Child abuse

Child abuse is the harming (physically, emotionally or sexually), ill treatment, abuse, neglect, or deprivation of any child or young person.

Child physical abuse

Child physical abuse is physical trauma inflicted on a child. Objective evidence of this violence may include bruising, burns and scalds, head injuries, fractures, intra-abdominal and intrathoracic trauma, suffocation and drowning. Injury can be caused by impact, penetration, heat, a caustic substance, a chemical or a drug, but the definition also includes physical harm sustained as a result of fabricated or induced-illness by carer (Munchausen syndrome by proxy).

Child neglect

Child neglect is the failure of caregivers to adequately provide for and safeguard the health, safety and well-being of the child. It applies to any situation in which the basic needs of a child are not met with respect to nutrition, hygiene, clothing or shelter. It also comprises failure to provide access to adequate medical care, mental health care, dental care, stimulation to promote development, or attendance to a child’s moral and spiritual care and education.

Child sexual abuse

Child sexual abuse is the involvement of dependent, developmentally immature children and adolescents in sexual activities that they may not fully comprehend and to which they are unable to give consent.

Psychological maltreatment

Psychological maltreatment of children and young people consists of acts that are judged on the basis of a combination of community standards and professional expertise to be psychologically damaging. Such acts are committed by individuals, singly or collectively, who by their characteristics (e.g. age, status, knowledge and organisational form) are in a position of differential power that renders a child vulnerable. Such acts damage, immediately or ultimately, the behavioural, cognitive, affective or physical functioning of the child. Examples of psychological maltreatment include acts of spurning (hostility, rejecting or degrading), terrorising, isolating, exploiting or corrupting and denying emotional responsiveness.

Signs of neglect and emotional abuse are often non-specific, but suspicion should be raised when infants, preschoolers or school age children behave in the following ways:

• Persistently angry, socially avoidant, defiant, disobedient and overactive.
  
• Anxiously attached, watchful of, or ambivalent to, their parents.
  
• Limited ability to enjoy things.
  
• Low self-esteem, depressed or unresponsive.
  
• Developmental and emotional retardation, poor social skills and over-inhibition.

Signs of sexual abuse are also usually non-specific, but may include the above and various behavioural problems (phobias, bad dreams, eating and sleeping disorders, depression, school problems or delinquency). There may be overt manifestations of sexual preoccupation, including precocious and inappropriate sexual activity, promiscuity and aggressive sexual behaviour.

Mental health service psychiatric consultation is often useful in conjunction with the involvement of local child protection services.

In assessing and treating an injured child, there is a duty to accurately diagnose or exclude child abuse in the differential diagnosis. Most injured children examined have injuries as a result of accidental childhood trauma. If the patterns of injury are familiar and easily recognised as usually being caused by accidental trauma and the injuries are consistent with the alleged mechanisms of injury, then the child can be investigated and treated without mentioning the possibility of inflicted trauma.

Aims of assessment

• Differentiate accidental from deliberately inflicted trauma.
  
• State an opinion about the likely cause of the child’s injuries.
  
• Investigate and manage all medical aspects of the child’s care.
  
• Take action to protect the child from additional harm. This usually involves working in partnership with police, protective workers and support agencies.
  
• Intervene to prevent re-injury to this child or another child in the family.

Staff must discuss all cases of possible child abuse with a senior paediatric fellow or paediatrician. Consider child abuse especially when:

• A child has been severely injured.
  
• A child has had multiple injuries in the past.
  
• Any injury has occurred in a child <18 months old.
  
• History is inconsistent or the mechanism indeterminate.

History

Professionals dealing with injured children must become familiar with the manifestations of accidental and inflicted trauma and take a thorough and detailed history of the alleged mechanism of injury:

• Determine precisely when, where and how the injury occurred.
  
• Who provided the history and who (if anyone) witnessed the injury.
  
• Note the child’s developmental capabilities.
  
• What previous injuries, illnesses or emergency department presentations the child has had.

Detail information related to the child’s health, growth, nutrition, physical and emotional well-being. Also note the family’s access and attendance to services.

Examination includes the nature and appropriateness of a child’s clothing, cleanliness of the skin and nails, nutritional status, growth percentiles, evidence of infections, infestations and other medical conditions.

Medical opinion should reflect the doctor’s assessment of objective signs of physical neglect, as well as historical evidence of environmental neglect (e.g. if an infant is left unattended in the bath) or medical neglect (medical conditions not treated).

Aim for a single assessment by a suitably trained medical practitioner who has access to facilities for paediatric genital examination and photographic documentation. This doctor should have expertise in assessment, preparation of medical reports and presentation of evidence in court. All other medical practitioners are encouraged to seek advice from regional experts. Doctors must ensure that examination is in accordance with local policies, procedural guidelines and legislation.

These guidelines are for the uncommon situation when the examination cannot be deferred and a clinician with expertise in the assessment of child sexual abuse is not available to conduct the examination, provide supervision or peer review.

Informed consent and the assent of the child are required. Document the time, circumstances and people present.

History

A full paediatric assessment is required. The evaluation should include:

• The nature of the sexual contact (digital, penile, vaginal, rectal, oral or a foreign object).
  
• The time and circumstances of the alleged abuse, whether ejaculation occurred and whether a condom was used.
  
• The identity of the alleged perpetrator(s).
  
• Genital symptoms and concerns (pain, discharge, bleeding or possible injury).

Examination

An examination should be performed as soon as possible after the alleged assault.

• Note signs of injury on general examination.
  
• Ask the child to indicate the exact sites on their body where there was contact with the offender.
  
• The external genitalia should be carefully examined for debris from the crime-scene and signs of injury.
  
• Girls may be examined in the frog-leg position using labial traction or labial separation techniques. Adequate visualisation of the posterior hymenal rim may be achieved with the girl in the knee–chest prone position.
  
• Boys may be examined in the supine position, flexing the boy’s knees to visualise the anus.
  
• An otoscope provides light and magnification when a colposcope is not available. Many medical examination lights provide a source of magnification and are ‘cold’ to touch. Ensure the child is comfortable with the procedure and understands the equipment being used.
  
• Semen may fluoresce under ultraviolet light.
  
• Speculum examination is not usually required in prepubertal girls or adolescent girls who are not sexually active. Examination under anaesthetic should be considered only if the clinician suspects internal injuries that might require surgical repair.
  
• Collect the child’s clothing (including underwear) for forensic evaluation. Collect forensic specimens. Seek advice if uncertain about what specimens to collect and how to handle the specimens. Forensic swabs should be air-dried, labelled and handed to police. Document the chain of transmission of evidence, i.e. record the name of the person to whom the forensic specimens are handed and the time and date this occurs.
  
• Swabs and slides for microbiological tests should be performed as clinically indicated. Blood tests for hepatitis B and C, as well as screening tests for syphilis (VDRL) and HIV should be considered when the history raises concern about the transfer of body fluids. Note the need for repeat serology after 3 months. Consider urine polymerase chain reaction (PCR) for identification of Chlamydia and gonococcus.
  
• Consider pregnancy prophylaxis if within 72 h of sexual contact. Arrange for a follow-up pregnancy test (see chapter 28, Gynaecological conditions, p. 359).
  
• Consider sexually transmitted infection (STI) prophylaxis with azithromycin.
  
• Arrange for follow-up tests for STI.
  
• All abused children and their parents should have access to appropriate counselling.

Management

• Multidisciplinary assessment of the child and their family is recommended for all children in whom child abuse is suspected.
  
• A child with moderate or severe injuries should be admitted to hospital for evaluation.
  
• Medical staff are expected to attend case conferences with police and protective workers in order to share information and plan intervention.
  
• Medical reports should be prepared by the senior medical staff responsible for the child’s care. The report should use language appropriate for non-medical professionals; it should be clear, concise and informative, including an opinion as to the possible causes of the injuries.
  
• Before appearing in court, medical staff are strongly advised to consult with senior medical colleagues who are experienced in this field.

Tertiary referral centres

Most major metropolitan paediatric hospitals have established tertiary reference centres for the assessment and treatment of child abuse. Paediatricians and other medical professionals working in these centres provide expert advice in relation to the assessment of injuries and the management of suspected child abuse. Seek advice early.

Senior medical staff should write (or supervise the preparation of) the medical report. This report will provide information to non-medical agencies. The report can form the basis of a statement; it will need to be signed and witnessed by the police at a later date. The statement can then form part of the evidence in bringing criminal charges to court. Subsequently, doctors may receive a subpoena (sometimes years later) to give evidence as a witness. It is very useful to have a clear report as a reminder of the case details. Doctors are also required to take the original notes (or hospital record) of the consultation to court and can be cross-examined about the details of this record. Ensure the original notes are clear and non-ambiguous. Use simple medical language in the report.

Providing a medical report involves describing what was observed, which draws on the report writer’s experience as a doctor with knowledge of anatomy, physiology, growth and development. However, doctors are not expected to be detectives. For example, medical professionals can offer a description of bruising and may be able to reach a conclusion about the likely mechanism of injury but should refrain from saying who they believe did it and when.

Hints on format for report writing

Heading

Do not use any identifying patient details apart from name and date of birth. Do not include address. Confidentiality cannot be ensured for a report that may pass to legal and welfare systems. Even so, all reports should be headed ‘confidential’.

Introduction

Document your credentials clearly. This includes academic qualifications and year of graduation/conferring of degrees, relevant past experience and current position. State who was examined, when and where it took place and who else was present in the room, part or all of the time.

Consent

Record the name of the person giving consent for the medical evaluation and the preparation and release of the report.

Presenting history

• Circumstances: who referred the child, what information they provided, e.g. Senior Constable Jack Cracklaw requested a medical examination of child A following allegations of attempted digital vaginal penetration by person X, occurring two days prior.
  
• History taken from child/adolescent, e.g. I obtained the following history from child B. Child B told me that ’person X touched …’
  
• History taken from accompanying person, e.g. Child B’s mother told me that ‘I went into child B’s bedroom and saw …’

This style of narrative can seem repetitious but provides an unambiguous record and structured report (without winning a literary award). The medical report does not need to contain details of non-relevant medical history, though this should form part of the original history.

Physical examination

• General statement includes whether the child was cooperative, overview of level of function and growth parameters.
  
• General physical examination should mention relevant positive findings in detail, e.g. ‘the following bruises were noted. ’ A numbered list is useful in avoiding any ambiguity and helps divide those injuries for which there is an explanation from those where the mechanism remains unclear.
  
• Genital examination should be described separately when this is relevant. It is important to note the position of the child and and any additional lighting and magnification that was used.

Experience is required in the interpretation of abnormal genital signs and genital examination should not be undertaken without full consideration of possible management options, including the need for collection of forensic specimens.

Investigations

Investigations should be noted, with results and interpretation.

Conclusions and opinion

Keep concise. Try to answer the question that is being asked (e.g. the pattern, extent and distribution of bruising observed exceeds that likely to occur as a result of accidental childhood trauma).

Recommendations

Professional recommendations about intervention to improve the child’s health, safety, development and well-being.

Court appearances