Adopted by the 36th World Medical Assembly, Singapore, October 1984 and amended by the
41st World Medical Assembly, Hong Kong, September 1989
42nd World Medical Assembly, Rancho Mirage, CA., USA, October 1990
44th World Medical Assembly, Marbella, Spain, September 1992
the 47th General Assembly, Bali, Indonesia, September 1995 and
the WMA General Assembly, Pilanesberg, South Africa, October 2006

1. One of the most destructive manifestations of family violence and upheaval is child abuse and neglect. Prevention, early identification and comprehensive treatment of child abuse victims remain a challenge for the world medical community.
2. Definitions of child abuse vary from culture to culture. Unfortunately, cultural rationalizations for harmful behaviour toward children may be accepted, all too readily, as proof that the treatment accorded children is neither abusive nor harmful. For instance, the work contribution of children in the everyday lives of families and in society should be recognized and encouraged as long as it also contributes to the child's own development. In contrast to this, exploitation of children in the labour market may deprive them of their childhood and of educational opportunities and even endanger their present and future health. The WMA considers such exploitation of children a serious form of child abuse and neglect.
3. For purposes of this Statement, the various forms of child abuse include physical, sexual and emotional abuse. Child neglect represents a failure of a parent or other person legally responsible for a child's welfare to provide for the child's basic needs and an adequate level of care.
4. The World Medical Association recognizes that child maltreatment is a world health problem and recommends that National Medical Associations adopt the following guidelines for physicians:
5. Physicians have both a unique and special role in identifying and helping abused children and their troubled families.
6. Linkage to an experienced multidisciplinary team is strongly recommended for the physician. A team is likely to include such professionals as physicians, social workers, child and adult psychiatrists, developmental specialists, psychologists and attorneys. When participation on a team is not possible or available, the individual physician must consult individually with other medical, social, law enforcement and mental health personnel.
7. Primary care physicians (family practitioners, internists, paediatricians), emergency medicine specialists, surgeons, psychiatrists and other specialists who treat children must acquire knowledge and skills in the physical assessment of child abuse and neglect, the assessment of child development and parenting skills, the utilization of community resources, and the physician's legal responsibilities.
8. The medical evaluation of children who are suspected of having been abused should be performed by physicians skilled in both paediatrics and abuse evaluation. The medical evaluation needs to be tailored to the child's age, injuries, and condition, and may include but is not limited to blood testing, trauma radiographic survey, developmental and behavioural screening. Follow up radiographs are strongly urged in some children who present with serious, apparently abusive injuries.
9. The medical assessment and management of sexually abused children consists of a complete history and physical examination, as physical and sexual abuses often occur together; examination of the genitalia and anus; the collection and processing of evidence including photographs; and the treatment and/or prevention of pregnancy and venereal disease.
10. It is necessary for physicians to determine the nature and level of family functioning as it relates to child protection. It is essential for the physician to understand and be sensitive to how the quality of marital relationships, disciplinary styles, economic stresses, emotional problems and abuse of alcohol, drugs and other substances, and other forms of stress relate to child abuse.
11. The signs of abuse are often subtle, and the diagnosis may require comprehensive, careful interviews with the child, parents, caretakers, and siblings. Inconsistencies between the explanation(s) and characteristics of the injury(s) such as the severity, type and age, should lead to a concern for abuse.
12. In any child presenting to a medical facility, the emergent medical and mental health needs should be addressed first. If abuse is suspected, safety needs must be addressed prior to discharge from the facility. These measures may include but are not limited to:
    1. reporting all suspected cases to child protective services;
       
    2. hospitalizing any abused child needing protection during the initial evaluation period;
       
    3. informing the parents of the diagnosis if it is safe to do so; and
       
    4. reporting the child's injuries to child protective services.
13. If hospitalization is required, a prompt evaluation of the child's physical, emotional and developmental problems is necessary. This comprehensive assessment should be conducted by physicians with expertise or through a multidisciplinary team of experts with specialized training in child abuse.
14. If child abuse is suspected, the physician should discuss with the parents the fact that child maltreatment is in the differential diagnosis of their child's problem. During such a session, it is essential that the physician maintain objectivity and avoid accusatory or judgmental statements in interactions with the parents.
15. It is essential that the physician record the findings in the medical chart during the evaluation process. The medical record often provides critical evidence in court proceedings.
16. Physicians should participate at all levels of prevention by providing prenatal and postnatal family counselling, identifying problems in child rearing and parenting, and advising about family planning and birth control.
17. Public health measures such as home visits by nurses, anticipatory guidance by parents, well-infant and well-child examinations should be encouraged by physicians. Programs that improve the child's general health also tend to prevent child abuse and should be supported by physicians.
18. Physicians should recognize that child abuse and neglect is a complex problem and more than one type of treatment or service may be needed to help abused children and their families. The development of appropriate treatment requires contributions from many professions, including medicine, law, nursing, education, psychology and social work.
19. Physicians should promote the development of innovative programs that will advance medical knowledge and competence in the field of child abuse and neglect. Physicians should obtain education on child neglect and abuse during training as medical students.
20. In the interests of the child, patient confidentiality must be waived in cases of child abuse. The first duty of a doctor is to protect his or her patient if victimization is suspected. No matter what is the type of abuse (physical, mental, sexual), an official report must be made to the appropriate authorities.

14.10.2006