Child protection and the health professional: mandatory responding is our duty

The Medical Journal of Australia ISSN: 0025729X 7 September 2009 191 5 246-247 ©The Medical Journal of Australia 2009 www.mja.com.au Editorials very Australian state has enacted mandatory reporting of child abuse. Child abuse is a ubiquitous problem affecting at least one in 13 children, and among Indigenous Australians, this rate is higher. The most important comorbidities for child abuse — poverty, domestic violence, mental ill health and substance misuse — are seen by all health professionals on a daily basis. Mandatory reporting of child abuse aims to achieve better outcomes for children and families where abuse is thought to have occurred or has occurred. It arose in the United States out of the correctly perceived need to allow health workers to report concerns about child abuse to statutory child protection agencies without fear of subsequent litigation for breach of confidentiality. The assumption is that the child protection agency will pick up the baton and protect the child. Current research clearly indicates that this is not the case. The recent Wood Inquiry into the New South Wales child protection agency (Department of Community Services) has outlined the perils of this false expectation; no child protection agency can cope with all the referrals that it receives. Mandatory reporting is not essential to good child protection. However, good communication between agencies and practitioners is essential; when this fails, disaster strikes. There are, sadly, many examples of these failures in Australia (where the case of Daniel Valerio is one of the best known) and overseas (eg, the cases of Victoria Climbié and Baby P). Management of child abuse does require mandatory responding. There is an obligation on each and every one of us who work in the community as a health professional to respond, and this must involve more than completing a mandatory reporting form. If we are to make a difference to children’s lives, all health professionals must respond when they suspect child abuse. The difficulty for all of us is that, unlike in other areas of medical practice, few patients are either willing or able to outline their suffering in a standard consultation. On many occasions, the parent deliberately sets out to mislead the practitioner in situations where child protection issues exist. This may be done maliciously, out of pride, or out of fear of prosecution. Thus health professionals need to have an index of suspicion, and then act on that suspicion in a way that does not jeopardise further the safety of the child. This suspicion is often outside the comfort zone of many health care practitioners. Of reports made to statutory agencies, substantiation rates vary from 2.4 to 9.3 per 1000 reports. Substantiation is not a cure for the child in question; all it does is confirm that the original concerns were correct and that the child needs help. The vast bulk of cases are unable to be substantiated, and this may result in the protection agencies feeling that such cases are no longer a priority; this potentially endangers children even further. The onus is thus on health practitioners, you and me, to respond. How can we do this? Responding can take many forms, depending on what is needed. It must never be assumed that someone else will fix it. • If a particular case requires major social intervention, and if statutory agencies have not acted or have acted inappropriately, phone/write/fax/email them and alert them to your concerns. On occasion it may entail being more tenacious than you are used to being. • If the issue is the mental ill health of a parent or child, ensure that the parent gets help either from you or from someone else. This may require repeated contact with mental health agencies. Mental Health Care Plans are very useful in this setting. • Child abuse is a criminal matter that puts children at risk. In such cases, ensure that police are involved and are taking appropriate action. • If there are medical matters affecting a parent’s ability to parent, these need to be addressed. If you are in doubt about what you see when a child presents, arrange for the child to be admitted and for the protection issues to be investigated while the child is safe. At a general practice level, responding appropriately in child protection cases may involve reviewing the patient on a number of occasions in order to obtain a clearer picture, and being in contact with your local child protection agency and other health care providers. Doctors often falsely believe that they can do better alone than by involving child protection services. Every capital city in Australia has at least one child protection unit at their children’s hospital, from where advice can be obtained. There is often a moral and legal fear that reporting may do more harm than good for the child and his or her family. A groundless report can cause anguish; however, inaction injures many more children than the odd report that should not have occurred. With Australia-wide mandatory reporting, the onus is now on us to provide mandatory responding. Only by responding in an appropriate manner, case by case, will we be able to facilitate better outcomes for children and, in turn, for society at large. Mandatory responding at the individual level and as a public health issue is the universal panacea for child abuse; mandatory reporting is only one tool in that response.