MANAGEMENT OF CHILD ABUSE:

IT’S NOT ONLY ED’s PROBLEM

Dr Shamsuriani Md Jamal
Consultant Emergency Physician
HCTM National University Of Malaysia
 AIM
• Legislations surrounding child abuse & Mandatory
reporting
• Multidisciplinary approach management of child abuse
• Malaysia experience: OSCC
COVID -19 & CHILD ABUSE
FIGURE 1. Number (A) and proportion (B) of
emergency department (ED) visits related to
suspected and confirmed child abuse and neglect
among children and adolescents aged <18 years, by
week — National Syndromic Surveillance Program,
United States, 2019–2020

FACTORS CONTRIBUTING:
• Job loss
• Closing of schools
• Accessibility to child protection services
“As child health professionals, child protection plays a role
in everything we do. It is about protecting individual
children identified as suffering, or likely to suffer, significant
harm as a result of abuse or neglect”
Royal College of Pediatric & Child Health
DEFINITION OF CHILD ABUSE
 CHILD PROTECTION
• Article 19 of the UN Convention on the Rights of the
Child (UNCRC)
• Safeguard children from violence, exploitation, abuse,
and neglect.
Legislation and policies that surround safeguarding children

• The Children Act 1989 (as amended).

• The Children and Social Work Act 2017.
• Keeping Children Safe in Education 2019.
• Working Together to Safeguard Children 2018.
• The Education Act 2002.
• The United Nations convention on the Rights of the Child 1992.
• The Equality Act 2010.
• The Children and Families Act 2014.
• The Human Rights Act 1998.
 REPORTING CHILD ABUSE
• Mandatory reporting of a suspicion of abuse is required
for physicians and other medical providers in many
regions.
• Clinicians must know and abide by mandatory reporting
statutes in the jurisdictions where they practice.
 CHILD PROTECTION SYSTEM
• The set of laws, policies, regulations and services needed across all social
sectors – especially social welfare, education, health, security and justice –
to support prevention and response to protection-related risks.
• These systems are part of social protection & extend beyond it.
• Responsibilities are often spread across government agencies with
coordination between sectors and levels
United Nations Economic and Social Council (2008), UNICEF Child Protection Strategy, E/ICEF/2008/5/Rev.1, par. 12-13 .
 CHILD PROTECTION SYSTEM-ELEMENTS

CHARACTER COMPONENTS APPROACH CONTEXT COORDINATION LEADERSHIP

 MULTIDISCIPLINARY APPROACH
• The protection of children from abuse is a shared responsibility
• Coordinated and cooperative approach that combines the
expertise and resources of agencies and disciplines within the
medical profession at different times and in different ways in the
intervention process
• Child-centered approach to minimize trauma to the victim
• Child abuse and neglect may be encountered in any clinical practice
setting.
• ED is a common entry point into the health care system
• Primary and secondary prevention efforts for children at risk of
maltreatment before a devastating outcome occurs.
• High index of suspicion by primary physicians : Family
physician/Emergency physician
SCREENING QUESTIONS FOR CHILD ABUSE
ESCAPE QUESTIONNAIRE
1. Is the history consistent?
2. Was seeking medical help unnecessarily delayed?
3. Does the onset of the injury fit with the development level of the child?
4. Is the behaviour of the child, his or her caregivers and their interaction appropriate?
5. Are findings of the head-to-toe examination in accordance with the history?
6. Are there signals that make you doubt the safety of the child or other family members?
*6-item checklist addressing risk factors for child abuse, which may be predictive for child
abuse in any child.
Ref: Dato Dr Amar Singh HSS, Consultant Pediatrician
RED FLAG EXAMINATION FINDINGS
TEN-4 FACES p
• In children less than 4 years of
age, bruises on these areas
raise concern for physical abuse
• ANY BRUISE on a child less than
4 months of age is concerning!
96% sensitive and 87% specificity

Pierce et al. Rule to Predict Abuse in Young Children Based on

Bruising Characteristics. JAMA 2021
• For children whose examination is normal, the patient
and family should be informed that the absence of
physical findings does not exclude abuse
• The anticipated involvement and intervention of child
protective services and law enforcement should be
discussed with the child and parents
 AIM OF MANAGEMENT
Treatment of injuries

Mandatory reporting

Safe environment for child

Counselling and social support

 MULTIDISCIPLINARY AGENCY :
SUSPECTED CHILD ABUSE AND NEGLECT (SCAN) TEAM

Medical Social Medicolegal

• Emergency doctors • Social worker • Police

• Paediatrician • Child Protection Officer • Legal assistance
• Gynecologist/Surgeon • Teachers
• Psychiatrist/Psychologist
• Forensics
• Family physician

HEALTH FACILITIES
COMMUNITY/TEMPORARY PLACEMENT

• Social welfare department
• Child Protection Officer
• Family counseling
• Court order
Child presents with
suspected abuse
• ED
Assessment by treating
• Family practitioner clinic doctors
• Pediatric clinic
Findings suggestive of abuse Findings not suggestive of abuse
• Witnessed or disclosed abuse • No injuries or risk factors indicating
• Injury pathognomonic of abuse present
abuse • No historical indicators of abuse
• Injuries Suggestive of • Physical exam findings explained by
Abuse not explained by appropriate mechanism or medical
plausible mechanism etiology
• Occult injuries identified
RECCOMENDATIONS
• Treat injuries RECCOMENDATIONS
• Mandatory reporting • Treat underlying condition
• Pediatric/Gynecology/Urology/S
urgery
• Social worker involvement
CHILD ABUSE FLOWCHART-HOSPITAL
DISPOSITION
• Protective admission
• Temporary placement
BASED
• Discharge to safe carer
 SCAN TEAM CORDINATOR
• Conduct an evaluation of the events - identify the best
immediate disposition for the child.
• Options include:
– Protective hospitalization
– Placement with relatives or in temporary housing
(sometimes a whole family is moved out of an abusive
partner’s home)
– Temporary foster care
– Going home with prompt social service and medical
follow-up
• Court order may be needed to take away the child into
temporary placements
POLICE/LAW ENFORCEMENT
• Provide immediate protection to child
• Investigation of offences and when,
appropriate, prosecution of offender
CHILD PROTECTOR/SOCIAL WORKER
• Investigation and assessment of whether
child need care and protection
• Ensure protection of child in placement of
child
• Assist in rehabilitation of child and family

• MEDICAL TEAM
• Emergency doctors
• Family physician
• Paeditrician
• Psychiatrist
 PSYCHOLOGY SUPPORT
• Victims of child abuse are at risk for short- and long-term
psychological disturbances :
– posttraumatic stress disorder (PTSD)
– depression and suicidality
– social phobias
– anxiety disorders
– attention problems
– poor self-esteem
•
 PSYCHOLOGY SUPPORT
• Factors that are associated with more adverse
psychological sequelae:
– longer duration of the abuse
– use or threats of force and violence
– fathers as perpetrators or multiple perpetrators
– adolescent age at the onset of the abuse
– multiple incidents of abuse
– genital penetration
 MALAYSIA
EXPERIENCE:
ONE STOP CRISIS
CENTER (OSCC)
 ONE STOP CRISIS CENTER (OSCC)
• 24-hour centre
• Located at the emergency department/unit
• Serve as the entry point of child abuse cases to the
hospital
• Providing a private area where the child and family can be
interviewed by the health personnel, welfare officers or
police, and initial medical examination performed.
 PROCEDURES
PROCEDURES FOR
FOR HANDLING
HANDLING SCAN
SCAN CASES
CASES

Flow chart
Flow chart

Brought
Brought by
by parents/
parents/ Brought
Brought by parents/ Brought byby
teacher/
teacher/ public
public to
to Brought by
police/NGO/GP
teacher/ public to police/NGO/GP
hospital
hospital police/NGO/GP
referral
hospital to hospital
referral to hospital
referral to hospital

Triage
Triage at
at
Triage at
Accident
Accident &&
Accident &
Emergency
Critical/semi-
Critical/semi- Emergency
Critical/semi- Emergency
critical
critical
critical Non-
Non-
Non-
critical
critical
critical

At
At Emergency
Emergency Dept
Dept OSCC/
OSCC/ Ward
Ward
At Emergency Dept OSCC/ Ward
Call
Call relevant
relevant specialities
specialities Review
Review by
by SCAN
SCAN Team
Team Prior
Call relevant specialities Review by SCAN Team Prior appt.
appt. made
made with
with
Give
Give acute
acute medical/surgical
medical/surgical Examination
Examination Prior appt.
SCAN
SCAN team
made with(by
team member
member (by
Give acute medical/surgical
treatment Examination
Treatment SCAN team member (by
treatment Treatment JKM/
JKM/
treatment
Proper
Proper documentation
Treatment
JKM/Police JKM/
documentation JKM/Police report
report police/NGO/other
police/NGO/other
&Proper documentation
& collection
collection of
of evidence
evidence as
as JKM/Police
Case report
Case conference
conference police/NGO/other
doctors)
& collection of evidence as doctors)
required
required Case conference doctors)
required

Discharge
Discharge according
according to to case
case conference
conference decision
decision
Discharge according
Inform to case conference decision
Inform Child
Child Protector
Protector && police
police about
about discharge
discharge
Inform Inform Child Protector & police aboutvideo
discharge
Inform the
the Police
Police Child
Child Protection
Protection Unit
Unit for
for video interview
interview
Inform the Police Child(if
Protection Unit for video interview
(if available)
available)
(if available)
Follow-up appointment
Follow-up appointment
Follow-up appointment

Review
Review at
at follow-up,
follow-up, Networking
Networking
Review
with at follow-up, Networking
with agencies,
agencies, Rehabilitation
Rehabilitation
with agencies, Rehabilitation
 A 14 yo girl
• Presents with history of shortness of breath and palpitation.
• Triage: history was not forthcoming, child appeared anxious. She was
hemodynamically stable.
• Send to OSCC
• Further history: suicidal ideation in social media, detected by mother,
afraid of the father, was physically & emotionally abused since 4 yo.
Mother confirmed the history. Has 3 other smaller siblings
 A 14 yo girl
• Activated SCAN team
– Pediatrician
– Child Psychiatrist
– Social worker
• Mandatory police reporting was made by ED MO
• Protective admission to pediatric – parents refused and
absconded. Police was alerted. Enforced on admission of
the child.
 TAKE HOME MESSAGE
“We must do all we can to ensure that children are protected from
all forms of violence, abuse, neglect and bad treatment by their
parents or anyone else who looks after them”. Article 19 UNCRC

“The best interests of the child must be a top priority in all

decisions and actions that affect children” Article 3 UNCRC
”