Child abuse and neglect

Definitions and terminology

In this guide, the term ‘child abuse and neglect’ is used to refer to:

• any act or omission of care by a parent or other caregiver that results in harm, the potential for harm or the threat of harm to a child⁵

or

• any intentional and non-intentional behaviours by parents, caregivers or other adults considered to be in a position of responsibility, trust or power that results in a child being harmed physically or emotionally.⁶

The terms ‘child maltreatment’ and ‘non-accidental injury’ are also often used in the literature.

There are five types of child abuse and neglect:⁵

• Physical abuse – intentional use of physical force or objects against a child that results in, or has the potential to result in, physical injury.

This includes hitting, kicking, punching, beating, stabbing, biting, pushing, shoving, throwing, pulling, dragging, shaking, strangling, smothering, burning, scalding and poisoning.

2. Emotional abuse – behaviour that conveys to a child that they are worthless, flawed, unloved, unwanted, endangered, or valued only in meeting another’s needs.

This includes blaming, belittling, degrading, intimidating, terrorising, isolating or otherwise behaving in a manner that is harmful, potentially harmful or insensitive to the child’s developmental needs, or can potentially damage the child psychologically or emotionally. Threatening, yelling, taunting and debasing (eg ‘You’re worthless’, ‘You’re dumb’, ‘No-one likes you’) constitute emotional abuse. Witnessing intimate partner abuse/violence (IPAV) can also be classified as exposure to emotional or psychological abuse.

3. Sexual abuse – any completed or attempted sexual act, sexual contact, or non-contact sexual interaction.

This includes penetration, touching a child inappropriately and exposure to sexual activity, filming or prostitution.

4. Neglect – failure to meet a child’s basic physical, emotional, medical/dental, safety or educational needs. This includes:

• • failure to provide adequate nutrition, hygiene or shelter
  • failure to ensure a child’s safety, which can include failure to provide adequate food, clothing or accommodation
  • not seeking medical attention when needed
  • allowing a child to miss long periods of school
  • failure to protect a child from violence in the home or neighbourhood or from avoidable hazards.

5. Exposure to domestic and family violence – children living in families where domestic and family violence occurs (any incident of threatening behaviour, violence or abuse that is psychological, physical, sexual, financial or emotional) are considered victims of child abuse. Clinicians need to ensure, where possible, that the child or children and the non-abusive parent are in a safe environment. Depending on your state or territory law, mandatory reporting may be required in this situation if safety cannot be ensured. State and territory laws on what forms of abuse are mandated to be reported can be found here.

Adverse childhood experiences

Experiencing any of these types of abuse is classed as an adverse childhood experience (ACE). ACEs are stressful and potentially traumatic events that a child or young person experiences before the age of 18. In addition to child abuse and neglect, ACEs include other potentially traumatic experiences such as maladaptive parenting practices, divorce or separation, having a mentally ill caregiver or a caregiver who engages in substance abuse, or experiencing socioeconomic adversity.⁷

Population studies suggest that 40–60% of adults have experienced at least one ACE, and 25% of adults have experienced at least three ACEs.⁸

ACEs can have lasting negative impacts on health and wellbeing.⁹⁻¹¹ Higher ACE scores have been associated with poorer physical and mental health and with greater use of health-harming behaviours such as substance abuse.^9,12 Considering any potential ACEs occurring within a family may be a useful framework for assessing for abuse. To learn more about the ACEs study, refer to this presentation by Dr Vince Felitti MD. Also refer to this discussion of ACEs by the US Centers for Disease Control and Prevention.

Effects of child abuse and neglect

Experience of child abuse or neglect is linked to many conditions in babies, children and young people. Babies and children may experience detrimental effects in their cognitive, emotional, behavioural and social development.¹³ This can undermine a child’s capacity for trust, intimacy, agency and sexuality. A study of adolescents found that experiencing child abuse and neglect primarily accounted for their mental health symptoms.¹⁴

Adult victims/survivors of child abuse and neglect are more likely than the general population to experience physical health conditions such as obesity and heart disease.^9,12 Adult victims/survivors are also twice as likely than the general population to experience serious depression, and are 12 times more likely to commit suicide.^9−11,15,16

For more information, refer to the chapter on adult survivors of child abuse.

Prevalence

Internationally, nearly three in four children aged two to four years regularly suffer physical punishment and/or psychological violence at the hands of parents and caregivers. One in five women and one in 13 men report having been sexually abused as a child aged 0–17 years.¹⁷ Approximately 2.5 million Australian adults (13%) have experienced abuse during their childhood. This includes 1.6 million adults (8.5%) who experienced childhood physical abuse and 1.4 million adults (7.7%) who experienced childhood sexual abuse.¹⁸

In Australia from 2017–18, approximately 26,400 children aged up to 12 years had one or more child protection notification substantiated (excluding New South Wales as data were not available).⁶ While notification rates fluctuated during the COVID-19 pandemic, substantiation rates remained stable.¹⁹ These figures are likely an underestimate of the prevalence of child abuse and neglect in Australia. Children aged under one were around twice as likely as other age groups to have at least one child protection substantiation.⁶ Family violence is a factor in more than half of the substantiated child protection cases and children are present at more than half of police attendances in Victoria.²⁰

In 2017–18, 14% of reports that were substantiated came from medical or health personnel.⁶ Medical and health personnel are the third most common source of notifications for investigated cases, after police and school personnel.⁶

The most common form of substantiated childhood abuse is emotional abuse (59%), followed by neglect (18%), physical abuse (15%) and sexual abuse (8%).⁶

Between 2000 and 2012, 284 children and young people were victims of filicide (death caused by parent or parent equivalent).²¹ Filicides constituted 18% (238 of 1356) of domestic homicide incidents.²¹

Risk factors for child abuse and neglect

Babies

Children who experience abuse and neglect within the first two years of life can experience significant developmental consequences.²² Several factors can contribute to risk in this age group, many of which may be identified during routine care, particularly in the care of pregnant women.

Risk factors include:²²

• use of hazardous drugs or alcohol during pregnancy
• a family violence situation
• mental health problems or intellectual disability, which can compromise a parent’s ability to care for their child
• poor attachment to the infant
• absence of social supports or isolation
• unstable housing or financial situation
• history of own abuse or neglect or that of another child in the family.

The baby’s health needs may compound these difficulties.

Supporting families during this early stage of childhood, particularly during the antenatal period, can provide opportunities to identify special needs and assist families to plan for the care of their baby. In some contexts, this may involve referring the child or family to support services, or making a report to the appropriate child protection service in your state or territory. 

Children

Once a child’s mobility increases and they begin to explore and learn about their environment, they are at greater risk of accidental trauma and therefore require close supervision.²² Behaviours such as substance abuse or conditions like mental illness or intellectual disability can hinder a caregiver’s ability to provide appropriate supervision and care.^22,23 Inadequate supervision and neglect can lead to physical harm and, in extreme cases, fatality.²² Emotional neglect can negatively impact on children’s development and ability to form intimate relationships.^13,22,23

It can be difficult to distinguish between injuries resulting from using force with a child and accidental injuries. It can also be difficult to determine whether or not an accidental injury is a result of neglect. Questions to ask yourself that may help in distinguishing between accidental and non-accidental injury include:

• Does the story support the injury? Does the story change over the course of the discussion?
• Is there a pattern of ‘accidental injury’? This may indicate ongoing neglect.
• Is the child placid and passive during the examination?

Maladaptive parenting practices resulting in punitive disciplinary parenting practices can increase children’s risk of physical harm. It is important to be aware of the dynamic between child and caregiver to help you identify behaviour that may be concerning.

A shared responsibility

Responding to child abuse and neglect is a shared responsibility in our community. Everyone plays a role across the education, social and health sectors in recognising and responding to this issue. It is important to remember that collaboration across these sectors creates the multidisciplinary response needed to effectively respond to child abuse and neglect.

The role of GPs

GPs play a special role in maintaining the health of individuals and families over time. Through this ongoing relationship with families, GPs are often aware of changing dynamics, circumstances and stresses within a family unit. As such, GPs are uniquely placed to identify situations that may give rise to child abuse and neglect.

GPs can intervene at three levels:

1. 1. Recognise risk factors and intervene early to reduce risk of abuse and neglect and prevent harm (primary prevention).
   2. Recognise harm and respond appropriately to mitigate future harm (secondary prevention).
   3. Support the ongoing wellbeing of both the child and the family to manage the long-term negative impacts of harm.

The case studies at the end of the chapter provide examples of recognising and responding to child abuse in general practice. The case studies and characters are fictitious but have been based on the collective experiences of 38 GPs and nurses who participated in a PhD study.²⁴

We strongly recommend registering with the VEGA (Violence, Evidence, Guidance and Action) Project) and undertaking the free short training module, ‘Recognising and responding safely to child maltreatment’. This is a Canadian website created by experts in prevention of family violence and it has excellent demonstrations of how to approach this issue in clinical practice.

Recognising and responding to child abuse and neglect: A stepped approach

When working with children and families, the key steps in recognition and response are:

• Recognising vulnerability and risk
• Assessing harm
• Providing an initial response and intervention
• Seeking additional advice
• Notifying the appropriate child protection service in your state or territory
• Ongoing care

Recognising vulnerability and risk

Many families experience vulnerability at some stage.²⁵ This vulnerability may be time limited or it can be significant and long-lasting, and its effects can stay with a child through adulthood.²⁵

GPs and other primary care clinicians are often the first point of contact for families under stress and for children at risk of abuse.²⁶ It is important to remain aware of the possibility of abuse when caring for children, particularly children with emotional or behavioural issues or unexplained injuries, or when their parent is experiencing IPAV.

Child abuse can present in myriad ways, and its effects vary from child to child. While some children may present with bruising or injuries that raise suspicion, most do not. In the majority of children, direct physical injuries cause less morbidity than the long-term effects of the violence on the child’s neurological, cognitive and emotional development and health.¹⁰

Therefore, when seeing a child, it can be very difficult to know whether the root cause of a presentation is definitively abuse or neglect. The family may also be actively trying to hide the abuse or neglect.

Be alert to adults whose children may be at risk. Children in families where one or both caregivers are abusing alcohol are at high risk of neglect and other forms of abuse.²⁷

Other commonly cited risk factors for child abuse and neglect include:^17,28

• children with medical needs or a disability
• risky social or family context (including family violence, poverty or poor housing or social contexts involving intergenerational trauma)
• lack of social support
• children of caregivers with a mental illness, intellectual disability or substance abuse issues that impact upon the tasks of parenting.

If concerned about a child being vulnerable to or at risk of abuse and/or neglect, consider engaging the child and their family with support services as appropriate to address vulnerabilities. This may mean referring the child or family to, or working with, social or welfare, financial, legal or mental health support services within the community in an integrated care model.

Also consider services that can respond within the context of the family’s cultural needs. For example, Aboriginal and Torres Strait Islander services such as Orana Gunyah Victorian Aboriginal Child Care Agency, or culturally and linguistically diverse services such as InTouch Multicultural Centre Against Family Violence are available for referral. For more recommendations on preventive services for Aboriginal and Torres Strait Islander communities, refer to the RACGP’s National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people, page 44.

Your state or territory child protection service, Primary Health Network or even local council may have suggestions for where to find support services for vulnerable families. Some examples of support services or where to find them for each state are included in Table 9.1.

It is important to consider cumulative harm when responding to the wellbeing of the child and family and intervene early (refer to Case study: Michael).

When working with any adult patient, not only those with risk factors such as substance abuse, consider any children for whom the adult may be responsible. If you believe the adult is not capable of caring for their children at that time (eg because of physical or mental health problems, disabilities or substance abuse), early, supportive intervention may reduce any harm to the children.

In cases where you have serious concern for the immediate safety of a child, a report is mandatory (refer to Case study: Sarah). If an adult discloses abuse or neglect of a baby or child, GPs are not required to examine the baby or child before making a report to a child protection service.

A report to the appropriate child protection service is mandatory when you have serious concerns for the immediate safety of the child. Refer to Table 9.5 for more information.

Table 9.2. details the physical and behavioural signs of abuse that require a response to mitigate future harm (secondary prevention).

Source: Child maltreatment: A ‘what to do’ guide for professionals who work with children. Public Health Agency of Canada, modified 2012. Adapted and reproduced with permission from the Minister of Health, 2021.

Assessing harm

Asking children about possible harm

For comprehensive guidance on the practice of asking children about possible harm, access the free short training module, ‘Recognising and responding safely to child maltreatment’ on the VEGA (Violence, Evidence, Guidance and Action) Project website. The following text is based on this module.

Some points to note:

• To move from considering child abuse in a list of differential diagnoses for a sign/symptom to suspecting child abuse has occurred (ie having a serious level of concern), further inquiry about a sign or symptom is often required.
• You may not be able to rely solely on information from the caregiver when asking about signs and symptoms.
• Healthcare providers should inquire about child abuse only to the extent needed to determine that there is a reason to suspect child abuse.
• It is not the healthcare provider’s role to confirm or investigate whether child abuse has occurred; this is the role of child protection services.
• Forming a suspicion that child abuse has occurred means that a mandatory report to the relevant child protection service must be made in accordance with the laws in your state or territory.

Before asking a child about signs and symptoms of abuse it is important to:

• Have sufficient training and support on how to provide a safe response to a child’s potential disclosure. If you do not feel able to ask the questions, seek support or consult with child health experts such as paediatricians or social workers.
• Create a private safe space for the consultation in the care setting and allow adequate time.
• Have an established approach at your clinic for making referrals to external services, including support or child protection services.
• Use professional interpreters if required and not family, friends, or other staff.

The VEGA training identifies four key strategies for making an inquiry about child abuse with a child:

1. Separate the child from the caregiver
2. Discuss the limits of confidentiality with children
3. Conduct a phased inquiry
4. Understand how children tell

Separating the child from the caregiver

• Children need privacy; ensure the conversation cannot be overheard, even by the caregiver.
• Seeing the child alone depends on their developmental stage and age to be interviewed – some child experts indicate this may be from about eight years of age.
• It is important that you are practised in what to say to the caregiver about this step of seeing the child alone. For example, ‘It is part of my practice to see children alone for part of the consultation to get their views and so I can do the best job for you and your child’.
• It is important not to imply to the caregiver that you have suspicion of abuse as this may lead to the caregiver leaving prematurely and increasing risk to the child.

Discuss the limits of confidentiality with children

• Children should not be assured absolute confidentiality.
• Inform the child in developmentally appropriate terms that what is discussed is confidential except if someone’s safety is at risk (eg someone is hurting themselves or others or is not being looked after). Check they understand the term ‘safety’.

Conduct a phased inquiry

• Begin with the presenting concern, then proceed to inquire about the child’s wellbeing, finally inquire about safety in the home.
• Remember you only need to ask questions to the point where you have enough information to suspect abuse. Do not ask further questions of the child once you have this information. It is up to child protection workers to fully investigate the abuse.
• Thank the child for sharing the information and say you will be getting help for the child and family.
• If you are suspicious but the child does not disclose or denies problems, you may need to follow up or seek advice if the child’s behaviour is very high risk (eg running away).
• The VEGA training has many examples of questions to use. An important principle is to avoid asking leading questions such as, ‘I see a bruise on your eye – did your dad hit you?’ as this assumes the bruise was caused by hitting and hitting was done by dad.

Examples of questions

Physical/emotional abuse/neglect

• ‘How do the people in your family get along?’
• ‘Has anyone made you feel afraid? Can you tell me about that?’
• ‘What happens when you get into trouble or don’t listen to your [caregiver]’
• ‘I notice you have a bruise on your [body part]. Tell me about that. How did it happen?’
• ‘Do people in your family ever make you feel bad about yourself?’ ‘Tell me what that looks like; does anything else happen? What’s the worst thing that happens?’
• ‘Who takes care of you?’

Sexual abuse

• ‘My job is to keep children safe. Some kids have worries about their bodies. Do you have any worries about yours?’
• ‘Parts of our bodies are sometimes called private parts. Do you know where your private parts are [may need to explain parts where you pee or poo]. What do you call yours?’
• ‘Has any child or adult touched or hurt your private parts?’ ‘Has anyone made you touch or look at their private parts?’
• ‘Sometimes teenagers are asked to do sexual behaviours they don’t really want to. Has that ever happened to you?’

Third person technique

Suggestions using the ‘third person’ technique – talking about others first before the child/adolescent – are:

• ‘Sometimes children are good at keeping secrets. What type of secrets do you think children are good at keeping?’
• ‘Sometimes I see children I worry about. I saw someone else who was sore like you, what do you think happened to them?’
• ‘Some children can get scared at home, what do you think makes them scared?’
• ‘Sometimes kids worry about a lot of things, like when they have a fight with their friend, or when someone was mean to them. Kids also worry about things in their home, maybe about mum and dad fighting or when their mum or dad was mean to them. Sometimes kids are scared and don’t know what to do. Do you sometimes worry about things like that?’
• ‘Does anything happen that makes it hurt for you to wee?’

Questions to ask older children

• ‘Growing up can be a really tough time. Sometimes parents and kids don’t see eye to eye on the same things and that can be really difficult. How are things going with your parents?’
• ‘Do you ever compare how your parents treat you with how your friend gets treated by their parents? How do they compare?’
• ‘What happens when people disagree with each other in your house?’
• ‘What happens when things go wrong at your house?’
• ‘What happens when your parents or carers are angry with you?’
• ‘Who makes the rules? What happens if you break the rules?’
• ‘How good are the good days? What makes them so good?’
• ‘How bad are the bad days? What makes them so bad?’

It is also important to ask the caregivers when you see them on their own about how the family is getting along and fear and safety in the home (refer to VEGA training).

Understand how children tell

Children may minimise what is happening and find it difficult to tell someone what is happening for the first time because they:

• feel shame or guilt
• do not recognise their experiences as abuse
• are coerced or attached to the person who is abusing them
• fear the consequences of telling (eg abuse worsens, family might split up, no-one will believe them, they might go into care)
• have communication difficulties.

It is important to recognise that children may not tell even if asked, they may communicate their abuse indirectly (eg by their appearance), and they may spontaneously disclose maltreatment. Children’s communication of abuse may refer to recent or past events and may occur gradually over time. Children may not disclose if they feel unsafe (eg are in an unsafe environment or with the unsafe perpetrator).

Document information using verbatim quotes whenever possible.

Ensure you document what is observed and heard from whom, when and why this is of concern. Document all actions taken and the outcome.

Children need to be asked age-appropriate questions in a safe environment without hint of judgement toward the child or their caregiver who may be the abuser (refer to Case study: Michael).

Note:It is important to remember not to provide absolute assurances to children that you can keep them safe. For example, you should not say, ‘I promise this will not happen to you again’. It is not necessarily within your control.

Asking questions of caregivers

If your suspicions of abuse or neglect are strengthened after further questioning, consider gently discussing the behaviour of the caregiver in a supportive way that recognises the challenges of family life and the current stresses within the household. There is no obligation to discuss these behaviours with the caregiver. Only do so if you feel that the environment is safe and calm. However, where you become seriously concerned for the immediate safety of the child, a report to the relevant child protection service in your state or territory is mandatory and caregivers do not need to be informed of this.

To open a discussion with a caregiver who uses abusive behaviours, you may like to gently encourage reflection on what they need to help them behave in a way that makes them feel good about their role as caregiver and partner (refer to Table 9.3 and Case study: Sarah).

Table 9.3 contains some questions you might ask a caregiver who uses abusive behaviours or a protective caregiver. A protective caregiver is one that does not behave abusively towards their child and uses their resources to actively protect the child from perpetrators of abuse.

Providing an initial response and intervention

If a child or young person, parent or caregiver discloses child abuse and neglect, it is important to:

• be aware that the child may be feeling scared, guilty, ashamed, angry, powerless and responsible for the abuse
• be aware of the potential shame, guilt and helplessness the caregiver may be feeling about the situation
• show your care and concern by validating their feelings and reassuring them that they are safe with you and they have done the right thing.

You can use the LIVES acronym to help guide your initial response:³⁰

• Listen with empathy. You can use non-verbal communication such as eye-contact and nodding to convey your attention.
• Inquire about a patient’s needs and concerns. It is important to show respect for a patient’s assessment of their own needs. Use open-ended question to ascertain needs, and address these needs in a treatment plan. This will help the patient to feel empowered.
• Validate a patient’s experience and feelings. Try not to minimise their experience by using ‘it could be worse’ statements. Validating the severity of a patient’s experience can help build trust and willingness to open up. It can also provide the patient with reassurance.
• Enhance safety by undertaking safety planning. You can use the safety planning guide in Box 9.1 to help you frame a discussion around safety planning. This may be a particularly useful exercise to do with a protective caregiver.
• Support by determining what resources and referrals are needed to respond to the patient’s individual needs.

Other initial interventions are outlined in Table 9.4.

Evidence-based recommendations for preventing child abuse

When discussing evidence-based interventions that may help with children, parents and carers, provide an explanation of what the intervention will involve and how you think it may help.

Interventions for a child under five years

Various strategies that promote early and secure infant–parent attachment, promote non-violent modes of discipline and create family conditions for the positive mental health development of the child are effective in preventing child abuse.³¹

Offer an attachment-based intervention (eg SafeCare) to parents or carers who have neglected or physically abused a child under age five. Ideally these programs aim to:

• improve the way the parents nurture their child
• improve understanding of what their child’s behaviour means
• help them respond positively to cues and expressions of child’s feelings
• improve how they manage their feelings when caring for their child.³¹

Consider child–parent psychotherapy for parents who have physically or emotionally abused or neglected their child or where the child has been exposed to domestic violence.

Offer an attachment-based intervention to foster carers looking after children under five years who have been abused or neglected.³¹

There is a high level of evidence to support home visiting programs for parents with babies and infants (aged 0–2 years) with suspected child abuse or in circumstances where the child may be exposed to domestic violence.³² Examples include:

• community child health nurse home visiting program (number of visits per family range from 18–34 sessions)
• Right@home (25 sessions of approximately 60–90 minutes, delivered by specially trained maternal child health nurse and social worker)
• Parents as teachers (at least 12–24 one-hour home visits annually for at least two years depending on the level of risk and needs delivered by specially trained educators).³²

Interventions for a child or young person aged 12 or under

There is strong evidence that programs focusing on parenting improvement and support are effective in preventing child abuse. The two most widely evaluated and widely applied models for delivering these strategies are training in parenting programs and home visitation programs.³²

Consider a comprehensive parenting intervention for parents and children under 12 if the parent or carer has physically or emotionally abused or neglected the child. Ideally it should address:

• parent–child interactions
• caregiving structures and parenting routines
• parental stress
• home safety.

Examples of programs with a very high level of evidence that are available in Australia are:³²

• Triple-P program for parents of children aged 0–16 years
• Incredible Years for parents of children aged 0–12 years.

Examples of programs with a high level of evidence that are available in Australia are:³²

• SafeCare for parents of children aged 0–5 years
• Circle of Security Parenting Intervention for parents of children aged 0–6 years (different languages are available for this program)
• Tuning in to Kids for parents of children aged 18 months – 18 years.

There is a medium level of evidence to support psychological therapy for children exposed to trauma.³² These interventions focus on enhancing mother–child interactions, enhancing the mother’s sensitivity to her child and positive parenting. They are delivered by a psychologist or nurse and in individual or group settings. An example is Parents Under Pressure for parents of children aged 0–12 years.

An evaluation of Caring Dads, an evidence-based behaviour change program, was conducted by the University of Melbourne.³³ The evaluation found that there is promising evidence of positive behaviour change in fathers who have abused, neglected or exposed their children to domestic violence. The program is delivered by an accredited facilitator and is available in multiple locations across Australia.

There is a high level of evidence to support school-based education programs to prevent sexual abuse and tackle bullying.³²

For interventions relevant to particular age groups, refer to the NICE guideline on child abuse and neglect

Notifying child protection services

GPs and nurses have a legal responsibility to report child abuse and neglect. If you believe the child has suffered, or may suffer, significant harm as a result of abuse or neglect and are in need of protection, you must notify the relevant child protection service in your state or territory. This may be clear immediately or only after monitoring a situation over time (eg initial warning signs in the child’s behaviour may not warrant a report, but later information – such as a crisis event – may clarify the situation).

It is important for health professionals to be aware of mandatory reporting laws in relation to child abuse. Each Australian state and territory has different legislation regarding what must be reported by whom (refer to Table 9.5).

Seeking additional advice and information when unsure about reporting

Where you are unsure of whether abuse is taking place, but are concerned about a child or their family, you may need to seek additional advice and information by way of secondary consultation. Part of forming a reasonable belief is believing that another reasonable person in your situation would reach the same conclusion.

Secondary consultation may be obtained by speaking with colleagues in your practice, paediatricians or social workers to review the case and reach a consensus. You can also call a child protection service or your medical defence organisation and ‘test’ the case, without disclosing the child’s identity, to establish whether it requires reporting. However, this option may not be available for every child protection regional intake service.

Some states provide an alternative service for clinicians to obtain advice about whether a mandatory report should be made. For example, in Victoria The Orange Door is a state-based child service that provides support to vulnerable families and secondary consultation to assist clinicians with management options, including mandatory reporting.

If you seek additional advice but are still unsure about whether to report, the general advice is to make a report regardless of any uncertainty.

For more information see information from the Australian Government Australian Institute of Family Studies.

Source: Heyes N. Mandatory reporting of child abuse and neglect. Melbourne: Australian Institute of Family Studies, 2020.

Making the decision to report

Making a report can be a very challenging and conflicting time for a GP or nurse. There are many factors that you might weigh as you make the decision to report. Following are some questions you may ask yourself when considering whether to report.

Is reporting actually needed for this situation?

There may be situations where the abuse and neglect you suspect is not mandated to be reported. The threshold of suspected abuse that needs to be reported differs across states and territories (refer to Table 9.5). For example, New South Wales mandatory laws specify a report for all types of abuse and neglect where there has been or will be significant harm. Victoria requires reporting only for physical and sexual abuse where at least one of the child’s caregivers have not and are not likely to protect the child from harm. Therefore, a report is mandated in New South Wales for a child who is experiencing serious emotional abuse, but a report would not be mandated if that child were living in Victoria.

If reporting is not required, you can still make a voluntary report; however, be aware that this type of report may be a lower priority for child protection services. In this case, you can help the child and the family engage with support services and monitor the situation. You can notify child protection services if the situation evolves to require mandatory reporting.

I’m worried about how the family will react if I make a report. What strategies can I use to help me manage this?

You are not required to let a family know if you are making a report to a child protection service, and the service is mandated not to reveal the source of the report. However, there may be some cases where your anonymity cannot be guaranteed. In these cases, some GPs have felt that a safer option, both for maintaining the relationship with the family and for the GP’s own safety, is to cautiously let the family know about intention to report. Previous and ongoing research suggests that a family’s negative reactions can be managed and the relationship between family and practice can remain intact.³⁴⁻³⁶ However, if it is unsafe to continue the relationship, you can give the family options about seeing another GP within the clinic or in another clinic altogether. A discussion about your decision to report can be undertaken in the following ways:

• Engaging the protective caregiver and working with them to make a report. It is important to make it clear to the child protection service that the caregiver working with you is protective.
• Framing it as your legal responsibility – you can cite the mandatory reporting laws as ‘forcing your hand’ to make a report to the child protection service. You can do this in the following way:

‘I can see you’re going through a really hard time, and it must be so difficult for you. There are things we can do to work on how you’re managing. One of those things is letting a welfare service know you’re in need of help. Unfortunately, I do have to let Child Protection know. I understand that you might not want to, but because of mandatory reporting laws, my hands are tied. It doesn’t mean I think you’re a bad parent/your parents are bad. Everyone just needs help sometimes. But you and I can work together to come up with some other strategies for helping you cope with what’s going on and how you’re feeling’.

• Framing it as an avenue to get help for the family:

‘Things seem so tough for you right now that I don’t think anyone can handle doing it on their own. I have decided to let Child Protection know what’s going on, they may be able to help you access some services that can help you cope with the situation. It doesn’t mean I think you’re a bad parent. It means that you’re in a situation where you can’t be the best parent you want to be/your parent can’t be at their best. That’s not your fault.’

If the family does have a negative reaction, it’s important to put your safety first. You may like to call in a colleague as a witness and to help you feel safer about the confrontation. You might like to ask the family to sit in an area where they can calm down before you discuss the matter with them further.

Do I have any potential biases?

When dealing with abuse, it can be difficult to lay aside your feelings and view the situation objectively.

Some GPs worry about how their relationship with the family may influence their suspicion of abuse and neglect.³⁷ The relationship with the family seems to have a dual effect: knowing about family dynamics may alert a GP or nurse to a potential abuse situation, but on the other hand, some GPs or nurses may not feel able to accept that abuse is happening in a patient’s family.³⁷

Factors like your relationship with the patient’s family can influence your personal threshold of suspicion. The ‘personal threshold of suspicion’ refers to the level of suspicion a GP would need before they felt their reporting duty was activated.³⁷ This threshold of suspicion can vary between individuals and may or may not align with the threshold of the law.³⁷ The personal threshold of suspicion is dynamic and can be influenced by different factors, as seen in Figure 9.1. It is important to reflect on what your personal threshold might be and how it aligns with the law. You can find out about your personal threshold of suspicion by considering or discussing with others what behaviours, signs or symptoms would trigger you to report.

Figure 9.1. Factors influencing the personal threshold required to identify or report child abuse³⁷

Source: Kuruppu J, McKibbin G, Humphreys C, et al. Tipping the scales: Factors influencing the decision to report child maltreatment in primary care. Trauma Violence Abuse 2020;21:427–38.
Reproduced with permission from SAGE Publications.

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Making the report

When you feel a report is appropriate, call your centralised Child Protection helpline or local Child Protection Division Intake Service. The contact details for of the reporting authority in each Australian state and territory are listed here. Some states such as Western Australia and New South Wales have an online reporting option.

If you, as the GP, have concerns and are also aware that another team member or agency has made a report, it is still important to make your own an independent report. This report may add weight of evidence or contribute additional information not previously made known to the child protection service.

After making the report

If a family is aware or becomes aware that you have made a report to the child protection service, be mindful of the possibility that you may lose the family as patients. This is a commonly reported outcome of making a report. However, there are situations where GPs have maintained their relationship with the family following a report (refer to Case study: Sarah). The suggestions in this guide have been made with the intention of helping you maintain your therapeutic relationship with the family. If this relationship remains intact, the GP’s ongoing roles and responsibilities after making a report may include:

• continuing to monitor the child’s behaviour in relation to ongoing harm, through follow-up appointments
• continuing to assess and respond to the child’s physical and mental health needs
• coordinating care, helping families access appropriate services and supports, including Aboriginal and Torres Strait Islander or culturally and linguistically diverse services
• liaising with other professionals and child protection workers in relation to a child’s wellbeing
• providing written reports for case planning meetings or court proceedings in relation to a child’s wellbeing or progress.

The child or young person may feel distressed, guilty, ashamed, confused or frightened, and will need support throughout the protective intervention. Professionals involved with the family may be in a position to offer ongoing support by:

• liaising with child protection workers to ensure they are giving appropriate support to the child or young person
• providing support to the family where appropriate
• dealing sympathetically and effectively with changes to the child’s behaviour that may occur in response to intervention.

Ongoing care

Beyond the initial stages, GPs play an important role in providing support to manage the impact and longer-term effects of harm related to child abuse and neglect. This role may be carried out as part of continuous and ongoing care over time or for a new patient presenting with historic, imminent or ongoing abuse and neglect.

As discussed earlier, if not already in place, consider engaging the child and their family with support services as appropriate to address vulnerabilities (eg social or welfare, financial, legal or mental health services within the community). Refer also to the section, Evidence-based recommendations for preventing child abuse<<link to section earlier in this chapter>>.

The dynamic of vulnerability and risk of abuse and neglect can change over time. Therefore, working with the patient’s family to build an ongoing relationship can allow you to provide support, advice and problem-solving around the health issues associated with child abuse and neglect.

There may have been a scenario where an initial report did not lead to allocation of a child protection worker. If you have ongoing concerns, it may be necessary to make a new report. In the case where the child and family are engaged with a child protection service but concerns about abuse remain, it may be possible to ask to speak to the child protection worker to raise any new or ongoing concerns.

Managing GP safety

Recognising and responding to child abuse and neglect can be an emotionally taxing task. You may find yourself managing families’ emotions, as well as your own, when dealing with an issue as sensitive as child abuse and neglect. Deciding to report a case against a child or family’s wishes can be particularly difficult. Some GPs and nurses fear retaliation from the family on a personal or professional level. These are common and valid concerns. Take the time to work through any personal conflict and fears and consider your own physical and emotional safety. Some strategies that may help include:

• coming to the decision to report within a team environment (ie with colleagues in your practice) as this may help reassure you of the decision and alleviate the emotional burden
• seeking supervision from a colleague or from an external source
• engaging in a de-identified debriefing with a trusted colleague, friend or family member
• reflectively reassuring yourself of the ‘evidence’ and the importance of responding to child abuse and neglect
• considering having a colleague with you if you decide to tell a family about a report and you are concerned about their reaction
• increased engagement in your usual self-care routine
• consulting your medical defence organisation for decision support.

Remember that if you make a report in good faith that is not substantiated, the law protects you professionally as a mandated reporter.

If you experience a response from the family that makes you fear for your safety or the safety of those around you, inform police and take out an intervention order. Please note that this situation is rare.

Refer also to the chapter on self-care.

My name is Sarah and I’m a GP working in a small private clinic in Victoria. I have a patient base that I know well. The other day, a patient of mine with an intellectual disability who recently had a baby missed her appointment. I was keen to see her to make sure things were going okay as I knew she was part of a vulnerable population experiencing a situation that can be highly stressful. I usually communicate with her through her case worker but when I rang, it was clear her case worker was on holidays. I was sure this was why my patient had missed the appointment and it increased my concern about her vulnerability. I rang my patient personally and made another booking, hoping she would turn up. She didn’t and I was worried but I didn’t get a chance to follow up. A couple of days later, she came in of her own accord. Her baby was extremely unwell. I saw she was distressed but I felt the confusion under her distress. She didn’t understand why he was in the state he was in. The child had lost weight, was minimally responsive to interaction and did not smell or look clean. I immediately sent him to hospital with my patient.

While I knew reporting was mandated for a case of significant harm, I debated about making a report to Child Protection. I felt this was a case of significant harm resulting from neglect due to my patient’s intellectual disability. However, I knew the system was already heavily involved with my patient’s situation and I knew that support had been stepped up when she had her baby. I was aware that she was getting the most support possible from an overloaded system. I also knew that any neglect that resulted was not intentional and she was not being malicious. She loved her baby. I understood that she was simply ignorant, and I felt guilty about reporting her to the authorities.

That said, I had read that a report must be made for every new incident that occurs or if new information comes to light, even if Child Protection was already involved. I assuaged my guilt by reminding myself that the life of the child is the priority and that making a report is not a judgement. It is a means of accessing further support for my patient to prevent the situation from happening again. My thoughts were backed up by a few close colleagues I decided to talk to. Talking to them helped me feel secure in my belief that neglect had occurred, whether or not it was intentional. Additionally, I had witnessed the Child Protection system provide support for my patient in the past so I was confident in my belief that I needed to let them know what had happened to ensure they provided more support. >

I decided to follow up with my patient and her baby a few days after her baby was discharged from hospital. In my follow-up, I decided to explain my decision to report the incident to Child Protection. I felt that complete transparency would help me maintain my relationship with her to ensure she kept receiving care. She was pretty upset with me at first because she believed I was making judgements about her as a parent. I repeated to her the assurances that I gave myself – that her child and support for her was the priority. I also described how impressed I was that she recognised the warning signs and had brought the child to me on her own. I made sure to recognise the progress she had made in this respect and invited her to come to regular appointments with me so we could practise those skills together. She calmed down when she saw that I wasn’t trying to judge her and that I wanted to continue my help and care.

I’ve been seeing my patient regularly for several weeks now. Each appointment, we focus on a different care-giving skill around baby’s health that is quick and easy to learn in a 15-minute appointment. I know my help is supplemented by that of her case worker and a maternal child health nurse. I can see she’s becoming more confident in her parenting skills and her baby is now thriving. Child Protection have yet to follow up on my report but I relayed all events to my patient’s case worker when she returned from holidays. The two of us have decided to keep an eye on my patient, especially during periods where her child’s needs are changing. We’ve worked out a management plan, one that my patient was a part of developing. I feel more confident in my support for her through motherhood.

I’m Michael and I’m a GP working in a large community practice clinic in New South Wales. I’m currently seeing a family who I met recently. The family is composed of a mother and her two sons, one aged 10 and the other 6. I’ve been seeing a lot of this family because of the 10-year-old boy. In the last few months, he’s been engaging in physically dangerous behaviour at school and has needed to come in for his injuries. I’m seeing him now with a similar presentation.

I’ve been consistently building rapport with the 10-year-old boy, and I decide to see him alone to explore what might be behind his behaviour. I explain to his mother that it’s part of my practice to see kids on their own because I want to encourage confidence in seeking medical care on their own.

I explain to the boy that, only if he feels comfortable, we are just going to have a five-minute chat. He says he feels comfortable and his mother, while a little wary, accepts. When she leaves, I tell the boy in an age-appropriate way about his rights to confidentiality. I ask him to tell me again how his injury happened. There’s no variation from the story he gave me previously, he seems confident in explaining it and the story does tally with his injuries.

Now I want to find out why he’s behaving in such a risky manner. I ask him how things are going at home. He says, ‘They’re okay, but it’s just different since mum and dad split.’ I ask him how things are different, and I’m surprised by his answer. He doesn’t say much but he talks about feeling more responsible. I ask him what makes him feel more responsible and he replies, ‘Just some things mum says.’ I ask him how he feels if he doesn’t meet those responsibilities and he replies, ‘Like I failed and I’m worthless’. I ask him what helps him to feel better and he talks about his risky activities at school – it’s a place where he doesn’t have to act responsibly. I decide to stop the questioning there because I feel he is becoming tense. I remind him that he is safe and it’s okay to talk about how things feel. When he’s ready I call his mother back into the consultation room. After hearing what the boy had to say, I feel I need some time to think through what I should do next. I ask to see the family again and finish the appointment.

Upon reflecting on the consultation, I’m more concerned than before. I suspect that this boy might be feeling pressured by his situation to take on more responsibilities in a way that makes him feel worthless if he doesn’t meet his mother’s needs. I think about his words ‘just some things mum says’, and I feel like there are elements of poor parenting technique at play. I wonder when poor parenting crosses the line into emotionally abusive behaviour.

To answer this question, I decide to consider the cumulative harm on the 10-year-old boy. I try to take stock of what I’ve noticed about the family. There are a few things about their family dynamics that concern me. The mother went through a divorce a little over a year ago and in the few months I’ve been seeing them, she’s had three partners. In my discussions about coping mechanisms with the mother, I can see she is beginning to rely more heavily on alcohol. She tells me her consumption has risen since the divorce but it’s not yet at a concerning level. I worry about what effect her coping mechanism is having on her two boys. I know the six-year-old is displaying behavioural problems. As for the 10-year-old boy, I’ve noticed how very protective he is of his younger brother. I’ve noticed how anxious he is generally and how he seems to constantly scan his environment. I’ve also noticed that his school uniform, which has been torn for weeks from his risk-taking behaviours, has not been replaced. Despite all this, I can see that the mother clearly loves her boys but it’s obvious that she’s going through a difficult time. The boys seem to be in a bit of a risky situation that may be escalating but I’m not sure if there’s anything else going on.

I consider making a report to Child Protection. On the one hand, given the boy’s risk-taking behaviour and constant low-level distress, there is the potential for significant harm over time. However, after careful consideration and speaking to my colleagues, I feel that my suspicions and the current severity of the harm from any potential abuse does not reach the threshold of the law. I decide to monitor the situation and place some supports around the family to respond to the risk of harm. If the family does not respond to the supports well, I can re-visit the idea of reporting in order to access more support for the family.

At the next appointment, I speak to the mother about some of my concerns around the boys’ health and behaviour. I explain the precautionary measures I want to take including engaging her and the boys in therapy, engaging her in some help for her increased alcohol consumption and possibly attending a parenting program to help her with strategies to meet her children’s needs on her own. We develop a plan together. I invite the boys to add pictures of things they’d like to do for fun. I tell them that participating in those activities can be part of the plan to help everyone stay on track. While the boys are busy drawing outside the consultation room, I have a kind but frank discussion about the possible emotional state of her boys following the divorce and the instability new partners might bring. The mother is defensive at first, but I keep approaching her from a place of wanting what is best for her boys. I try to pose myself as part of her support team and eventually she calms down and understands my points. We arrange several follow-up appointments. I make it clear that I will speak to the boys individually as part of their care. She agrees. I’m confident that these measures will help the situation, but I am also confident in my decision to report if the situation deteriorates.

• Mandatory reporting guide for New South Wales
• Preparing to report child abuse in South Australia (the tips here can be used for other states and territories) 
• National Institute for Health and Care Excellence (NICE) guidelines on recognising child abuse and neglect 
• Free educational resources for health professionals recognising and responding to child abuse and neglect