Child abuse: diagnosis, reporting, and investigations

Richard and colleagues¹ suggest abandoning the term “shaken baby syndrome” and point out that it may be advantageous to separate the therapeutic and clinical investigative aspect of the condition. We believe that such an approach, extended to all forms of abuse perhaps combined with mandatory reporting, is likely to resolve the present crisis in child protection. The present system is failing to safeguard children and reassure doctors of their own safety.

We suggest that in all forms of child abuse there should be a clear separation of clinical care of the child from forensic and criminal investigations. Children who are abused may present to hospital with a variety of symptoms and signs. Our approach to such children should be primarily clinical in nature. In clinical practice we undertake various investigations to define our diagnosis. In a suspected case of meningitis we investigate to find out both the causative organism and in some instances why the child is prone to such an infection. We should have a similar approach to children whose clinical condition suggests abuse. A diagnosis such as shaken baby syndrome or Munchausen syndrome y proxy implies causation that paediatricians are unable to make in clinical setting. Therefore we suggest that such terms are abandoned in clinical practice. The clinical diagnosis may be fractures, salt toxicity, developmental impairment, etc.

In the majority of these situations, treatment of the clinical condition does not require investigations by social services or the police. We refer these children to the authorities in the best interests of the child. It is at this point that our therapeutic relationship with the parents becomes strained. The college reassurances that the present legal system provides adequate safeguards provides little comfort to the majority of practicing paediatricians in the light of recent events.

The investigations require expertise in understanding the relevance of clinical signs in a legal context or in forensic medicine. The majority of paediatricians have no formal training in forensic medicine. The GMC reminds us that it is good medical practice that we stay within our capabilities.

It is time that we rethink our approach to child protection with regard to diagnosis, reporting, and investigations.