Child Protection: What You Need to Know

In New Zealand, 2019–2020 figures show 12,800 children and young people (1.1% of the population aged under 20) were found to have been abused or neglected, however “because of under-reporting, the actual figure is probably much higher”.³ 

Healthcare services provide a key opportunity to intervene in child protection. This article highlights the importance of having sufficient resources and knowledge for healthcare practitioners to identify and respond to domestic and family violence (DFV), maltreatment of children, and situations where a child may need protection from unintentional harm. 

Protecting children from harm is a paramount initiative in all societies, as reflected in the United Nations’ Sustainable Development Goals, which aim to “end abuse, exploitation, trafficking and all forms of violence and torture against children”.⁴ 

Yet child abuse remains a major public health challenge. Filicide – the deliberate act of a parent killing their own child – is the second most common type of domestic homicide in Australia, after intimate partner homicide.⁵ 

Research by the Australian National Research Organisation on Women’s Safety (ANROWS) on filicide sought to better understand the complex issues associated with protecting children from DFV, as well as the progression of DFV to filicide. It focussed on the period 2010–2018 when there were 138 filicide victims across Australia. 

The report recommended better training for primary healthcare providers.² And it recommended that any risk of violence towards women be considered as a risk of violence towards their children.⁵ 

Similarly, the Australian Child Maltreatment Study (ACMS) – “the first national survey in the world to study in detail the experiences and associated health and social outcomes of… child maltreatment”⁶ – found child maltreatment was associated with greater likelihood of both hospital admissions and consultations with health care professionals.⁷ 

This article highlights the importance of having sufficient resources and knowledge for healthcare practitioners to identify and respond to domestic and family violence

Identification and Indicators of Child Abuse

The ACMS research categorised five types of childhood abuse: 

• Physical abuse,
• Sexual abuse,
• Emotional abuse,
• Neglect, and
• Experienced exposure to domestic violence.⁸

There are a wide range of child abuse indicators, which can vary by the age of the child, as well as the type of abuse. Guidance on behavioural or physical signs of stress is available from multiple online sources, including Act for Kids and the New South Wales Government.. 

These are summarised briefly below. 

Physical indicators could include injuries (bruises, welts, cuts, burns, fractures etc.) that are unlikely to be accidental; delays in language development; delays in emotional, mental or physical development; appearing consistently dirty and unwashed; being consistently inappropriately dressed for weather conditions; and having unattended health problems or a lack of routine medical care. 

Behavioural indicators in infants or toddlers could include self-stimulatory behaviours (rocking, head banging), crying excessively or not at all, a parent or carer who is unresponsive or impatient to the child’s cues. Older children may show unusual fear; or be unusually aggressive; may display overly compliant behaviour; have poor interpersonal skills or show behaviours that are not age appropriate (either overly infantile or overly adult).9,10 

Everyone’s Responsibility

Child abuse is everyone’s responsibility. 

ANROWS has recommended that every health screening of a child should be considered an “essential checkpoint” for a child to be risk assessed for harm.⁵ 

As primary healthcare providers, eye care professionals are in a prime position to observe children who may be at risk, or those who have become victims.¹¹ 

An optometrist is likely to spend more time in consultation with a child and parent than a GP and as such, may have better capacity to assess for vulnerability to harm. 

An optometrist has the capacity to photo evidence and monitor for facial injury in the context of bruising around the eye area. Trauma indicators once identified should be noted in detail. Note any delay in presentation from actual time of reported injury and its appropriateness for injury described. Red flag inconsistencies for suspicion of child harm. 

Evidence validating an escalating pattern of domestic violence seen in a victim may be used in court at some later point in time. 

Clinical ‘Red Flags’

In the optometric setting, deprivation or forfeiting of an optical appliance can translate into a significant visual disability for a child in need. For a child with a significant refractive error this could cause behavioural change. 

If reluctance to provide a child with glasses is a financial concern, referral to a government-funded spectacle scheme may help.¹² 

But where there is complete disregard by the carer in setting up a purchase intention, or failing to collect spectacles, and/or access to eye care/ spectacles is being used to control a child’s behaviour, this could be seen as coercive control. 

Alerting the parent that an optical item is essential is critical. Ensure the parent prioritises collection of the optical appliance. 

A consistent lack of routine medical care and poor hygiene may be indicators of neglect. In the clinical setting this can present as recurrent corneal infections/blepharitis, poor eye contact in communications, and general withdrawal. 

Abuse, in particular sexual abuse, may be suspected in cases where there is a dramatic behaviour change in a child. The child may simply ‘shut down’ mentally and physically, trying to process what happened. This may present as functional vision loss in an optometry setting. 

Often this type of violence is completely unknown to the parent and disclosed at a much later time. Recent parental separation, or a new person within the home in the childcare arrangement should be explored. 

If you witness a child being hit in a public or in a semi-public space (such as restrooms) this should be interrupted and discussed with the parent or child carer. Explain by leading with the statement, “hitting is not an acceptable form of punishment for children”. 

If inappropriate actions or behaviour follow, the police should be notified. Hitting may be a de-escalation of more common harsher behaviour behind closed doors. It is also not permissible for older siblings to reprimand younger siblings in a forceful manner. 

Abuse, in particular sexual abuse, may be suspected in cases where there is a dramatic behaviour change in a child.

Head Trauma 

Abusive head trauma (AHT) is a head, neck or brain injury that happens when an infant is shaken or hit on purpose. Shaken baby syndrome is a type of abusive head trauma.¹³ Retinal haemorrhages can occur from the tearing of small veins within the eye.14 Clinically, the volume of haemorrhages can be too numerous to count and affect all layers of the retina.¹⁴ All infants should be screened for retinopathy, where the parent reports a fall/trauma. 

New technologies such as mobile phones with retinal camera adaptors and/or clever use of a BIO condensing lens enable viewing and documentation. This is a particularly useful screening method for outreach clinics and where telehealth can be accessed. As this condition is little understood, researchers have modelled synthetic eyes with gel elements to replicate the forces within the eye. It appears that repetitive oscillating forces, rather than one large jerk, cause the small vessels to shear. It is also thought to represent the highly anxious reaction of parents/carers in attempts to stop a crying baby. The level of anxiety and frustration escalates in response to an inconsolable infant. 

Retinal haemorrhages are one of the clinical signs used to identify and better understand the nature of certain presenting head traumas. The diagnosis of AHT should be based on the existence of multiple components including subdural hematoma, intracranial pathology, retinal haemorrhages as well as rib and other fractures consistent with the mechanism of trauma. The differential diagnosis must exclude those medical or surgical diseases that can mimic AHT, such as traumatic brain injury, cerebral sinovenous thrombosis, and hypoxic-ischemic injury. Small retinal haemorrhages resolve quickly in infants so ophthalmological review and documentation within 24 hours is critical for a baseline.¹⁴ 

A newly developed paradigm requires pattern differentiation between medical and traumatic retinal haemorrhages by an ophthalmologist. This is best approached by referral to the nearest eye hospital where a CT scan can follow if necessary. 

Indigenous Families

According to government guidelines,⁹ when seeking to identify family violence in Aboriginal and Torres Strait Islander communities it is important to recognise: 

• Aboriginal and Torres Strait Islander family violence may relate to relationships that aren’t captured by the Western nuclear family model (grandparents, uncles and aunts, cousins and other community and culturally defined relationships),
• Aboriginal and Torres Strait Islander family violence can also include cultural and spiritual abuse, and
• Perpetrators of Aboriginal and Torres Strait Islander family violence may not be Aboriginal and Torres Strait Islander people.⁹

“Aboriginal and Torres Strait Islander family violence occurs in a historical context of colonisation, dispossession, and the loss of culture. This has resulted in the breakdown of kinship systems and of traditional law, racism, and previous government policies of forced removal of children from families. However, this should never detract from the legitimacy of the survivor’s experience of violence, or your obligation to report and respond to any suspected family violence.”⁹ 

Cultural Differences

Australia is a multicultural society, and this presents challenges when identifying child abuse. Culturally and linguistically diverse (CALD) and refugee families face a number of unique risk factors and challenges, which may lead to their involvement with child protective services. Additionally, they may not be aware of the statutory role of the child protection system.¹⁵ 

What is acceptable in some cultures may not be considered lawful or acceptable in others. 

This notion may provide a shield of naivety for the perpetrator to feel their behaviour is acceptable. The US Child Abuse and Neglect Prevention Board highlighted, for example, that “immigrant caregivers who move from unsafe places to safer locations are sometimes perceived as being inattentive or less vigilant of their children, because they see the environmental threats to their children as being so much less than their previous location”.¹⁶ 

“In some cultures, physical punishment is not only acceptable but considered good parenting practice. In other cultures, shaming or yelling are acceptable ways to elicit compliance from a child.”¹⁶ 

Encouraging non-judgmental conversation is also a way for a patient to debrief or reflect on events or feelings

Creating A Safe Space

Domestic violence is under-reported. Keep in mind that patterns of abuse and DV are cyclical. The offender apologises and there is a period of calm immediately afterwards which is then followed by a re-escalation. Maintaining trust by offering a high level of attention in the examination process and in a calm manner are critical. 

Perpetrators of domestic violence are unlikely to present their behaviour pattern in a public place. Listening to patient history regarding the home environment, stress factors, sleep patterns and elements exacerbating patient ill health becomes critical to understanding any risk/s of harm. 

Encouraging non-judgmental conversation is also a way for a patient to debrief or reflect on events or feelings. Patients respect your rooms as a ‘safe space’ and a ‘therapeutic space’. Trauma indicators once identified should be noted in detail. Evidence validating an escalating pattern of domestic violence seen in a victim may be used in court at a later time. 

Follow-up is critical in situations where a patient or caregiver discusses their own concerns about a situation of risk or harm. When there is DFV present in a child’s home, they cannot be exposed to this violence without being directly affected by it. Children experience DFV as victims in their own right. 

Conclusion

This article aims to give eye health professionals better insight into situations of abuse and domestic violence, and atypical presentation of patients to clinics that become ‘uncomfortable knowledge’. 

“Mandatory reporting legislation varies across Australian states and territories around the types of abuse that must be reported, the groups of people mandated to report, reporting thresholds, and the penalties for noncompliance.”17 

In New Zealand, mandatory reporting is currently the subject of intense debate. 

It is, therefore, important to seek out the correct information for your location.  

Knowing how to address, respond, and advocate for patients at risk of harm is of paramount importance. Early intervention is beneficial, particularly with vulnerable age groups or where the parent may lack insight (for example, a child parent). 

A helpline or professional assistance should be offered. It is also important for you to debrief your network of healthcare professionals. 

The decision to stay silent or avoid conversations about child abuse is not acceptable. 

Esther Euripidou is a locum optometrist based in Sydney’s eastern suburbs. Alongside her optometry work, she has been an advocate for domestic violence support for those in need. She has a strong interest in supporting vulnerable community groups. She is also a volunteer with Sydney Children’s Hospitals Foundation and the Starlight Foundation in art therapy programs and fundraising. 

References

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2. Australian Bureau of Statistics, 1 in 7 Australians have experienced childhood abuse (media release, 22 Nov 2023) available at: abs.gov.au/media-centre/media-releases/1-7-australians-have-experienced-childhood-abuse [accessed Sept 2024].
3. Dalley B, Child abuse, Te Ara – the Encyclopedia of New Zealand, available at: TeAra.govt.nz/en/child-abuse, published 5 May 2011, reviewed and revised 7 Jan 2024 [accessed Sept 2024].
4. United Nations, Sustainable Development Goal 16.2, available at: un.org/sustainabledevelopment/peace-justice/.
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11. . Zero Abuse Project, Evidence collected in Child Abuse Cases .Optometry considerations, available at: zeroabuseproject.org/wp-content/uploads/2023/03/105_Evidence-Collection-in-Child-Abuse-Cases_508_FINAL.pdf [accessed Sept 2024].
12. Optometry Australia, Subsidised spectacle schemes (webpage) available at: optometry.org.au/practice-professional-support/patient-practice-management/subsidised-spectacle-schemes-ndis/ [accessed Sept 2024].
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