The Irish Medical Organisation would like to thank the Joint Committee on Health and Children for the opportunity to comment on the heads and general scheme of the Children First Bill.
Doctors, particularly general practitioners and community health doctors, are at the front line in dealing with instances and the threat of child abuse. To doctors, the protection of children is of paramount importance. Like other front-line professionals, doctors have a duty to protect children and to report suspected incidences of child abuse. The Medical Council Guide to Ethical Conduct and Behaviour requires doctors to be familiar with Children First: National Guidelines for the Protection and Welfare of Children and to report any concerns about alleged or suspected sexual, physical, emotional abuse or neglect of children to the appropriate authorities. The Children First Bill will place this duty on a statutory footing.
Mandatory reporting is based upon the highest possible motives - to protect children, to prevent abuse of some of the most vulnerable in our society and to reassure parents and families of the safety and security of their children. There are definite clear advantages to mandatory reporting and these would include endorsement at the highest level that child abuse is absolutely unacceptable in any guise or form; an explicit statement that government, statutory and professional bodies have, as one of their core aims, the protection of our children; that any barriers to reporting are minimised; and that reporting is encouraged at the earliest possible stage.
In jurisdictions where mandatory reporting has been introduced, issues with the definition and diagnosis of child abuse have inflated the numbers of false reports adding unnecessary stress and damage to the affected families. At the same time, mandatory reporting is unlikely to be effective without an adequately resourced public health and social care infrastructure to assess and protect children post-reporting. The IMO has grave concerns that unless issues of diagnosis and resources are addressed, the unintended consequences of mandatory reporting could divert needed resources from those children at the greatest risk of abuse.
In order to report suspected child abuse, mandated professionals and designated officers must be able to recognise abuse. For physicians this requires precise definitions of what constitutes abuse and adequate training to identify and diagnose symptoms of physical, emotional and sexual child abuse and neglect. Long-term emotional abuse or neglect is often as potentially fatal as physical abuse yet the severity of the sign does not necessarily equate to the severity of the abuse.
There is a significant deficiency, internationally, of evidence-based case-controlled studies that would enable medical practitioners to diagnose child abuse with the level of certainty equivalent to that required by statutory and judicial systems. In jurisdictions that have introduced mandatory reporting, ambiguities in definitions and diagnosis have had multiple negative consequences for children, suspected perpetrators and medical practitioners. In particular, over-zealous reporting of suspected abuse as a ‘better safe than sorry' approach will result in consequent trauma for both children and suspected perpetrators in the many cases that will arise where no abuse will have taken place. Trauma arising from intrusive medical investigations may be both emotional and physical. Following the introduction of mandatory reporting of child abuse in the United States in the 1980s, there was a tenfold increase in the number of children investigated for abuse. The proportion ultimately demonstrated to be unfounded rose from 35% to 65% in one decade. Mandatory reporting can also lead to the avoidance of engagement in roles or duties relating to child abuse management since medical practitioners prefer risking sanctions to the social and professional consequences of erroneous reporting. While legal protection for those reporting allegations of child abuse can help and is provided for under the Protections For Persons Reporting Child Abuse Act 1998, reports that turn out to be false positives have the potential to destroy not only a family's relationship with its general practitioner but with the medical profession in general.
To support doctors in their statutory duty to report allegations of child abuse, the Irish Medical Organisation has made several recommendations. Precise definitions of abuse should be provided including the definition of emotional abuse. Child protection training for physicians should be provided at undergraduate level, post graduate level and on an ongoing basis as part of compulsory continuing professional development programmes. This training should include the recognition of known symptoms and diagnosis of abuse in both the victim and the alleged perpetrator, engagement with patients on the issue of abuse and adequate report writing skills. Another recommendation is that physicians should have access to specially trained medical practitioners, social workers and members of the Garda to whom they can bring doubts and concerns. Under the Bill, the HSE is to provide advice to designated officers but this function will become redundant if advice provided by the HSE is not an acceptable defence in the context of a decision not to report.
There is also a need to clarify reporting requirements for consensual sex among mature minors. The Bill presumes that consensual sexual activity permitted by law is not sexual abuse. Under current legislation children under the age of 15 years may not consent to any sexual activity, while those between the ages of 15 and 17 years may consent to sexual activity but not to sexual intercourse. In addition, females below the age of 17 years cannot be charged with statutory rape but males under the age of 17 years can be charged. Minors frequently seek advice from a GP about contraception or the treatment of sexually transmitted infection. Under the Non-Fatal Offences Against the Person Act 1997, people under 16 years can never consent to medical treatment. GPs often proceed with a consultation with a minor employing Gillick competence and the Fraser guidelines from the United Kingdom. This anomaly in the Irish system leaves Irish doctors remarkably exposed.
The IMO is concerned that the question of mandatory reporting will greatly hinder the doctor-patient relationship. A scenario is possible whereby a GP would have to disclose the sexual activity of a patient to the social services, which could lead potentially to the boyfriend being tried for statutory rape as a result. This would deter minors from seeking legitimate help from physicians in Ireland and the issue requires clarification in the Bill.
Ms Durville has already referred to the fact that in Ireland social services for children are recognised as grossly deficient. Lack of funding and successive recruitment moratoriums have severely hampered services. The resulting difficulties include delays in intervention, inconsistencies in assessment procedures, regional variations in family support services and therapeutic services, no 24 hour community care service and the lack of resources available for prevention and early intervention, leading to a crisis-driven service. Doctors also experience difficulties accessing Garda officers with a special interest and expertise in child protection.
Ms Durville also referred to an article in The Irish Times by Dr. Helen Buckley which discussed how the number of substantiated cases has fallen. With mandatory reporting the number of cases reported is likely to rise even further. In addition to an increase in false positives there is a danger that the number of false negatives, that is to say, cases that are screened out by error, will also increase or that the threshold for intervention will be elevated as further pressure is put on resources. The screening and triage of reports is resource intensive. Even with the recent increase in funding for child protection services, mandatory reporting is likely to further divert resources from services to protect children suffering abuse and neglect or from the provision of services for those cases that fall below the threshold for intervention.
Following the introduction of mandatory reporting in New South Wales in 1999, the rate of reporting to child protection services increased by 600% in eight years. The proportion of time invested by child protection services in processing reports was so great that few resources were available as a result for the children suffering abuse and neglect. Fewer than one eighth of reports were substantiated while the remainder did not warrant statutory intervention but would have benefited from support services delivered in a less formal manner in the community.
All cases reported to the child protection services require a mandatory medical history and examination together with a formal report from at least one medical practitioner. A total of four centres exist for the assessment of child sexual abuse. St. Louise's unit in Crumlin hospital and St. Clare's unit in Temple Street hospital have no in-house community paediatrician and assessments are carried out on request. The Family Centre in Cork has three community paediatricians available on an on-call basis and Waterford community child centre has one half-time equivalent community paediatrician. Other parts of the country have no formal assessment centres. In 2011, the community paediatrician in Waterford saw almost 200 cases and each assessment took on average one full working day. Specialised community paediatricians have the training and accumulated clinical experience to enable them to diagnose abuse with some degree of clinical certainty.
The IMO recommends that the development of adequate assessment and support systems should be enacted prior to plans for mandatory reporting to foster the confidence of service users and medical practitioners in optimum outcomes from reporting. Countries with functioning public health and social care infrastructure can experience increased reporting of child abuse in a non-mandatory environment compared to countries that have mandatory reporting systems. The IMO also recommends that the impact of the children first Bill on child protection services is monitored and that a review of the legislation should take place within three years. There is a need for investment in prevention and early intervention in line with international best practice, which suggests that prevention and early intervention can lead to better outcomes. Medical assessments require substantial resource provision and expertise and are more appropriately provided by specialised community paediatric services rather than GPs.