Suspected Non-Accidental Injury in a Pediatric Therapy Session
A 6-year-old boy is referred for occupational therapy because of difficulties with handwriting and attention at school. He attends with his mother, who is quiet and answers questions briefly. During the session the therapist notices a cluster of bruises on the back of his left upper arm and flank, roughly matching fingertip patterns, and a healing burn on the forearm about 2 cm across with a sharp edge. The mother says he 'falls a lot' and 'does not listen.' The boy is clingy with the therapist, flinches when the mother raises her voice, and says 'I am not allowed to tell.' He is otherwise well, with no fever. The mother asks the therapist not to write anything down because 'the school will get the wrong idea.' The therapist works in a community clinic with a named safeguarding lead and a written child protection policy. The family has no prior involvement with social services as far as the therapist knows.
1. What in this presentation raises concern, and what is the threshold for acting?
Read the worked answer
Several features raise concern, and together they cross the threshold for action:
- Bruise pattern: clustered bruises on the back of the upper arm and flank with a fingertip-like pattern are unusual for ordinary falls. Accidental bruises in mobile children tend to occur over bony prominences (shins, knees, forehead), not the back of the arm or flank.
- Burn: a 2 cm burn with a sharp edge and a healing appearance is not typical of a splash or contact burn from daily life; sharp demarcation can suggest a deliberate contact injury.
- Explanation mismatch: 'falls a lot' does not account for the pattern or the burn.
- Behaviour: flinching at a raised voice, clinginess, and the statement 'I am not allowed to tell' are significant. A child's disclosure, even partial, must be taken seriously and recorded in his words.
- Mother's request not to document: this is a red flag for concealment and must not be agreed to.
The threshold is not certainty. The professional standard is reasonable suspicion, which is met here. The therapist should not investigate, question the mother about the cause, or attempt to prove or disprove abuse. The correct action is to follow the clinic's child protection policy: report to the named safeguarding lead the same day, and make a referral to the appropriate child protection service in line with local law. The therapist does not need the mother's permission to report, and should not tell her that a report is being made if doing so would place the child at risk; the safeguarding lead and child protection service will advise on that.
2. The mother asks you not to write anything down. How do you respond, and what do you record?
Read the worked answer
Response to the mother: be calm and do not argue. Explain that you keep records of every appointment as part of your professional duty, and that you cannot agree to omit them. Do not promise confidentiality you cannot keep, and do not disclose that a referral is being considered if that would endanger the child. A workable phrasing: 'I understand you are worried about how this looks. I keep notes for every child I see; that is part of my job and I cannot change that.' Then redirect to the child's needs.
What to record, factually and without interpretation:
- Date, time, and who was present.
- The child's words verbatim: 'I am not allowed to tell.'
- The location, size, colour, and shape of each bruise and the burn, using a body map if the policy provides one. Describe, do not diagnose ('cluster of bruises, back of left upper arm, approximately fingertip-sized').
- The mother's explanation and the child's behaviour, described neutrally.
- The mother's request not to document, and your response.
- The action taken: who was informed, when, and what was referred.
Do not record speculation about who caused the injury, or opinions about the mother's character. Record facts and the actions taken. Keep the record secure and share it only on a need-to-know basis. If the child protection service requests a report, provide the factual record.
3. What are your ongoing obligations after the referral, and what do you do if the parents withdraw the child from therapy?
Read the worked answer
Ongoing obligations:
- Continue to be vigilant at every contact: note new injuries, changes in behaviour, and the child's statements, and record them.
- Do not investigate. Do not question the child beyond what he volunteers, and do not confront the parents. The child protection service leads the enquiry.
- Cooperate with the child protection service and the safeguarding lead, providing records and attending case discussions as required.
- Maintain the therapeutic relationship where safe and appropriate, and continue to address the original referral (handwriting, attention) if the child remains in therapy.
- Follow up on whether the referral was received and what the outcome was, within the limits of information sharing.
- Look after yourself: seek supervision and support; this work is distressing.
If the parents withdraw the child:
- Record the withdrawal, the date, and any reason given.
- Inform the safeguarding lead immediately; withdrawal after a concern is itself significant.
- The child protection service should be told, because they hold the statutory responsibility and can act even if therapy stops.
- Do not attempt to pursue the family yourself or to pressure them to return; that could compromise the enquiry.
- Keep the door open professionally: a letter offering re-referral if needed, without implying surveillance.
The therapist's duty is to the child's safety, which continues regardless of whether the family remains in the service.