Child abuse (Signs of)

Understand fear and attachment

No matter how bad the abuse is the child may not be able to tell anyone:

• It’s not neat and tidy - there is a complicated web of reasons why a child may be reluctant to share information

• One of the biggest barriers to disclosure – the child’s fear of and/or psychological attachment to their abuser

  • Won’t talk or can’t articulate clearly, may lie or be evasive

  • Massive tension – should I/shouldn’t I tell

  • The fear of the unknown is sometimes greater than the fear of continuing abuse (e.g., what will happen to me or my family if I tell?)

I didn’t disclose for the following reasons:

At first, I didn’t know what abuse was:

• Family isolation

  • I didn’t realise that these things didn’t happen in other families – it was totally normal for me, so it didn’t occur to me to disclose anything 

  • No information taught at school about what constituted abuse – so I didn’t recognise it as ‘abnormal’

When I realised it was abuse:

• Abuser was main caregiver.  I believed that I needed that abuser in my life – no matter what was done to me

• I thought that if I was believed my family would be broken up

• Fear of increased abuse - what would happen to me if I told

• Never occurred to me that anyone could or would help so I thought there was no point in disclosing

• There was no one trustworthy to tell

• Little opportunity to talk to anyone alone

• The majority of the medical practitioners I saw were male

• I started asking for help when I was in my early teens (to school staff and a GP) but even though the content of my comments remained consistent over many years, they were too vague and so it was never reported as suspected abuse

Listen carefully

You may be the first (or only) person the child tells…

• Don’t dismiss vague or offhand comments

• Telling you that “I don’t feel good at home” could mean more than an argument with a parent

• Pursue the conversation, even if it is over multiple visits

• Information will come in bits and pieces – it is too overwhelming for a child to give you large chunks of information

• If a child feels unheard they may shut down for years

Assume - don’t

Don’t assume you know the ‘why’: 

• Don’t assume that you have the full picture

• Don’t necessarily accept the first or most logical explanation

  • That beautifully dressed child who won’t make eye contact and never speaks may not be shy

  • The child who runs around the room and screams when picked up by his/her parents does not necessarily have ADHD

  • The child who has no visible injuries but cringes on examination may not be cold

• Ask yourself – could trauma be an underlying reason for behavioural, physical and mental health problems

• Consider if past diagnoses ‘fit’ – are they really behavioural issues?  Does the child have ADHD or are they traumatised?  Is the teenager with the eating disorder actually refusing to eat?

• Consider what the underlying reason may be for (and ask the child why they think they have):

  • Fear of particular medical procedures

  • Reluctance to take certain medications

  • Fear of examinations

  • Conditions such as eating disorders, mental health problems, regular gastric bugs

  • Problems sleeping

• Don’t assume that a seemingly functional family is actually functional 

Work at it like a jigsaw

Work at it like a jigsaw –

don’t rely on a child to disclose.  Abuse is more likely to be noticed through a collection of small signs by multiple people.  Don’t rely on children or families to share the same information that they have just shared with you with other health care professionals (or anyone else).  You may be the only person they tell.  If they tell anyone.

Collaborate/communicate:

• with other health care professionals/service providers

  • If they disclose, the child is more likely to tell a bit to one person, another bit to another person – so the full picture is missed if there is no communication

  • Streamline information sharing

  • Note small things that just don’t seem right.  Make the information available to other people where appropriate

  • If there are multiple health care professionals involved, make sure there is someone coordinating the ‘team.’  Don’t assume that someone else is taking care of it

  • Don’t assume a school or other organisation (or even someone you have referred the family to) has flagged the child for possible abuse

  • If there is any suspicion of abuse, make sure that it is recorded very visibly – so that it is less likely to be lost in a volume of other information

    With the child/family 

Be aware - To the child you are a power figure.  In their mind power figures abuse

• Continuity of care is important

• Let the child feel collaborative – talk to the child.  Talk their language

• Build trust and relationship

• Tell them that you CAN help

• Encourage more regular GP visits

• Encourage long appointments

• Gender is important – if you need to refer ask the child whether they would prefer a male or female

• Get to know the family.  Especially information such as how isolated they are (is the child home schooled, do they socialise, do they have friends, relatives nearby, where do they live?)

  With patients

• Education – “what constitutes abuse”.  Even colourful pamphlets or pin-up information in GP waiting rooms or offices may be useful – simplified for children.  Pinned at child height.  Isolated children may not have access to this information anywhere else

Keep asking

Ask that extra question.  Then ask one more.

• Signs of abuse are not necessarily overt - Many types of very damaging abuse can be hidden

• Don’t just look for classic signs of abuse.  Be curious.  Question little clustered ‘out of place’ signs that something is not quite right and which occur consistently over time.  Those things which just don’t fit. For example:

  • Inappropriate clothing – jumpers, clothing with high necks in summer

  • Emotionless children/Inappropriate facial expressions

  • Consistent pattern of small injuries in unusual places

  • Children who cringe when touched

  • Parents who ask for sedating medication for a child

  • One parent who answers every question on behalf of the rest of the family (even when questions are directed to other people)

  • The child who looks at a parent before they answer any question

  • Families who seem amiable to referrals or treatments for the child but who then consistently drop out

  • Families who consistently refuse treatment for the child

  • Child who makes no attempt to interact with a parent

  • Very subdued child

• Follow up ‘vague’ comments by the child

• Ask lots of questions and keep asking

• Don’t ask leading questions but do ask direct, detailed questions – they are actually easier to answer in addition to providing that extra information

• When possible talk to the child alone but be aware that they may have been coached in what to say

• The child may never be able to tell you, and you may never know what’s really going on.  But please keep trying. 

Prescribing

Risk vs benefit.  Medicating may make things worse rather than better – in unintended ways

• Some diagnoses

  • Can be used by abusers to explain away signs of trauma by saying the child is mentally ill/ADHD/developmentally delayed etc., thus should not be believed

  • The sedating side effects of some medications (even those with sedation as only a possible mild side effect) can make a child a ‘sitting duck’.  Consider the possible impact of any medication on children if you suspect child abuse.  Even very mild sedation of an abused child may significantly reduce their ability to avoid physical and/or sexual abuse. Weakened reflexes, heavy sleep can worsen abuse – both in severity and frequency

How abuse can be missed

It can be very easy to miss

• I didn’t have the more easily recognised overt signs of abuse or neglect

• There was no mandatory reporting when I was a child

• I didn’t see a GP often enough for patterns to emerge

• My family presented well - put on a show for medical appointments – well dressed, articulate, loving

• I was told what to say/not to say to doctors

• Many injuries could be explained away as ‘accidents’

• Historical diagnoses which were not questioned - Trauma symptoms were attributed to behavioural issues, various illnesses or mental health problems

• Insufficient information sharing and a lack of coordination between health service providers – each one thought the other was caring for me

• Multiple house moves over a large geographical area – my patient files were unavailable

• I hid some injuries out of fear and treated them myself

• Injuries I didn’t treat myself were treated by school staff which meant that there were no hospital or GP records

• Some of my physical needs were provided by school staff (not reported – no mandatory reporting)

• Lack of opportunity for people in the community to notice - geographically isolated, dysfunctional extended family, lack of family friends, little opportunity to socialise with peers outside school hours

• My family told people that I had behavioural issues and mental illness so shouldn’t be believed

• For multiple reasons I felt unable to directly disclose

• When I did start asking for help, I was too vague and so no one pursued the conversation

What I wish I could have told my GP as I grew up

What I wish I could have told my GP as I grew up

• I seem difficult – there’s a reason and I can’t tell you what it is.  Please try not to get frustrated

• You are another power figure.  Power figures have hurt me.  Be aware that you scare me

• I am beautifully dressed.  My parents seem very loving.  But there are terrible things happening at home.  They say I’m shy and that’s why I never smile.  I’m not shy

• My parents are lying to you

• I need to see you more regularly

• Please watch me closely whenever you see me.  Note how I behave

• I want you to look closely at those strange little bruises that I have all the time.  Please be curious

• I have no one else to tell.  I think I want to tell you.  On the other hand, I’m scared to tell anyone.  I know that you’re not a mind reader, so I need you to note all those strange little things about me and ask me what is going on.  Keep asking

• Please ask me lots of direct, detailed questions because I don’t know how to open the conversation or keep it going – it’s too hard.  I need you to keep trying to work it out.  Don’t give up

• Keep following up on my vague comments and be aware that it is difficult to find any other way to give you information

• Ask me why I don’t want you to examine me, why I can’t sleep and why I don’t want that medication

• Please do not prescribe me sedating medication.  It is making things worse

• Talk to me on my own

• I need you to listen to me, really listen and believe me

• If you have to refer me to someone please ask me if I’d like to see a male or a female

• No, the person you referred me to is not dealing with it.  They think that you are

• I need you to be patient, consistent and caring - even if I never disclose, I will know that I have someone in my life who is kind – that knowledge is very powerful

  Please read my mind.  Please find a way to make all this stop

This version written Oct, 2019; revised Feb, 2021