VFPMS guidelines for forensic evaluation of suspected child abuse

  • These clinical practice guidelines provide advice to assist decision-making in clinical situations when child abuse and neglect are considered. They do not serve to replace health services' procedural guidelines or restrict discretion and good judgement in complex situations.

    Clinical Practice Guidelines for child abuse and neglect, vulnerable children and "at risk children" are considered within 4 categories, recognising that differing forms of child abuse often co-exist.

    1. Physical harm / Non-accidental injury
    2. Sexual harm / Sexual abuse
    3. Neglect
    4. Vulnerable child / at risk of abuse

    Medical practitioners are encouraged to seek advice from the Victorian Forensic Paediatric Medical Service (VFPMS), senior medical staff and to always operate within jurisdictional legislative requirements.

    Physical harm / Non-accidental injury (NAI)

    Children who attend with an injury that might have been inflicted need a full assessment of their physical condition and psychosocial situation.

    The priorities in dealing with child physical abuse are to:

    1. suspect physical harm / non-accidental injury
    2. diagnose, treat and document the child's injuries
    3. interpret a pattern of injury or findings leading to the suspicion of abuse
    4. notify and involve the Victorian Forensic Paediatric Medical Service (VFPMS)
    5. assess the child's psychosocial situation
    6. provide, when consent is given or legislation requires information sharing in the absence of guardian's consent , a verbal and/or written report to Child Protection and the Police. VFPMS may be responsible for this task
    7. plan for the child's safe discharge and ongoing medical /psychological care.

    Contact 

    Victorian Forensic Paediatric Medical Service

    (24 hours 7 days a week) 

    1300 66 11 42

    Assessment of a child's psychosocial situation may be conducted as a multidisciplinary assessment by professionals within the health service, including social workers and mental health professionals, working in partnership with Child Protection, police and community-based professionals.

    Management of suspected NAI

    NAI_algorithm

    Admission or discharge?

    Admission to hospital should be arranged when it is medically necessary (head injury, fractures, failure to thrive etc) or when it is necessary for the child's safety.

    A low threshold for admission is appropriate when dealing with an injured child.

    Consider NAI in any infant who presents with an unexplained encephalopathy. Any infant with a cerebral injury, from shaking or direct trauma, should be admitted to ICU for monitoring overnight. Delayed deterioration may occur. (At RCH - ICU admission should only be declined following assessment by the ICU consultant).

    The safe discharge of the child is the responsibility both of the hospital and Child Protection.

    SCAN (Suspected Child Abuse and Neglect) multi-disciplinary professionals' meetings

    All admitted patients should be the subject of a SCAN meeting held within 24 hours of admission.
    The SCAN protocol is designed to help coordinate early discussions with Paediatric medical staff, Victorian Forensic Paediatric Medical Service, Child Protection and police.

    See SCAN meeting resources.

    Medical investigation of suspicious injury

    Forensic investigation of suspicious bruising

    First line investigation of bruising

    • FBE
    • APPT
    • PT
    • Fibrinogen
    • Calcium
    • LFT (proteins)
    • U&E, Creatinine

    Extended clotting profile

    • Factor VIII, IX, XI, XIII
    • Von Willebrand’s screen (and blood group)
    • Platelet function tests
    • +/- Lupus anticoagulant (+/-additional tests for lupus)
    • +/- Inflammatory markers (if vasculitis suspected)

     

     

    Forensic investigation of suspected intra-abdominal trauma

    • Amylase and lipase
    • LFT
    • FBE
    • Fibrinogen
    • Dipstick urine (blood)
    • Ultrasound
    • CT abdomen if significant concerns about paralytic ileus, intra-abdominal haemorrhage and elevated amylase (> 3 hours post trauma)

    Forensic investigation of suspected abusive head trauma

    • Consider radiological imaging (MRI and/or CT brain scan) of the brains of infants and young children who might have been shaken.
    • Consider MRI cervical spine
    • Investigate as for fracture
    • Consult with an ophthalmologist (and arrange for examination by the ophthalmologist)
    • Investigate as for bruising when intracranial haemorrhage exists
    • Urine Metabolic screen
    • Admission to ICU should be considered  whenever altered conscious state has occurred after suspected shaking because of the high risk of further neurological deterioration caused by progressive brain swelling

    Forensic investigation of suspicious fractures

    Radiological investigation

    Infants and Toddlers aged < 2 years

    The optimal method for radiological investigation of occult fracture has not been determined for children aged less than two years. Protocols vary between regions. 

    The following guidelines have been developed mindful of the need to minimise a child’s exposure to radiation (ALARA principle) balanced with the need to adequately investigate concerns regarding occult fracture in the context of suspected child abuse.

    As a general principle, order investigations only when a positive result might result in intervention that increases a child’s safety or might result in additional action of some sort.

    As a general guide we recommend the combination of Skeletal Survey and Bone Scan for children aged less than two years when there is a reasonable suspicion that the child has suffered an occult fracture.

    Recommendation: < 2 years old – Skeletal Survey and Bone Scan

    Exceptions

    However, if one of the following fractures is detected as the only injury then additional radiological investigation is not necessary. 

    • Distal radius/ulna fracture in a toddler aged > 9 months AND a history of a fall
    • Distal tibia/fibula fracture in a toddler aged > 11 months AND fall while walking. “Toddler fracture” 
    • Single linear skull fracture in a child aged > 12 months AND a history of a fall or adult landing on child
    • Clavicle fracture in the newborn
    • Clavicle fracture in 2nd year of life AND a history of a fall

    In regions where Bone Scan is not available or when parents refuse consent for Bone Scan then a second Skeletal Survey performed 2 weeks after the first Skeletal Survey may be considered. Note that this process is likely to miss some occult fractures (particularly rib fractures in infants). Strategies will need to be put in place to ensure safe care for the infant between Skeletal Surveys and safe plans to ensure that the second Skeletal Survey is performed and the infant is not lost to follow up.

    “Double reporting” of Skeletal Surveys (reporting by two independent radiologists) is encouraged.

    Children aged > 2 years

    Most children aged > 2 years will develop symptoms and signs of injury when a fracture is present.  We recommend X-rays of the site(s) of suspected fracture with coned views if required.

    Recommendation: > 2 years : Radiograph (x-ray) sites of clinically suspected fracture(s).

    However, Skeletal Survey might be indicated because of a strong suspicion of occult fracture in a child aged > 2 years. Bone Scan might be considered as an adjunct to Skeletal Survey under such circumstances.

    Occasionally MRI or ultrasound might also be considered.

    Notes

    • Skeletal Surveys must be performed according to recommended protocols.
    • X-rays might fail to detect rib fractures and some long bone fractures.
    • Bone Scan is not a sensitive tool for the detection of skull fractures. If skull fracture is suspected, obtain a skull radiograph or CT scan. Note that the dose of irradiation must be weighed against the need to determine whether a skull fracture exists. 
    • Bone Scan might not detect CML.
    • Bone Scan is unlikely to detect most fractures that occurred > 12 months previously.  

    Blood tests to investigate suspicious fracture

    First line tests:

    • Calcium
    • Phosphate
    • LFT
    • U&E Creatinine
    • Vit D
    • FBE

    Second line tests:

    • Magnesium
    • Copper
    • Parathyroid hormone
    • Syphilis serology
    • Urine Metabolic Screen
    • Inflammatory markers

    Also consider genetic tests for OI.

    Forensic investigation of suspicious burns and scalds

    If suspicions exist about intentional thermal injury such as scalds and contact burns in children aged < 3 years, then skeletal survey, bone scan and additional investigations for other forms of child abuse should be considered.

    Toxicological tests

    Toxicology tests might be considered when ingestion or poisoning is possible as a result of care-giver neglect or intentional exposure/ ingestion. Also consider toxicology tests in children with unexplained altered conscious state, head injury, thermal injury and sexual assault.

    • Consult with forensic experts before collecting samples.
    • Ensure chain of evidence procedures if sending samples to forensic laboratory
    • Collect blood and urine if ingestion or poisoning was within prior 24 hours
    • Collect urine if ingestion or poisoning was more than 24 hours previously
    • Consult with VFPMS if considering sampling hair for toxicological analysis.

    Forensic toxicology laboratories and hospital biochemistry laboratories differ significantly in the analytical techniques used for drug detection and in the way that results are reported. Send samples to the laboratory that can perform the required tests.

    Sexual harm / Sexual abuse

    All children about whom there are suspicions of sexual abuse should be discussed with the VFPMS in the first instance. This will facilitate exclusion of the diagnosis of sexual assault in children who have not been sexually assaulted but who have conditions such as genital symptoms that are sometimes confused with sexual assault. This will reduce angst and suffering in children and their caregivers when there is an unreasonable suspicion of sexual assault. 

    In general, genital examinations for forensic purposes will only be performed by appropriately trained and experienced consultants.

    The priorities in dealing with child sexual abuse are to:

    1. suspect sexual harm
    2. consult with the Victorian Forensic Paediatric Medical Service (VFPMS) to determine the best person, place and time for forensic evaluation.
    3. when a child has made an allegation of sexual assault, notify and involve local Centre Against Sexual Assault (CASA) counsellor
    4. diagnose, treat and document the child's injuries
    5. assess the child's psychosocial situation,
    6. provide, when consent is given or legislation requires information sharing in the absence of guardian's consent, a verbal and/or written report to Child Protection and the Police. VFPMS is usually responsible for this.
    7. plan for the child's safe discharge and ongoing medical / psychological care.

    After consultation with the VFPMS, when an urgent forensic examination by VFPMS is deemed to be unnecessary, limited inspection for a specific purpose such as determination of the amount of bleeding or the extent of a rash or discharge may be performed with the cooperation of the child.

    After a recent sexual assault (< 72 hours) rapid evaluation is required. Contact the VFPMS, and speak to the consultant on-call. Collection of forensic evidence is an important consideration. You may be advised to assess and treat any urgent medical problems (eg. bleeding), being careful to collect any clothing that is removed in the process. Ensure the child is as comfortable as possible and has appropriate emotional support. Await the on-call VFPMS consultant who will perform the forensic examination as a joint response with the CASA counsellor.

    STI prophylaxis :  Azithromycin 1 g stat

    Pregnancy prophylaxis: Postinor (post coital contraception) within 72 h of sexual contact. Arrange for a follow-up pregnancy test

    HIV prophylaxis:   NPEP (according to ASHM post exposure prophylaxis guidelines)

    Management of suspected sexual assault

     

    SA_algorithm

    Post sexual assault sexually transmissible infection screen

    At time of examination (optional)

    • First pass urine
    • Gonorrhea and Chlamydia PCR

    Baseline tests (2weeks post assault)

    • First pass urine (unless test performed when child examined and results negative)
    • Gonorrhea and Chlamydia PCR
    • Blood serology for:
      • Hep B
      • Hep C
      • HIV
      • syphilis

    At 3 months blood serology

    • Hep C 
    • HIV

    At 6 months blood serology

    • HIV

    Neglect

    Neglect is a form of maltreatment that arises when a child’s basic needs are not met. This may be due to acts of omission or commission on the part of a caregiver. Neglect of a child can be defined as the failure to provide for the development of the child in all spheres: health, education, emotional development, nutrition, shelter and safe living conditions, in the context of resources reasonably available to the family or caretakers, and causes or has a high probability of causing harm to the child’s health or physical, mental, spiritual, moral or social development. This includes the failure to properly supervise and protect children from harm as much as is feasible. There are often many modifiable and non-modifiable factors at the level of the child, caregiver, family, community and society to consider when assessing the potential harmful effects of child neglect*. 

    The evaluation of child neglect is a complex process that should involve assessment of the child's physical health, growth, development, behaviour, safety, emotional / psychological wellbeing and relationships. 

    Evaluation of child neglect should be mindful of the cumulative harms that occur when a child has been neglected over significant periods of time, particularly when neglect may have occurred at critical periods of the child's development.

    Evaluation of child neglect should assess the scope and extent of child neglect, the child's current needs and the caregivers' capacity to meet their child's needs.

    The priorities in dealing with child neglect are to:

    1. suspect and diagnose child neglect 
    2. document neglectful events, situations and circumstances that constitute evidence of neglect.
    3. document findings (examination findings and results of investigations) that constitute evidence of harm that occurred as a result of neglect.
    4. assess the child's psychosocial situation, particularly the child's support systems
    5. intervene to moderate neglectful situations and remediate the negative impact of neglect.
    6. consult with the Victorian Forensic Paediatric Medical Service (VFPMS) in situations of serious harm to children or when seeking advice regarding case-management or preparation of medico-legal reports.  
      1. VFPMS will provide the medico-legal report for a child seen at VFPMS Clinic.
      2. VFPMS proforma can guide assessment and opinion formation.
    7. provide, when consent is given or legislation requires information sharing in the absence of guardian's consent, a verbal and/or written report to Child Protection and the Police. VFPMS can help you write the report for a child you assess.
    8. plan for the child's safe discharge and ongoing medical / psychological care.

    In situations of suspected neglect a multidisciplinary assessment should be performed using information gathered from a number of sources that include community-based health and welfare professionals, Child Protection and police. Social workers and/ or mental health professionals should contribute to the assessment of children's psychosocial situations, safety and parental capacity to meet children's needs. 

    Neglect may be categorised according to the following domains. Table 1 depicts the range of deficits in care, omissions or failures to adequately provide for a child’s health, growth, development and emotional wellbeing.

    Categories of Child Neglect

    Neglect type Manifestations of this type of neglect 
    PhysicalInadequate or inappropriate food, clothing, warmth, shelter, hygiene and personal care. 
    Developmental/educational Failure to provide suitable tools and opportunities for learning

    Failure to provide adequate stimulation for cognitive development

    Failure to enrol a child in school or provide adequate home schooling, poor or erratic attendance at school, truancy
    Environmental Unsuitable or unhygienic, dirty or cluttered living conditions
    Restricted access to suitable environment for learning and play
    Medical/dental Failure to provide proscribed medical needs. This includes deficits in preventive health care such as immunisation, screening for medical and developmental problems, mental health care, and medical treatment.
    Poor dental hygiene, periodontal disease and dental caries
    Supervisory Failure to provide age-appropriate supervision and to prevent common childhood accidents
    Abandonment Abandoning a child with no means of support
    Emotional Failure to provide reliably responsive care in order to meet child’s emotional needs. Failure to provide adequate nurture, affection, psychological support and guidance. Failure to provide intervention to address emotional and psychological problems


    The forensic evaluation of neglect involves a search for tangible evidence that caregivers have failed to provide adequate protection, stimulation or care for a child. Table 2 provides a framework for considering the numerous ways in which neglect might harm a child. The framework is built around the acronym “N.E.G.L.E.C.T.I.N.G.”.

    N.E.G.L.E.C.T.I.N.G. framework

     Think about Assess Recommend
    NURTURE

    Security of attachment (warmth and love)

    Relationship with carers (reliably responsive)

    Is child’s wellbeing a priority?

    Is child left alone/abandoned

    Changes of primary caregiver? Stable placement? 

    Early parenting centre (mother-baby unit)

    Infant mental health /parenting supports

    Child and family psychology/therapy

    Extended family support

    Parenting education / support groups

    Supportive MCHN & GP & NGOs 
     

    EMOTIONAL NEEDS

     

    Ask about exposure to;

    • Parental drug/alcohol use
    • Parental mental illness
    • Violence in the home

    Ask child about feelings of worth, safety, love, discipline, role at home

    Moral guidance to encourage good citizenship 

    Parental drug/alcohol rehab programs

    Men’s behaviour change programs

    Parental mental health assessment

    Be aware of the concept of cumulative harm and comment on it – trial of capacity to change.

    Alternative placement might be considered 

    GROWTH & NUTRITION

     

    Stature, overweight or underweight?

    Diet – balanced, healthy?

    Growth parameters and history - plot

    Adolescents – body image

    Clinical evidence nutritional deficiencies?

    Consider blood tests for nutritional /vitamin abnormalities  (including NAFLD) 
     

    Poor growth– appropriate medical Ix plus paediatric F/U 3 monthly, dietician referral

    Obesity –Dietician, weight clinic, bloods for fatty liver and lipid profile, realistic exercise plan

    Clear advice regarding change

    LEARNING & DEVELOPMENT

     

    Screen for delay using Brigance, ASQ or similar

    Contact kinder staff/school teachers and ask about;

    • Attendance
    • Achievement
    • Homework
    • Learning potential
    • Attention/behaviour
    • Peer relationships
    Comparison assessments before and during/after periods of OOHC might be useful 

    Developmental skills assessment

    Consider further multidisciplinary assessment of medical conditions that affect learning (eg ASD, ADHD) or Ix for genetic/metabolic causes of Devel Delay

    Enrol in childcare

    Educational psychology assessment

    Test vision and hearing

    Cognitive tests

    Speech and language processing tests 
    ENVIRONMENT AT HOME 

    Stability/Transience/quality of residence

    Number of schools/homes /rate of change

    Evidence of environmental neglect – contact CP/family supports/workers for information

    Exposure to hazards/safety in the home – needles, vermin, unhygienic substances

    Supervision in the home (left alone/unsupervised) 

    Housing recommendations/support

    Enrol in childcare

    Removal of children from home until cleaned up

    Ongoing commitment to improving environment at home

    Provide safe sleeping and play spaces

    Protect from hazards 
    CLOTHING 

    Clean? Malodourous? In need of repair?

    Well-fitting footwear and clothing?

    Appropriate for weather?  
     
    TEETH 

    Good dental hygiene

    Routine teeth cleaning (owns a toothbrush?)

    No caries, healthy gums and oral soft tissues 

    Dental assessment and treatment

    Diet for healthy teeth 
    IMMUNISATIONS, INFESTATIONS & INFECTION 

    Up to date? – check ACIR

    Lice, scabies, worms

    GIT, ear, skin infections 

    Organise vaccination catch-up (RCH or MMC)

    Treat infestations & infections 
     

    NORMAL SOCIAL ACTIVITY

    Time to play and people to play with

    Suitable toys

    Engages with peers (d/w school/kinder)

    Caregivers promote spiritual and cultural identity and sense of belonging 
     

    Enrol in childcare /school

    Encourage out of school activities for pleasure and social connectedness

    Consider spiritual /cultural needs 
    GENERAL HEALTH 

    Vision and hearing

    Hospital/healthcare attendances and FTA’s

    Number of different Dr’s consulted

    Sexual health

    Mental health (adolescents, suicide risk etc)

    Consider factitious illness by proxy

    Vision and hearing checks

    Provide clear advice re healthcare

    Refer for regular paed f/u if required

    Register with local GP. Plan for preventive healthcare and surveillance/monitoring of health and growth 

    *WHO Report of the consultations on Child Abuse Prevention. Geneva, Switzerland. March 1999

    A single-page .pdf version of the NEGLECTING framework is also available. 


    A report to Child Protection should occur when the child has suffered or is likely to suffer significant harm and the parents have failed to protect or are unlikely to protect the child from such harm.

    A referral to Child FIRST should occur when there are significant concerns about a child's wellbeing.

    Vulnerable child / At risk

    The priorities in dealing with a vulnerable child are to:

    1. suspect and identify vulnerability
    2. assess the child's psychosocial situation
    3. conduct a multi-disciplinary assessment of vulnerabilities and protective factors using an ecological framework that focusses on the child, their caregivers, family, community, support systems and agencies that might better support children and their caregivers
    4. refer to services to modify risk and promote resilience / protection.
    5. Plan ongoing monitoring of the child's safety, wellbeing and vulnerability to harm

    After a multi-disciplinary assessment, when significant concerns exist about a child's wellbeing, referral to Child FIRST should occur.

    Notes

    All medical staff working in the Emergency Department & Wards must be aware of the possibility of child abuse, and be able and prepared to act appropriately if it is suspected.

    Medical and Nursing staff are mandated reporters who must notify Child Protection after forming a belief, on reasonable grounds, that a child has been, or is likely to be, physically or sexually abused and the parents have not protected, or are unlikely to protect, the child from such harm. There is an obligation upon all hospital staff to notify Child Protection if they have formed a belief that a child is in need of protection. See Children, Youth and Families Act 2005 - SECT 162

    For Victorian Health Professionals:

    The Victorian Forensic Paediatric Medical Service is available 24/7 for forensic medical advice and consultation.

    As well as regular clinics each Monday to Friday, the VFPMS provides a 24 hour service for evaluation of possible causes of injury and advice for professionals regarding evaluation of suspected child abuse. They can also advise on good medical report writing, provide peer review of medico-legal reports and can liaise with the external agencies.

     

    Victorian Forensic Paediatric Medical Service

    (24 hours 7 days a week) 

    1300 66 11 42

     

    In Melbourne

    The Victorian Forensic Paediatric Medical Service is situated at RCH and MMC

    • At RCH - at Clinic C on the 1st floor of the East building at RCH (9345 4299)
    • At MMC - opposite radiology on the ground floor at MMC, Clayton (9594 2155).

    Refer to Department of Social Work for psychosocial assessment when there are concerns about risk of harm to a child.

    • At Royal Children's Hospital contact Social Work Department 9345 6111 and after hours via RCH switchboard 93455522
    • At Monash Children's Hospital contact Social Work Department  95942290 and after hours via MMC switchboard 95946666

    Refer children and their family members for counselling to a Centre Against Sexual Assault when an allegation of sexual abuse has been made.

    • At Royal Children's Hospital contact Gatehouse  93456391 and after hours via RCH switchboard 93455522
    • At Monash Children's Hospital contact SECASA 03 9594 2289 and after hours via MMC switchboard 95946666 or Sexual Assault Crisis Line (SACL) 1800 806 292 (Freecall Victoria).

    Resources

    SCAN meeting resources

    (Suspected Child Abuse or Neglect)

    Recording of decisions made at SCAN meetings.

    • The social worker is responsible for distribution of the agenda.
    • At the start of the SCAN meeting a person should be appointed to record the minutes.
    • Minutes of the SCAN meeting should be distributed to all attendees within 24 hours of the SCAN meeting.
    • Amendments to the minutes (if necessary) should be made without delay and the agreed final version of the SCAN meeting minutes filed in the patient's medical record.