Identification of Child Abuse by Doctors

It is not the doctor’s duty to confirm abuse. Doctors who work with children may suspect that a child is a victim of abuse or neglect, for example, when:
• The child speaks about it;
• The parent mentions it;
• The parent reports symptoms related to abuse;
• The child has relevant injuries;
• Child protection services or the police express suspicion that the child is a victim of abuse;
• Another specialist (surgeon, nurse) suspects the child may be a victim of abuse.

Effective Recommendations:

• Consult with other specialists who have experience with child abuse issues;
• Document your suspicions and prepare a medical report;
• If there is suspicion, report it to child protection services/police within 48 hours;
• If you receive no response, it is your responsibility to continue making reports.

Remember:

• The child's safety is paramount;
• Do not blame anyone directly for harming the child;
• Maintain objectivity as much as possible;
• A "suspicion" is not a "conclusion/diagnosis"; it is the starting point for seeing more;
• Share information with relevant parties;
• Making a diagnosis is like a "puzzle" – many different details are needed for an accurate diagnosis, and you may only hold one piece of the puzzle;
• Speak to the child in a way that matches their age and development level. Share your suspicions and thoughts with parents if doing so won’t endanger the child;
• The child should only be discharged from the hospital if it will not put them in danger.

Reporting

When there is a suspicion that a child is a victim of abuse or neglect, medical personnel are obliged to report it to child protection (Social Services Agency) and/or law enforcement agencies.
• If reporting by phone, confirm the report in writing within 48 hours. A written report should be confirmed within one working day. If no action is taken within three working days, repeat the report.
• Generally, it’s best to discuss the report with the parents beforehand, if it does not endanger the child.

Situations that require immediate reporting:

(a) Police:
• Sexual abuse, rape;
• Dead or severely injured child due to suspected abuse;
• Threats to life.

(b) Child Protection Services and/or Police:
• Suspected abuse or neglect (when there’s concern that other children in the family are at risk);
• Witnesses to serious forms of abuse.
Child protection services and the police have the authority often necessary to protect the child.

Assessing the Situation

Accurate recording of all information is essential when dealing with child abuse issues. Every detail matters, as sometimes life and death depend on it.

Basic Principles:
• The child should understand as much as possible what is happening;
• The examination should consider the child’s needs as much as possible;
• If there’s a suspicion, assess the condition of other children as well;
• Ensure you have the specific knowledge required for the case;
• Always document conversations, accounts, examination results;
• Use an interpreter if needed;
• Older children may prefer a male or female doctor, and their preference should be considered where possible;
• Try not to examine the child alone (even if a caregiver is present).

Severity Level

The doctor conducting the examination should determine the urgency and timing for it:
• If possible, a physical injury should be examined on the same day;
• In cases of acute (recent) sexual abuse, the examination should take place as soon as possible. Follow legal requirements – notify the police immediately upon suspicion of sexual abuse.
• In medical practice, it’s common for doctors to discover signs of non-acute (previous) sexual abuse during an examination; the child may have a sexually transmitted infection. Follow legal requirements – notify the police immediately upon suspicion of sexual abuse.
Location and Process of Examination
• The examination location should be as child-friendly as possible.
• Do not use physical restraints (infants may need a holder).
• Talk to the child both during and before the examination;
• Explain what you are doing without causing fear, and offer reassurance if needed;
• The child may choose who they want to be present (parent, caregiver, social worker, nurse, friend);
• Documentation should be detailed, dated accurately, organized, and signed; reports and statements should be prepared as promptly as possible.
Preparing a Medical Report

When preparing a report, it’s important to consider the intended audience. If the report is for law enforcement or child protection services, specific nuances should be carefully addressed – keep in mind that your report may become a subject of court review. Any inconsistency between the medical record and the final report could be used by the defendant’s lawyer to challenge the case as fictional.
It is essential to document accurately and promptly any information provided by the child, which should be conveyed with the same precision in the final report.

The report should include the following information:
1. The author’s full name, workplace, position, profession, and qualifications;
2. Detailed history, completed examinations, and results;
3. Differential diagnosis and reasoning for the final diagnosis;
4. Clearly state that this is a professional opinion and on what it is based.
Practical Recommendations for Preparing the Report:
1. Use non-technical language where possible, or provide explanations in parentheses;
2. Separate sections into the case history, conducted examinations and results, summary, opinion, and conclusion;
3. Record the date and time of examination and evaluations chronologically – this is crucial;
4. Record information obtained from a third party (parent, guardian, companion) verbatim;
5. Record the child’s statements verbatim;
6. Always distinguish facts from opinions.
Additional Considerations:
• A routine examination may not confirm abuse, but you may still suspect it occurred. For example, the child reports abuse, but signs may have diminished or disappeared over time.
• Define your scope of responsibility and avoid taking on other professional roles (e.g., social worker, police investigator).
• The report is a legal document. If you lack experience, consult a more experienced colleague before sending the report.
• Share your report with the parent or guardian if they are not suspected abusers.

Remember: The child’s safety and well-being are the top priority. Other considerations, even confidentiality, are secondary.

Ideally, a report should be prepared within 24 hours, signed, and sent to the relevant agencies – the police and/or child protection services. The report should be marked as "confidential" and not shared with others.

Keep in mind that a new report may be requested during the investigation or in court proceedings, and the information should align with previously submitted reports.