Child abuse and neglect

Child abuse and neglect includes physical assault, sexual assault, emotional maltreatment, psychological harm, neglect (including medical neglect), and experiences of domestic and family violence.

• Child abuse and neglect is common. It can be missed and misdiagnosed. Diagnosis requires a high index of vigilance, together with careful investigation and interpretation of injuries.
• Child abuse and neglect can occur in children of all ages, but infants and young children less than 5 years of age are most at risk. Non-accidental injury is a significant cause of harm, even death, especially in infants and young children.
• If you suspect non-accidental injury, you must manage the child’s immediate injuries and wellbeing concerns, and complete a top-to-toe examination. Discuss all concerns about possible child abuse with a senior clinician (where possible).
• Children with suspected non-accidental injury should be referred to a paediatric service for an urgent assessment. Doctors or nurses can also contact the Child Abuse and Sexual Assault Clinical Advice Line (CASACAL) on 1800 244 531, to speak to a specialist child protection paediatric consultant for further medical and forensic advice.
• Complete the online Mandatory Reporter Guide to support decision-making around child safety, welfare and wellbeing concerns.
• Report all suspected risk of significant harm matters to the Child Protection Helpline on 13 21 11 in accordance with mandatory reporting obligations or e-report.
• Contact the NSW Health Child Wellbeing Unit (8.30am to 4.30am Mon – Fri) on 1300 480 420 for advice and support.

Identifying child abuse and neglect

Children who have experienced abuse or neglect may not always present to the emergency department with obvious symptoms of trauma.

Considerations

• Is the injury or fracture type inadequately explained by the account of what happened?
• Is the injury inconsistent with the developmental age of the child?
• Was there an unreasonable delay in presentation?
• Is there radiological evidence of old or healing fractures?
• Has the person presented to the ED or orthopaedic service with previous unexplained injuries or fractures?
• Is there a history of the child's siblings having unusual injuries?
• Is this child’s life at risk due to their unmanaged medical condition or failure to follow medical advice?
• Are there significant psychosocial concerns, e.g. concerns about past and current domestic violence, parental mental health and/or drug and alcohol concerns?

Types of injuries or health conditions often associated with abuse or neglect

• Any type of bruising or fracture in an infant, particularly if not yet walking
• Bruising in well-protected parts of the body, see TEN-4-FACESp Bruising Rule fact sheet (PDF)
• Long bone fractures in children under 18 months
• Head trauma and related injuries, particularly in children under 2 years old
  • Presenting features may range from severe neurological compromise (coma) or an increased head circumference to symptoms such as drowsiness, vomiting, irritability, or marked changes in tone or breathing (including apnoea in infants)
• Unexplained oronasal bleeding in children under 2 years old
• Unmet medical needs (including severe failure to thrive or morbid obesity)

Assessment

The child should be seen by a paediatrician for a child protection assessment. This provides an informed opinion about the probability that injuries have been caused intentionally. It will commonly require an admission to hospital.

• The child protection assessment will include completion of the NSW Health Suspected Child Abuse and Neglect (SCAN) Medical Protocol, a standard template for medical staff to record a forensically oriented medical assessment of a child or young person. The SCAN Medical Protocol should be completed by local paediatric service medical staff.
• Where there are concerns for infants regarding possible abusive head trauma, they should always have their head circumference measured and plotted against their other growth parameters.
• Further medical investigations may be arranged, if clinically appropriate, by the paediatric team during the child’s admission as part of the child protection assessment.
• The hospital on-call social worker (and Aboriginal Health Worker, where appropriate) should be contacted to support the psychosocial assessment and engagement with the family.
• ED staff should carefully document their concerns in the patient file, including the outcome of a thorough top-to-toe examination of the child.

Mandatory reporting for NSW Health staff

NSW Health staff, including ED staff, are legally required to report suspected risk of significant harm to children and young people.

If you suspect abuse or neglect (past or recent):

1. Complete a report using the Mandatory Reporters Guide. It only takes a couple of minutes and will help guide your next steps.
2. Contact the Child Protection Helpline (24/7) on 132 111 if directed by the Mandatory Reporters Guide and/or you suspect a child or young person is at imminent risk of significant harm.
3. Document your concerns and interventions in the client file.

If you are directed by the Mandatory Reporters Guide, or you are not sure what to do, contact the Health Child Wellbeing Unit on 1300 480 420 (Monday–Friday, 09:00am – 4:40pm) or via e-report. Also, document your concerns and interventions in the client file.