Guidelines for preventive activities in general practice

Injury prevention

Bullying and child abuse

      1. Bullying and child abuse

Injury prevention | Bullying and child abuse

Case finding age bar

0-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 ≥80
Child abuse includes physical abuse, sexual abuse, emotional abuse and neglect as well as children experiencing adult domestic violence.1 National figures reflect high levels of child abuse in Australia.2 Sixty-two per cent of Australians have experienced child abuse and neglect and 40% of 16–24-year-olds have experienced more than one type of abuse.3 The prevalence of sexual and emotional abuse is higher among girls compared to boys, with rates of sexual abuse reported at 37% for girls and 19% for boys, and rates of emotional abuse at 36% for girls and 25% for boys.4

Child abuse is most commonly perpetrated by someone within the family, or by a person known to the child.1 Children less than one year of age are particularly vulnerable, especially to physical abuse and poor attachment to parents.1 Child abuse is associated with immediate and long-term health problems including in mental health, physical health and health risk behaviours, and increased use of health services.2 People who have experienced child abuse and neglect are two times more likely to have had six or more visits to a GP in a 12-month period.2

Bullying in children and young people has been defined as ‘any unwanted aggressive behaviour(s) by a peer or sibling that involves an observed or perceived power imbalance and is repeated multiple times or is highly likely to be repeated’.5 Bullying can be direct (physical or verbal) or indirect (relational/social, social exclusion, spreading rumours, psychological/stalking, cyberbullying). It is also common and harmful, with up to half of children experiencing bullying at some stage.6,7 Bullying can result in significant increases in behavioural and mental health problems, including suicide.8,9

Sibling bullying can start in toddlers (typically aged 2–6 years) and is common between the ages of six and nine years. Sibling bullying can involve two-way sibling bullying, with both parties being a bully and a victim.1

Case finding

Recommendation Grade How often References
Consider the risk of child abuse, if people caring for a child are presenting with the following factors:
  • hazardous use of alcohol or use of illicit drugs, particularly during pregnancy
  • a family violence situation (50% overlap with intimate partner abuse and violence)
  • 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.
 
Practice point Opportunistically 1
 
GPs and parent/carers should maintain an awareness and ask about the possibility of both peer and sibling bullying in children with risk factors. Refer to Box 1. Practice point Opportunistically 1

All health practitioners need to be aware of their legal obligations under state or territory mandatory reporting requirements when they suspect child abuse.1 While research shows that the response to child abuse is challenging for GPs and can threaten the therapeutic relationship, strategies such as reframing any reporting as seeking help for the child or emphasising mandatory reporting duty can help maintain the therapeutic relationship.10 Health practitioners can play a crucial role in providing support to families affected by adverse circumstances through offering ongoing supportive and trauma-informed care and linking to services as required. GPs can intervene at three levels:

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

Unlike in the case of adult perpetrators, in situations where the child or adolescent is using violence, young people who use violence against their parents are legally children and therefore their protection, safety and developmental needs need to be taken into consideration.1

Box 1. Risk factors for peer and sibling bullying1

Individual:

  • Physical (eg overweight, disability, chronic illness)
  • Behavioural (eg externalising and disruptive behaviours including aggression, learning disability)
  • Gender (eg LGBTQIA+)
  • Emotional dysregulation (eg impulsivity)
  • Adverse childhood experiences

Family:

  • Structural family characteristics (eg first born, having an older brother, having step-siblings)
  • Domestic violence
  • Financial difficulties
  • Negative family dynamics (eg conflicting partnerships, arguing, hostile communication), interparental conflict
  • Parenting quality (eg harsh discipline or failure to discipline, lack of parental warmth, neglect, interparental hostility and abuse)

Supporting parents who have experienced trauma to understand the effects on, and care for, their children provides an opportunity to help transform cycles of intergenerational trauma to cycles of nurturing and recovery.11 

Health practitioners also have a role in preventing, detecting and managing abuse in their patients with disabilities. People with disabilities are a vulnerable group within our society and among general practice patients.1 They are at increased risk for neglect and for multiple forms of abuse, including verbal, psychological, physical and sexual abuse.1

  1. The Royal Australian College of General Practitioners. Abuse and violence – Working with our patients in general practice (White Book). 5th edn. RACGP, 2021.
  2. Mathews B, Pacella R, Scott JG, et al. The prevalence of child maltreatment in Australia: Findings from a national survey. Med J Aust 2023;218(Suppl 6):S13–S18.
  3. Higgins, D.J., Mathews, B., Pacella, R., et al. The prevalence and nature of multi-type child maltreatment in Australia. Med J Aust 2023, 218(Suppl 6):S19–S25.
  4. Australian Institute of Family Studies. Child protection and Aboriginal and Torres Strait Islander children. AIFS, 2020 [Accessed 18 May 2023].
  5. Wolke D, Tippett N, Dantchev S. Bullying in the family: Sibling bullying. Lancet Psychiatry 2015;2(10):917–29.
  6. Jadambaa A, Thomas HJ, Scott JG, Graves N, Brain D, Pacella R. Prevalence of traditional bullying and cyberbullying among children and adolescents in Australia: A systematic review and meta-analysis. Aust N Z J Psychiatry 2019;53(9):878–88.
  7. Tucker CJ, Finkelhor D, Shattuck AM, Turner H. Prevalence and correlates of sibling victimization types. Child Abuse Negl 2013;37(4):213–23.
  8. Bowes L, Wolke D, Joinson C, Lereya ST, Lewis G. Sibling bullying and risk of depression, anxiety, and self-harm: A prospective cohort study. Pediatrics 2014;134(4):e1032–39.
  9. Dantchev S, Hickman M, Heron J, Zammit S, Wolke D. The independent and cumulative effects of sibling and peer bullying in childhood on depression, anxiety, suicidal ideation, and self-harm in adulthood. Front Psychiatry 2019;10:651.
  10. Kuruppu J, Humphreys C, McKibbin G, Hegarty K. Tensions in the therapeutic relationship: emotional labour in the response to child abuse and neglect in primary healthcare. BMC Prim Care 2022;23(1):48.
  11. National Aboriginal Community Controlled Health Organisation and The Royal Australian College of General Practitioners. National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people. RACGP, 2018.
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