Do Australian Paramedics Understand Their Professional and Legal Obligations Regarding Child Abuse and Neglect?

Abstract

Child abuse and neglect (CAN) causes significant harm to Australian children, resulting in significant health and social impacts. Paramedics frequently encounter patients experiencing CAN, though they often report little education and training. Little is known about their capacity to detect CAN or their willingness to report suspected cases. This study aims to explore the understanding of Australian paramedics of key legislation and organisational policies. A novel, 23-item exam-style questionnaire and 10 short vignettes depicting CAN were presented to a sample of Australian paramedics working in the state of Victoria. Analysis of item-level responses and associations with gender, location of work, and skillset was undertaken. Participants provided the correct response for knowledge items 62.7% of the time (range per item: 23.0–73.3%). Participants responded “unsure” for items between 3.2 and 24.9% of the time (average 11.0%). Participants correctly identified that each vignette contained a depiction of CAN between 51.8 and 94.3% of instances. Participants were least knowledgeable or willing to report CAN when depicted as emotional abuse or domestic and family violence. Australian paramedics appear reasonably well educated and informed with respect to CAN; however, they also appear to be less able to recognise emotional abuse and children exposed to domestic and family violence than other types of CAN, which may require targeted intervention. It is possible that paramedics may not be detecting and reporting CAN based on risk to the child and may be attempting to determine the validity of disclosures or have a too high threshold for indicative signs of CAN. Future research should focus on determining the most effective strategies and interventions to increase detection and willingness to report.

Appendix

Appendix 1 Full questionnaire and correct answers

Part 1 Knowledge of obligations

Considering the relevant national legislation in Australia, the Victorian legislation, and the policies and clinical practice guidelines (CPGs) of Ambulance Victoria, please answer the following questions to the best of your ability:

Please do not consult your CPGs or any other sources when attempting to answer the questions.

(All questions answered by: true/false/unsure options)

Question	Correct answer
Paramedics registered in Victoria are listed as mandatory reporters of child abuse in the Children, Youth, and Families Act 2005	F
All adults in Victoria must make a report to Victoria Police or Child Protection Services when they form a reasonable belief that a sexual offence has been committed by an adult against a child, unless they have an exemption from reporting or they have a reasonable excuse	T
If a Victorian paramedic, who does not have an exemption or a reasonable excuse, fails to make a report to Victoria Police or Child Protection Services when they become aware that an adult has committed a sexual offence against a child, they may be charged with a crime that could lead to imprisonment	T
To make a report to Victoria Police or Child Protection Services about an adult sexually abusing a child, you must have firm evidence to prove it	F
For each of the following scenarios, state if you think a Victorian paramedic would be expected to make a report to Victoria Police or Child Protection Services in regards to an adult sexually abusing a child:   1. A child tells you they have been sexually abused by an adult   2. A child tells you they know someone who has been sexually abused by an adult   3. A parent tells you their child has been sexually abused by an adult   4. You observe signs in a child that you believe could be related to sexual abuse by an adult   5. A child’s behaviour or development leads you to believe they may have been sexually abused by an adult   6. You overhead someone talking about a child who you have not seen, and they state that they think the child might have been sexually abused by an adult	1–5 = true, I would be expected; 6 = false, I would not be expected
You become aware that a senior paramedic colleague is likely to have committed a sexual offence against a child. You can be exempt from reporting this to anyone as you have a reasonable fear that if you do report, it you may lose your job	F
You attend a 13-year-old child who discloses to you that they have been sexually abused by their stepparent. You discuss this with your more senior partner, who says they do not believe the child. You can be exempt from reporting this to anyone, as it is the responsibility of the most senior paramedic to decide if a report should be made	F
You become aware that a paramedic colleague is likely to be sexually abusing their own child. You can be exempt from reporting this to anyone as it may detract from the public’s trust in the ambulance service	F
You become aware that an adult has sexually abused a child. The adult says to you that they would harm themselves if anyone found out. You can be exempt from reporting this to anyone if you have a reasonable fear for the safety of the adult offender	F
You attend a 20-year-old female who discloses she was sexually abused by a stepparent when she was 14 years old. The patient requests that you do not report this offence to anyone, as she wants to move on with her life. You can be exempted from reporting this to anyone	T
You attend a 15-year-old who discloses a sexual assault by an adult. Before telling you this, they state they wish the information to be kept confidential and they do not want you to report this to anyone. You are not required to report this to anyone, as the child has requested confidentiality	F
You attend a 15-year-old female who believes she is pregnant. The 19-year-old father is present. The female patient explains to you that the relationship is consensual. You are not required to report this to anyone, as the relationship is considered consensual	F
You make a report to Child Protection Services when you suspect an adult has emotionally abused a child. The case is subsequently investigated by Child Protection Services, who find no evidence of abuse. You can now be held liable by your employer and/or Victoria Police for making an incorrect report	F
If you encounter a child who you believe is at risk of harm from family violence and you report your concerns to a mandated reporter (e.g. a nurse or doctor) you do not have to also make a report to Child Protection Services or the Ambulance Victoria Integrity Officer	F
Your employer expects you to make a report to Child Protection Services or the Ambulance Victoria Integrity Officer if:   • you believe a child you assess is at risk of sexual abuse but has not actually been abused   • you believe a child you assess is at risk of physical harm but has not actually been harmed   • you believe a child you assess is at risk of psychological harm but has not actually been harmed   • you believe a child you assess is at risk of emotional harm but has not actually been harmed   • you believe a child you assess is at risk of neglect but has not actually been harmed	(All T)

Part 2 Vignettes

Please read the following vignettes and respond to the subsequent questions.

Questions for each vignette

• 1. This scenario contains indications that abusive or neglectful behaviours may be occurring

(response options: agree/disagree/unsure)

• 2. My employer would expect me to make a report about this case to an appropriate person (e.g. Victoria Police, Child Protection Services, or the Ambulance Victoria Integrity Officer)

(response options: agree/disagree/unsure)

• 3. How likely do you think you would be to make a report to an appropriate person (e.g. Victoria Police, Child Protection Services, or the Ambulance Victoria Integrity Officer) if you encountered this case

(response options: 5-point-Likert: 1 = very unlikely, 2 = unlikely, 3 = unsure, 4 = likely, 5 = very likely)

1	You attend a 25-year-old after their 6-year-old child called the ambulance because they were hungry and were unable to rouse their parent. On arrival, you are able to rouse the patient with a painful stimulus, and they confirm they have taken heroin, but refuse to be transported to ED. They ask you to leave and then lay down and return to sleep
2	You attend to a 2-month-old child who has not been feeding well and is now dehydrated with low blood sugar. The child’s parents state the child is constantly crying and they cannot get them to feed. They state they are unsure what to do about it so they have just been leaving the child to cry in their crib until they are ready to feed. The child has not been fed for 20 h
3	You attend a 15-year-old who recently returned home from a friend’s party crying and told their parent that an unknown older person at the party kept trying to pinch their bottom and then tried to kiss them. The patient’s parents called the ambulance when they could not calm the patient. On arrival, the patient reports no injuries requiring ambulance management and refuses to talk with you about what happened. The patient declines your offer of transport to ED and becomes upset when you attempt to talk to them further about the incident. The parent thanks you for coming and says you can leave and they will talk to their child in the morning
4	You attend a 14-year-old who is intoxicated at night in a local park with a group of friends. While assessing the patient, a friend who is also intoxicated states that the patient is “messed up” because their parent “keeps touching them”. The patient gets angry and tells the friend to stop lying
5	You attend to a 5-year-old with a rash and breathing difficulties. During your assessment of the child’s skin rash, you noticed bruising to the child’s bottom. You ask the parent about the bruising and they state the bruises are from spankings. They explain their child can be very naughty, and both parents use spankings to teach them to behave
6	You attend to a 4-year-old with a possible broken wrist. You are met by a person who introduces themselves as a foster carer and states the child is in a statutory child protection placement. The foster carer tells you how clumsy the child is and that they are always falling over—hence how they broke their wrist. The carer comments that the child has new bruises every day. You notice bruising of various states of healing on the front and back of both of the child’s lower legs, both wrists, and their right upper arm. The child is quite fixated on their wrist and when asked about the injury says that they fell while running in the backyard
7	You attend to a 32-year-old who is intoxicated. The patient’s partner called the ambulance when they returned home with their 2 children and were unable to rouse them. You assess the patient who is severely intoxicated. The patient begins to get angry at their partner, and during an episode of shouting accuses them of “abusing our children”. The patient’s partner calmly denies this and states that the patient has PTSD from their own childhood trauma, and often makes these claims. The partner states the patient is being seen by a psychologist and they have already been reported to Child Protection Services who found no evidence of abuse. The children observe the entire scene and hear everything that you discuss
8	You are called to a 28-year-old patient who appears to have a skull fracture. On arrival at the house, you are met by 3 children who take you to the patient who is on the floor and is bleeding from the right eye socket. The patient’s left eye appears to be healing from a recent black eye. The patient states that they slipped and hit their head on the wall. There are no other adults present in the house. You note that there is little furniture in the house, only mattresses and some broken furniture. The children wear stained and dirty clothing and appear to you to be afraid
9	You attend a 13-year-old who had a panic attack at school. The patient has calmed down by the time you arrive and is quite embarrassed that you were called by the school. The school nurse states the patient has a history of anxiety attacks. The patient keeps saying they are fine and they want to return to class, and they were “just a bit upset about an exam result” and that “they did not want to upset their parents”. You perform a quick assessment, during which you notice a few superficial linear scratches to the patient’s left forearm. When you finish your assessment the patient says they are going back to class and stands up to leave. As they exit the room the patient says: “No one better tell my parents about this”
10	You attend a 15-year-old whose parent called the ambulance when they came home and discovered their child was intoxicated. The child is only slightly intoxicated and states their parent is overreacting. During your assessment, you discover that the child is being seen by a psychologist for depression and anxiety, and they also state to you that they have a poor relationship with their parents, who constantly ridicule and criticise them