© Springer Science+Business Media Dordrecht 2015Ben Mathews and Donald C. Bross (eds.)Mandatory Reporting Laws and the Identification of Severe Child Abuse and NeglectChild MaltreatmentContemporary Issues in Research and Policy410.1007/978-94-017-9685-9_18
18. Mandatory Reporting of Child Abuse and Neglect by Health Professionals
Australian Institute of Family Studies (AIFS), 485 La Trobe Street, Melbourne, VIC, Australia
Sydney Nursing School, The University of Sydney, Sydney, NSW, Australia
KeywordsChild abuse and neglectReporting by health professionalsAustraliaLegislationPolicyClinical issuesMandatory reportingPaediatric care and child abuseMedical care and child abuseNursing care and child abuse
The Australian Institute of Family Studies (AIFS) is committed to the creation and dissemination of research-based information on family functioning and wellbeing. Views expressed here are those of individual authors and may not reflect those of the Australian Institute of Family Studies or the Australian Government.
The role of Australian health professionals in reporting child abuse and neglect, in particular medical and nursing personnel, has increased substantially during the past two decades. This chapter discusses key issues related to the recognition and reporting of child abuse and neglect by health professionals in Australia. The responsibilities of not only recognising but reporting all forms of child maltreatment by doctors and nurses are introduced. Health professionals, like teachers, police and other professional groups, are variously obligated through policy and legislation to report their knowledge or suspicion of child maltreatment. As well, health services impose policies in line with the legislation specific to their jurisdiction to assist clinical staff in responding when they know of, or have a reasonable suspicion of, harm being caused to a child. In most Australian states and territories, if doctors and nurses know or suspect that a child is, has been or is likely to suffer significant harm, then they have a legal obligation to report this to designated authorities.
A Case Study: Sarah’s Dilemma
In the case study below, we provide a scenario that is typical of the experience of health professionals working in Australian hospital emergency departments. The case study is used to illustrate the issues that they face and that are discussed throughout the chapter:
Sarah is a Registered Nurse working a Saturday afternoon shift in the emergency department of a busy regional hospital in Australia. In the State in which she works, Sarah has a legal obligation to report knowledge or suspicion of child abuse and neglect in her professional role when she has a reasonable suspicion that a child has been, is being, or is likely to be, significantly harmed.1 Sarah has been to all the training sessions offered by the hospital regarding reporting of child maltreatment and is aware of her responsibilities.
At 5 pm, three year old Brittany presented to the hospital with her mum, Julie, and step-father, Garry for treatment of a laceration on her forehead, caused when she fell against the coffee table. This was the fifth time Brittany had been brought to the hospital for an injury. None of the previous physical injuries had been considered significant and she had never been admitted to the hospital for ongoing treatment of her injuries. Nevertheless, Sarah was concerned about a pattern emerging. She became suspicious of the previous injuries and concerned about future harm to the child. Sarah was concerned for a number of reasons. Garry, like many men in the district, had a well-paid position at the mine site within the district. He was known in the community as a heavy drinker. Each of Brittany’s injuries had occurred when Garry was at home and not while he was away at work. While explaining to Sarah how Brittany sustained the injury, Julie consistently deferred to her partner Garry’s version of events. While she would initiate an explanation, she seemed to be watching his reactions carefully and would be silent when he interrupted her. Brittany did not go to Garry for comfort and cried if Julie left the cubicle.
Sarah was aware of her obligations to report her suspicions but was unsure if reporting would be the right thing to do for this family. Sarah’s own father was an alcoholic and she grew up with him. Occasionally he was abusive to her mother and herself and she feels she has turned out well despite this. She feels she knows the family well and has a very good rapport with Julie in particular. Garry is away much of the time and Julie is a good mum to Brittany. The town they live in is small and many of the men who work on the mine drink heavily while at home. Garry behaves in much the same way socially as any of the other workers. Sarah is concerned that if she makes a notification of child abuse it might affect her relationship not just with this family but with others in the community, violating a trust that has developed. She is also concerned that it will only exacerbate the home situation and inflame Garry who will blame Julie for the situation, and may even discover that Sarah is the one who reported the abuse. She is not confident that her identity will be protected and worries about the consequences of reporting. She is not sure if she should confer with her colleagues.
Health Professionals and Child Protection
Access to Families with Children, Especially in the Early Years
Health professionals play an important role in recognising and reporting child maltreatment in Australia. The health system including community and hospital services provides a first point of contact capable of intervening in child abuse and neglect. Until a child starts school or an early childhood education programme, they spend their time at home. The outside world may be largely unaware of what occurs within families. This magnifies the responsibility of the health professional in terms of identifying, documenting and reporting child maltreatment.
Few, if any, children would start formal education without having contact with a health professional at some stage prior to that time. In Australia, there is a robust Community Child Health Service in all states and territories. Community child health nurses are well trained in screening for child abuse and neglect risk indicators. Mechanisms through which child maltreatment occurs and is maintained within families generally include developmental history, personality factors, cultural expectations, familial interactions and child characteristics (Daro 1993; Zeanah et al. 1997). At the same time, it is difficult to recognise child maltreatment even for children like Brittany who present numerous times in early life for injuries. It is estimated that one in six children presented to an emergency department for physical injury and that between 1 and 10 % of these children have actually suffered physical abuse (Benger & Pearce, 2002). Children under the age of 12 months are more likely than older children to be admitted to the hospital for injuries sustained through maltreatment. Unfortunately, they are also more likely to die from their injuries (McKenzie and Scott 2011; O’Donnell et al. 2011).
Perceived Role/Reporting Practice
In Australia, reports by health professionals accounted for only 13.5 % of all reports to statutory child protection authorities. This is compared to 24.6 % from police and 15.1 % from schools (Australian Institute of Health and Welfare 2013). In Canada, other professional groups report more child abuse and neglect than health-care professionals do. In that country, school personnel, police and social workers all report more child abuse and neglect than health-care professionals (Tonmyr et al. 2009). Further research is needed to disentangle the underlying reasons for these figures. It may be that health professionals are primarily exposed to children who present with physical injury or illness. Unfortunately though, there is still the possibility that they may not view child protection as part of their role to the same extent as police, social workers and others.
A survey of the General Practitioners in Queensland, Australia, revealed that even though 97 % were aware of their legal requirement to report child maltreatment, and 69 % had done so at some stage, 26 % had decided, at least once, against reporting their knowledge or suspicion of abuse or neglect (Schweitzer et al. 2006). Unfortunately, it was beyond the scope of this particular study to be able to elicit which forms of maltreatment were less likely to have been reported. Results did reveal that if the doctor thought this was a one-off presentation of maltreatment and not likely to be repeated, then a report, they said, would not be made. Further harm to the child was thought to be very unlikely.
Similarly in their study of Queensland nurses, Fraser et al. found that of the 930 registered nurses they surveyed, 21.1 % had never reported maltreatment. Of those who had made reports in their professional role, 26.6 % had also decided not to report maltreatment on at least one occasion (Fraser et al. 2010), despite mandatory reporting requirements. These studies reveal that despite the legal obligation placed on doctors and nurses to report suspicion or knowledge of child maltreatment, sometimes they do not. The reasons are quite well known, as will be discussed in this chapter. The way forward in improving these rates is less clear.
Based on the studies reviewed above, there appears to be a number of impediments to health professionals reporting child maltreatment. The first of these that we will discuss is recognition of past, current and future abuse and neglect. Before clinical staff can respond and report, they must first make the connection that what they are seeing is child maltreatment. In the case of physical abuse, discerning whether a presentation such as the lacerated forehead from a fall, as in our case study, or a broken arm is due to falling down a flight of stairs or being pushed down those stairs is not easy.
There is quite a significant and well-enough understood literature about the injury type and the relationship of injury presentations and physical and sexual abuse in particular. Certain physical injury presentations are more likely to have resulted from maltreatment. Any fracture in a preambulatory child is concerning; however, fractures of the femur (Leventhal et al. 2007), rib fractures, bucket handle or corner fractures (caused by twisting forces), skull fractures or a combination of a skull and long bone fractures are immediately associated with abuse (Bandyopadhyay and Yen 2002). Head injury is the most common cause of abusive injury-related death in children (King et al. 2006), and abused children are more likely to sustain a head injury than other children, particularly in those under 2 years of age (Berkowitz 1995; DiScala et al. 2000).
Head injury in infants is commonly associated with acceleration-deceleration injuries that point to the infant having been shaken, potentially a shaken baby syndrome. When considering the causes of injury, it is not enough to undertake a physical assessment of injury and risk alone. Shaken baby syndrome often presents with subdural or subarachnoid bleeds, cerebral oedema, long bone and/or rib fractures, retinal bleeds and little or no craniofacial trauma (Cadzow and Armstrong 2000; Kairys et al. 2001; Reece and Sege 2000). These injuries can be difficult to diagnose as patients may not exhibit any external signs of trauma, and the symptoms may mimic gastrointestinal symptoms (Jenny et al. 1999; Kairys et al. 2001; Keenan et al. 2004).
When a child presents for treatment of an injury and the parents/caregivers cannot explain how that occurred, it should be a cause of concern (Scott 2012; Scott et al. 2012). Other injuries may result as an unintended consequence of corporal punishment, for example, a child attempting to avoid being struck and falling.
In the case study presented herein, Brittany’s presentation makes the diagnosis much less certain. Her parents don’t seem to be telling the same story of how the injury occurred, her father appears to have been drinking, and the mother appears to be worried about saying too much.
A family approach to assessment including psychosocial risk needs to be employed. Child abuse and neglect are known to be associated with parental alcohol or drug misuse, domestic violence, mental health issues, inadequate housing, financial stress and social isolation, and all of these issues need to be considered when assessing for abuse and neglect. Understanding the context of what is occurring at home and how that impacts on the family can provide a greater understanding of a child’s wellbeing within that family (Scott 2013) and inform health professionals in their decisions about reporting abuse and neglect. At the same time, it is necessary for the emergency department staff to recognise the risks of abuse and neglect and make a report of suspicion. That is, they are not making a decision to substantiate the suspicion, rather linking the risk indicators to confirm that a report is necessary based on the seriousness of the harm or the potential harm to the child.
The Impact of Training in Recognition of Abuse-Related Injury
In interviews with Australian doctors, nurses and child protection liaison officers, Scott et al. (2012) hoped to better understand factors that influence them identifying, documenting and reporting child protection issues in emergency departments. The majority of the nurses and doctors clearly understood the procedures for reporting child maltreatment. However, they reported that training in recognising maltreatment had only ever occurred during their university courses. For many, no training had ever been undertaken (Scott 2012).