Approach
Child abuse is often an ongoing process. If the diagnosis of child abuse is being considered, the parents and/or caregivers should be informed of all relevant investigations and referrals being made, unless doing so places the child or other family members in possible danger.
Management of injuries/specialist consultation
Individual injuries should be managed as appropriate, irrespective of whether they are caused by abuse or accident. However, where abuse is considered, the physician should ensure that an appropriate search for additional or hidden injuries is also carried out.
Social services
The safety of a child is paramount, and it is therefore vital that the child is in a place of safety while ongoing investigations are conducted. This is a decision that requires immediate liaison with child welfare/child abuse and neglect social workers and other team members.
When physical abuse has been recognized, child protection procedures are implemented. These will vary according to the individual circumstances of the case. In some countries, cases are registered on a register of children at risk, and the progress of the family and welfare of the child are monitored at regular intervals by the relevant social and healthcare agencies. When a child is taken into care (e.g., fostering, kinship care, or adoption) access visits for parents may be negotiated and may be supervised when relevant.
It is important to consider potential risks posed to siblings and other children remaining in the home environment during this time. The social services and/or social care team will make a decision regarding the level of risk in any individual situation. This is often influenced by other information regarding the family (e.g., the family known to the social care or primary care team) and information from the medical team evaluating the index child. Medical evaluation of all children in a potentially abusive or neglectful home is necessary. Medical evaluation of siblings of an abused or neglected child should include a head-to-toe examination, a skeletal survey if the child is <2 years of age, and other testing deemed necessary by the examining physician.
Reporting to authorities
While legislation such as mandatory reporting varies among countries, and also between states in the US and Australia, the overriding principle of "paramountcy" (i.e., that the welfare of the child is paramount) is universal.
Doctors are required to share information with other agencies, and with social work and law enforcement bodies, to ensure that the child's needs are met and he or she is protected from harm. Doctors may be asked to provide written reports for use in multidisciplinary meetings, police investigations, and civil or criminal courts, and may be required to appear as witnesses (of fact or as experts) in court. The provision of criminal justice support services, alongside clinical and therapeutic services, may help to reduce the recurrence of the same type of violence in the short term, as well as symptoms of trauma. WHO: seven strategies for ending violence against children. Opens in new window
Mental health services
Mental health services should be considered following immediate management of injuries. Cognitive behavioral therapy is increasingly used, but must be individualized. Family therapy is also indicated in certain situations, to support other members of the family.[165] For younger children, play therapy may be an option.
Sexual abuse
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