First line of defence
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Editor,
I was recently interviewed by your writer, Heather Wiseman, for the article regarding a GP’s role in reporting child abuse to the government (‘First line of defence’, News Reviews, 15 February).
I have previously experienced disappointment and alarm at the failure of the Queensland Department of Child Safety to heed and respond to my reports.
After your article I was contacted by the Queensland Minister for Child Safety and Women, Ms Margaret Keech, who requested a meeting with me at my practice.  She attended and we spoke for an hour.  Also in attendance was a family court lawyer who has had parallel difficulties.  We had a very frank and constructive discussion regarding problems that GPs and lawyers have in communicating with the department.
Other issues were also raised, such as problems accessing medical histories of children in foster care because of strict interpretation of the privacy laws.
Your article has already had a measurable and beneficial impact.  Within a few days of the meeting, a ministerial briefing was despatched and all the cases we discussed have been re-opened.
Dr Thomas Lyons, Eagleby, Qld.

HE was seven years old when he started playing a disturbing new game with his younger sister:  pretending to have sexual intercourse.  Deeply distressed, his mother turned to her GP for support.

Dr Thomas Lyons, who works in a marginalised suburb outside Brisbane, reported the case to Queensland’s Department of Child Safety, detailing why the mother was convinced the boy was being abused.  But late last year, two years after the GPs report, the now “grief- stricken” woman returned.

The alleged abuser still had access to the child and the child’s sexual behaviour has become so frequent that his once-supportive school has transferred him in order to protect other children.

Dr Lyons’ calls to the Department of Child Safety revealed that caseworkers believed the mother was anxious, strung out and could not be taken seriously.  It’s a judgment Dr Lyons isn’t convinced the department’s “young, inexperienced and incredibly arrogant” staff are well equipped to make, but he’s been told the case is closed and won’t be revisited.  He’s now turned to the Minister for Child Safety’s office for support, lobbying for access to the child’s file.

Dr Lyons, who finds himself making about four reports of child abuse each year, says the department is usually dismissive and tends to steer clear of difficult cases.

“Most of the time they’ve found reasons not to investigate, or the allegations difficult to substantiate, and so months later nothing has happened,” he says.  “They have no rigor at all.  They’re completely lethargic to the point of being indifferent.”

The department told Australian Doctor it could not comment on the specifics of the case.  But whether its decision in this case was well-founded or not, potentially devastating shortcomings within the child protection system extend well beyond Queensland.  There’s broad agreement among leading authorities on child abuse that the crisis is national.

“We are failing the most vulnerable children in Australia by our reactive, bureaucratic and legalistic child protection system,” says Professor Dorothy Scott, director of the Australian Centre for Child Protection at the University of SA.

“State child protection services are completely overwhelmed.  They’re like overloaded casualty departments in a health system without GPs.  Looking for the child who is seriously at risk is like looking for the needle in the haystack.”

In January, the Australian Institute of Health and Welfare revealed that abuse and neglect notifications have increased by more than 50% in the last five years, to 309,517 last financial year.

A spokesperson for the NSW Department of Community Services, which receives about 60% of all reports made in Australia, told Australian Doctor it had experienced an 80% increase in reports through its helpline, compared with five years ago.

A series of child deaths in the lead-up to Christmas have added heat to the issue.  In NSW and Queensland alone, a 19-day-old baby died with fractures to his ribs and skull, a two-year-old boy died after being released from foster care, a 10-year-old girl was raped and murdered, a seven-year-old girl starved to death in her bedroom and a two-year-old boy’s body was found in a suitcase floating in a pond.

Professor Scott says such tragedies can galvanise change.  With the recent change in Federal Government, she believes the climate is right for national reform.

So far, federal intervention has been limited to remote Aboriginal communities in the NT under the previous government’s controversial response to the Little Children are Sacred report.

Details of the new Labor Government’s policies for children in remote communities are still being finalised, but there are some signs of a broader federal interest in the issue of child abuse.  Federal Minister for Families, Housing, Community Services and Indigenous Affairs Ms Jenny Macklin is working on plans to give state and territory child protection authorities powers to recommend that Centrelink quarantine income support and family payments.

“Parents have an obligation to ensure children attend school and have adequate food and shelter,” Ms Macklin’s spokesperson says.

But Professor Scott is hoping for a deeper change in philosophy – to one with less emphasis on reporting and a greater investment in prevention, which would include a much greater role for GPs.

“We really need national leadership – a summit led by the prime minister calling all states and territories and relevant professionals together to tackle this as a national priority,” she says.  “We need to remove the risk from children rather than thinking about removing children from risk.”

GPs are “vital” in making children safer, by detecting marginalised and vulnerable families and mobilising the support these parents may need to better nurture their children and prevent abuse occurring.  Yet “GP’s have been completely neglected in child protection policy”, Professor Scott says.

“We need to be able to provide the resources for GPs to do comprehensive assessments and referrals for vulnerable children and families before it gets to the stage of mandatory reporting to a child protection agency.”

Just as general practice has adopted a more significant role in mental health, Professor Scott expects bolstered funding, training and community-based resources will enable GPs to play a crucial role for vulnerable children.  She does acknowledge though that while GPs are likely to be seeing marginalised parents, it’s not clear whether they are seeing the most vulnerable of abused children.

This may partly explain why doctors are one of the least likely professional groups to make notifications.  Last financial year in NSW for instanced, 0.6% of finalised cased were referred by GPs compared with 28.5% reported by police, who refer the most (see box *).

Dr Elizabeth Hindmarsh, a GP who worked in an inner-Sydney practice for almost 30 years, says she reported cases of suspected abuse but didn’t come across many.  Someone who has abused a child is unlikely to bring them to a doctor still covered in bruises.

“GPs only see children for very short periods of time, so it’s not always easy to know when abuse is occurring,’ she says.  “It has always concerned me that we knew there was child abuse out there but we were not necessarily picking that up.”

Dr Ian Cameron, a GP on the NSW Ombudsman’s reviewable child deaths team, says GPs are better placed than the bureaucracy to identify families at risk and offer support.  Simply asking, “Are you worried about the children?” can create an important opportunity for parents to voice concerns.

“The GP can start an intervention that’s about health and wellbeing, rather than a departmental or police response.”

While some GPs may be reluctant to accept increased involvement, Dr Cameron agrees a new focus on prevention is necessary.

“Kids who are at most risk are vulnerable about a whole lot of areas – education, risk-taking, anti-social behaviour – and GPs may not see it as a health-related issue,” he says.  “Ultimately, I think GPs are well placed to make a difference, and ultimately I do believe it is a health issue.”

AMA president Dr Rosanna Capolingua says the current system leaves GPs frustrated by the ‘then what’ question that follows detection and reporting of child abuse.  If a new approach required more of GPs, “we would need to know that there are very solid support and intervention services there that we could trust and refer to”, she says.

“If a GP feels helpless, it would be about knowing they could refer a family to an intervention or support group that would make a difference.  That’s the great space that needs funding.  GPs can’t go into the home and that’s where a lot of work needs to be done.”

Some GPs are not aware of the range of resources that do exist, according to director of child protection services at Adelaide’s Women’s and Children’s Hospital Dr Terence Donald.  When he has gone to speak at large group practices in Adelaide, the GPs were not aware of local community supports, such as an Anglicare office just down the road.

“They hadn’t considered it would be useful to meet with staff there,” he says.  “That’s not a criticism.  It’s a statement of how far training needs to redirect itself.  Registrars are starting to appreciate they have to take the initiative to find out what services are available and develop some kind of relationship with these service providers.”

Dr Donald, who is a medical education consultant for the Australian Centre for Child Protection at the University of SA, says the training GPs receive is largely ad hoc and the content largely influenced by the doctors they encounter during their hospital and practice-based training.  He believes an additional clear, prescriptive curriculum is needed.

“In the absence of a set curriculum, their training will be hit and miss.  It’s not clear who gives the training at the moment.  They might get someone like me with a broad perspective, or might get someone who talks about suspicious bruises.”

As a paediatric forensic physician, Dr Donald says he has “zero chance” of engaging a family when a child is referred to him by community services, because the parents assume he is taking the department’s side.

“One of the first things I say is, ‘You really need someone who will listen to you and advise you’ – and a GP is in the perfect situation to do that.”

Where abuse has occurred, support services for traumatised children are “virtually non-existent in most states”, Dr Donald says.  He sees this as the key measure of just how badly the system is letting down vulnerable children.

“No system we can ever develop can prevent children being harmed, but therefore the least we can do is treat children who have been harmed,” he says.  “If you’re treated for the trauma you’ll be able to live your life in an optimal way.  If you haven’t been treated, you go into relationships where things are not good for you, you’ll have a child and get stressed and hurt the child.

“It’s a really important form of primary prevention that’s hardly given any notice.”

 CHILD ABUSE LOOKS TO BE ON RISE

The Australian Institute of Health and Welfare’s latest report says there is strong evidence that the number of substantiated cases of child abuse and neglect is on the rise across Australia.  The report reveals that:

  •  Medical practitioners were one of the least common sources of finalised child abuse notifications last financial year.  However, reporting rates varied greatly across states:  in SA doctors made 10.2% of notifications compared with 3.4% in Victoria, 1.4% in WA, 0.6% in NSW and 0.2% in Tasmania.
  • A relatively high proportion of substantiated cases involved children living in lone mother families and in two-parent step-families or blended families.
  • The most common type of substantiated abuse in NSW, Victoria, Queensland, SA and ACT was emotional abuse.  In the NT it was physical abuse and in WA and Tasmania it was neglect.
  • The number of children living in out-of-home care rose by 102% in the past decade.
  • The rate of Aboriginal and Torres Strait Islander children in out-of-home care is more than eight times the rate for other children.
  • Nationally the number of substantiated reports of abuse or neglect increased by 45% in the past four years.

Reference:
Child Protection Australia 2006-2007, Australian Institute of Hewalth and Welfare, Canberra, January, 2008.

 GPS IN PLACE FOR EARLY INTERVENTION

Sydney GP Dr Bronwyn Gould says GPs are well placed to identify families where children are vulnerable and support them before abuse becomes an issue.

“You can see mums or dads in the waiting room who are losing it, who have inappropriate expectations of the child, and so get cross when a baby soils their nappy in the surgery,” says Dr Gould, a former chairwoman of the Australian Council for Children and Parenting.  “As a GP you can work with those families, helping them to understand what you expect the kids to do, and to be adaptable.

“You can do a lot of work helping them problem solve, anger management [and] plug them into support agencies before the wheels fall off for the kids.”

If GPs do make a report, there is great benefit in their continuing to support the family, when possible, Dr Gould says.  “Even if you’re looking at an extreme case where a child is removed, both of those parents [may] go on to parent again.”

Dr Gould, who has carried out forensic investigations on abused children in a hospital setting, says it can be difficult for GPs when a parent is concerned their daughter has been abused and asks them to check the child’s vagina because it is red.

“I used to be one of the people who did it, but even now I would hesitate.  The knowledge and expertise around what is indicative of abuse is constantly being refined.”

GPs are often pressured to examine a child, but while it’s appropriate to check for STIs – using urine tests, not swabs – the child should be referred to a tertiary hospital with a specialised child protection unit.

“A normal genital examination does not exclude sexual abuse,” Dr Gould says.

Dealing with cases of suspected child abuse is difficult and can leave GPs feeling they’re in a no-win situation.

“Remember, the real person in the no-win situation is the child,” Dr Gould says.

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