The services to children with the intention of raising

The Children First Act
2015, which was signed into law on 19th November 2015, sets out the steps which
should be undertaken to ensure that a child or young person is protected from harm.
The Act places a number of legal obligations on specific health professionals
and organisations providing services to children with the intention of raising
awareness of child abuse and neglect and compelling the reporting of such abuse,
improving child protection arrangements within organisations and promoting
cooperation and communication between agencies to assist TULSA with their evaluations
(Children First Act, 2015). The protection of children and young adults is the
responsibility, not just of their parents and families, but also of the
community and professionals in society. It is therefore important that health
professionals and organisations that provide services to children can recognise
when a child or young person is being harmed and what action should be taken in
order to protect the child and contribute to their on going safety (Department
of Children and Youth Affairs, 2017).

Child welfare and
protection is based on a legal framework provided mainly by The Children First
Act 2015, which places a number of statutory obligations on specific
professionals, including medical practitioners, and organisations within the
community to ensure the safety and wellbeing of children. Section 7 of the Act
is that the best interests of the child is the principal concern and therefore
any ‘reasonable grounds for concern’ that a child has been, is being or is at
risk of being abused or neglected should always be reported to The Child and
Family Agency (TULSA), for failure to do so could result in on going harm to
the child (Children First Act, 2015). Such grounds for concern include matters
where the child’s health, development or welfare have been, or are likely to
be, seriously affected, for example an injury or behaviour that is consistent
with physical or emotional abuse, consistent signs that a child is suffering
from emotional or physical neglect, admission from the child themselves that
they have been abused or from someone who saw the abuse and any concerns about
possible sexual abuse. It is important to note that a doctor or health
professional that has been informed of abuse from the child is ‘not required to
judge the truth of the claims or the credibility of the child’ (Department of
Children and Youth Affairs, 2017). Any report of known or suspected abuse or
neglect subsequently should be reported in person, by telephone or in writing
and should always be supported by evidence with as much information given as
possible so as to aid TULSA in their investigations.

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Exceptions from the
requirement to report include Underage Consensual Sexual Activity, in which a
sexual relationship is taking place where one or both parties are under the age
of consent (17 years) but the age difference is not more than 2 years, where
there is no difference in the maturity or ability to consent between both
individuals and when the young person clearly states that they do not want the
information to be disclosed to TULSA. There is also no legal obligation to
report if the concerns are developed outside of professional duties. While
failure to report does not lead to criminal sanctions, under no circumstances
should a child or young person be left in a situation that may expose them to
harm (Children First Act, 2015).

To report or not to
report is an ethical question that many medical practitioners have to answer when
faced with concerns over suspected child abuse mainly due to the difficulty in
differentiating between symptoms of abuse and harmless manifestations of
something unrelated to abuse (Shanley et
al., 2009). It is not the willingness to report that causes difficulty but
rather the confidence around the validity of the concern that results in
hesitancy, as well as the subsequent consequences that could happen if they are
mistaken (Buckley, 2015). Doctors often only see a snapshot of a child’s life
and accordingly only have a limited window of opportunity to establish the
presence of abuse and neglect. Consequently, the reality of reporting suspected cases
of child abuse is not as black and white as it may seem in theory, especially
for cases of emotional abuse and neglect. This is mainly due to a high level of
ambiguity and the fact that these forms of abuse are subjective and subsequently
have the potential to be interpreted differently.

When faced with
suspected cases of child abuse and neglect, there are many factors that play a
role in a doctor’s decision to report. A major ethical issue is the doctor’s
relationship to the family. Familiarity with a family and a positive past
history could result in a doctor being less likely to report suspicious
injuries, while meeting families for the first time or having prior concerns may
be more likely to sway the doctor towards reporting. Another issue that faces
doctors in their decision to report is the chance that reporting the situation
may result in negative implications for the child and family (Shanley et al., 2009). This is especially true
where an injury or behaviour, or lack of adequate explanation for said injury,
may be the only indicator of possible abuse and cause for concern.

This poses an ethical
challenge in that a mistaken report could have significant negative
repercussions for the child and their family, as well as damage to the
doctor/patient relationship, both within the family and the wider community,
thus impacting on the level of trust that has been built up. In particular,
children who have been taken from their parents even for a few hours, let alone
days or weeks may suffer the lasting effects of the distress from being
separated from their family, while wrongly accused parents are typically
anxious for both themselves and their child and may be exposed to considerable
stigma, even when proved to be false (Barry and Redleaf, 2014). Alternatively,
a doctor may be faced with the implication that the child is being subjected to
abuse and that their failure to report may result in on going harm to the
child.

In the case where a
child or young person has disclosed that they are being abused, but are clear
that they know not want this to be divulged to anyone else, doctors are faced
with the challenge of whether or not it is ethical to break confidentiality.
Confidentiality is central to the trust between the doctor and patient and thus
a core element of the doctor/patient relationship. By sharing information of
their abuse, the child is demonstrating the level of trust they hold with the
doctor and often takes a great deal of bravery on their behalf, something which
is recognised by the doctor. Consequently breaking this child’s trust is an
ethical challenge that may hinder or delay many doctors. However it is
important to note that the sharing of information in such situations is
important for the care and safety of the patient (Medical Council, 2016).

Ultimately a doctor’s responsibility is the
wellbeing and safety of their patients. However, in their duty of care many
healthcare professionals face ethical dilemmas with regards to children who may
be victims of child abuse and neglect. Every child deserves to be safe from
abuse and with the implementation of the Child First Act 2015, the best
interests of the child are of principal concern with mandatory reporting
required for any doctors who come into contact with children they genuinely
believe to be, or at risk of being, abused so that it may be fully and fairly
investigated. While it is often poses ethical challenges in deciding whether to
report suspected cases of abuse, it does not negate a doctor’s professional and
legal responsibility to protect children by doing so. It is thus important that
despite the wide range of ambiguity associated with many cases of suspected
abuse, it is essential that the doctor rely on both his/her training and
instincts in determining whether to take a closer look at the situation. It is
important that the possible diagnosis of child abuse or neglect is approached
in the same manner and with the same diligence as any other childhood disease
or disorder