RCH Clinical Practice Guideline Family Violence

VFPMS Guideline: Recommended forensic evaluation of physical abuse

Physical abuse is the physical use of force (with or without an implement) against a child that causes, or has the potential to cause, physical injury.

Different terms are used to refer to injuries caused by physical abuse, including non-accidental injuries (NAI) and inflicted or abusive injuries. The term “intentional” is sometimes used, but because intentionality cannot be determined on the basis of an objective medical assessment, this term will be avoided.

Any child for whom abuse of any kind (including physical abuse) is suspected needs a full assessment of their physical condition and psychosocial context. A detailed history should be obtained and a thorough physical examination should be performed. Sometimes investigations are required, as will be discussed in detail in the VFPMS symptom/sign-specific guidelines. This often includes searching for occult injuries because young children are not able to accurately describe their symptoms or the forces that have been used against them.

Key points:

Many inflicted injuries are occult and will not be reported (or detected) by the child’s carer.

Concerns of abuse should be raised in the following circumstances:

• No history to account for the injury.
  
• History of unwitnessed trauma.
  
• History of family violence.
  
• History incompatible with the child’s age or developmental capabilities.
  
• History is not a plausible explanation to account for the injury.
  
• Inconsistent or changing histories.
  
• Unreasonable delay in seeking medical attention.
  
• Any injury in a non-ambulatory child.
  
• History of another child causing significant injury.
  
• Certain injuries with high specificity for abuse (for example ear bruising, posteromedial rib fractures or any injury in a non-ambulatory child).
  
• An infant with an unexplained encephalopathy (suspect Abusive Head Trauma).
  

N.B. VFPMS staff recommend a non-judgemental, sensitive approach to these cases. We recommend asking children only necessary and open-ended (non-suggestive) questions about their suspicious injuries. The presence of an observer is strongly recommended at all times.

Suggested management flow-chart for suspected physical abuse

Admission or discharge from hospital?

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

Admission to hospital should be arranged when it is medically indicated or if it is necessary for the child’s safety. When a child is admitted for suspected child maltreatment, a SCAN (Suspected Child Abuse and Neglect) meeting will need to be held within 24hours of admission. SCAN meeting resources available here.

Any infant with a cerebral injury, from shaking or direct trauma, should be admitted to ICU for monitoring overnight. Delayed deterioration may occur.

Discharge from hospital is a shared responsibility of hospital staff and Child Protection staff.