Recognising child abuse

It is important to be vigilant and to own and act on your concerns, explains Dr Mona Kular.

A cigarette burn can be classed as a non-accidental injury
A cigarette burn can be classed as a non-accidental injury

Child protection has been increasingly publicised in recent years following the tragic death of Victoria Climbie in 2000, which revealed a catalogue of failings along the pathway of child protection.

A series of investigations followed in order to ensure that child protection procedures work correctly. The public inquiry launched after the death of Victoria Climbie culminated in the publication of Lord Laming's report in 2003.

Some of these key recommendations in the context of primary care include GPs receiving child protection training as part of their vocational training scheme and at least every three years thereafter; training in recognising child abuse to be introduced for all primary care staff; and the notion of the first person with any concern taking the responsibility for acting on it.

The government's response to the Lord Laming report is a document called 'Every Child Matters', published in 2003.

Child abuse
Child abuse can take the form of physical abuse, physical neglect, emotional or psychological maltreatment, or sexual abuse. It is important to be aware that physical abuse rarely exists alone; it is often associated with sexual and, more commonly, emotional abuse.

Very young, fully dependent children are most at risk of severe injury as a result of physical abuse, due to their fragility and immobility.

Recognising child abuse
Most children will be registered with a GP, who will invariably be the first point of contact for healthcare. It is in primary care then, that potential child abuse should be recognised, identified, assessed and referred.

However, this is not always the case. Barriers to recognising child abuse include:

  • Looking for the wrong things.
  • Not looking at all or not seeing the child.
  • Underestimating or normalising the problem.
  • Doing nothing; the jigsaw nature of information held by various individuals.
  • Trust and relationships with patients being jeopardised.
  • Inter-professional relationships not working well.
  • Lack of confidence in the system.

There are many signs of abuse in children but they can be difficult to spot (see box).

It is also worth noting that there are ways to recognise opportunities for early intervention, prior to the occurrence of child abuse.

This includes identifying 'troubled families' - those with issues such as chronic ill health, poor housing, unemployment and financial problems - and 'troubled parents' - those with issues of mental health problems, substance or alcohol abuse and domestic violence.

Acting on your concerns
'Own and act on your concern' was one of the key recommendations of the Lord Laming report. The first person with concern has the responsibility to act upon it.

Remember fully to document the consultation and reasons for concerns, and any details of external physical examination undertaken.

Internal or further examinations should only be carried out by specialists in this field.

Useful further information can be gained from health visitors, and by checking the Child Protection Register to see if concerns have previously been raised about that child or any of its siblings.

Guidelines for action
Practices and primary care organisations (PCOs) should have child protection guidelines in place to ensure that avenues for reporting concerns are known and available.

Each PCO should have a designated doctor and nurse for child protection issues and it may be wise to discuss concerns with this contact.

Essentially, if concerns exist and continue after discussion with colleagues and designated contacts, then a referral should be made immediately to social services with a written referral within 48 hours.

If immediate concerns exist regarding that child's safety, then urgent discussion needs to be held between the healthcare professional involved, social services, the police and the PCO's designated child protection contact.

The DoH guidance, 'What to do if you're worried a child is being abused, 2006', provides an up to date and comprehensive overview of the responsibilities of those involved.

Dr Kular is a GP registrar in Nottingham

This topic falls under section 8 of the GP curriculum 'Care of Children and Young People',

Contact Emma Quigley at GP Education on (020) 8267 4805 or email

Learning points

1. Child protection is an important area and GPs should be aware of the key recommendations.

2. Various barriers exist to recognising child abuse, often due to gaps in knowledge and skills or reluctance to report.

3. Child abuse occurs in four main ways, each with their own manifestations.

4. There are distinct pathways and guidance for the reporting of suspected child abuse.


  • Every Child Matters, DoH, 2003.
  • Keep Me Safe, RCGP strategy for child protection 2005.
  • What to do if you're worried a child is being abused, DoH 2006.


Signs of child abuse
Physical abuse
  • Unexplained injuries.
  • Untreated/inadequately treated injuries.
  • Delayed presentation of injuries.
  • Injuries to unlikely areas such as thighs, back and abdomen.
  • Bruising in the shape of finger/hand marks.
  • Cigarette burns, human bites.
  • Scalds/burns.
  • Underweight or small for age.
  • Poorly clothed with inadequate protection from the weather.
  • Often absent from school for no reason.
  • Regularly left alone, or in charge of younger brothers or sisters.
  • Constant tiredness.
  • Poor social relationships.
Emotional abuse
  • Not easily recognisable but can lead to behavioural problems, learning difficulties, emotional and mental health problems.
  • Sudden fear of new situations.
  • Over-reaction to mistakes.
  • Self deprecation.
  • Extremes of passivity and aggression.
Sexual Abuse
  • Pain, itching or bleeding in the genital area.
  • Genital discharge or UTIs.
  • Abdominal pain or discomfort walking or sitting.
  • STIs.
  • Difficulties at school.
  • Fear or distrust of particular adults, withdrawal from social activities.
  • Use of inappropriate sexually explicit behaviour.
  • Descriptions of having special relationships or secret friendships.

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