Child Protection Training

Dr Kerry MilliganGP with Special Interest in Child Protection

Fiona MillerChild Protection advisor

2011

2

Pre-course Objectives

• National Guidance and Local Protocols• Legal requirements• Identification and Recognition• Referral pathways and post-referral

actions• Communication• GP role/Professional obligation

2

• UN Convention on the Rights of the Child 1989 (Protection, Provision, Participation)

• Age of Legal Capacity Act 1991(Enter legal commitments, give/refuse consent treatment)

• The Children(Scotland) Act 1995

• Protection of Children (Scotland) Act 2003(list individuals unsuitable to work with children)

Legislative frameworkLegislative framework

National Policies/Documents

NEW - National Guidance for Child Protection in Scotland 2010

http://www.scotland.gov.uk/Resource/Doc/334290/0109279.pdf(Presentation produced by the West of Scotland Child Protection Training Group)

National Guidance

Key Changes:• Categories of Registration removed• Updated definitions of abuse and neglect• Timescales for child protection processes

specified• Web based document, with links to other

relevant documents

www.scotland.gov.uk

Scale of Child Protection2008-2009

• Scotland -12,713 Child Protection Referrals an increase of 3% from the previous year.47%(n=5947) were male.49%(n=6268) and 4%(n=498) unknown

• 3628 registrations an increase of 29% from the previous year.1357 male and 1287 female.

• The category which showed the greatest increase (43%) was Emotional Abuse

• For the first time the ethnic group of children registered was recorded showing 82% were reported to be “White”

• The disability of registered children was also recorded for the first time 70 % no disability and only 7% with disability, 23%unknown.

9

Child Protection in Inverclyde

• Children on the CPR btwn 32 and 43 - 3 per 1000 children age 0-15 yrs,(Scottish average is 2.9 per 1000 age 0-15 yrs.)

• 114 child protection investigations leading to 44 case conferences

• Neglect commonest reason for registration -60% (47% nationally)

• In 73% reported domestic abuse incidents child associated with household 11

10

Inverclyde CPC• www.inverclydechildprotection.org

• Inverclyde Interagency Child Protection Procedures

• ‘Children and young people in Inverclyde have a right to be protected and be safe from harm from others. As professionals or others working with children you have a responsibility to help children who are at risk of abuse or neglect get the help they need when they need it. ‘

• Covers all aspect of child protection work- definitions, roles and responsibilities, medical examinations,legal powers

8

Seeing the riskA child may be harmed

- by an action such as violence or a sexual attack or mental cruelty or physical attack, including poisoning or suffocation

or

- through a failure to act – for example through a parent/carer not feeding a child or neglecting a child in other ways, including emotionally or through the child not being given appropriate health care

Types of maltreatmentMaltreatment Examples

Physical Bruising, fractures, burns, severe injuries

Sexual abuse Rape/indecent assault including sexual assault and internet abuse

Emotional Abuse Sustained or repeated demeaning, critical and unloving behaviours, verbal abuse

Neglect Failure to thrive, missed health care and/or educational opportunities

Induced illness Suffocation, poisoning, interference with feeding tubes and IV lines

Fabricated illness Falsifying histories, exaggerating disability, interfering with tests

Physical InjuryBruising• Prevalence, number and position of bruises is related

to increased motor development• Bruising in non independently mobile babies is very

uncommon (<1%)• Majority of school children have bruises• Common in abused children• Common sites – head (commonest site in abuse) and

neck, buttocks, genitalia, trunk and arms• Large multiple clusters or implement image“those who don’t cruise rarely bruise” Arch Pediart Adolesc Med

1999;80:363-366

Physical Injury• The face is the most commonly bruised site in fatally

abused children

• Fractures -It takes considerable force to produce a fracture in a child.

• 80% of abused children with fractures are less than 18 months old whereas 85% of accidental fractures occur in children over 5 years.

• Infants with fractures less than 4 months of age are more likely to have been abused.

Bruising - Site

Photographic EvidencePhotographic Evidence

Photographic EvidencePhotographic Evidence

Photographic EvidencePhotographic Evidence

Physical Neglect

• Regularly hungry, steals food

• Always dirty

• Inappropriately dressed

• Appears pale listless and

underweight

• Failure to attend important

appointments

• Insidious

• Links to other forms of abuse

• Nappy rash, impetigo, lice, scabies

• Failure to thrive

• Untreated or under treated medical conditions

• Poor dental health

• Repeated accidents

• Poor parental supervision

• Developmental delay

Jigsaw Jigsaw -- NeglectNeglect

Photographic EvidencePhotographic Evidence

Emotional Abuse

• …actual or likely severe adverse effects on the emotional and behavioural development of the child caused by persistent or severe emotional ill treatment or rejection.

Emotional Abuse

• Often difficult to spot

• All abuse involves some emotional abuse

• Few children on register because of emotional abuse alone

• Links with domestic abuse

Childhood sexual abuse

• ‘any person… exploits a child…in any activity intended to lead to the sexual arousal or other forms of gratification of that person or other person(s), including organised networks

• Includes contact and non-contact behaviours

Childhood sexual abuse

• CSA substantially underreported prevalence studies show a range of 7-30% of girls and 3-13% of boys

• UK study found one in five girls and one in four boys experienced CSA

• Men in 90% of cases• More than 1/3 of rapes recorded by the police

are committed against children under 16 years

• Cawson, P. et al (2000)

Childhood sexual abuse• Persistent or recurrent genital or anal symptom (for example, bleeding or

discharge) in a girl or boy, without a medical explanation, that is associated with behavioural or emotional change.

• Genital, anal or perianal injury in a girl or boy, with an absent or unsuitable explanation.

• Anal fissure, when constipation, Crohn’s disease and passing hard stools have been excluded as the cause.

• Gonorrhoea, chlamydia, syphilis, genital herpes, hepatitis C, HIV or trichomonas infection in a child younger than 13 years if there is no clear evidence of vertical transmission or blood contamination.

• Unusual sexualised behaviours in a prepubertal child (for example, oral–genital contact with another child or doll, requesting to be touched in the genital area, or inserting or attempting to insert an object, finger or penis into another child’s vagina or anus).

• NICE, When to suspect child maltreatment, Quick reference guide 2009

• ‘It is… generally recognised that emotional abuse is at the core of physical and sexual abuse, and might have a greater effect in the long term than physical or sexual abuse.’

(Iwaniec 1996: 4)

Alice

• ‘He used to threaten me, he said if I told anyone what was going on he would hit me twice as hard. We weren’t allowed friends and no one from the village or school of my age was allowed to visit…I was frightened most of the time I was living there. I don’t think I told anyone what he was doing.’

• An Inspection into the Care and Protection of Children in Eilean Siar

Increased vulnerability: child factors

• Prematurity, early separation after birth• Physical or learning disabilities• Behavioural problems• Difficult temperament or personality• Soiling and wetting past developmental

age• Screaming and crying interminably and

inconsolably

Risk Factors

• Substance Misuse• -4-6% of children in Scotland have a parent

with a drug problem (Hidden Harm 2003)

• Mental health Problems• - 33% of child death reviews identified a

parent with mental health problems (Falkov 1996)

• Domestic Abuse• - 25% of children in need of protection come

from homes where domestic abuse is known

Parental Substance Misuse

• 26% women and 44% men drink more than twice recommended amount

• 39% referrals to Children’s Reporter indicate alcohol misuse by parents

• 45,000 and 65,000 people affected by drug misuse in Scotland

• 41,000-59,000 children living with parents affected by drug misuse

• 1.3 - 2 million children affected by parental alcohol misuse

• 1 in 3 affected not seen

Domestic Abuse

• 1 in 4 women experience domestic violence in their lives (BMA 1998)

• 18% of women attending A&E (with an injury) – cause is domestic violence (BMA 1998)

• 30% of domestic violence is known to start or escalate in pregnancy (CEMD – 1994-96)

• In 60% of child abuse cases, where the father is the perpetrator, the mother is also being abused (Mullender 1998)

Increased vulnerability: parental factors

• Alcohol and substance misuse

• Poor and unstable parental relationship

• Poor parenting skills• Parents abused as

children• Post-natal depression• Poverty and social

exclusion• Male in house-hold not

father

• Young, immature and socially isolated

• Learning disabilities• Aggression and poor

impulse control• Mental health problems

including depression, psychopathic and personality disorder

• Domestic violence

SW Role and Responsibility

•Receive child protection referrals and investigate allegations of abuse.

•Decide whether to respond under child protection procedures.

•Discuss referrals with police.

•Joint investigation.

•Promotion of welfare and supporting families

•Organise and manage case conferences

SW Role and Responsibility

Is there an immediate risk to the child?

• Child Protection Order (s57)• Police power to remove child (s61)

(without authorisation)• Child Assessment Order (s55)• Exclusion Order (s76)

All references are to the Children (Scotland) Act 1995

Child Protection Orders

• Require the child to be produced• Removal to and retention of child in

place of safety• Prevent removal of the child• Child’s location is kept secretAny person may apply though usually SWSheriff will decide conditions

Process of Joint Investigation

• Case discussion/planning meeting• Investigative interview• Medical examination• Other interviews/information

gathering• CP Case Conference

Assessment Process• Recognition and Referral• Immediate protection and planning of

investigation• Investigation• CPCC and decision to register• Comprehensive assessment and

planning• Implementation and review

Where children are supported at home, the child protection plan mustclearly identify the objectives to be achieved, with timescales, that signaleither the withdrawal of support to the family or, if the objectives are notachieved, indicate the point when further action must be taken. This isparticularly important in cases of child neglect where often there is nosingle event that ‘triggers’ matters escalating to an application for a courtorder. ….Realistic timescales need to be applied for these cases to ensurethat a child is not subjected to long-term neglect.’Laming, para. 3.12

• Have I the subjects consent?

• If not, is sharing this information necessary to ensure the welfare of the child?

• How much information should I share?

ConfidentialityConfidentiality

• All staff have a responsibility to protect children even if the child is not a patient

• Concern of significant harm always overrides confidentiality

• When discussing with another agency- What info is needed, Why, What they will do with it, Who else needs to be informed?

Sharing Information Sharing Information --A guide to good practiceA guide to good practice

Questions?

Contact

• Contact Detailskerrymilligan@nhs.net

Child Protection Unit0141 201 9225

www. nhsggc.org.uk/childprotectionunit