Radiography 27 (2021) 1073e1077
lable at ScienceDirectContents lists avaiRadiography
journal homepage: www.elsevier .com/locate/radiA qualitative description of how Ghanaian radiographers identify
suspected child physical abuse
W.K. Antwi a, *, P. Reeves b, F. Christine c, L. Aziato d
a Dept. of Radiography, School of Biomedical & Allied Health Sciences, University of Ghana, Ghana
b Sheffield Hallam University, Sheffield, UK
c Clinical Hypnotherapy, Todwick, Sheffield, UK
d School of Nursing, University of Ghana, Ghanaa r t i c l e i n f o
Article history:
Received 4 February 2021
Received in revised form
13 April 2021
Accepted 20 April 2021
Available online 15 May 2021
Keywords:
Child protection
Physical abuse identification
Radiographers* Corresponding author.
E-mail addresses: wkantwi@chs.edu.gh (W.K.
(P. Reeves), cmferris@btopenworld.com (F. Christine),
https://doi.org/10.1016/j.radi.2021.04.007
1078-8174/Crown Copyright © 2021 Published by Elsa b s t r a c t
Introduction: Child physical abuse is intentionally inflicted injury of a child and presents a challenging
diagnosis to clinicians mostly as a result of doubts about whether the findings were perpetrated by carers
of these children. Suspected child physical abuse cannot be reported without its initial identification,
substantiation and reporting. Imaging findings is one way of providing evidence of abuse in court.
Methods: A qualitative design was used to gather data. Twenty (20) radiographers were recruited using
purposive criterion sampling to share their experiences of mode of identification of suspected child
physical abuse. Semi-structured interviews were conducted to gain deeper insight into their experiences.
Results: Radiographers' suspicion or identification of child physical abuse was based on four (4) con-
structs: pre-radiographic observation; child's physical signs; caregiver secrecy and imaging findings.
These observations provoked further investigations through questioning of the child (if of verbal age),
parent or both. Their initial suspicion through assessment of cases was sometimes strengthened by the
imaging findings.
Conclusion: Radiographers suspected child physical abuse using several approaches some of which were
found to be unacceptable although it led to other important information, such as additional imaging
performed by the radiographers without doctor consultation. However, being able to identify child
physical abuse is important in child protection activities.
Implication for practice: Identification and reporting of suspected abuse to the appropriate child pro-
tection authorities are imperative for child protection. The possibility that some experienced radiogra-
phers may fail to deal with serious instances of child abuse exist. A radiographer's inability to identify
such cases, could that the victim would miss the required protection from the professional.
Crown Copyright © 2021 Published by Elsevier Ltd on behalf of The College of Radiographers. All rights
reserved.Introduction
The occurrence of injuries amongst infants is not unusual; many
of which are accidental, others may have been inflicted through
abuse of which health professional should take note.1 Child physical
abuse presents a challenging diagnosis to clinicians mainly because
there could be uncertainty about whether the findings were
inflicted by guardians of these children or not.1 Identification and
notification of suspected abuse is imperative for child protection. AAntwi), p.reeves@shu.ac.uk
laziato@ug.edu.gh (L. Aziato).
evier Ltd on behalf of The CollegeUnited Nations Children's Fund (UNICEF) country report on Ghana
indicated that, approximately 90% of children reported some form
of violence and placed Ghana in the 8th position in the world with
serious child rights violations.2 One study3 which examined 153
school children on corporal punishment in Ghana, found that 61.4%
(n ¼ 153) of the children were physically punished by their parents
or a caretaker; seven out of ten pupils found the school to be the
most likely environment where they would receive physical pun-
ishment. It has been established that children continue to experi-
ence additional abuse when not identified or reported.4
The doctor should be able to distinguish non-accidental injuries
from those which are accidental, perform a thorough and cautious
investigation with suitable supporting assessments, non-of Radiographers. All rights reserved.
W.K. Antwi, P. Reeves, F. Christine et al. Radiography 27 (2021) 1073e1077judgmentally evaluate the account provided for the injury, and
establish the likelihood that the description actually relates with
the nature, brutality, and age of the injury.5
However, various child protection studies have established
some key obstacles faced by health care professionals in reporting
child abuse.6,7 These impediments included the health care prac-
titioner's unease about the possibility of wrongful identification of
the abuse, concerns about being segregated and stigmatised, a gap
in the practitioner's awareness of contemporary facts about iden-
tifying and reporting abuse6,7 and, cultural influences.8 It is also
understood that, the diagnosis of abuse becomes difficult where
children are nonverbal or are unable to provide a history, and
sometimes when faced with elusive physical abuse signs which
may be muddled with other common paediatric diagnoses.1
Moreover, defining whether marks and bruising were from phys-
ical chastisement establishes abuse can be very problematic.1 This
is particularly true for cultures that accept corporal punishment as
child discipline.8,9 Irrespective of reasons deterring professionals
from reporting, it is worth noting that there is 50% probability that
an abused child could suffer subsequent mistreatments.10 Despite
the reported hindrances that sometimes prevent health pro-
fessionals from notifying the appropriate authorities of suspected
abuse, reporting is indispensable in guaranteeing the wellbeing of
children.11 However, this can only be possible when inflicted
physical abuse is identified by the health care professional and
there is willingness to report.
Radiographers play an important role in advancing child pro-
tection in the medico-legal context.12-15 Hidden evidence of abuse
can be revealed through the quality images radiographers produce,
and moreover the images are used to estimate the age of these
fractures.16 Additionally, these images may be required in court of
inquiry.12,13,15,17 The contribution of radiographic assessment of
children suspected to have suffered physical abuse has been
reported.5,12,13,15,18e20 This notwithstanding, the clinical implica-
tion of a radiographer's ability to recognise or suspect abuse may
prompt reporting, could support child protection authorities within
the hospital. The current study is an extension of two previous
publications of the authors8,20 which identified factors that led to
spectator attitude towards child protection by the radiographers.
The current study also sought to explore Ghanaian radiographers'
method of identification of suspected physical abuse amongst
children who presented for radiographic examination.
Method
The current study builds on previous work8,20 and details of the
methods are discussed. A qualitative design was used to gather
data. Twenty (20) radiographers were recruited to the current
study from the register of the Ghana Society of Radiographers and
the society's social media platform using purposive criterion sam-
pling. Semi-structured interviews were conducted before the
COVID-19 pandemic.
Participants’ interviews were audio recorded and the reports
provided by participants were transcribed and analysed by the first
author. The thematic analysis and themes developed were
reviewed by the co-authors. The data was managed with NVivo
Version 10 (developed by QSR International, Melbourne Australia).
Themes developed formed the discussion of this paper.
Ethical consideration
Ethical approval was sought and granted by the Institutional
Ethical Review Boards/Committees such as Ghana Society of Radi-
ographers; ID NO: GSR/EEC/V1/003, Ghana Health Service, ID NO:
GHS-ERC:14/01/14 and Sheffield Hallam University. Written1074informed consent was sought and obtained from all the
participants.Results
The study involved 16 males and 4 females with a mean age of
30 years andwork experience between 5 and 29 years. Radiography
in Ghana is male dominated and although the number of radiog-
raphers in Ghana stands at 250 at the time of study, the 20 par-
ticipants had indicated an encounter with suspected cases of child
physical abuse to qualify for participation. All were married with
children except one female radiographer who was single and had
no child. Participants were from major teaching, regional and
municipal hospitals, and some polyclinics. Four (4) thematic con-
structs were developed out of thematic analysis of the transcribed
interviews: pre-radiographic observation; child's physical expres-
sions; caregiver secrecy and imaging findings were considered.
These are analysed under separate headings below.Pre-radiographic observation
Observations by some participants before the X-ray examination
of the child were important in determining whether a case before
them appeared to be physical abuse. Through history taking some
were able to establish, or suspect that abuse might have occurred.
“… if it is not indicated on the request form as an abuse, I only talk
to the patient or the mother of the child to find out what happened.
It is then that I get to know whether it is an abused child or not”.
(Rad 03)
“… upon interrogation and talking with the child, the child ended
up giving us a clue that it was themother who caused such a degree
of injury to him. (Rad 20)
They normally interviewed the child further which occasionally
led to the cause of the abuse:
“… and when I asked the child why the mother did that (beat him),
he said it was because the father beat the mother”. (Rad- 06)
Some participants were dissatisfied with the brief clinical in-
formation on the X-ray referral form. Simple clinical histories such
as “trauma”, created confusion because they were unable to deci-
pher from such short information. The doctors neither stated what
form of trauma the child had experienced nor the right protocols
they wanted for the examination if the “trauma” written on the
referral form implies an abuse.
“It is like they do not tell us on the request form the child has been
physically abused or suspect abuse but they tell you it is a trauma
case. (Rad 07).
“So maybe, through your own investigation before you come out to
know that the child has been abused”. (Rad 07)
“The doctor too has written trauma and trauma can be anything…
but after you have done the case you probe further and you see that
no this is not ordinary accident but there is something wrong”. (Rad
04)
Another problem reported was clinical histories which mis-
matched the injuries observed on the child.
“The history indicated a fall but if you look at it, they you could see
they even poured water on the child, and there were bruises as well
W.K. Antwi, P. Reeves, F. Christine et al. Radiography 27 (2021) 1073e1077so if you look at the injury and history, there is no relation” (Rad-
06)
The history taking by some participants was occasionally
affected by language barriers. This cultural problem hindered a
participant's attempt to query further.
“Ammm the only problem is when they don't speak your language
or English it becomes difficult to probe or ask questions. In
such situations am unable to tackle issues the way it should be”
(Rad -14)
Child's physical signs
A few of the participants suspected abuse when the child pre-
sents with unusual emotional expressions and doubtful physical
injuries.
“… when they came it was like the child has been crying and
experiencing some discomfort” (Rad-02)
“… the physical appearance of the person sometimes gives you a
certain suspicion” (Rad-05)
“… the child was as if you know has been run over by a train, he
looked like somebody whowas not being well taken care of and this
one was so obvious because the way the parents even interacted
with the child in my presence you could tell that this was a child
who was undergoing abuse”. (Rade20)
“… I had a baby and I was to do a pelvic x-ray for the child who had
burns at the genital area and … it was too bad I wanted to know
what happened ” (Rad-10).
Apart from using child's emotional and physical signs as a clue
to suspect physical abuse, radiographers may also take cues from
parental behaviour.
“From the look of the child and how he was crying, I felt that it was
not just an ordinary injury because in the first place the mother lied
tome that the child fell but looking at how there were swellings and
lacerations on the head, I decided to ask more questions” (Rad-12).
Clues such as the child's anxiety and unwillingness to talk and
lack of parental warmth created suspicion that the child was
probably abused. In particular, Rad-07 and Rad-14 reported
“Most often when they come, it is like because they have been
abused, the child is scared even to talk and then the parents are so
agitated that they put some fear in the children so they cannot even
open up … most often the parent will be shouting at the child at
times they will even go to the extent of even beating them in front of
you” (Rad-07).
“Children suffering from child abuse … are afraid of their parents
and also sometimes because the child is not allowed to talk when
they bring them here by the behaviour of the parents” (Rad-14).
Caregiver secrecy
Parents sometimes were not ready to divulge any information
and this, combined with poor parental warmth, was a clue for some
participants to suspect physical abuse. For example,1075“…whoever brought the child is not ready to talk to you” (Rad-15).
“… the way the parents even interacted with the child in my
presence you could tell that this was a child who was undergoing
abuse” (Rad 20).
On some occasions, the radiographer was fortunate to have a
verbally cooperating child who was ready to talk when the
accompanying parent gave false information.
“… this child was somehow cooperating so we got to find out that
no, this was an abuse issue he (child's father) was trying to cover up
the whole situation but from the child, we managed to gather some
information in that situation”. (Rad-06)
“… I asked those who brought the child to leave the room and when
I further probed the child, I realised that he was even more afraid to
tell me what caused the fracture to the femur … So the boy could
not give me the information I needed but I realised that it was a
typical abuse case ” (Rad-15).Imaging findings
Imaging results helped some radiographers to confirm or
disprove their suspicion of probable physical abuse. Some of these
radiographers did not initially probe for information until the im-
aging was completed and findings were suspicious.
“Most of them you finish the procedure and the radiographs will tell
you this person has a fracture… you probe further and you see that
no this is not ordinary accident but there is something wrong… you
asked the mother what exactly happened then maybe that is where
they will come out with the truth”. (Rad-04)
“Yes, it is when we see the radiograph that is when we further ask
the relatives who accompanied the victims what happened. We do
not just give the films out but we try and investigate in a way to
know what happened to the child. That is when they tell you the
actual story when you see the outcome of the report” (Rad-16)
Multiple healing fractures identified by a radiographer after the
imaging made the radiographer look for other clues to confirm the
suspicion of probable abuse.
“There was one particular case … the patient came in with a
request with the history of trauma … it was the right upper limb
but as I began to do it, I realized that there were several other
fractures that were healing also. I became suspicious and so I began
to get more inquisitive and tried to find out what really was the
problem” (Rad-20).
The radiographers suspected abuse when the patient was, for
the second time, referred for follow up X-rays.
“… I did what the clinician actually requested for - a chest x-ray
which we carried out but there seems not to be any major problem;
only for them (child and parents) to come after some weeks and the
same procedure is carried out and you could see some fracture
healing, I mean callus formation around some of the ribs and you
could suspect that something fishy is happening”. (Rad-02)
Although not acceptable in the scope of practice in Ghana, for a
radiographer to use his or her discretion to perform additional
W.K. Antwi, P. Reeves, F. Christine et al. Radiography 27 (2021) 1073e1077projections, one participant did that to confirm his suspicion of
physical abuse.
“… but on the same humerus there was another fracture you know
that was healing and then I just per chance did a radiograph of the
radius and ulna including the wrist and found two other fractures”.
(Rade20).
This raises a questionwhether the radiographer's discretionwas
right or wrong.
Discussion
Managing child abuse cases generally depends on abuse iden-
tification, reporting and subsequent action. This study explored
Ghanaian radiographers' method of identification of suspected
physical abuse among children. Child physical abuse has been
described as any destructive action directed against a child with the
infliction of injuries such as bruises, slashes, burns, fractures, head
and orofacial injuries, internal abdominal injuries or poisoning.21 It
is appropriate for radiographers to recognise a child who has been
abused as they play an important part in the chain of child pro-
tection in healthcare. The actions taken by radiographers have
implications for the welfare of the child who have been abused.
This formed part of the significant issues addressed in the current
study. The requirement to identify physical abuse falls on all those
involved in the care of children including experts in the area of
diagnostic imaging.22 In the context of Ghana, the study found that
cases of child physical abuse were either identified or suspected by
Ghanaian radiographers through several evaluation processes. A
few of the radiographers’ suspicions of physical abuse depended
upon the appearance of the child, especially the injuries observed
before the imaging procedures were done and also from further
information sought either from the child or parent. This was
regarded as an important step because as primary care pro-
fessionals they have, by the nature of their work, the opportunity to
examine children when positioning them for any radiographic ex-
amination.15 Moreover, as a result of the growing occurrence of
several types of abuse, it is required that those providing the service
to children who report with any of the sub types of mistreatment,
undertake thorough evaluation of the child for identification of any
other form of abuse.23 This however, does not imply or support the
radiographer to undertake discretional projections as part of this
assessment. One would have thought the imaging findings could
assist the referring clinicians to go ahead to order other tests.
The identification of child abuse is necessary to provide the
necessary intervention for the victim. Evidence suggests that the
timely recognition and diagnosis of abuse and neglect are vital
because the condition is associated with morbidity and significant
mortality rates.24 This, against the high incidence of child physical
abuse in Ghana,25,26 makes it appropriate for radiographers to be
able to identify any form of abuse and rely on such observations.
Aspects important in child protection include notification when
abuse is identified which should prompt investigations to sub-
stantiate the allegation.27 This would allow for action to be taken to
prevent further abuse.4 Consequently, it is critical for professionals
who handle children not to ignore steps such as the initial identi-
fication and reporting their suspicion.
As evidenced in the current study, the imaging findings enabled
some radiographers to seek further information from the parents to
help them understand what actually caused the injury particularly
when the imaging findings were doubtful, consistent with previous
studies.13,15,28 Through this process, radiographers in the current
study were able to get useful information to establish non-
accidental injuries. This information could be given to the1076radiologists to provide good reports if the hospital has a radiologist
or to the Social Welfare Department (SWD) which is the legal
department in the hospital supposed to handle abuse cases. How-
ever, a previous study by the authors established that these radi-
ographers were not aware they should report their suspicion to the
Social Welfare.20 The case identification steps used by participants
in the current study were, in large part consistent with other
studies.15,29,30
The findings also identified that participants in the current
study used observation of poor parental or caregiver relations with
the child to suspect abuse, particularly when no cordiality was seen
between the child and parent/caregiver.
Children require parental warmth and sense of belonging for
their sound development and a child lacking this should draw one's
attention that the child might be at risk of abuse. There have been
unsupported reports of parents attempting to harm their children
even in the imaging department where the radiographer was the
other adult present as the parent was in the room, had to intervene
and prevent further abuse.31 Similarity was established in the
current study where radiographers observed parents beating and
yelling at their children in their presence. However, one radiogra-
pher who had experienced such negative parental behaviour did
not act because to him it was a family affair.8,9
A clinical issue that bothered the radiographers in the current
study centred on the nature of the referral history provided. There
was a consensus among the majority of participants interviewed
that the information usually provided by the doctors was often
either inadequate or imprecise or did not correlate with the
observed injuries.32-34 ‘Trauma’ as history to some participants is
not specific enough as to whether the condition presented by the
child was due to non-accidental or accidental injury. This concern
was not surprising as radiography procedures apply specific im-
aging protocols to accomplish a clinical investigation based on the
clinical history and test presented. This is not unique to the Gha-
naian situation since doctors may also not be sure, or even be aware
of a possible non-accidental injury if they are inexperienced or false
history were presented by parents/caregivers. However, in the
current study, participants' concerns were relevant because not all
fractures (or trauma cases) seen in a child suggests abuse or
otherwise unless supported with required clinical history.18 In
contrast to these arguments, one would also expect that once
trauma was indicated and particularly in children, it would be
prudent for the radiographer to have in mind that abuse could also
be a possible cause for which reason the X-ray referral has been
made for differential diagnosis. Doctors may face numerous ob-
stacles to identify child abuse which could affect the history they
provide the imaging department such as criteria to arrive at abuse.4
Moreover, the diagnosis of child physical abuse has been a chal-
lenge because of disbelief by health professionals that caregivers
could hurt children.1 For this reason, clinicians generally, should
continuously contemplate on other reasonable approach of medical
diagnoses in advance before establishing with conviction that the
child's injury is from abuse.35
The current study can establish that radiographers studied were
diligent to unravel the cause of child's injuries through further
probing, which sometimes gave them fruitful information. This step
by some Ghanaian radiographers is relevant to this debate because
health professionals could have expressive and hidden pre-
conceptions that may affect their ability to distinguish abuse from
non-abuse cases.4 In particular, a study identified that some Gha-
naian radiographers by their cultural affiliations, did not accept
corporal punishment as a form of abuse.8 Ironically, when a parent
through corporal punishment or child discipline, inflicted injuries
to the child, these radiographers saw such cases as a family affair
and normal.8 Although the child may go through the hands of
W.K. Antwi, P. Reeves, F. Christine et al. Radiography 27 (2021) 1073e1077several professionals, any professional suspicious of abuse which
might have been missed in the chain of events should alert au-
thorities whether it would ensure or guarantee the child's well-
being. Moreover, radiographers in the current study, against their
scope of practice, discretionally performed additional imaging
protocols. This they did to confirm their suspicion of physical abuse
without consultationwith the referring doctor to ascertainwhether
it was necessary. However, their reasons for non-communication
with the doctors have been extensively explored in a previous
work by the authors.20 For example, the study found that some of
the cases came from different hospitals and getting in touch was a
problem and besides some doctors got angry when contacted on
such issues. However, the need to communicate with the referral
source for further information is necessary or imperative to clarify
the original information.36 This is because of the possibility of
having information which is inconsistent and unreliable as was
reported in the findings of the current study. Despite these diffi-
culties radiographers seeking further clarification from the doctor
in charge of the child could be an appropriate step.37 Additionally,
the findings of the current study found the behaviour of some
caretakers/parents' nondisclosure of the truth which could have
affected the referral histories. It is certain that if a parent or the one
in charge of the child's care fail to be truthful, constructing the right
diagnosis becomes particularly challenging.38 It is important for
radiographers in Ghana to identify their key roles in cases of sus-
pected child abuse and act accordingly.
Conclusion
The clinical method for identification of suspected physical
abuse in children by radiographers in Ghana was explored.
Radiographers studied used several means such as parental
behaviour, child physical signs, and radiographic findings to
support their suspicion or identify a child at risk of physical abuse.
An unacceptable professional behaviour was identified where
some radiographers, in trying to establish abuse, were found to
use their own discretion to perform additional projections
without consultation with the referring clinician. Although
identifying any form of abuse, is a significant step towards the
attempt to safeguard children against any successive mistreat-
ment, the approach to establish physical abuse should be done
within acceptable protocols.
Conflict of interest statement
None.
Acknowledgement
The authors are grateful to the Ghana Society of Radiographers,
Ghana Health Service and School of Biomedical & Allied Health
Sciences, University of Ghana, and Sheffield Hallam University, UK,
who made this study possible.
However, the study was an extract from a PhD study sponsored
by School of Biomedical and Allied Health Sciences, University of
Ghana.
References
1. Glick JC, Lorand MA, Bilka KR. Physical abuse of children. Pediatr Rev
2016;37(4):146e58.
2. United Nations Children's Fund. UNICEF annual report for Ghana WCARO. 2012.
3. Imoh TDA. Children's perceptions of physical punishment in Ghana and the im-
plications for children's rights [Online] provided by Childhood. Sage; 2013.10774. Flaherty EG, Robert S. Barriers to physician identification and reporting of child
abuse. Pediatr Ann 2005;34(5):350e6.
5. Lee HS. Diagnostic evaluation of physical abuse in children. J Korean Med Assoc
2008;51(3):234e43. https://doi.org/10.5124/jkma.2008.51.3.234.
6. Lazenbatt A, Freeman R. Recognizing and reporting child physical abuse: a
survey of primary healthcare professionals. J Adv Nurs Pract 2006;56(3):
227e36.
7. Russell M, Lazenbatt A, Freeman R, Matcenes W. Child physical abuse: health
professionals' perceptions, diagnosis and responses. Br J Community Nurs
2004;9(8):332e8.
8. Antwi WK, Reeves P, Ferris C, Aziato L. Behavioural beliefs of Ghanaian radi-
ographers and the reporting of child physical abuse. Radiography 2019;25(1):
51e7.
9. Attakorah AK. A Functional Child Welfare Policy. The missing link in socio-
eeconomic development. The face of child abuse in Ghana [Online]. GhanaWeb;
2013.
10. Vallone R, Addona F, D'Elia L, Vicari S. Child abuse: a multidisciplinary
approach. Pediatr Child Health 2009;19:S207e10.
11. Legano L, McHugh MT, Palusci VJ. Child abuse and neglect. Curr Probl Pediatr
Adolesc Health Care 2009;39(33e9):31.e1e4.
12. Davis M, Reeves P. The radiographer's role in child protection: comparison of
radiographers' perception by use of focus groups. Radiography 2006;12(2):
161e8.
13. Davis M, Reeves P. Maintaining the chain of evidence in child abuse cases.
J Diagn Radiogr Imaging 2004;5(2):61e8.
14. Rigney D, Davis M. Radiographers and non-accidental injury in children- an
Irish perspective. Radiography 2004;10(1):7e13.
15. Hogg P, Hogg D, Carena Eaton C, Sudbery J. Child protection in radiographic
practice. Radiography 1999;5(3):127e9.
16. Carty H. Non-accidental injury: a review of the radiology. Eur Radiol 1997;7(9):
1365e76.
17. Doheny C, Davis M, Grehan J. Is child protection within the clinical
environment the sole responsibility of the clinician? Radiograp Ireland
2014;18(5):2e5.
18. Kraft JK. (iv) Imaging of non-accidental injury. Orthopaedic Trauma 2011;25(2):
109e18.
19. American Academy of Pediatrics. Diagnostic imaging of child Abuse. Pediatrics
2009;123:1430e5.
20. Antwi WK, Reeves P, Ferris C, Aziato L. Exploration of Ghanaian radiographers'
reporting of suspected physical abuse amongst children. Radiography 2021.
https://doi.org/10.1016/j.radi.2020.12.011.
21. Paavilainen E, Astedt-Kurki P, Paunonen-Ilmonen M, Laippala. Caring for
maltreated children: a challenge for health care education. J Adv Nurs
2002;37(6):551e7.
22. Hattingh L. Non-accidental injury. Curr Orthop 2007;21:301e9.
23. Mangion M, Buttigieg SC. Multi-type childhood maltreatment: associations
with health risk behaviours and mental health problems in adolescence. J Child
Serv 2014;9(3):191e206.
24. Dubowitz H, Bennett S. Physical abuse and neglect of children. Lancet
2007;369:1891e9.
25. Global Initiative. Corporal punishment of children in Ghana. Report prepared by
the global initiative to end all corporal punishment of children [Online]. Global
Initiative; 2015.
26. United Nations Children's Fund. Ghana. Advocating for development that leaves
no child behind [Online]. UNICEF; 2013.
27. Bromfield L, Holzer P. A national approach for child protection. Project Report.
National Child Protection Clearinghouse. Melbourne: Australian Institute of
Family Studies; 2008.
28. Brown AM, Henwood S. Good practice for radiographers in non-accidental
injury. Radiography 1997;3(3):201e8.
29. Legano L, McHugh MT, Palusci VJ. Child abuse and neglect. Curr Probl Pediatr
Adolesc Health Care 2009;39(33e9):31.e1e4.
30. McDonald KC. Child abuse: approach and management. Am Fam Physician
2007;75(2):223e8.
31. Davis M, Reeves P. Diagnostic radiographers and their role in child protection
situations-an exploration of bystander intervention. Child Abuse Rev
2009;18(3):205e14.
32. Antwi WK, Griffiths M. Status of radiation protection in diagnostic imaging in
Ghana. Saarbrücken Lambert 2012.
33. Triantopoulou C, Tsalafoutas I, Maniatis P, Papavidis D, Raios G, Siafas I, et al.
Analysis of radiological examination request forms in conjunction with justi-
fication of X-ray exposures. Eur J Radiol 2005;53(2):306e11.
34. Jumah KB, Gorden-Harris L, Agahowa JI. Common faults in filling of radiological
request forms. East Afr Med J 1995;72(11):744e5.
35. Baz B, Wang NE. Physical abuse of children: identification, evaluation, and
management [Online]. Relias Media; December 2013.
36. Hyden PW. Child abuse. Top Emerg Med 1999;21(2):58e69.
37. van Rijn RR, Sieswerda-Hoogendoorn T. Educational Paper: imaging child
abuse: the bare bones. Europ J Pediatr 2012;171(2):215e24.
38. Jenny C, Hymel KP, Ritzen A, Reinert SE, Hay TC. Analysis of missed cases of
abusive head trauma. J Am Med Assoc 1999;281:621e6.