Chapter 95: Child abuse

Public and medical awareness of child abuse has markedly increased in recent decades, and the possibility of child abuse and neglect has to be kept in mind by the family doctor. It may surface in families from all walks of life and where a good trustful relationship exists between parents or children and doctor.

While reporting rates continue to increase (at 34 per 1000 Australian children in 2012¹), the true incidence of child abuse is much greater and also difficult to assess.

The various types of abuse¹ (and their estimated incidence²) are shown in FIGURE 95.1.

• The younger the child the greater the risk.

• The more disabled the more vulnerable.

• Indigenous children are 8 times more likely to be the subject of substantiated abuse than non-Aboriginal children.

• The number of children who are deemed at risk and placed in out-of-home care (OOHC) has increased in recent years, with the rate in 2012 at 7.7 per 1000 Australian children nationally. Roughly half of these are in foster care, and half in relative/kinship care, with a small (5%) proportion in residential (paid workers) care.

Child abuse and neglect are collectively referred to as child maltreatment. This refers to any non-accidental behaviour by parents or other adults or adolescents that is outside the norms of conduct and entails a substantial risk of causing physical or emotional harm to a child or young person. Such behaviours may be intentional or unintentional, and can be through omission (i.e. neglect) or commission (i.e. abuse).

Deciding whether behaviour constitutes maltreatment can depend on:

• cultural issues (e.g. corporal punishment)

• developmental age of the child

• the severity, frequency and duration of the behaviour

• the behaviour itself, or the result of the behaviour (a definition issue)

Physical abuse (non-accidental injury)

Physical abuse is defined as the non-accidental use of physical force against a child that results in harm to the child. It include behaviours such as hitting, shoving, slapping, shaking, throwing, punching, kicking, biting, burning, strangling and poisoning. Munchausen syndrome by proxy (see below) is considered physical abuse.

Neglect

Neglect is defined as the failure by a parent/caregiver to provide a child (when they are in a position to do so) with the conditions that are culturally accepted as being essential for the child’s physical and emotional development and well-being.

Emotional maltreatment

This is where a parent or caregiver conducts inappropriate verbal or symbolic acts towards a child, and/or there is a pattern or failure over time to provide a child with adequate non-physical nurture and emotional availability. This can take the form of rejecting, isolating, terrorising, ignoring or corrupting, and can damage the child’s self-esteem and social functioning.

Sexual abuse

Sexually abusive behaviour refers to any sexual activity between an adult and a child below the age of consent; non-consensual sexual activity between minors (e.g. a 14-year-old and a 10-year-old); or any sexual activity between a child under 18 years of age and a person in a position of power or authority (e.g. parent, teacher).² It is sometimes difficult to determine whether a behaviour constitutes sexual abuse, depending on variables such as age, development and cultural norms.

Behaviours can include fondling of genitals, masturbation, oral sex, vaginal or anal penetration by a penis, finger or any other object, fondling of breasts, voyeurism, exhibitionism or exposure to pornography. In contrast to other forms of maltreatment, the labelling of an act as sexual abuse also depends on the relationship between perpetrator and victim (e.g. age difference, being related).

Other types of child maltreatment

• Munchausen syndrome by proxy—this is the term used when a parent or guardian creates an illness in a child so that the perpetrator can develop or maintain a relationship with medical staff or transfer his or her responsibilities. A ‘devoted parent’ may continually present a child for medical treatment yet deny the origin of the problem—namely, the parent. Often the mother is the abuser. The abuse may be of physical or medical neglect. The masquerade may be simple or very sophisticated. Children may be indirectly abused by the lengthy or invasive investigations. Be cautious where there has been unexplained illness or death of a sibling.

• Incest—defined as intercourse between biological family members.

• Fetal abuse behaviour, such as smoking, drinking or illicit drug use, during pregnancy that endangers a fetus.

• Bullying, or peer abuse (see CHAPTER 94)

• Sibling abuse

• Witnessing community violence

• Institutional abuse

• Organised exploitation (e.g. child sex rings, child prostitution)

• State-sanctioned abuse (e.g. female genital mutilation in parts of Africa, the Stolen Generations in Australia)

Female genital mutilation

This comprises all procedures involving partial or total removal of the female external genitalia or other injuries to the female genital organs, whether for cultural or other non-therapeutic reasons (WHO definition).

It is also referred to as female circumcision.

The real cause seems to be a combination of several interrelated factors: personal, familial, social/cultural and societal stress. Abused children exist at all levels of society, although the majority of abused children who come to the attention of authorities are from families where there is high mobility, lack of education, loneliness, poverty, unemployment, inadequate housing and social isolation. Sexual abuse, occurring alone, does not follow these patterns and can occur under any socioeconomic circumstance.

Both men and women physically abuse their children. While women are the parents most responsible in cases of neglect and emotional abuse (probably because of a dominant role in childcare, social and economic disadvantage and being the only one responsible for the care of children in a single parent arrangement), men are more likely to abuse their own or other’s children sexually.

The child can be abused at any age (even adolescents can be victims of abuse and neglect). It is important to keep this in mind—it does happen.

Although the medical profession remains the foremost focus of child abuse reporting (they are the most likely to encounter injured children and are the most qualified to diagnose abuse), they still contribute only a small percentage of the total reporting to central registries.⁷ This could be because there is underdiagnosis of the problem but it could also be because of under-reporting.

Reasons given⁷ as to why GPs don’t report more cases of child abuse include:

• concern about drain on time and finances

• breaching doctor–patient confidentiality

• lack of undergraduate education on the topic

• risk of alienation and stigmatisation to the family

• the feeling by some GPs that they can work on the problem with the family without outside intervention

• a breakdown of the doctor–patient relationship

• uncertainty about what to do

• personal and legal risks (e.g. fear of court, libel suits, irate parents), especially if they ‘get it wrong’

• reluctance until absolutely certain of diagnosis

It will always be difficult to take the first step but it is important and it can help, no matter how small that first step is.

A skilled, sensitive, diplomatic interview is fundamental to management. Guidelines include:

• a relaxed, non-judgmental approach

• sensitivity to all people involved

• appropriate questions—open-ended, not leading

• using verbatim quotes from the child where possible and waiting silently for a reaction

• recording notes carefully

Physical abuse^8,9

Physical abuse should be suspected, especially in a child aged under 2 years, if certain physical or behavioural indicators in either the child or the parents are present. Inflammation, bruising, abrasions and lacerations are the most common presentations of the physically abused child, with equal incidence in boys and girls. As well as the consequences of the physical injuries, victims of physical abuse are more likely to develop a variety of behavioural and functional problems including conduct disorders, physically aggressive behaviour (e.g. become bullies), poor academic performance and decreased cognitive functioning. Children suffering traumatic brain injuries from physical abuse (e.g. hitting head or shaking) are at risk of disabilities including ADHD, seizures, spasticity, blindness, paralysis and developmental delay.

Parents and carers can tend to misinterpret normal child behaviours (e.g. crying and tantrums) and respond to them inappropriately. A vigilant GP can actually help prevent abuse by providing ‘anticipatory guidance’ to parents on normal child behaviour, educating them on appropriate responses to behaviours, and offering themselves as a resource to which they can turn if the child’s behaviour becomes unmanageable or overwhelming.

Risk factors:

• maternal smoking

• >2 siblings

• low infant birth weight

• unmarried mother

• poverty

• significant life stressors in parents

• caregiver role conflicts

• living in house with unrelated adult (50 times more likely to die from inflicted injuries)

Physical abuse indicators

Accidental injuries such as bruises or fractures are common in children, but tend to follow certain patterns. A GP should be aware of cases where the injury or injuries suggest a non-accidental cause is possible, when the history doesn’t match up with the injury or developmental age of the child, or when the behaviour of the parent and/or child is suggestive of non-accidental injury.

Bruises

Bruises are commonly found on the front of the body over bony prominences (e.g. forehead in toddlers, knees and shins in older children). Suspicious bruises include:

• finger-shaped bruises (e.g. thumb grip marks)

• multiple bruises/welts of different ages (the colour of a bruise doesn’t reliably indicate when it occurred)

• bruises in premobile children

• bruises away from bony prominences—face, scalp, neck, buttocks (see FIG. 95.2), genitalia, earlobes, behind the ears

• abdominal bruising (consider damage to internal organs, including organ rupture)

• multiple bruises of uniform shape

• multiple bruises in clusters

Scalds and burns

Beware of:

• a scald of uniform depth, sparing flexures, uniform burn line demarcation, bilateral and no splash marks (suggests forced immersion)

• unusual position (e.g. back of hand, genitals)

• cigarette butt-type burns

Fractures

Look out for:

• metaphyseal fractures of the proximal humerus and proximal or distal tibia are highly suggestive

• other fractures commonly non-accidental: rib (especially posterior), clavicle, vertebral body, sternum, scapula

• multiple, especially bilateral

• complex or multiple skull fractures

Shaking and brain injury

Shaking a baby is a critically dangerous thing to do, a danger often underestimated by perpetrators. The relatively large head size and weak neck muscles can easily lead to serious injury. Suspicion of traumatic brain injury should be raised when there is:

• unexplained encephalopathy

• unexplained vomiting, irritability and apnoeas

• altered states of consciousness

• neurological symptoms and signs

• torn frenulum or retinal damage

History

• Unexplained injury

• Different explanations offered

• Vague or changing history

• Injury unlikely to have occurred in manner stated

• Unreasonable delays between injury and presentation

• Presentation inconsistent with child’s developmental capabilities

• Evidence of neglect (clues include failure to thrive, dental caries, severe nappy rash, poor wound care)

Remember Munchausen syndrome by proxy.

Behavioural indicators

• Wariness of adult contacts

• Inappropriate clothing (e.g. long sleeves on a hot day)

• Apprehension when other children cry or shout

• Behavioural extremes

• Fear of parents

• Afraid to go home

• Child reports injury by parents or gives inappropriate explanation of injury

• Excessive compliance

• Extreme wariness

• Attaches too readily to strangers

Management

If suspected or disclosed, a thorough assessment, with detailed documentation (including measurement and photography of bruises/other injuries) of findings should be undertaken. A detailed history and thorough examination of all areas of the body is required. In a general practice setting, getting help with this difficult situation would often be useful. Discussing (immediately) with colleagues or child protection authorities is advisable, with the safety of the child (and other cohabiting children) being ensured at all stages. Verbatim comments should be written down and, if possible, information gathered from other sources or witnesses.

The family doctor should diplomatically confront the parents and/or carers and always act in the best interests of the child. Offer to help the family. An approach would be to say, ‘I am very concerned about your child’s injuries as they don’t add up—these injuries are not usually caused by what I’m told has been the cause. I will therefore seek assistance—it is my legal obligation. My duty is to help you and, especially, your child.’

Acquiring essential help

• Psychosocial assessment of child and family: involves social worker and multidisciplinary assessment

• Admission to hospital: for moderate and severe injuries

• Investigations done in conjunction with specialists

• Case conference (where appropriate)

• Mandatory reporting: notify child protection authorities

Emotional abuse

Physical indicators

• There are few physical indicators, but emotional abuse can cause delay in physical, emotional and mental development.

Behavioural indicators

• Extremely low self-esteem.

• Compliant, passive, withdrawn, tearful and/or apathetic behaviour.

• Aggressive or demanding behaviour.

• Anxiety.

• Serious difficulties with peers and/or adult relations.

• Delayed or distorted speech.

• Regressive behaviour (e.g. soiling).

Neglect

Poor parenting or neglect occurs in at least 5% of children under 5 years.¹⁰

Physical indicators

• Consistent hunger.

• Failure to thrive, or malnutrition.

• Poor hygiene.

• Inappropriate clothing.

• Consistent lack of supervision.

• Unattended physical problems or medical needs.

• Abandonment.

• Dangerous health or dietary practices.

Behavioural indicators

• Stealing food.

• Extending stays at school.

• Consistent fatigue, listlessness or falling asleep in class.

• Alcohol or drug abuse.

• Child states there is no caregiver.

• Aggressive or inappropriate behaviour.

• Isolation from peer group.

Sexual abuse^3,5

• Only 6% of child sexual abuse is by strangers. Most are known by parents and child; that is, familiar people in familiar environments, especially within the family.

• A child may disclose up to 12 times before they are believed (listen for hints).

• Most (but not all) of the adults who sexually abuse are men.

• Boys are assaulted less commonly than girls, but are less likely to disclose if they are assaulted.

• Adolescents are perpetrators in at least 20% of cases.

• Child sexual abuse is usually about power rather than sexual gratification.

Clinical indicators that may suggest child sexual abuse are presented in TABLE 95.1.

Clinical approach

Ideally, the child should be assessed by experienced medical officers at the regional sexual assault service, so the temptation for the inexperienced GP to have a quick look should be resisted. For the practitioner having to assess the problem, a complete medical and social history, including a behavioural history, should be obtained prior to examination.

The child’s history must be obtained carefully, honestly, patiently and objectively, without leading the child. The history is more important than the physical findings as there are no abnormal physical findings in many confessed cases.

Examination

A parent or legal guardian must give informed consent before the child is physically examined. It is recommended that the physical examination of any child suspected of being sexually abused is performed by a paediatrician or forensic physician experienced in the area of sexual abuse.

The crisis situation

It is important to realise that the child will be in crisis. Children are trapped into the secrecy of sexual abuse, often by a trusted adult, through powerful threats of the consequences of disclosure. They are given the great responsibility of keeping the secret and holding the family together or disclosing the secret and disrupting the family. A crisis occurs when these threats become reality.

Management

It is important to act responsibly in the best interests of the child. When we encounter real or suspected child abuse, immediate action is necessary. The child needs an advocate to act on its behalf and our intervention actions may have to override our relationship with the family.

Some golden rules are:

• Never attempt to solve the problem alone.

• Do not attempt confrontation and counselling in isolation (unless under exceptional circumstances).

• Seek advice from experts (only a telephone call away).

• Avoid telling the alleged perpetrator what the child has said.

• Refer to a child sexual assault centre or Protective Services Unit where an experienced team can take the serious responsibility for the problem.

Supporting the child

• Acknowledge the child’s fear and perhaps guilt.

• Assure the child it is not his or her fault.

• Tell the child you will help.

• Obtain the child’s trust.

• Tell the child it has happened to other children and you have helped them.

Prevention of abuse, particularly self-perpetuating abuse, can be helped by creating awareness through media attention, programs in schools and the community in general, and increased knowledge and surveillance by all professionals involved with children. Clear guidelines on reporting and the accessibility of child abuse clinics are important for the strategies to be effective. Teaching children how to protect themselves offers the greatest potential for prevention.⁵

Non-offending parents, who are the secondary victims of the abused child, will require help and guidance from their family doctor on how to manage the crisis at home.³ Parents should be advised to reassure the child of support and safety and to maintain usual routines. The child should be allowed to set the pace, without overattention and pressure from the parents. Siblings should be informed that something has happened but that the child is safe. Ensure that the child will inform if the perpetrator attempts further abuse. Parents need substantial support, including alleviation of any guilt.

An unhappy consequence of the crisis is the problem of broken relationships, which may involve the separation of the child from the family. At least one hitherto unsuspecting parent will be devastated if a parent is responsible for the abuse. The sexually abused child needs to be living with a protective parent or carer, with the abusive parent living separately.

Support for doctors

The attending doctor also requires support, and sharing the problem with colleagues, mentors and family is recommended. Some helpful guidelines are as follows.

• Carefully record all examination findings (take copious notes).

• Always keep to the facts and be objective.

• Do not become emotionally involved.

• Work with (not for) the authorities.

• Avoid making inappropriate judgments to the authorities (e.g. do not state ‘incest was committed’, but rather say ‘there is evidence (or no evidence) to support penetration of . .’).

• If called to court, be well prepared; rehearse presentation; be authoritative and keep calm without allowing yourself to be upset by personal affronts.

The main difficulty in diagnosing child abuse is denial that it could be possible.

All forms of child abuse can result in PTSD (from a single incident) or complex trauma (cumulative). Because of the high rate of child abuse, much of it unreported and hidden away for many years, adult survivors of child abuse are likely to be presenting to GPs on a frequent basis, often unknowingly.

The effect is more likely to be noticed in adulthood. We may encounter the sequelae of the issue, for the first time, in women in their early 30s and men in their late 60s.¹¹

Childhood trauma, especially in the first few years during formative brain development, can lead to lifelong problems with dealing with stress. Unresolved trauma restricts the capacity to respond flexibly to life challenges. Patients may present with diverse and puzzling symptoms, including medically unexplained symptoms. Substance abuse, mood disorders and other psychological impairments may result.

A GP should be aware of this possibility, and screen for trauma from child abuse in patients presenting with such issues. Take particular care with physical examination, particularly in sensitive areas or involving internal examination, and realise that many patients on whom we are doing Pap tests or rectal examinations may be survivors of child abuse. Procedures can also cause pain, and may re-traumatise such a patient. Practising in a ‘trauma informed’ manner involves paying attention to the way we perform a service or procedure, as well as what it comprises, and being sensitive to the context of what may have come before. Trauma from previous child abuse can often be helped by appropriately targeted counselling and psychological therapies.

• Suspect child abuse.

• Recognise child abuse.

• Consult the child protection authorities.

Unless there are exceptional circumstances, referral to an appropriate child abuse centre, where an expert team is available, is recommended. If doubtful, relatively urgent referral to a paediatrician is an alternative. There is also the National Child Abuse Helpline: phone, 1800 99 10 99, email helpline@childwise.org.au.

The Royal Children’s Hospital Melbourne, Clinical Practice Guidelines: Child Abuse, <https://www.rch.org.au/clinicalguide/guideline_index/Child_abuse/> (accessed 14/5/2018).