Introduction
Rainbow Clinic for Abused Children, April 2020
The Role of Healthcare Workers in Child Abuse
Behavioural & Physical Indicators in Abused Children
History Taking in Suspected Child Abuse
The Role of Healthcare Workers in Child Abuse
The role of healthcare workers (HCWs) is to suspect and recognise child abuse; examine such cases thoroughly; meticulously collect evidence; accurately document the clinical findings; provide the necessary treatment (prophylactic and other); refer the child for appropriate counselling and report the case to the relevant authorities. The HCW must be prepared to testify to his/her findings in a court of law.
Laws Relating to Child Abuse
- HCWs MAY NOT refuse to see patients in whom abuse is suspected (National Health Act of 2003).
- ANY suspected abuse MUST be reported [Criminal Law (Sexual Offences and Related Matters) Amendment Act of 2007]. Failure to report is against the law.
- There will be “No legal proceedings against these persons, notifying in good faith”
- The SA Sexual Offences Act of 2007 allows for broader definitions of sexual offences e.g. “penetration” includes ANY degree of penetration with ANY body part, including animal body parts.
Behavioural & Physical Indicators in Abused Children
- Poor child-parent interaction/scared of parents
- Nightmares
- Wary of adult contact
- Aggression
- Withdrawn/sad/depressed child
- Poor self-concept, reluctance to undress
- Developmental delay/regression of milestones
- Decreased school performance
- Secondary enuresis/encopresis
- Sexualised behaviour, including excessive inappropriate masturbation
- Recurrent genito-urinary tract infections (bladder infections, vaginal discharges)
- Pregnancy
- Recurrent non-specific abdominal pain
Who Sees Sexual Abuse Cases?
- ALL sexual abuse cases must be assessed, even if chronic abuse is suspected.
- ALL doctors should be able to assess abuse cases.
- After hours, acute cases (<72hrs) to be assessed in Ward 17 and fully dealt with at the time.
- After hours, chronic cases to be seen in Ward 17 and if necessary (e.g. safety issues), slept over to be discussed in the morning with Dr Cartwright (or alternatively with the Social Worker), or to be seen in POPD (Paediatric Out-Patients Department).
- Please DO NOT simply tell parents to come back for Dr Cartwright the next day with no arrangement in place, as she is not always available.
- SAECKs are stocked in Ward 17. If SAECKs are not available, SAPS to be contacted to bring a kit (see contact numbers in Resources section of this document). If no kit is available from SAPS, PLEASE collect evidence using two normal swabs (1 to NHLS, and 1 sealed for SAPS).
- It is the responsibility of the FIRST doctor who sees the case to complete the Form 22 and the Medical Report. Dr Cartwright may be consulted with regard to assistance with filling in the forms.
- The law obliges ALL doctors to see sexually abused children, and all are urged to see, and learn to manage, these cases.
History Taking in Suspected Child Abuse
A comfortable environment with safe boundaries should be used when taking a history. The questioning should be tailored to individual children and their caregivers, that is, a disclosure of abuse may not be obtainable in the initial session, or it may be necessary for children to be questioned separately from the parents. A team approach (e.g. doctor, social worker and psychologist) may be useful where possible to avoid having the child and his/her family repeating traumatic details. Questioning should be open-ended to avoid yes/no answers.
A history is suspicious for possible abuse where it:
- Is incompatible with the injury
- Is developmentally impossible
- Is vague
- Changes when repeated
- Changes in separate interviews
- Is given by the child alone
- Reveals repeated injuries
- Suggests delay in seeking treatment
It may be useful to allow the child to play, e.g. with a doll’s house and differently dressed dolls (not necessarily anatomically correct dolls) and to ask open-ended questions around the play. If the child discloses, note in the first person exactly what he/she says e.g. “My uncle put his finger in my flower”. It must be carefully noted what the child is referring to when he/she uses terms such as “flower”, or if the child physically shows the doctor what happened (a written description of what the child showed). Disclosures such as these are admissible as evidence in court, and it is thus vital that they are accurately recorded.
Step by Step Guide to the Management of Child Abuse; Rainbow Clinic, RMMCH; Version: July 2023