Protecting children

Professionals in child health, primary care, mental health, schools, social services, and law-enforcement ... all contribute to the recognition of and response to child maltreatment. In all sectors, children suspected of being maltreated are under-reported to child-protection agencies. Lack of awareness of the signs of child maltreatment and processes for reporting ... and a perception that reporting might do more harm than good, are among the reasons for not reporting. Strategies to improve recognition ... include training, use of questionnaires for asking children and parents about maltreatment, and evidence-based guidelines for who should be assessed.¹

As family doctors we are inevitably witness to pain and suffering. At times, things we see and hear are so upsetting that we are personally affected, sharing in the pain and experiencing vicarious distress. None of us is immune; it is the reality of our relationships with patients. We must be vigilant not to ignore clues or unconsciously avoid inviting these painful histories. We must encourage difficult conversations through our willingness to listen. And we must always be mindful that our own histories can determine what stories might affect us personally and thus elicit some of the same feelings our patients are experiencing.

While all stories of abuse and neglect touch us, perhaps it is abuse of children, sexual or other, that is most distressing and most likely to trigger our interventions. The Internet has provided a new environment in which abuse of children can occur, while health system pressures can compromise the time we spend with patients in actively exploring the more painful and often-hidden parts of their lives.

What resources can help address these situations? While renewed attention to mental health; integration with teachers, social and psychological providers, and agencies; and shared care models with psychiatry are helpful, I recently learned of another vital national resource: the Canadian Centre for Child Protection. This service is personally supported by the current Minister of Health. The very appropriate “tag line” for this organization is “Helping Families. Protecting Children.” Centre staff take reports of child sexual exploitation from the public and field calls for information or help from local, national, and international agencies. Early in my presidency I met with them and several sister organizations committed to grappling with childhood abuse. The following statistics were sobering: about 1 in 10 children will be sexually abused before they turn 18—1 in 7 girls and 1 in 25 boys; and it is estimated that 7% to 12% of children are sexually abused.² Further, “According to Statistics Canada, children under the age of 18 accounted for over half (55%) of all victims of sexual offences reported to police in 2012.”³ In most cases the accused was an acquaintance (44%) or a family member (38%). More than 82% of images assessed by Cybertip.ca, Canada’s national tip line for online exploitation, depicted children younger than 12 years of age; 57% were of children younger than 8; more than 35% of all images showed serious sexual assaults; and 83% of images were of girl children.³

While there is weak evidence that screening for sexual abuse results in reduced harm, experts at the meeting familiar with the literature suggested this might be related to the lack of coordinated programs to intervene when necessary after screening. Surely for family doctors, case finding based on office observations is appropriate and imperative, even if there is some doubt regarding the value of screening.

I left the meeting with several useful resources.

• Child Sexual Abuse. It Is Your Business defines sexual abuse, lists concerning behaviour, advises on risk reduction, offers tips on responding to observations of “odd” interactions with children, and gives real-life examples of what disclosure from a child might “sound like” or “look like.”³

• Commit to Kids Sport Edition for Sport Leaders and Commit to Kids Sport Edition for Parents are helpful guides to protecting children in sport organizations, and Commit to Kids. Helping Organizations Prevent Child Sexual Abuse is an invaluable manual for identification and prevention of abuse in various settings (www.commit2kids.ca).

For identifying child abuse, “hints of disclosure” are particularly relevant for family doctors. Behaviours that should alert you to the need for further exploration include freezing (not showing) emotions; excessive sadness and worry; extreme aggressiveness and risk taking; sudden resistance to being alone with a person whose company was previously enjoyed; and unexpected hostility toward caregivers.

Two links worth noting, for yourselves and your patients, are www.commit2kids.ca and www.kidsintheknow.ca. The former is a resource for parents and organizations; the latter links to tools and resources from the Canadian Centre for Child Protection, including resources relevant for FPs.

Vigilance in our practices is vital for our patients, their children, our own children, and the health and future of our communities. In many ways, it is a call to protect, to advocate, and to be socially responsible. While I hope you search as you go about your clinical work, I hope you do not find.

• Copyright© the College of Family Physicians of Canada