Child Protection in Primary Care

Dr Andrew Mowat

Named Doctor for Child Protection

East Lincolnshire PCT

“Child Protection in Primary Care”Radcliffe Medical Press Ltd 2001

Dr Janet C Polnay MB BS BSc(Hons) MA Associate Specialist in Paediatrics Named Doctor for Child Protection, Nottingham

City Hospital NHS Trust Senior Doctor in Child Protection (Primary Care),

Nottingham Community Health NHS Trust Medical Advisor, Nottingham Health Authority Formerly, GP Principal, Nottingham

Sources of Stress for Families

social exclusion

known domestic violence

known mental health problems

known drug/alcohol problems

Working Together to Safeguard ChildrenDoH 1999

High Risk Situations

Schedule 1 Offender previous children of household on register parent who has been victim themselves

concealed pregnancy

Prevalence

Local Authority (Section 47) enquiries 160,000 per year (England) 25000 unsubstantiated 25% lead to Initial Child Protection Conference

75% of those placed on Child Protection Register percentage rising steadily 1993-2000

Currently, 30,300 children on CPR27 per 10,000 pop under 18 yrs

Gibbons et al 1995

Categorising Child Abuse

Child Protection Register Physical Sexual Emotional Neglect

Actual Likely

Categories

Category Number % of total registrations

Neglect 12900 44

Physical Injury 9500 32

Sexual abuse 5100 17

Emotional abuse 4100 17

Other 600 2

Source: Government Statistical Service 2000

Historical Context

Children as possessions of parents

Corporal punishment “necessary” children inherently bad

NSPCC 1890 BSCC Liverpool 1883

Battered Child Syndrome (Kempe, 1962)

First UK Government guidance 1970

Cleveland enquiry Butler-Schloss, 1988

Legal Milestones

The Punishment of Incest Act 1908 Children & Young Persons Act 1933

Schedule 1 offences Children Act 1989

established paramountcy of the Child’s interests established ACPCs

Working Together under the Children Act 1989 Working Together to Safeguard Children 1999

Human Rights Act 1998 New Lincolnshire ACPC Guidelines 2001

Parental Responsibility

“all the rights, duties, powers, responsibilities and authority which, in law, a parent of a child has in relation to their child and his property”

normally rests with the parents (if married at time of child’s birth) or mother (if not)(unless agreed formally, or by marrying the mother subsequently)

can be acquired only by court order residence/adoption order care order

Private Law

Children Act Section 8

Residence Order

Contact Order

Prohibited Steps Order

Specific Issue Order

Public Law

Local Authority Duty to investigate Children Act Section 47

Emergency Protection Order

Police Protection remove to “suitable accommodation” for 72 hrs

Children Act Section 31 Care & Supervision Orders

Domestic Violence

100 women per year in England & Wales killed by present/former partners

Family Law Act 1996: provides for Occupation Orders Non-molestation Orders Powers of Arrest Amended Children Act 1989 to allow exclusion orders

attached to Interim Care/Emergency Protection Orders

Ethical problems

Rights of the Child duty of care confidentiality

Rights of the Family best place to care for a child is in their own family

Rights of the (alleged) Abuser innocent until proven guilty

Duty to Society Rights of the Doctor / Nurse

Ethical concepts

Utilitarianism examines moral dilemmas seeks to make decisions based on outcomes applies to large populations e.g. “the greatest good for the greatest number”

Deontological applies to individuals based on the duties of the doctor and the rights of the

patient (and, of course, vice versa)

Ethical framework

Patient Autonomy Beneficence

“above all, do no harm” “do good where possible”

Confidentiality Truthfulness Duty to Society

Ethical Guidance

United Nations Declaration (1959) Children Act (1989) GMC: Confidentiality: Protecting and Providing

Information (2000) DoH: Working Together to Safeguard Children

(1999) Area Child Protection Committee procedures

(red book)(2001)

Potential Conflicts

Recognition/Referral to Social Services Response to Section 47 enquiry Case Conferences: reports & attendance Case Reviews (Part 8)(or managerial)

The GPs Role

Opportunities already exist: awareness that child abuse occurs communication systems which allow information

exchange between professionals

Training Needs/Responsibilities GP Training Staff Training

GP Attitudes

Reasons for non-attendance inconvenient timing, location sense of low priority

Potential solutions: improve reporting skills keyworker to present information on GPs behalfPOLNAY Janet C. General practitioners and child protection case

conference participation: reasons for non-attendance and proposals for a way forward.

Child Abuse Review, 9(2), March/April 2000, pp.108-123.

Multi-Agency Working

Wide range of other agencies involved in care of child (see next slides)

Most used to inter-agency cooperation Isolated GP

too many competing priorities? lack of trust of other agencies? absence of any organisation within GP? “Confidentiality” often used as an excuse

GPs have no knowledge of other agencies’ agenda

Primary Healthcare Team

GP GPs Partners GPs Registrar other Doctors Health Visitor Midwife

Practice Nurse District Nurse Reception Staff Practice Manager Dispenser Counselling

Extended Health Workers

School Nurses Accident & Emergency Hospital Paediatrics Community Paediatrics Mental Health Services Education Behavioural

Support Educational

Psychology

Learning Disability Team

Occupational Therapy Speech Therapy Physiotherapy Audiology Optometry PHCT previous area Ambulance Service

Non-Health Agencies

Social Services Education

Secondary Primary Nursery Special

Police Probation Service

Parents, Family Neighbours Home Care NSPCC Youth leaders Religious Friends

Child Protection Register

Maintained by LACPC Lists all children

considered to be at risk Receives enquiries

from any health professional will ask for your details,

including reason for enquiry, and call you back

Assessment Framework

Developmental health education emotional

Parenting capacity care/safety

Family / Environment support financial housing

Child Protection in Primary Care

Recognition

Communication

Knowledge

Note keeping

Recognition

Awareness General Characteristic Features Specific Features of:

Physical Abuse Emotional Abuse Sexual Abuse Neglect

Characteristic Clinical Features (General)(1)

Delayed presentation Changing or ill-defined

accounts History not consistent

with examination findings

Injury not consistent with child’s developmental level

History of shaking

Unrealistic expectation / perception of carer

Inappropriate response from carer

Child’s interaction with carer: “frozen watchfulness”

Child’s own account

Characteristic Clinical Features (General)(2)

Unusual site of injury behind the ear in the hair in the mouth soft tissue e.g. buttocks

Extensive bruising Bruises / Scars of

different ages

Previous suspicion or record of abuse (consider multi-generational abuse)

Indication of Domestic Violence

Unexplained injury / illness of recurring pattern

Physical Abuse

May involve: hitting shaking throwing poisoning burning/scalding drowning suffocating

or otherwise causing physical harm to a child

Munchausen Syndrome by Proxy (MSBP) a parent or carer feigns

the symptoms of, or deliberately causes, ill health in a child

Specific Features: Physical Abuse (1)

Bruises face (baby) mouth (frenulum) grasp marks or fingertip

bruising unusual sites (ears, genitals,

back, abdomen) outline (handprint, shoe or

belt mark) extent / type of bruise

Differential Diagnoses

Burns/Scalds site (perineum, face & head,

genitalia, hands, feet, legs) “glove or stocking”

look for splash marks regular edges depth on injury “hole in the doughnut” scald

on buttocks cigarette burns

Differential Diagnoses

Specific Features:Physical Abuse (2)

Bites Human or Animal?

Animal: puncture, cut and tear skin

Human: bruise, usually crescent shape, ?individual teeth seen: breaking of skin unusual

difficult to distinguish child or adult bite

Fractures ?presenting feature or

incidental finding may only be detected

by Radiology may present as:

reluctance to move limb limp swelling / pain

Specific Features: Physical Abuse (3)

Poisoning children ingest harmful

substances because: lack of supervision deliberate self-harm administration by carer

non-accidental poisoning often present “fits, faints or funny turns”

Suffocation/Submersion non-accidental suffocation

may present as cot death, or “fits, faints or funny turns”

non-accidental submersion difficult to identify

usually toddlers sometimes left with

inappropriate carer

Munchausen Syndrome by Proxy

presentation (often repeated) with illness fabricated by carer

carer denies any idea of cause

signs improve on separation from carer

symptoms/signs may be invented, or directly caused

(suffocation, given medicines e.g. insulin). Tests may be

interfered with (blood added to urine / stool / vomit)

(temperature recording manipulated)

often comes to light after (multiple) Paediatric referrals

Emotional Abuse

the persistent emotional ill-treatment of a child, such as to cause severe and persistent adverse effects on the child’s emotional development

may involve making the child feel:

worthless / inadequate unloved valued only for meeting

someone else’s needs inappropriate expectations

for their age/development frightened corrupted / exploited

Specific Features: Emotional Abuse (1)

Relationship Characteristics Negative Attitudes of parent to child Conditional Parenting Emotional unavailability Inappropriate expectations Failure recognise individuality Inconsistency of expectation/response Somatic symptoms (see below)

Glaser (1993)

Specific Features: Emotional Abuse (2)

Infants physical (FTT, multiple

A&E, infections, bruising, nappy rash)

developmental (general delay)

behavioural (attachment disorders: anxiety, avoidance)

Preschool physical (short/light,

microcephaly, unkempt)

developmental (language, attention, immaturity)

behavioural (overactive, aggressive, indiscriminate friendliness)

Specific Features: Emotional Abuse (3)

School physical (short/light,

poor hygiene, unkempt) developmental (learning

difficulties, low self-esteem, immaturity)

behavioural (poor relationships, aggressive, destructive, soiling)

Teenager physical (short, under or

overweight, poor general health, delayed puberty, unkempt)

developmental (school failure) behavioural (truancy,

destructiveness [self/others], runaway, risk-taking behaviour – stealing, smoking, alcohol, drugs, sexual promiscuity)

Sexual Abuse

Sexual abuse involves forcing or enticing a child or young person to take part in sexual activities, whether or not the child is aware of what is happening

The activities may involve: physical contact, including

penetrative (e.g. rape or buggery) or non-penetrative acts

non-contact activities, such as involving children in looking at, or in the production of, pornographic material or watching sexual activities

encouraging children to behave in sexually inappropriate ways

Specific Features: Sexual Abuse

Strong Associations Statement from Child STD Pregnancy Sexualised behaviour Genital Bruising

“love bites” of concern

Mild Associations Genital trauma or

infection Other less specific

enuresis depressive somatic

headache, abdo pain, sleep disturbance, loss of appetite

self-harm

Neglect

the persistent failure to meet a child’s basic physical & psychological needs, possibly resulting in serious impairment of child’s health or development

May involve failure to provide adequate

food, clothing, shelter failure to protect from

danger / physical harm failure to ensure access to

appropriate medical care / treatment

failure to meet basic emotional needs (overlap emotional abuse?)

Specific Features: Neglect

Overlap with Emotional Abuse

Inappropriate parenting physical

failure to thrivepoor hygiene“deprivation

hands/feet”

Refusal to seek / accept medical advice overt

where harm fairly obvious as sequel e.g. withholding insulin for diabetes

covert where harm not

immediately obvious eg persistent non-attendance at appointments

Communication

Regular, known and easy channels GP ⇆ HV

avoid rushed corridor conversations if possible

Look to improve GP ⇆ A&E/Hospital channels

Sharing Relevant information within PHCT

regular planned meetings or case reviews?

Knowledge of Procedures

Every GP must have available a folder documenting ACPC procedures to be followed if recognise or suspect abuse

Unless this is regularly updated, will quickly become unfamiliar and frightening

Members within PHCT may develop special interest and awareness

Clinical Governance issue

Area Child Protection Committee

Countywide statutory committee representing

Social Services Health Education Police Probation NSPCC Armed Services County Domestic Violence

Coordinator

Note Keeping

Identifying Children already on Register Clear tagging of notes of children at risk or

in need so that other PHCT workers can interpret information in correct context

Tagging of sibling’s notes to indicate risk

Action following recognition

Don’t PanicDon’t Panic1. Refer to LACPC Guidelines2. Share concerns with colleagues

Senior Paediatrician Primary Care

Medical Nursing

3. Interrogate Child Protection Register

Professional Support

Designated Doctor/Nurse at HA level training, case reviews,

management

Named Doctor/Nurse at PCT level at each NHS Trust

Practice colleagues

Practice Child Protection Team

Concentration of expertise

Improved response fitting together the

pieces

Time-consuming can we have a team for

everything?

Organisation

Practice Lead ? Doctor ?Health Visitor

Regular meetings allows sharing of information/concerns allows monitoring of children in need

Channels of communication when urgent need arises, links already made

The Children’s National Service Framework

The general themes of the NSF will be::

inequalities/access children with disabilities involving parents/children

in choices integration and

partnership transition to adult services

The Children’s National Service Framework

External Working Group: Children in Need Co-Chairs:

Professor Norman TuttDirector of Social Services, London Borough of Ealing

Professor Margaret LynchProfessor in Community Paediatrics, King's Guy's and St Thomas' School of Medicine, University of London; Consultant Community Paediatrician, Community Health South London

Summary

Child Protection is an important problem Presentation to GP does not happen often

enough (especially in rural areas) to maintain confidence/skills

Training and support are readily available Practices may benefit by developing a

smaller team with more expertise

The GP’s Role

The general practitioner’s role in safeguarding children is so vital. The GP and other members of the primary healthcare team are often the first to notice when a child is potentially in need of extra help … or at risk of harm.

Because of their knowledge of children and families, GPs have an important role to play in all stages of child protection processes.

Rt. Hon John HuttonMinister of State for Health, January 2001

Reflection

Quo vadis?

Bibliography

1. Lincolnshire Area Child Protection Committee (2001) Code of Practice LACPC2. Department of Health (1991a) The Children Act 1989:Guidance and Regulations. HMSO London3. Department of Health (1991b) Working Together under the Children Act. HMSO, London4. Department of Health (1991c) Child Abuse: a Study of Inquiry Reports 1980-1989 HMSO, London5. Department of Health (1995a) Child Protection: Medical Responsibilities. HMSO London6. Department of Health (1995b) Child Protection: Messages from Research. HMSO, London7. Department of Health (1999) Working Together to Safeguard Children The Stationery Office, London8. Department of Health (2000) Framework for the Assessment of children in need and their families. The Stationery Office, London9. Government Statistical Service (2000) Children and Young People on Child Protection Registers Year Ending 31 March 2000 Government

Statistical Service, London10. General Medical Council (1993) Professional Conduct and Discipline: Fitness to Practice General Medical Council, London11. General Medical Council (1995) Duties of a Doctor General Medical Council, London12. General Medical Council (2000) Confidentiality: Protecting and Providing Information. General Medical Council, London13. British Medical Association (1996) Medical Ethics Today: Its Practice and Philosophy. BMJ Publishing Group, London14. Hobbs CJ, Hanks HGI and Wynne JM (1999) Child Abuse and Neglect. A Clinician’s Handbook Churchill Livingstone, London15. Polnay JC and Blair M (1999) A model programme for busy learners. Child Abuse Review. 8: 284-8.16. Polnay JC (2000) General Practitioners and child protection case conference participation. Child Abuse Review. 8:108-23.17. Polnay, JC (2001) Child Protection in Primary Care Radcliffe Medical Press, Abingdon18. Reder P, Duncan S and Gray M (1993) Beyond Blame Routledge, London19. Simpson CM, Simpson RJ, Power KG, Salter A and Williams GJ (1994) GPs and health visitors’ participation in child protection case

conferences. Child Abuse Review 3: 211-3020. Glaser D (1993) Emotional Abuse. In Hobbs CJ and Wynne JM (eds) Balliere’s Clinical Paediatrics International Practice vol. 1 no. 1, ch.

13. Balliere Tindall, London21. Skuse D (1997) Emotional Abuse and Neglect. In: Meadow R (ed) ABC of Child Abuse (3e). BMJ Publishing Group, London