Mandatory reporting, child protection, elder abuse, impaired driver (Austroads), notifiable diseases

1. Definition and clinical relevance

• Child abuse encompasses physical abuse, sexual abuse, emotional abuse and neglect.
• It is a leading cause of preventable childhood morbidity and mortality.

Where it presents:

• Emergency departments, general practice, community clinics, inpatient wards
• Possible cause for many different presentations, not just obvious injury
• Must remain on your differential across a wide range of encounters

Why it matters for junior doctors:

• Legal (mandatory) obligation to notify statutory child protection authorities when you have a reasonable suspicion of abuse (most Australian jurisdictions)
• Child's safety, and that of any cohabiting children, must be ensured at every stage
• A child who attends with injury or suspected abuse must be assessed top to toe: occult injuries are common, a single visible lesion may be the tip of the iceberg

Three basic rules to memorise:

• Suspect child abuse
• Recognise child abuse
• Consult the child protection authorities

Time critical presentations (mandate urgent specialist involvement):

• Suspected inflicted head injury
• Recent (less than 72 hours) sexual assault
• Poisoning
• Child sexual assault requires a specialist service response and should not be managed in isolation

2. Key values, thresholds and decision rules

• Key rule: you report suspicion, not certainty.
• You do not need to prove abuse before notifying.
• Your role is clinical recognition and reporting; investigation is the role of statutory agencies and law enforcement.

3. Approach: presentation and differential

History

• Discuss all concerns with a senior clinician early.
• Gather a careful history, and where possible corroborate with other sources or witnesses.
• Document verbatim comments from the child and carers.

Features in the history that raise concern for maltreatment include:

• A history of repeated trauma treated at the same or different emergency departments.
• The history of injury changes or differs between parents or caregivers.
• A pattern of hospital or doctor "shopping."
• Parents responding inappropriately to medical advice or failing to comply (for example, leaving a child unattended in the department).
• A mechanism implausible for the child's developmental stage (for example, an ambulant injury reported in a non-mobile infant).
• Sociodemographic associations for physical abuse, emotional abuse and neglect include lack of education, loneliness, poverty, unemployment, inadequate housing and social isolation.
• Both men and women physically abuse children; women are more often responsible in neglect and emotional abuse (reflecting a dominant childcare role and social disadvantage), while men are more likely to be responsible for sexual abuse. Sexual abuse occurring alone does not follow socioeconomic patterns and can occur in any circumstance.
• A child can be abused at any age, including adolescents.

Examination

Perform a top-to-toe examination in every suspected case. Findings on careful physical examination that warrant more intensive investigation include:

• Multiple bruises of different colours (suggesting injuries of different ages).
• Injuries whose distribution or type does not fit the stated mechanism.
• Signs suggestive of inflicted head injury.

For suspected sexual assault, examination should be conducted by, or in conjunction with, a specialist service rather than opportunistically by a non-expert.

Differential

Not all suspicious findings are abuse, and it is important to keep a genuine differential:

• Non-inflicted (accidental) trauma, which can mimic inflicted injury.
• Medical conditions predisposing to bruising or fractures (bleeding or bone disorders).
• Culturally specific practices that are not abusive.
• However, keep in mind that dismissing abuse prematurely is a common and dangerous error.
• When in doubt, escalate and report.

4. Investigations

• Investigations are guided by the presentation and directed by senior and specialist clinicians.
• Certain scenarios are time critical and investigations should not be delayed.

Bedside

• Full clinical examination and detailed contemporaneous documentation, including body maps and verbatim quotes.
• Photodocumentation of injuries where local protocols permit and with appropriate consent processes.
• Poisons Information Centre 13 11 26 for suspected poisoning.

Bloods

• Directed screening for bleeding disorders where bruising is unexplained, to help distinguish medical causes from inflicted injury.
• Investigations for suspected metabolic or bone disorders where fractures are the concern.

Imaging

• CT should be used as the initial diagnostic tool to evaluate possible intracranial injury and other injuries relevant to the evaluation of NAI, including skull fractures.
• In an intoxicated child with a head injury, treat the neurological findings as due to the head injury; the decision to scan or observe should be informed by risk factors for intracranial injury rather than the intoxication.
• Have a lower threshold to image infants less than 6 months, who are at higher risk of intracranial injury.
• A skeletal survey for occult fractures is a standard component of the NAI workup and should be organised through the paediatric/child protection team.

5. Management

Management is stepwise and always centres on the safety of the child and any cohabiting children.

• Step 1: Ensure immediate safety.
• Stabilise and resuscitate as clinically indicated.
• For inflicted head injury, follow standard acute head injury management: airway, breathing and circulation first, with aggressive detection and treatment of seizures.
• Step 2: Escalate early.
• Discuss all concerns about possible abuse with a senior clinician.
• For suspected NAI, admit under the general paediatric team and consult the Child Protection Unit.
• For recent sexual assault, involve the specialist child sexual assault service urgently.
• Step 3: Notify statutory authorities.
• In most Australian states it is mandatory to notify the relevant statutory child protection authority about suspected abuse.
• Every clinician should be familiar with the reporting pathway in their jurisdiction.
• Reporting a reasonable suspicion is a legal obligation, not a matter of discretion, and does not require proof.
• Step 4: Communicate with the family diplomatically and honestly.
• Act in the child's best interests, and be transparent about your obligation.
• A helpful framing is to acknowledge concern about the injuries while making clear you must seek assistance because it is a legal duty.
• For example: "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." Offer to help the family.
• Step 5: Communicate with investigative agencies.
• You may be asked to communicate medical findings to law enforcement and child protection services.
• Be as precise as possible about the medical findings, and translate medical terms for personnel who may not be conversant with them.
• If asked about a mechanism of injury that lies outside your expertise, it is entirely acceptable to say so rather than speculate.
• Step 6: Trauma-informed follow-up.
• Deliver all care in a trauma-informed manner, attending to how a service or procedure is performed and being sensitive to what the child may have experienced before.
• Trauma from previous abuse can be helped by appropriately targeted counselling and psychological therapies; arrange onward referral through local pathways.

6. Australian-specific considerations

• Mandatory reporting is legislated at the state and territory level. The exact wording, who is a mandated reporter and which categories of abuse are covered vary between jurisdictions, so familiarise yourself with your local legislation and reporting portal.
• Statutory duty overrides ordinary confidentiality. Notification of suspected child abuse is a recognised statutory exception to patient confidentiality, in the same way as notifiable disease reporting.
• Female genital mutilation / cutting (FGM/C) is illegal in Australia. It is illegal to perform it, and it is illegal to take a girl overseas for the procedure. Explanation of the medical risks should be respectful and non-judgemental, particularly during pregnancy, and families should understand the legal position. Suspicion that a child may be taken overseas for FGM/C is a child protection concern and referral should be treated as urgent rather than routine. This is a relevant issue to raise when families of at-risk girls seek travel advice.
• Refugee and migrant children, including those from immigration detention or the Humanitarian Programme, may have complex health and safeguarding needs; incorporate child protection thinking into comprehensive post-arrival health assessments.
• Use the Poisons Information Centre (13 11 26) for suspected poisoning, which is one of the time-critical presentations.
• Referral pathways typically run through the hospital Child Protection Unit, the state child protection service, and, where a crime is suspected, police.

Clinical pearls

• Suspect, recognise, consult. These three words drive safe practice; if you suspect, you must escalate and report.
• You report a reasonable suspicion, not proof. Do not wait to be certain before notifying.
• Multiple bruises of different colours, changing histories, doctor shopping and a mechanism implausible for the child's developmental stage are red flags.
• Always examine top to toe; the visible injury may be the least significant one, and occult injuries are common.
• Three presentations are time critical: suspected inflicted head injury, sexual assault within 72 hours, and poisoning. Escalate urgently.
• For suspected NAI, CT is the initial imaging for possible intracranial injury and skull fractures; have a lower threshold in infants under 6 months.
• FGM/C is illegal in Australia, including taking a child overseas for it; treat concern as an urgent referral.
• Be honest with families about your legal obligation while offering to help; frame it around the best interests of the child.