Child Abuse / Non-Accidental Injury

Extremely common.

Types of abuse

• Physical abuse — activities causing, or with the potential to cause, injury.
• Emotional abuse — anything conveying to the child that they are worthless, unloved, etc.
• Sexual abuse — including exposure to inappropriate sexual activity (e.g. pornography) or sexual activity itself.
• Neglect — failure to meet a child’s basic physical, emotional, medical or educational needs.
• Exposure to intimate partner abuse — children in households with intimate partner abuse are considered abuse victims themselves, given the significant long-term psychological harm this causes. See Domestic/Family Abuse and Violence.

Prevalence

Internationally: ~20% of women and 5–10% of men report childhood sexual abuse; 25–50% report physical abuse. Emotional abuse is the most common form, followed by neglect, physical abuse, then sexual abuse (which is ~2× more common in girls than boys).

Australian data (child protection substantiations, 2017–18): the most common substantiated form is emotional abuse (59%), followed by neglect (18%), physical abuse (15%) and sexual abuse (8%) — the same ordering as above. Around 26,400 children aged up to 12 had at least one substantiated notification that year (NSW data unavailable), and children under 1 were about twice as likely as other age groups to have a substantiation. An estimated 2.5 million Australian adults (13%) report having experienced abuse during their own childhood — 1.6 million (8.5%) physical abuse, 1.4 million (7.7%) sexual abuse. Medical and health personnel are the third most common source of substantiated notifications (14%), after police and school personnel — GPs have a genuine, quantifiable role in detection, not just a theoretical one.

Effects of abuse and neglect

Abuse and neglect affect cognitive, emotional, behavioural and social development, undermining a child’s later capacity for trust, intimacy and healthy relationships; one adolescent study found abuse/neglect primarily accounted for their mental health symptoms. Adult survivors are more likely than the general population to develop physical health conditions such as obesity and heart disease, are twice as likely to experience serious depression, and are 12 times more likely to die by suicide. Considering a child’s broader adverse childhood experiences (ACEs) — maladaptive parenting, parental separation, a mentally ill or substance-using caregiver, or socioeconomic adversity — alongside possible abuse is a useful assessment framework, since ACEs compound each other’s harm.

Risk factors

Parental drug/alcohol abuse (high co-occurrence with neglect and other abuse); family breakup; work stress; new sibling; relocation; inadequate parenting/poor infant-parent attachment; unrealistic developmental expectations; belief in harsh physical punishment as effective/acceptable; inability to arrange good-quality childcare when the parent is absent.

Additional risk factors — child-related: unplanned/unwanted pregnancy, preterm birth, disability, chronic illness, or behavioural difficulties. Household/community: poverty, social isolation, high rates of violent crime, lack of safe childcare, and cultural norms condoning harsh corporal punishment. Specifically antenatally/in infancy (the period of greatest developmental vulnerability): hazardous alcohol/drug use during pregnancy, a family violence situation, parental mental health problems or intellectual disability, poor infant-parent attachment, absence of social supports, unstable housing/finances, and a parental history of abuse or neglect (their own, or of another child in the family) — many of these are identifiable during routine antenatal care.

Presentations suggesting abuse/NAI

• Delayed presentation.
• Vague or inconsistent history between family members, or a changing history over time without reason.
• Injury inappropriate for the child’s age or developmental stage — e.g. a 6-week-old “rolling off a bed”; a long-bone fracture in a pre-ambulant child.
• Caregiver’s capacity to supervise/protect the child appears impaired.
• Lack of concern for the child’s injury/pain.
• A child/young person with an STI, or displaying inappropriately sexualised behaviour.
• Parental inaction toward a self-harming child or one expressing suicidal thoughts.
• Useful questions when distinguishing accidental from non-accidental injury: does the story support the injury, and does it change over the course of the discussion? Is there a pattern of accidental” injury (may indicate ongoing neglect)? “Is the child unusually placid or passive during the examination?
• Bruising is the most common sign of physical abuse but is often overlooked as a sentinel injury — it is rare in non-ambulatory children and should raise suspicion when seen. In ambulatory children, accidental bruising typically affects the knees, shins, and bony prominences (e.g. forehead); bruising on the face, ears, neck or torso, or bruises at visibly different stages of healing, is concerning for inflicted trauma.

Physical and behavioural signs by abuse type (adapted from the White Book’s Table 9.2): physical abuse — bruising of soft tissue (head, neck, trunk, arms), clustered/patterned bruising or bruises at different healing stages, burns (hands, feet, genitalia), inadequately explained fractures, head injury with intracranial bleeding, retinal haemorrhage. Emotional abuse — speech problems, developmental delay, unexplained physical symptoms. Neglect — a child found unsupervised, unmet medical needs, abandonment, malnutrition/poor growth, poor hygiene. Sexual abuse — genital/anal trauma, an unexplained STI or vaginal/urethral discharge, pregnancy. Non-specific behavioural signs across all types: anxiety, depression, low self-esteem, disruptive or aggressive behaviour, hyperactivity, sleep disturbance/nightmares, loss of previously-attained skills (e.g. bedwetting), unusual fear of physical contact, blunted emotional response to pain, withdrawal/passivity, suicidal ideation, and — particularly in neglected children — begging for or stealing food.

Mandatory reporting

A legal requirement across Australia — generally, GPs must report on a belief on “reasonable grounds”, though the exact threshold is state-specific:

• NSW: reasonable-grounds belief that a child is at “risk of significant harm” — including neglect (basic physical/psychological needs unmet), physical/sexual abuse or ill-treatment, or serious psychological harm.
• QLD (simplest to summarise): becomes aware of, or reasonably suspects, circumstances leading to a significant detrimental effect on the child’s physical, psychological or emotional wellbeing.

If unsure whether a situation meets the mandatory reporting threshold, use your state/territory’s Mandatory Reporter Guide — in NSW, via https://reporter.childstory.nsw.gov.au/s/mrg.

To report (NSW): call 132 111 (Child Protection Helpline, 24/7, for imminent/high risk of significant harm). For support: Child Wellbeing Unit, 1300 480 420. Other states have their own equivalent lines — check local pathways.

From the NSW Department of Communities and Justice Child Protection Helpline.