WMA Statement on Child Abuse and Neglect
Adopted by the 36th World Medical Assembly, Singapore, October 1984
and revised 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
47th WMA General Assembly, Bali, Indonesia, September 1995
57th WMA General Assembly, Pilanesberg, South Africa, October 2006
and 67th WMA General Assembly, Taipei, Taiwan, October 2016
and revised by the 68th WMA General Assembly, Chicago, United States, October 2017
OVER-ARCHING PRINCIPLE
1. The welfare of children[1] is of paramount importance. Health professionals should put the welfare of children at the centre of all decision-making related to the child and act in the best interests of children in all of their interactions with children, young people, families, policy-makers and other professionals.
INTRODUCTION
2. One of the most destructive manifestations of family violence and upheaval is child abuse[2] in all its forms. Prevention, protection, early identification, suitable interventions and comprehensive treatment of child abuse victims remain challenging for the world medical community. The World Medical Association (WMA) has called for increased health support of children living on the streets in its Statement on Supporting Health Support to Street Children, but it is also important to address the root causes of child abuse in all its forms.[3]
3. 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 of 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 only as long as it also contributes to the child’s own development. In contrast, exploitation of children in the labour market deprives them of their childhood and of educational opportunities and endangers their present and future health. The WMA considers such exploitation of children a serious form of child abuse in all its forms.
4. For the purposes of this Statement, the various forms of child abuse include emotional abuse, physical abuse, sexual abuse, child trafficking, child exploitation and child neglect. 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.
RECOMMENDATIONS
The WMA recognizes that child abuse in all its forms 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 families.
6. All physicians should be educated about the paramount importance of the welfare of children.
7. Physicians must be aware of and observe local laws regarding consent to undertake examinations of children. Physicians must act in the best interests of children in all of their interactions with children, young people, families, policy-makers and other professionals.
8. Collaboration with an experienced multidisciplinary team is strongly recommended for the physician. Such a team is likely to include physicians, social workers, child and adult psychiatrists, developmental specialists, psychologists and attorneys. When participation in a team is not possible or such a team is not available, the physician must consult with other medical, social, law enforcement and mental health personnel as appropriate.
9. 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, psychological and emotional assessment of child abuse in all its forms, the assessment of child development and parenting skills, the utilization of community resources, and the physician’s legal responsibilities.
10. All physicians who treat children, and those adults with caring responsibilities for children, should be aware of the principles of the UN Convention on the Rights of the Child as well as relevant national protective legal provisions applying to children and young people.
11. 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 blood testing, a trauma radiographic survey, and developmental and behavioural screenings. Follow up radiographs are strongly urged in some children who present with serious, apparently abusive injuries.
12. The medical assessment and management of sexually abused children includes 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. Specific attention should be paid to the child’s right to privacy.
13. It is essential for the physician to understand and be sensitive to the following: the quality of relationships between care-givers; disciplinary actions or styles used within the child’s home; economic stresses on the family; emotional stresses or issued experienced by members of the family; mental health problems exhibited by any members of the family; violence between the care-givers or other members of the family; substance use and abuse, including alcohol and legal and illegal drugs; and any other forms of stress that could relate to child abuse in all its forms.
14. All physicians need to be aware that all forms of abuse of children by other children can occur. Recognition that this may be a result of prior or current abuse of the alleged abuser must be at the forefront of the physician’s mind when such situations are suspected or encountered.
15. The signs of abuse are often subtle, and the diagnosis may require comprehensive, careful interviews with the child, parent(s), care-givers, and siblings. Inconsistencies among explanation(s) and characteristics of the injury(s), such as the severity, type and age, should be documented and further investigated.
16. 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 should include:
- Reporting all suspected cases to child protective services;
- Hospitalizing any abused child needing protection during the initial evaluation period;
- Informing the parents of the suspicion of abuse or diagnosis of abuse if it is safe to do so; and
- Reporting the child’s injuries to child protective services or other relevant authorities.
17. 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.
18. If child abuse is suspected, the physician should discuss with the parent(s) the fact that child abuse is in the differential diagnosis of their child’s problem. Advice may be required from child protective services.
19. During discussions with the parent(s), guardians, or care-givers it is essential that the physician maintain objectivity and avoid accusatory or judgmental statements in interactions with the parent(s) or individual(s) responsible for the child’s care.
20. It is essential that the physician record the history and examination findings in the medical chart contemporaneously during the evaluation process. Injuries should be documented using photographs, illustrations, and detailed descriptions. The medical record often provides critical evidence in court proceedings.
21. 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.
22. Public health measures such as home visits by nurses and other health professionals, anticipatory guidance by parents, and 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 in all its forms and should be supported by physicians and their representative bodies.
23. 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.
24. Physicians should promote the development of innovative programs that will advance medical knowledge and competence in the field of child abuse and neglect. Inclusion of on-going reviews of knowledge, skills and competency in relation to protecting the rights of children and young people, promoting their health and well-being and the recognition of and response to suspected cases of child abuse and neglect is crucial in professional educational programs. Physicians should obtain education on child neglect and abuse in all its forms during training as medical students.
25. In the interests of the child, patient confidentiality may 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 the type of abuse (including physical abuse, emotional abuse, sexual abuse, trafficking, exploitation or neglect), an official report must be made to the appropriate authorities.
26. Inclusion of on-going reviews of knowledge, skills and competency in relation to protecting the rights of children and young people, promoting their health and well-being and the recognition of and response to suspected cases of child abuse in all its forms and neglect is crucial in professional educational programmes.
27. The undergraduate medical curriculum must include a mandatory course on child abuse, in all its forms, within the paediatrics program, that can be developed within postgraduate and continuing medical education for those intending to work within this field.
[1] The United Nations Convention on the Rights of the Child defines a child as anyone who has not reached their 18th birthday.
[2] Child abuse and Child maltreatment are used synonymously in this Statement.
[3] Neglect is the persistent failure to meet a child’s basic needs, likely to result in the serious impairment of a child’s health, well-being or development.