Child abuse: Social and medicolegal issues

INTRODUCTION — This topic reviews social and medicolegal considerations for suspected child abuse. Medicolegal aspects of mandated reporting in the United States and Europe are also discussed here.

The recognition, evaluation, and management of physical, sexual, and emotional child abuse and child neglect are discussed in detail separately:

●(See "Physical child abuse: Recognition" and "Differential diagnosis of suspected child physical abuse" and "Physical child abuse: Diagnostic evaluation and management".)

●(See "Evaluation of sexual abuse in children and adolescents" and "Management and sequelae of sexual abuse in children and adolescents".)

●(See "Child neglect: Evaluation and management".)

LEGAL DEFINITION — Child abuse or child maltreatment is a unique entity that is not only a medical diagnosis, but also a crime. Whereas legal definitions of abuse vary from jurisdiction to jurisdiction and have varying degrees of perpetrator intentionality (eg, reckless, negligent, or intentional), the medical provider should focus on the harm or potential harm to the child and not upon investigating or proving caregiver intent [1]. Health care providers who care for children have a professional and often legal obligation to identify and protect children who may be victims of abuse and neglect.

Definitions of specific types of child abuse are provided separately. (See "Physical child abuse: Recognition", section on 'Definition' and "Evaluation of sexual abuse in children and adolescents", section on 'Definitions' and "Child abuse: Epidemiology, mechanisms, and types of abusive head trauma in infants and children", section on 'Definitions' and "Child neglect: Evaluation and management", section on 'Definitions'.)

NOTIFYING PARENTS OR LEGAL GUARDIANS — One of the most difficult tasks in evaluating a child for the possibility of abuse is informing the parents or legal guardians that a report to Child Protective Services (CPS) or similar agency and consequent welfare investigation is necessary. This discussion may have been foreshadowed when the nature of and rationale for additional medical evaluation (eg, skeletal survey, toxicology screening) were explained. Reactions to such news may range from appreciation to hysterical denials or violence. The possibility of a violent reaction may be anxiety-provoking, even for a child abuse expert, and more so for a provider with less experience. In situations where a violent response is anticipated, precautions (such as arranging for a nearby security guard or police presence to prevent elopement with the child or violence against the health care provider) is prudent.

The clinician should approach the parents/primary caregiver in an empathetic, supportive, and non-accusatory manner while explaining the reasons why it is necessary to file a report of suspected child abuse or neglect. Whether or not the parents/primary caregivers have harmed their child, they deserve to know and must be told that a report is being made, the reasons for that report, and that CPS may conduct an investigation. The medical provider should emphasize that the primary concern is for the safety and well-being of the child. Parents/primary caregivers usually understand the need for the investigation when they are told that it is necessary for the safety of the child and, in regions with mandatory reporting, legally required when an injury appears inconsistent with the history. The parents/primary caregivers should also receive information regarding what will happen once the report is filed (eg, a visit from a CPS worker, social worker, and/or the police) (figure 1). (See 'Reporting suspected abuse' below.)

Examples of how to begin the conversation include:

●Summarize the situation:

•"We have identified the following concerning findings…."

•"The injuries we have found are very unexpected after the event you described…"

●Summarize the next steps:

•"When we find injuries like these that are not easily explained, we report to CPS to make sure your child is safe."

•In settings with mandatory reporting laws add: "We are also required to do this by law."

•"CPS takes the lead in determining whether there are additional steps to keep your child safe going forward." Depending upon the jurisdiction, inform who will be involved with investigating the report (eg, CPS worker and/or police).

REPORTING SUSPECTED ABUSE

Reporting legislation — All 50 states in the United States have enacted legislation that mandates reporting of suspected child abuse [2]. In Europe, 16 countries (including France, Spain, Norway, Sweden, and Italy) have mandatory reporting of child maltreatment by physicians [3]. Additionally, a growing number of countries across the world (including Canada, Australia, Israel, Japan, and India) have adopted some form of mandatory reporting legislation for some types of maltreatment [4].

A reporting system is most effective when combined with a public awareness program to educate the general population about signs of child abuse and methods of contacting professionals qualified to intervene, investigate, and assist children and families [5,6].

Mandatory reporting — Mandatory reporting of a suspicion of abuse is required for physicians and other medical providers in many regions. Clinicians must know and abide by mandatory reporting statutes in the jurisdictions where they practice. (See 'Reporting process' below.)

As an example, in the United States, there are differences from jurisdiction to jurisdiction on what persons are mandated to report, and the agency (or agencies) to which the report is made (eg, Child Protective Services [CPS], Department of Social Service [DSS], or the local police department) [7,8]. Most US states require certain professionals to report suspected cases of child abuse and neglect. These professionals include medical and mental health professionals, educators, child care providers, social service providers, and law enforcement personnel; some states also require clergy to report suspected child maltreatment [8].

In the reporting of child abuse and neglect, the duty to report supersedes client-professional confidentiality. Most US states provide immunity from legal liability for reporters in good faith [9], and, concurrently, almost all US states and territories have penalties for failing to report suspected cases (with Maryland, North Carolina, Wyoming, and Puerto Rico being the excepted jurisdictions) [8]. An internet compilation of all state child abuse reporting statutes can be found at the Child Welfare Information Gateway.

Reasonable suspicion or cause to believe — The vast majority of United States jurisdictions require reporting when an individual has a "reasonable suspicion" or "reasonable cause to believe" that abuse has occurred. But, what constitutes "reasonable suspicion" or a "reasonable cause to believe" is an issue that has perplexed and frustrated physicians for decades. Multiple studies have confirmed that physicians have a broad and variable interpretation of what constitutes "reasonable suspicion," with some physicians even requiring 75 percent or more probability of abuse before they would report [10].

United States courts have provided some clarification on this issue. The United States Supreme Court has defined "reasonable suspicion" (at least within the context of search and seizure) as something more than "an inchoate and unparticularized suspicion or 'hunch'" [11]. Thus, providers should understand that "reasonable suspicion" includes some objective evidence more than a "hunch." But, most importantly, providers should recognize that the threshold for reporting abuse does not require a high degree or incontrovertible certainty.

Barriers to reporting — Despite mandatory reporting laws in the United States, some primary care providers do not report suspected abuse. As mentioned above, one barrier to reporting has been the vague notion of what constitutes a "reasonable suspicion" or "reasonable cause to believe." Other barriers identified by mandated reporters (physicians and nurses) include [12-16]:

●Familiarity with patient families

●Concern about negative impact of reporting on the family if injury turns out to be nonabusive

●Inadequate training to recognize clinical manifestations of child abuse

●Cultural attitudes

●Perception that CPS intervention is ineffective

●Lack of support from professional societies

Reporting process — The reporting process varies by jurisdiction. As an example, in most US states, reports of child maltreatment are made orally by telephone or in person and then followed by a written report, usually within 36 hours to five days after the oral report is made (see 'The written report' below) [8]. Many US states have a toll-free number for reporting suspected child maltreatment; the phone number can be obtained from the Child Welfare Information Gateway or by calling ChildHelp (1-800-4-A-CHILD, 1-800-422-4453). When reporting, the medical provider should ensure that the parents/primary caregivers are informed that the child abuse report is being made and what will occur as a result of the report (figure 1). (See 'Notifying parents or legal guardians' above.)

Each governmental jurisdiction designates specific agencies to receive and investigate reports of suspected child abuse and neglect. CPS and/or law enforcement agencies are each responsible for conducting initial assessments or investigations in cases of child abuse and neglect, depending upon the nature of the abuse or neglect [8]. As an example, in most regions of the United States, CPS conducts the initial evaluation of reports of child abuse and neglect and offers rehabilitative services to families [8]. CPS is responsible for conducting family assessments, developing individualized case plans, providing direct services, coordinating services provided by other professionals, maintaining case records, reviewing case plans, and developing court reports. Law enforcement conduct investigations in furtherance of determining whether criminal charges are appropriate against particular individuals.

The written report — The purpose of the medical provider’s written report is to communicate with CPS or similar agency and court officials about the following:

●The nature of the child's medical condition or injuries (eg, failure to thrive, poisoning, burn, fracture, or sexual abuse)

●The reasons why abuse or neglect is suspected as the cause of the condition

●The strength of the suspicion

Hospitals and or state/national governmental bodies may have specific forms whose use is required for reporting child abuse and or neglect. When child abuse is reported by a physician, a copy of the written report should be filed in the patient's medical record. In many circumstances, the provider's medical note regarding the child maltreatment evaluation may suffice as the written report. If the medical note is used as the written report or a copy of the written report is filed in the patient's medical record, immediate action should be undertaken to temporarily restrict caregiver access to the medical record, pending the ongoing child welfare investigation.

The written report is the physician's primary vehicle of communicating to officials his or her concern regarding child abuse or neglect. The manner in which the report is completed may affect when and if an investigation will take place. The statement should be typed. It should be written in plain and understandable language, avoiding medical jargon, because most readers of such reports are neither medically nor scientifically trained [17]. The signature should be followed by the physician's printed name and contact information (eg, office address, phone number, and fax).

The written report should include [8]:

●The name, age, and sex of the child(ren)

●The name and address(es) of the parent(s) or other person who is responsible for the child (when the applicable form requires)

●A detailed history of the injury (as provided by the caregiver), including, but not limited to:

•Specifics regarding injury mechanism (eg, when a particular fall or other injurious event occurred, whether it was witnessed or not, positioning of the child, fall surface, and estimated height, or any other pertinent details). Within reason, a caregiver or child's words, in quotes, should be used as much as possible, with appropriate attribution.

•Any discrepancies between histories provided to different health care professionals. If differing histories have been provided, the different versions should be documented, including information regarding who provided which version, and to whom.

•Medical symptoms of the child preceding and immediately after an event (ie, presence or absence of apnea, seizures, respiratory change, altered mental status, swelling, bruising, skin denudation, or physical findings suggesting sexual abuse or child neglect).

•Relevant psychosocial factors of the family (eg, caregiver caretaking responsibilities, presence of other children in the home, mental health issues, substance use/abuse, or prior CPS involvement.

●Information about the setting of the alleged abuse (ie, whether it occurred at home or in an out-of-home setting such as a school or day-care facility).

●The physical examination findings, including a detailed description of the child's injuries, in clear language that is understandable to an individual without medical training. The use of Latin abbreviations and medical jargon should be avoided. The nature and possible causes of each injury should be discussed individually [17].

●Plain language description of other medical injuries, including fractures, intracranial bleeding, and other internal injuries not visible on photographs.

●Multiple, clear photographs (with a reference measurement) of the child's injuries, including skin lesions.

●A clear explanation of the reason for why child abuse is suspected. For example, if an explanation or explanations inconsistent with the injury have been offered, the reasons for the inconsistency should be explained (eg, "the four-month-old child is unable to climb out of the crib"). Similarly, it may be clear to a physician that a child with obvious immersion burns did not spill a pot of hot water on himself, but it may not be clear to those who have no medical training, no education in abusive injuries, and are unable to see the child. Thus, it is incumbent upon the physician to clearly state the discrepancy.

The more comprehensive the information provided by the reporter, the better able CPS staff and judicial sources will be in evaluating the appropriateness of the report for CPS intervention and response. Additionally, if there is suspicion of abuse, a recommendation should be made to have other young children in the home or other potentially abusive environment medically evaluated.

The physician may also be asked whether permanent physical damage or death will result from failure to obtain medical treatment. In answering this question, the physician should not only address the acute injuries but also the risk that the child will be reinjured if returned to the home situation; that is, the possibility of more severe injury or death if abuse escalates or neglect continues. Estimates for reinjury and death for physical child abuse are discussed separately. (See "Physical child abuse: Recognition", section on 'Approach'.)

THE MEDICAL RECORD — In the United States, the medical record is always a medicolegal document but never more so than in a potential criminal investigation.

Written documentation — Statements by caretakers, detailed description and clear photographs (with reference measurements) of all of the child's injuries, and objective observations of the emotional status of all family members should be carefully documented. This information will be useful both for legal agencies and to refresh the physician's memory in the event of court testimony, which may be required months or years later. Structured clinical forms may be helpful in making sure that all information crucial to the evaluation of child abuse is documented in the medical record (table 1) [18].

Statements made by the child or the parents/primary caregivers for purposes of medical diagnosis and treatment are an exception to the hearsay rule in US courts [19]. Thus, as mentioned above, as much as reasonably feasible, it is important to document verbatim pertinent history provided by the child and/or caregiver.

In addition to the information included in the written report, documentation in the medical record should include [20-22]:

●History of previous injuries or accidents

●Developmental history

●Procedures performed (eg, skeletal survey, dilated funduscopic examination, forensic evidence collection)

●Whether a child abuse/neglect report was made

●Diagnosis of "suspected child abuse or neglect," "probable child abuse or neglect," or "highly probable child abuse or neglect"

●The final disposition of the child

Photographs — Photography is vital for documentation of external injuries for legal purposes and also as part of the child's medical record. In some US states, permission from the parent or other legal guardian is necessary for photographs.

Key aspects of photodocumentation include:

●Digital photography should be utilized whenever feasible.

●Photographs must be of good quality, should be taken in appropriate lighting, such as in daylight or with an electronic flash, and against a neutral background.

●Skin findings are best documented against a blue background [23].

●The series of photographs should include a photograph of the child's face and name (for identification purposes).

●At least three images (overview, mid-range, and close-up) of each injury should be obtained [24], and all photographs should be timed and dated (many cameras do this automatically) [25].

●For a reference measure, a ruled edge in the field for size reference is preferred.

In some institutions, the physician may have access to an experienced medical photographer who can ensure proper photodocumentation. Photographs that may be used as evidence should be stored in a secure fashion, and in accordance with duration retention requirements for medical records. In many institutions, photographs obtained by the provider or the medical photographer are formally made part of the medical record. Care must be taken not to alter any photographic findings [23]. Images should always be transmitted securely to avoid violation of child pornography laws.

TESTIFYING IN COURT — Providing testimony in court related to a child maltreatment evaluation can be anxiety-provoking for medical providers. It is important to know the general nature of court systems, the roles of participants, the role of the medical expert, and the process of providing testimony.

The following information is a general synopsis, and not specific for all cases in all jurisdictions. For more detailed information on particular court systems, references are provided below, but providers should consult with a legal expert or child abuse pediatrician in their jurisdiction.

United States and international court systems — In middle- and high-income nations, two judicial systems predominate: the adversarial system (based in common law) and the inquisitorial system (based in civil law). Each system has advantages and disadvantages, and each has different roles for fact-finders (judges or juries), attorneys, and experts, and different treatment of medical (or forensic) experts.

In the adversarial system, which is the judicial system of the United States and the United Kingdom, the philosophical premise is that truth is attained through partisan advocacy by two (or more) sides before a neutral arbiter (jury or judge). Judges are more "passive" and function primarily to ensure a fair forum for disputes. Attorneys are active facilitators of evidence. Medical or forensic experts are recruited by one particular party and function as witnesses for that party. Expert witnesses may or may not provide a written report to the court, are subject to pretrial discovery processes (such as depositions), and often endure vigorous cross-examinations [26]. As parties may (and often do) call their own expert witnesses, this court system relegates complex medical or scientific cases to a "battle of the experts."

By contrast, the inquisitorial system, which is the judicial system of France, Germany, Italy, and many other countries, attains truth via a disinterested, but active, inquiry by a magistrate [26]. The judge plays a much more active role in the acquisition and assessment of evidence. In many countries, the judge selects a "court-appointed expert" from a nationally maintained list. Attorneys function to assist the court in its fact-finding mission. "Court-appointed experts" are bestowed special status as auxiliaries of the court. Because of their special status, court-appointed experts often do not testify, and their written reports suffice as evidence for the court. Additionally, unlike adversarial systems, when testifying, court-appointed experts do not experience vigorous cross-examinations; such examinations are more "civil" in nature. This court system is structurally designed to minimize, if not obviate, the "battle of the experts."

Courtroom setting — In the United States, courtroom hearings of child abuse cases may be heard in a criminal or a civil (family or juvenile) court.

Juvenile court proceedings are brought by the juvenile division of the district attorney's office, the juvenile court, or the local human services agency responsible for investigating reports of child abuse [27]. Juvenile court proceedings are typically less formal than criminal court proceedings with regards to evidence and burdens of proof. The purpose of the hearing is to address custody issues with regards to safety of the child (ie, whether the State should take temporary or permanent custody of a child) and the domestic problems that contributed to the unsafe home situation [28]. In juvenile court proceedings, the prosecutor is usually required to establish that abuse occurred by a "preponderance of the evidence" (except in termination of parental rights hearings, where "clear and convincing evidence" is required). Possible outcomes include placement of the child in foster care or the formulation of a treatment program to help the parent retain custody (eg, individual or family counseling, substance abuse treatment, parenting classes).

Criminal proceedings begin with the filing of charges by the state or federal government that has jurisdiction over the case [27]. The purpose of the hearing is to establish guilt or innocence. Criminal conduct must be established "beyond a reasonable doubt." Possible outcomes for perpetrators, if they are found guilty, include incarceration or, less commonly, monetary fines [27].

Courtroom process — In an adversarial system (eg, United States and United Kingdom), the medical expert's involvement with the court begins with a subpoena. A subpoena is a formal notification from the court that a hearing is taking place and that the medical provider is required to appear as a witness. Providers may receive either a subpoena ad testificandum (to testify) or a subpoena duces tecum (to testify and produce all documents related to testimony).

If a provider receives a subpoena duces tecum, the provider should recognize that the only person legally authorized to release medical records to the court is the legal owner of those records. For larger health care institutions, a formal process may already exist for compliance with subpoena requirements. Medical providers should consult with legal and/or medical records/health information management departments of their institution for such processes. If no such process exists, it is wise practice for the medical provider to ascertain the identity of the legal owner of the medical record and attain approval for release of documents.

The type of court proceeding can be gleaned from the subject headings of the subpoena. Juvenile proceedings will be labeled as "In the Interest of (name of a child)," whereas criminal proceedings will be labeled as a state or federal government versus a particular individual (ie, the State of Illinois versus John Doe, or the United States versus John Doe). The subpoena contains information regarding the date, time, and location of the hearing (eg, criminal or juvenile court), the name and phone number of the court, and the name of the attorney requesting the subpoena (who may be from the prosecution or the defense).

If approached, courts may be flexible regarding the time and day of the physician's appearance and may reschedule or place the physician "on call" to appear in court if and when needed. However, courts have the legal authority to require physical presence for testimony and refusing to come to court can be viewed as a criminal act. Thus, a subpoena should not be ignored, and the physician should arrange for alternative coverage of normal duties when scheduled or on-call to appear.

As mentioned above, in inquisitorial systems, an expert will be notified by a particular court that they have been appointed as the court's expert. With such special appointment, the expert is deemed to be an extension of the court and is afforded access to all materials necessary to render an opinion. In order to preserve neutrality of the court-appointed expert, parties to the case are not permitted to independently contact the expert prior to submission of the report (ie, no pretrial interviews or depositions). Once the court-appointed expert submits a written report, the parties may call their own experts to assist in the interpretation of court-appointed expert's findings. Also, as mentioned above, usually the court-appointed expert's written report will suffice as evidence, and testimony is uncommon.

Preparation — When it is determined that testimony of the medical provider is necessary, the provider should take the following steps in preparation for testimony:

●The provider should gather and carefully review all records and/or notes pertaining to the case, as well as radiographs, photographs, and laboratory results [29,30]. The provider should not alter records or notes; this casts serious doubt on the reliability of the provider as a witness. If upon review, additional information is remembered, it should be documented clearly and separately within the medical record, with a date and time the additional note is written, and clearly identified the note as an "addendum."

●In order to best educate the court, it is prudent for the provider to review recent literature or research that may be relevant to the child's diagnosis [27]. Finally, the provider may find it helpful to prepare visual aids, such as charts, graphs, or anatomic depictions, to clarify certain points to the judge or jury; however, this is not required.

In systems where pretrial contact with legal parties is permitted, it is prudent for the medical expert to meet with the party calling him or her to discuss testimony. This meeting accomplishes several ends [27]:

●The medical record and any photographs are reviewed with the attorney, and any medical information is clearly explained to that attorney.

●The physician gains an understanding of the entire legal case against the alleged abuser. This can help to focus testimony on the medical facts that support what the attorney seeks to prove.

●The physician may clarify the role of other witnesses (residents, nurses, auxiliary personnel).

●Additional documentation or demonstrative exhibits can be brought to the attention of the attorney.

●The physician's qualifications to testify (education, experience, any special training in child abuse or other specialties, experience in similar cases) can be clarified because these may be challenged on the witness stand.

●Specific questions that may be asked at trial can be reviewed, in order to help the physician make statements in an understandable and legally admissible form, and prepare the physician for cross-examination [29].

Direct examination — Direct examination is performed by the party calling the witness. Testimony in the direct examination phase is tailored to elicit information that will prove the elements of either the juvenile court or criminal allegation. Question-answer format in this phase is more open ended or non-leading (ie, "What did your physical exam show?" or "What is your opinion in this case with regards to whether these findings are from abuse or neglect?"). During this phase (and throughout all aspects of testimony), the following guidelines may help the medical provider keep his or her testimony accurate, understandable, and concise:

●Each question should be answered as completely as possible, but the response should be limited to information that is relevant to the question posed.

●Clarification should be requested if any question is not understood. If the physician does not know the answer to a question that is posed, they should say so; fumbling for a partially accurate answer may diminish credibility with the judge or jury.

●The use of medical jargon should be avoided; if it is necessary to use a word or phrase that is unlikely to be understood by the judge or jury, the word or phrase should be immediately explained in lay language [31].

●Questions to which objections are raised should not be answered until the judge has ruled on the objection and provided instructions regarding a response.

●If asked about a particular document or medical article, the physician should ask to see the material referenced before answering specific questions about that document.

●The physician should speak directly to the judge or jury (the finder of fact) as the audience.

Cross-examination — In adversarial systems, unlike inquisitorial systems, cross-examinations can be vigorous, aggressive, and sometimes disparaging. Unlike direct examinations, question-answer format by experienced cross-examiners will strictly adhere to leading questions, or "yes/no" answer questions (ie, "Doctor, isn't it true that you never examined this child?"). Structurally, cross-examinations are the legal vehicle by which attorneys attempt to discredit the testimony provided by the witness on direct examination. Toward this end, the attorney may try to intimidate the testifying provider or make the provider angry by challenging his or her qualifications, experience, or knowledge.

Other techniques may include:

●Asking complex questions or strings of several questions intended to confuse the witness. The expert may state that the question is confusing in its compound format and request that the questions be asked one at a time.

●Making restatements: "In other words, Doctor, what you are saying is…" The expert should listen to the restatement carefully and should not agree unless his or her statement has been restated accurately and carries the precise meaning they intend to convey to the judge or jury.

As one of the primary objectives of adversarial cross-examinations is to diminish the expert's credibility by making the expert seem argumentative, evasive, or, worse, aggressive, the medical expert should remain calm and courteous at all times. Anger, self-defense, and condescension diminish credibility. Questions should be answered as succinctly as possible; additional information should not be volunteered. The expert should not feel pressured to make or agree with statements that are incorrect or partially correct; they may ask the judge for time to make lengthier explanations when warranted or state that the question cannot be answered as posed.

If a question cannot be answered accurately with a yes or a no, explain to the court why this is the case. A useful example of such is the following exchange:

An attorney asks, "Yes or no, have you stopped beating your wife?"; an appropriate response would be, "I cannot answer that question with a simple yes or no because it is based on an untrue premise."

It can be helpful to remind the court that a yes or no answer can run afoul of the oath to tell the whole truth.

Ethical testimony — Child abuse evokes emotional responses. The role of the medical provider is to be an educator of medical information to court systems; not to advocate for one particular side or another. Unfortunately, on occasion, that emotion translates into biased evaluations and biased testimony. In particular, testimony that proposes unsubstantiated alternative explanations for cases of abusive head trauma or denies its existence, should be treated with stringent scientific review, and, when appropriate, renounced [32,33]. There is a large consensus supporting the current diagnostic criteria for abusive head trauma, which includes experts from the American Academy of Pediatrics and the World Health Organization. Furthermore, evidence suggests that abusive head trauma is not overdiagnosed by child abuse experts, but, in fact, may be underdiagnosed. (See "Child abuse: Evaluation and diagnosis of abusive head trauma in infants and children", section on 'Diagnosis'.)

Medical providers giving testimony in child abuse cases should take extra precautions to ensure that information conveyed to courts is complete, accurate, and objective. Some of these precautions can include participation in multidisciplinary team assessments of suspected abuse cases and consultation with medical or forensic experts in the field of child abuse. The American Academy of Pediatrics recently revised its policy statement (and accompanying technical report) on Expert Witness Participation in Civil and Criminal Proceedings [34]. Some helpful provisions of that statement include that medical providers:

●Be actively and meaningfully engaged in clinical practice in the medical specialty or area of medicine about which they testify

●Take all necessary steps to provide thorough, fair, objective, and impartial review of the medical facts

●Render an opinion only after reviewing sufficient medical records and documents to enable the formation of unbiased and accurate conclusions

●Provide objective, valid opinions that are well supported by their clinical experience and the best evidence-based medical literature, regardless of whether it is to be used by the plaintiff/prosecutor or defendant

●Present testimony that reflects the generally accepted standard within the specialty or area of practice, including those held by a significant minority

Although testimony is only required in a small percentage of child abuse cases, the medical or forensic expert that provides ethical testimony in these cases will facilitate just outcomes and enhance the reputation of medical providers in general.

RESOURCES — On a global level, Preventing child maltreatment: A guide to taking action and generating evidence is a tool developed jointly by the World Health Organization and the International Society for Prevention of Child Abuse to assist national governments in establishing programs to prevent, detect, and respond to child abuse [35].

Other resources that may be helpful in the evaluation and management of suspected child abuse are listed in the tables (table 2A-B).

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Child abuse and neglect".)

SUMMARY AND RECOMMENDATIONS

●Reporting child abuse – Providers in many countries are mandated to report suspected child abuse and neglect. It is imperative that providers be knowledgeable of the requirements in the region where they practice. Information regarding child abuse reporting statutes in the United States is available from the Child Welfare Information Gateway. (See 'Reporting suspected abuse' above.)

●Reporting process – The parents or legal guardians of the child(ren) should be informed that the child abuse report is being made. This disclosure should focus on the medical provider's concern for the child's well-being and the legal mandate to report. The parents should also receive information regarding what the report means and what will occur (eg, a visit from a Child Protective Services [CPS] worker, social worker, and/or the police) (figure 1). (See 'Reporting process' above.)

●Documentation – In cases of suspected child abuse or neglect, the medical record should provide as much detail about the circumstances of the event as possible, including direct quotations from caretakers and photographs of the injuries (table 1). Thorough documentation may help to refresh the physician's memory in the event that they are subpoenaed to testify in court since the hearing may occur months or years after the alleged abuse. (See 'The written report' above and 'Written documentation' above.)

Photography is vital for documentation of external injuries, although in some jurisdictions, parental or legal guardian permission is required before photographs can be taken. When they may be used for legal purposes, photographs must depict the injuries accurately. They must be of high quality, taken in good light, and with an appropriate measurement reference. (See 'Photographs' above.)

●Testifying in court – The role of the medical provider is to be an educator of medical information to court systems; not to advocate for one particular side or another. Testifying in court can be difficult and intimidating for medical providers. Thorough documentation at the time of the evaluation and adequate preparation may serve to make it less disagreeable. When permissible in the appropriate judicial system, a pretrial interview with the attorney for whom testimony will be given provides an opportunity for the provider to review the medical record and photographs, gain an understanding of the entire case, and anticipate questions that may be asked during direct or cross-examination in the courtroom. (See 'Testifying in court' above.)

ACKNOWLEDGMENT — The editorial staff at UpToDate acknowledge Erin Endom, MD, who contributed to earlier versions of this topic review.