare, financial, legal, or mental health services).
• Changing Dynamics: Recognize that the dynamics of vulnerability and risk can change over time, requiring ongoing relationship building with the family.
• Follow-Up Reports: If an initial report did not lead to action, make a new report if concerns persist. If engaged with child protection services but concerns remain, communicate with the child protection worker.

Managing GP Safety

• Emotional Burden: Recognize the emotional toll of dealing with child abuse and neglect.
• Team Decision-Making: Make reporting decisions within a team environment to share the emotional burden.
• Seek Supervision: Get supervision from a colleague or an external source.
• Debriefing: Engage in de-identified debriefing with a trusted colleague, friend, or family member.
• Self-Reassurance: Reflect on the importance of your actions in responding to child abuse.
• Safety During Disclosure: Have a colleague present if you decide to inform the family about the report.
• Self-Care: Increase engagement in your usual self-care routines.
• Professional Support: Consult your medical defence organization for decision support.
• Legal Protection: Remember that making a report in good faith protects you legally as a mandated reporter.
• Handling Threats: If you fear for your safety or that of others, inform the police and consider an intervention order. This situation is rare but should be taken seriously if it occurs.