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Clinical guidelines

Abuse and violenceWorking with our patients in general practice

Chapter 6. Child abuse

Key messages

  • Child abuse is common, and most commonly perpetrated by someone within the family, or by a person known to the child.119 Children less than one year of age are particularly vulnerable especially to physical abuse and poor attachment to parents120
  • Child abuse is a major health issue causing immediate problems and often long-term serious health problems that continue into adult life. Health practitioners have a professional responsibility to be aware of services that help to prevent child abuse, and to detect and refer families at risk to appropriate services121
  • All health practitioners need to be aware of their legal obligations under state or territory mandatory reporting requirements when they suspect child abuse (refer to Table 10)

Recommendations

  • Health practitioners have a role in prevention of child abuse by identifying families at risk (eg where domestic violence is co-occurring) and referring to parent training programs and nurse home visitation programs122–124 Level I A
  • Harmful alcohol and drug use has a strong link with child abuse. Alcohol screening and brief interventions in health settings have proved effective in reducing alcohol use. The WHO recommends working to reduce alcohol consumption in adults with children in their care125 Practice point

Introduction

Child abuse is often called child maltreatment or non-accidental injury in the literature. In this guide, the term child abuse is used as defined by the WHO as:

physical and/or emotional ill-treatment, sexual abuse, neglect, negligence and commercial or other exploitation, which results in actual or potential harm to the child’s health, survival, development or dignity in the context of a relationship of responsibility, trust or power.

 

In addition, child abuse includes exposure to domestic violence, due to the long-term damage on children of experiencing or witnessing parental intimate partner abuse.60

Child abuse includes a wide range of behaviours:7,127

  • physical abuse – intentional use of physical force or objects against a child that results in, or has the potential to result in, physical injury which includes hitting, kicking, punching, beating, stabbing, biting, pushing, shoving, throwing, pulling, dragging, shaking, strangling, smothering, burning, scalding, and poisoning
  • emotional/psychological abuse – intentional behaviour that conveys to a child that he/she is worthless, flawed, unloved, unwanted, endangered, or valued only in meeting another’s needs which can include 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. This includes threatening, yelling, taunting, debasing (eg ‘you’re worthless’, ‘you’re dumb’, ‘no-one likes you’). Witnessing intimate partner abuse can also be classified as exposure to emotional/psychological abuse
  • sexual abuse – any completed or attempted sexual act, sexual contact, or non-contact sexual interaction which includes penetration, touching a child inappropriately and exposure to sexual activity, filming or prostitution
  • neglect – failure to meet a child’s basic physical, emotional, medical/dental, or educational needs; failure to provide adequate nutrition, hygiene, or shelter; or 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; and failure to protect a child from violence in the home or neighbourhood or from avoidable hazards
  • exposure to intimate partner abuse – children living in families where intimate partner abuse (any incident of threatening behaviour, violence, or abuse (psychological, physical, sexual, financial, or emotional) between adults who are, or have been, intimate partners or family members) occurs are considered to be victims of child abuse, whether directly or indirectly abused. Therefore you need to ensure, where possible, that the child or children and the non-abusive parent are in a safe environment. Mandatory reporting may be required in this situation if safety cannot be ensured.

All these above behaviours occur across all socioeconomic strata in society.127

Individual and community costs of child abuse

The Australian Institute of Family Studies reported in 2013 that the individual and community costs of child abuse in Australia were estimated to be $4 billion in 2007, with a further lifetime cost of the burden of disease being $6.7 billion. These costs were based on the adverse effects of child abuse, such as future drug and alcohol use, mental and physical illness, increased health service usage, homelessness and involvement with the legal system.128,129

Rights of the child

Child abuse is an international issue that has serious life-long consequences. There are a number of treaties and agreements that attempt to set the world standard for managing this difficult topic (refer to Further information for more information on the Convention on the Rights of the Child).

Prevalence

Internationally 20% of women and 5–10% men report childhood sexual abuse, while 25–50% children report being physically abused.126

In Australia from 2011 to 2012 there were 37,781 substantiated reports of child abuse and neglect made to Australian state and territory community services departments. These figures are the substantiated reports and are an underestimate of the prevalence of child abuse in Australia. These reports involved children aged <1 year to 17 years of age. Very young children aged <1 year had the highest rates of substantiation with children aged 15–17 years the least likely. During 2011–12, Aboriginal and Torres Strait Islander children had nearly eight times the substantiation rates of child abuse and neglect compared with non-Indigenous children.120

The most common form of substantiated childhood abuse is emotional abuse (36%), followed by neglect (31%), physical abuse, which varied across states and territories (13–29%) and sexual abuse (12% with a range 13–29%). Girls were more than twice as likely to experience substantiated sexual abuse while boys were more likely to experience neglect. Physical and emotional abuse was more likely to be substantiated for boys in most states and territories.120

Deaths from child abuse

In 2006, 27 Australian children died of assault related injuries; it was the third most common type of injury after transport related deaths (66 deaths) and drowning (46 deaths). Infants less than 12 months of age were most at risk. The Australian Institute of Criminology (2003) estimated that, on average, 25 Australian children are killed by their parents each year.130 This figure is likely to be an underestimate. Recent evidence suggests GPs are often consulted prior to the child’s death and that parental depression and the finalisation of a parental separation (often related to domestic violence) are possible red flags to improve the identification of children most at risk.131

The role of GPs

GPs can work on managing issues related to child abuse at three levels:

  • to prevent the problem from occurring
  • to detect the problem and respond when it does occur
  • to minimise its long-term negative impacts.121

Prevention

Preventive measures and identifying families at risk

Family situations change over time and GPs are often aware of these changes and the potential stress that it places on families. Because of this awareness, GPs are well placed to monitor families for a potential situation that may give rise to child abuse. These situations may include family break up, work stress, additions to the family, or moving location.

However, children in families where there is parental substance abuse, mental illness and/or domestic violence are at greater risk of child abuse.132 As the highest incidence of abuse and neglect happens in the first year of life, families with infants and toddlers may require specific attention and support.120 Children in the first 4 years of life are particularly vulnerable to the impact of child abuse on brain development.133

Other established risk factors for child abuse include:

  • inadequate parenting, including the failure of any infant–parent attachment
  • unrealistic expectations of child development
  • a belief in the effectiveness and social acceptability of harsh physical punishment
  • an inability to provide for high-quality childcare when the parent is absent.

Conversely, various strategies that promote early and secure infant–parent attachment and non-violent modes of discipline, and create the conditions within the family for the positive mental health development of the child, have been proved effective in preventing child abuse.

The evidence that programs focusing on parenting improvement and support are effective in preventing child abuse is strong. The two most widely evaluated and widely applied models for delivering these strategies are training in parenting programs and home visitation programs.122

The Triple-P program of training in parenting, as developed by the University of Queensland, is one example (www.pfsc.uq.edu.au).123 A number of independent outcome evaluations of Triple-P have shown it to be effective in improving family management techniques, parental confidence in effective child rearing, and behavioural outcomes, including health behaviour and aggression.123 Resources for parents can be found at www.families.nsw.gov.au/ resources/resources-index.htm

A meta-analysis of 40 family support prevention programs for those with children at risk of physical abuse and/or neglect returned similar positive, yet modest results.134 This analysis suggested reduction in manifestation of abuse, along with an increase of positive risk reducing behaviours such as parent–child interaction.

The Cochrane Report exploring school-based programs to prevent child sexual abuse (teaching school children about child sexual abuse and how to protect themselves) found some enhancement of children’s knowledge of abuse and their protective behaviours.135 The applicability of these studies to the Australian context needs further investigation – most of the studies were conducted in North America, there was no long-term follow-up, and several studies reported harm such as increased anxiety.

Refer to the adults surviving child abuse (ASCA) factsheet for GPs in the Further information section at the end of this chapter. It is useful to identify local services and have their details on hand to refer patients – in particular, parenting and home visit programs in your local area. It is also beneficial to work collaboratively with the local maternal and child health nurse.

Identification

Identifying suspected child abuse involves detection and response.

This is a very sensitive issue in general practice consultations for a number of reasons:

  • children do have accidents, and frequently have bruising on their bodies
  • children usually attend with other family members, for example, parents
  • children may present for a reason unrelated to abuse, but the GP may suspect abuse for other reasons.

Types of presentations in general practice

GPs are often the first point of contact for families under stress and for children at risk of abuse. It is important for us to remain aware of the possibility of abuse when caring for children, particularly children with emotional or behavioural issues or unexplained injuries, or when you have identified a woman is experiencing intimate partner abuse.

Within a consultation it can be very difficult to know definitively that the root cause of the presentation is abuse or neglect. The family may also be actively trying to hide the abuse or neglect.

Child abuse can present in myriad ways and these effects vary from child to child. While some children may present with bruising or injuries that raise suspicion, most won’t. In the majority of children, direct physical injuries cause less morbidity than the long-term effects of violence on the child’s neurological, cognitive and emotional development and health.136

Children in families where one or both parents are abusing alcohol or other drugs will have a high incidence of neglect and of other forms of abuse.125,137

Possible presentations in children and presentations in young adults

A recent meta-analysis of the health consequences of non-sexual child abuse provides the evidence for the health effects136 (Table 9).

Table 9. Summary of the strength of the evidence for related health outcomes136
Robust evidenceWeak/inconsistent evidenceLimited evidence

Physical abuse

Depressive disorders

Cardiovascular diseases

Allergies

Anxiety disorders

Type 2 diabetes

Cancer

Eating disorders

Obesity

Neurological disorders

Childhood behavioural/conduct disorders

Hypertension

Underweight/malnutrition

Suicide attempt

Smoking

Uterine leiomyoma

Drug use

Ulcers

Chronic spinal pain

Sexually transmitted infection (STI)/risky sexual behaviour

Headache/migraine

Schizophrenia

 

Arthritis

Bronchitis/emphysema

 

Alcohol problems

Asthma

Emotional abuse

Depressive disorders

Eating disorders

Cardiovascular diseases

Anxiety disorders

Type 2 diabetes

Schizophrenia

Suicide attempt

Obesity

Headache/migraine

Drug use

Smoking

 

STIs/risky sexual behaviour

Alcohol problems

 

Neglect

Depressive disorders

Eating disorders

Arthritis

Anxiety disorders

Childhood behavioural/conduct disorders

Headache/migraine

Suicide attempt

Cardiovascular diseases

Chronic spinal pain

Drug use

Type 2 diabetes

Smoking

STIs/risky sexual behaviour

Alcohol problems

 

 

Obesity

 

For more information, view this short presentation by Dr Vince Felitti MD, which provides a summary of the important links between childhood adversity and poor adult health: www.youtube.com/watch?v=GQwJCWPG478

Barriers to disclosure

There are many barriers to disclosure of child abuse, including:

  • the child fearing that they will not be believed138
  • the child assuming abuse is a normal life event139
  • wishing to protect the perpetrator as they may enjoy certain aspects of the relationship with them138,139
  • being threatened not to tell138,139
  • fearing negative consequences for themselves and their families, particularly their mother
  • experiencing disbelief, confusion, and unreality as they try to understand the trauma they have experienced in a context where their lives continue as if nothing has happened139
  • a lack of linguistic abilities to express the abuse or the cognitive ability to understand completely what has happened119,139
  • the perpetrator deliberately provoking confusion, where children may dismiss early incidents as ‘a dream’, ‘a nightmare’, or just their imagination139
  • the relationship between child and perpetrator119,140
  • the gender and ethnicity of the child – for example boys may be less likely to disclose sexual assault119,139
  • a perceived lack of opportunity to bring up abuse138
  • a feeling of being responsible for the abuse or feeling guilty for not telling sooner.139

All abuse is difficult for children to disclose, in particular sexual abuse.139

In relation to sexual abuse, the perpetrator is likely to have ‘groomed’ or threatened the child, which makes it difficult for them to reveal the abuse. Younger children may not be able to identify what is happening to them as abuse. Some older children think that what is happening to them happens to everyone, as they may have little contact with other families in order to make a comparison.

In identifying sexual abuse, GPs must remember the underlying thread of ‘lack of consent’. The child or young person may be forced to participate or cannot properly judge what their participation means. The display of pornography, or an adult exposing themselves to a child is considered abuse, despite the fact that this act may not contain any physical contact with the perpetrator.

Safe ways to ask families

Where you are unsure whether abuse is taking place, but concerned about a child or their family, you may need to seek external assistance from an appropriate service that safeguards GPs or assists GPs troubled by doubts whether the relevant circumstances call for mandatory reporting. In some Australian states there are resources that may be accessed by the person abused, or by a GP (refer to Resources).

Children need to be asked questions that are age appropriate and asked in a safe environment. Children often try to please adults and may give GPs the answer that the child thinks the GP wants. It is important to have the confidence to explore the possibility of child abuse but also to know the limitations and not to ask too many questions. An in-depth history should be left to forensic medical officers and trained social workers. Questions phrased in the third person can be very valuable in exploring the possibility of child abuse.

It is also important to remember that many of these children’s mothers will be victims of intimate partner abuse, although at times they may also be the perpetrator. In a case where mother and child are both being abused, both need to be supported, believed, not blamed and their safety ensured. Recommendations vary on the subject of what age a child can be so that it is safe to discuss abuse issues in front of them with another adult. Many experts think that the child needs to be pre-verbal to ensure safety from the perpetrator. On occasion it may be necessary for us to ask the child about abuse without the primary carer present.

Where the child is at risk, mandatory reporting is required as a matter of law.

Examining children

When you examine children, it is important to talk to them. Explain that you are only examining them because you are a doctor and to help them to understand why they are sick; other adults are not allowed to do the same things.

Questions you can ask during the examination include:

  • 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 another child 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 lots of things, like when they have a fight with their friend, or they feel their teacher was mean to them. Kids also worry about things in their homes, 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 you can ask older children:

  • How good are the good days? What makes them so good?
  • How bad are the bad days? What makes them bad?

Advice from an experienced colleague or child abuse service can also be helpful and this sharing of information may resolve the dilemma in circumstances of doubt.

Provided there is no disclosure of patient identity, there is no impediment to seeking assistance, in confidence, without patient consent.

In rural and remote areas there may be fewer services available and issues of confidentiality are very important and need to be meticulously implemented. However there is the opportunity for the community to come together and devise ways of dealing with child abuse issues. This takes leadership and commitment but also provides the chance for community empowerment.

Mandatory reporting

GPs have a responsibility to report child abuse or neglect. The laws are different in every state and territory. If you need advice you can ring your local reporting number and discuss your concerns without revealing personal details. Your medical defence organisation may provide other help and advice. Refer to Table 10 for the key features of ‘state of mind’ that activate the duty to report and the extent of harm.

The family, or the child’s needs, may require services additional to medical assistance, such as counselling or family services, or they might be managed appropriately in another way. Mandatory reporting does not affect a GP’s continuing professional obligation to the patient.

Management

GPs have a role in prevention, identification, mandatory reporting and helping to minimise the long-term effects of abuse.

Minimising the long-term effects of child abuse

The evidence-based ‘team approach’ across disciplines to the prevention and management of child abuse has improved care over the last 30 years.7

Preliminary studies suggest that for abused children, foster care may be more beneficial than home-based care.7 Kinship care is another option for children unable to remain at home.

In all societies there are many children affected by sexual abuse. The long-term effects will vary and can result in ongoing behavioural and psychological problems which can still be an issue in adulthood. There has been a Cochrane Review: Cognitive behavioural interventions for children who have been sexually abused.141 The studies show that CBT can be helpful to these children but the results were generally modest. Some of the issues experienced by these children were depression, post-traumatic stress and anxiety. Children who have been abused need to have these issues addressed in a relational intervention where they can be believed, supported and helped in a safe environment.

In order to manage child abuse it is important to work with the practice to identify:

  • early childhood services doing home visits
  • parenting programs using Triple-P
  • drug and alcohol services for parents in need of these services
  • allied health providers who provide CBT for children who have been sexually abused
  • domestic violence workers who can work with both the mother and the children.

A further way to source services is to ask your local primary healthcare organisation for a list of services in your area.

In rural and remote areas these services may not be readily available. You may need a response from the local community, or to ask for services to be provided or for local health professionals to receive further training.

Conclusion

This chapter has described the prevalence and major health effects of child abuse. GPs have a role in prevention, detection, mandatory reporting and minimisation of the long-term impacts of child abuse. GPs are ideally placed, as they see children frequently. There is good evidence that prevention through parenting training programs and nurse home visitation is effective.

Table 10. Key features of legislative reporting duties: ‘state of mind’ that activates reporting duty and extent of harm142
JurisdictionState of mindExtent of harm

ACT

Belief on reasonable grounds

Not specified: ‘sexual abuse ... or non-accidental physical injury’

NSW

Suspects on reasonable grounds that a child is at risk of significant harm

A child or young person ‘is at risk of significant harm if current concerns exist for the safety, welfare or wellbeing of the child or young person because of the presence, to a significant extent, of ... basic physical or psychological needs that are not being met ... physical or sexual abuse or ill-treatment ... serious psychological harm’

NT

Belief on reasonable grounds

Any significant detrimental effect caused by any act, omission or circumstance on the physical, psychological or emotional wellbeing or development of the child

QLD

Becomes aware, or reasonably suspects

Significant detrimental effect on the child's physical, psychological or emotional wellbeing

SA

Suspects on reasonable grounds

Any sexual abuse; physical or psychological abuse or neglect to extent that the child "has suffered, or is likely to suffer, physical or psychological injury detrimental to the child's wellbeing; or the child's physical or psychological development is in jeopardy"

TAS

Believes, or suspects, on reasonable grounds, or knows

Any sexual abuse; physical or emotional injury or other abuse, or neglect, to extent that the child has suffered, or is likely to suffer, physical or psychological harm detrimental to the child's wellbeing; or the child's physical or psychological development is in jeopardy

VIC

Belief on reasonable grounds

Child has suffered, or is likely to suffer, significant harm as a result of physical injury or sexual abuse and the child's parents have not protected, or are unlikely to protect, the child from harm of that type

WA

Belief on reasonable grounds

Not specified: any sexual abuse

Australia

Suspects on reasonable grounds

Not specified: any assault or sexual assault; serious psychological harm; serious neglect

Source: Adapted from relevant state and territory legislation.

Resources

Please refer to Tool 7 for resources nationally and in your area.

Further information

  • Oates, RK. Role of the medical community in detecting and managing child abuse. Med J Aust 2014, 200:7–8.
  • Ampe akelyernemane meke mekarle – Little children are sacred. Available at www.inquirysaac.nt.gov.au/pdf/bipacsa_report_summary.pdf
  • McCutcheon LK, Chanen AM, Fraser RJ, Dew L, Brewer W. Tips and techniques for engaging and managing the reluctant, resistant or hostile young person. Med J Aust 2007;187:S64 –7.
  • Never shake a baby – the Children, Youth and Women’s Health Service has produced this guide that explains why you shouldn’t shake a child and gives alternative methods to quieten a child. Available at www.cyh.com/HealthTopics/HealthTopicDetails.aspx?p=114&np=305&id=1913
  • Everyone’s got a bottom by Tess Rowley and illustrated by Jodi Edwards is a good book to consider having in the practice waiting room. It is available from Family Planning Queensland at www.fpq.com.au/publications/teachingAids/everyones_got_a_bottom.php.
  • Specific information for children of Aboriginal and Torres Strait Islander descent and their communities is available: Through young black eyes: A handbook to protect children from the impact of family violence and child abuse can be obtained from the Secretariat of National Aboriginal and Islander Child Care at www.snaicc.org.au/tools-resources/dsp-shop.cfm?loadref=141&id=55933BE0-2219-A8B0-B6948391962AFAC3
  • The Convention on the Rights of the Child is an interesting example of international responses to child abuse. Available at www.unicef.org/crc/files/Implementation%20Handbook%203rd%20ed.pdf
  • Benefits of programs: A detailed description by Professor Louise Newman and Peta Murcutt, available at www.abc.net.au/radionational/programs/lifematters/trauma-and-kids/4896956
  • ASCA factsheet for general practitioners: Understanding complex trauma, available at www.asca.org.au/Portals/2/ASCA Fact Sheet_GPs.pdf
  • Supporting patients experiencing family violence – resource from Australian Medical Association (AMA). Available at https://ama.com.au/article/ama-family-violence-resource
  • When she talks to you about the violence – video resource developed by AMA NSW. Available at https://vimeo.com/105645549

References

  1. MacMillan HL, Wathen CN, Barlow J, et al. Interventions to prevent child maltreatment and associated impairment. Lancet 2009;373:250–66.
  2. Renner LM, Slack KS. Intimate partner violence and child maltreatment: understanding intra- and intergenerational connections. Child Abuse Negl 2006;30:599–617.
  3. Hanson RF, Kievit LW, Saunders BE, et al. Correlates of adolescent reports of sexual assault: Findings from the National Survey of Adolescents. Child Maltreatment 2003;8:261–72.
  4. Australian Institute of Health and Welfare. Child Protection Australia 2011–12. Canberra: Australian Government, 2013.
  5. World Health Organization, International Society for the Prevention of Child Abuse and Neglect. Preventing child maltreatment: a guide to taking action and generating evidence. Geneva: WHO, 2006.
  6. Barlow J, Johnston I, Kendrick D, et al. Individual and group-based parenting programmes for the treatment of physical child abuse and neglect. Cochrane Review. The Cochrane Library, 2008.
  7. Sanders M, Markie-Dadds C, Turner K. Theoretical, scientific and clinical foundations of the Triple P-Positive Parenting Program: A population approach to parenting competency. The Parenting and Family Support Centre: University of Queensland, 2003.
  8. Mikton CA. Child maltreatment prevention: a systematic review of reviews. Bulletin of the World Health Organization 2009;87:353–61.
  9. World Health Organization. Child maltreatment and alcohol. Geneva: WHO, 2006.
  10. World Health Organization. Child maltreatment fact sheet 2010. Available at www.who.int/mediacentre/ factsheets/fs150/en/index.html.
  11. Gilbert R, Widom CS, Browne K, et al. Burden and consequences of child maltreatment in high-income countries. Lancet 2009;373:68–81.
  12. Australian Institute of Family Studies. The economic costs of child abuse and neglect 2013. Available at www.aifs.gov.au/ cfca/pubs/factsheets/a142118 /index.html.
  13. Taylor P, Moore P, Pezzullo L, et al. The cost of child abuse in Australia. Melbourne: Australian Childhood Foundation and Child Abuse Prevention Research Australia, 2008.
  14. Australian Institute of Family Studies. Child deaths from abuse and neglect 2014. Available at www.aifs.gov.au/ cfca/pubs/factsheets/ a142119.
  15. Brown T, Tyson D, Fernandez P. Filicide in Australia. Addressing Filicide: The International Conference; Prato, Italy, 30–31 May 2013.
  16. Dawe S, Harnett P, Frye S. Improving outcomes for children living in families with parental substance misuse: What we know and what we should do. Canberra: Australian Institute of Family Studies, 2008.
  17. Perry BD. Examining child maltreatment through a neurodevelopmental lens: clinical applications of the Neurosequential Model of Therapeutics. J Loss Trauma 2009;14:240–55.
  18. Geeraert L, van den Noortgate W, Grietens H, et al. The effects of early prevention programs for families with young children at risk for physical child abuse and neglect: a meta-analysis. Child Maltreatment 2004;9:277–91.
  19. Zwi K, Woolfenden S, Wheeler D, et al. School-based education programmes for the prevention of child abuse. Cochrane Review. The Cochrane Library, 2009.
  20. Norman R, Munkhtsetseg B, Rumma D, et al. The long-term health consequences of child physical abuse, emotional abuse and neglect: A systematic review and meta-analysis. PLos Med 2012;9:e1001349.
  21. Meredith V, Price-Robertson R. Alcohol misuse and child maltreatment. Australian Government, Australian Institute of Family Studies; 2011.
  22. Jensen TK, Gulbrandsen W, Mossige S, et al. Reporting possible sexual abuse: A qualitative study on children’s perspectives and the context for disclosure. Child Abuse Negl 2005;29:1395–413.
  23. Fontes LA, Plummer C. Cultural issues in disclosures of child sexual sbuse. J Child Sex Abus 2010;19:491–518.
  24. Foynes MM, Freyd JJ, DePrince AP. Child abuse: Betrayal and disclosure. Child Abuse Negl 2009;33:209–17.
  25. Macdonald G, Higgins J, Ramchandani P, et al. Cognitive-behavioural interventions for children who have been sexually abused. Cochrane Review. The Cochrane Library, 2012.
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