Technical Report WHO GUIDELINES FOR THE HEALTH SECTOR RESPONSE TO CHILD MALTREATMENT Acknowledgements ............................................................................................................................ 2 Acronyms and abbreviations ............................................................................................................... 3 Glossary ............................................................................................................................................. 4 Executive summary ............................................................................................................................. 6 Summary of guiding principles ............................................................................................................ 8 Summary of recommendations (R) and good practice statements (GP) ............................................... 8 1. Background .................................................................................................................................. 17 A. The magnitude of child and adolescent maltreatment .................................................................................. 17 B. Health consequences of child and adolescent maltreatment ........................................................................ 18 D. Objectives of and rationale for these guidelines ............................................................................................ 19 E. Target audience .............................................................................................................................................. 20 F. Scope of the guidelines ...................................................................................................................... 20 2. Methods ....................................................................................................................................... 22 A.Guideline contributors .................................................................................................................................... 22 B.Declaration of interests by external contributors ........................................................................................... 22 C.Identification of priority research questions and outcomes – scoping exercise.............................................. 23 D.Evidence retrieval ............................................................................................................................................ 23 E.Quality assessment, synthesis and grading of the evidence ............................................................................ 24 F.Formulation of recommendations ................................................................................................................... 25 G.Document preparation and peer-review ........................................................................................................ 26 3. Guiding principles derived from ethical principles and human rights standards ........................ 26 A. The principle of best interests of the child or adolescent .............................................................................. 26 B. The principle of evolving capacities of the child or adolescent ...................................................................... 27 C. The principle of non-discrimination ................................................................................................................ 28 D. The principle of participation ......................................................................................................................... 28 4. Recommendations and good practice statements ......................................................................... 29 A. INITIAL IDENTIFICATION ................................................................................................................................. 29 B. MEDICAL HISTORY, PHYSICAL EXAMINATION AND DOCUMENTATION OF FINDINGS .................................... 39 C. SAFETY AND RISK ASSESSMENT ...................................................................................................................... 44 D. INTERACTING WITH CAREGIVERS ................................................................................................................... 46 E. PSYCHOLOGICAL AND MENTAL HEALTH INTERVENTIONS .............................................................................. 48 F. ETHICAL PRINCIPLES AND HUMAN RIGHTS STANDARDS FOR REPORTING CHILD OR ADOLESCENT MALTREATMENT................................................................................................................................................. 58 G. TREATMENT OF PERPETRATORS .................................................................................................................... 61 H.FACILITATING UPTAKE OF SERVICES................................................................................................................ 63 I. CREATING A SUPPORTIVE AND ENABLING SERVICE-DELIVERY ENVIRONMENT FOR HEALTH-CARE PROVIDERS ............................................................................................................................................................................ 65 6. Research implications ................................................................................................................... 66 A.Initial identification ......................................................................................................................................... 66 B. Medical history, physical examination and documentation of findings ......................................................... 67 C. Safety and risk assessment ............................................................................................................................. 67 D. Interacting with caregivers ............................................................................................................................. 67 E. Psychological and mental health interventions .............................................................................................. 67 F. Ethical principles and human rights standards for reporting child or adolescent ........................................... 68 G. Treatment of perpetrators ............................................................................................................................. 68 H.Implementation considerations ...................................................................................................................... 68 7. Dissemination, implementation, monitoring and evaluation .......................................................... 69 Updating the guidelines .................................................................................................................... 70 Annexes ........................................................................................................................................... 71 Annex 1. Guideline contributors ......................................................................................................................... 71 Annex 2: Implications of the strength of the recommendation ......................................................................... 78 Annex 3: International and regional human rights treaties and consensus documents containing safeguards that are relevant for child and adolescent maltreatment .................................................................................. 79 Annex 4. List of supplementary materials in Web Annexes ................................................................................ 80 References ....................................................................................................................................... 82 Acknowledgements The Department for the Management of Noncommunicable Diseases Violence and Injury Prevention (NVI) at the World Health Organization (WHO) has produced this guideline document, under the leadership of Berit Kieselbach (responsible technical officer). The WHO Steering Group (Avni Amin, Alexander Butchart, Etienne Krug, Christopher Mikton, Claudia Garcia-Moreno,, Megin Reijnders, David Ross, Chiara Servili, Marcus Stahlhofer, Mark van Ommeren) gratefully acknowledges the contributions of all the Guideline Development Group (GDG) members: Mona Alkhawari, Maha Almuneef, Jane Barlow, Howard Dubowitz, Asvini Fernando, Jenifer Goldman Fraser, Omer Khan, Alison Kemp, Harriet MacMillan (Co- Chair), Bernadette Madrid (Co-Chair), Mary Joseph Marret, Ben Mathews, Joan van Niekerk, Joseph Rjumba, Rajeev Seth. Alexander Butchart coordinates the work of the violence prevention team. Christopher Mikton was the responsible technical officer at the start of the guideline development process. We also acknowledge the guidance of Cicely Marston as the GRADE Methodologist. NVI also thanks the following external contributors who peer-reviewed the guideline: Edward Chan, Sibnath Deb, Ilsa Dede, Lina Digolo, Martin Finkel, Kevin Lalor, Yanghee Lee, Marija Markovic, Noemí Pereda Beltran, Irene Petit, Josefina Luna Rodriguez, Dinesh Sethi and Hanna Vseviov. A special thanks to the systematic review teams: Jill McTavish (Lead) and Christine McKee (Identification, Psychosocial Interventions, Recurrence) and Elena Broaddus (Lead), Allison Ruark, Kerry Scott, Binita Adhikari and Osama Ummer (qualitative reviews for the good practices related