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Child Protection
Dr. Kerry MilliganGPwSI Child ProtectionChild Protection Unit
Irene McGugan
Child Protection Advisor
CPU
Aim of Session
To cover the following
National Guidance Abuse and neglect Risk and assessment Confidentiality
Role of Doctors and GMC Guidance
“if you believe a patient to be a victim of neglect or physical, sexual or emotional abuse and that the patient cannot give or withhold
consent to disclosure, you must give information promptly to an appropriate
responsible person or statutory agency, where you believe that the disclosure is in the
patient’s best interest.
[1/2]
Responsibilities of Doctors All doctors have a responsibility to take action when
they have concerns about abuse or neglect and refer to those with statutory responsibility for children’s welfare (children’s social care, police)
The involvement of health professionals is important at all stages of work with children and families
Doctors have a duty to cooperate with other agencies in investigation and management of child abuse and neglect.
[1/2]
Recommendation 8Given that GP records are likely to be the most accurate source of medical
history of a substances misusing parent, it is recommended that it be made the responsibility of the GP to ensure that such information is made available to
case discussions either by direct presentation by her/himself, or a
representative of the practice or by a written report
Revised standard invitation list implemented for all child care meetings ensuring Health Visitors/School Nurses and GPs are mandatory invitees
GP invites now sent electronically to the practice to ensure they are given as much notice as possible (This is now Policy in Renfrewshire)
Policy Context
Children’s needs at the starting point Universal services to provide prompt support in
the face of early signs of unmet need Early Intervention.(DFES 2004-Scottish Executive 2004)
Identification of the extent to which parenting is compromised by disadvantage and adversity and outlines strategies to provide timely support.
(DCSF 2007)
For Scotland’s Children
OUTCOMES FOR CHILDREN
All children in Scotland should be:
Confident Individuals; Effective Contributors; Successful Learners;Responsible Citizens. For this to happen, they need to have the following well being indicators:
•Safe
•Healthy
•Achieving
•Nurtured
•Active
•Respected and responsible
•Included
The Whole Me
Physical, social, educational,
emotional, spiritual & psychological
developmentW
hat I need from people w
ho look after me
How
I gr
ow a
nd d
evel
op
My wider world
Everyday care and help
Keeping me safe
Being there for me
Play, encouragement and fun
Guidance, supporting me to make the right choices
Knowing what is going to happen and when
Understanding my family’s background and beliefs
Being Healthy
Learning and achieving
Being able to communicate
Confidence in who I am
Learning to be responsible
Becoming independent, looking after myself
Enjoying family and friends
Support from family,
friends and other people
School Enough money Work opportunities for my family
Local resources Comfortable and safe housing Belonging
Early Adversity has a Long Term Impact
Research confirms the links between infant-parent attachment and psychological and behavioral development
Attachment can be influenced by interventions
Reflective functioning
Vulnerability of babies
The under-ones are statistically the age band most at risk of abuse
The homicide rate for under-ones is nearly five times greater than the average
One survey found that 52 per cent of one year-old children were hit or smacked weekly by their parents
Babies under one have the highest registration rate on the child protection register
Gordon R and Harran E (2001) Fragile: Handle with Care. Protecting babies from harm. Leicester, NSPCC.
National Guidance for Child Protection in Scotland 2010
31. Abuse and neglect are forms of maltreatment of a child. Somebody may abuse or neglect a child by inflicting, or by failing to act to prevent, significant harm to the child. Children may be abused in a family or in an institutional setting, by those known to them or, more rarely, by a stranger. Assessments will need to consider whether abuse has occurred or is likely to occur.
National Guidance Key Changes:
Updated definitions Broadening concept of abuse and neglect Categories of registration removed Registration of unborn babies Involvement of health at early stage Timescales for child protection processes
specified Management information Web based document
Indicators of risk
Domestic abuse Parental alcohol and drug misuse Disability Non engaging families Children and young people experiencing mental health problems Children and young people affected by mental health problems Children and young people who display harmful or problematic
sexual behaviour Female genital mutilation Honour based violence and forced marriage Fabricated or induced illness Sudden unexpected death in infants and children
Increased Vulnerability: Factors in the Child 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
[1/3]
Increased Vulnerability:Factors in the Parents Young, immature and socially isolated Learning disabilities Aggression and poor impulse control Mental health problems including
depression, psychopathy and personality disorder
Domestic violence
[2/3]
Increased Vulnerability: Factors in the Parents Single or substitute parent Poor and unstable parental relationship Poor parenting skills Parents abused as children Post-natal depression Alcohol and substance misuse Poverty and social exclusion
[3/3]
Critical Threshold Detection of abuse or neglect requires the
building up of a jigsaw of information (including paediatric assessment)
The critical threshold is the point at beyond which behaviour towards a child places the child at risk of significant harm and requires referral to children’s social care or the police.
In other situations a child may be ‘in need’ (‘The Child in Need’) and requires a referral to children’s social care.
[1/2]
Number and rates of children subject of a Child Protection Plan (Scottish stats)
2006 2007 2008 2009 2010
Scotland: Number of Children
2,288 2,593 2,433 2,682 2,518
Scotland:Rate per 10,000 Children
25 28 27 29 28
West of Scotland:Number of Children
836 983 985 1,018 1,012
West of Scotland:Rate per 10,000 Children
17 20 22 24 24
Number of children on the Child Protection Register by category of abuse/risk identified
Children who became the subject of a Child Protection Plan (%): Scotland (Scottish stats)
2006 2007 2008 2009 2010
Physical Neglect 44.9 48.3 44.6 44.8 44.4
Physical Injury 27.8 24.7 25.4 24.1 22.5
Sexual Abuse 10.8 8.6 6.7 6.3 7.2
Emotional Abuse 15.6 17.5 21.9 24.2 25.6
Failure to Thrive 0.2 0.2 0.3 0.4 0.1
Unknown 0.8 0.7 1.1 0.2 0.2
Number of registrations following a case conference by category of abuse/risk identified by conference
Confidentiality
Recent guidance from RCPCH:
The doctor’s duty is to act in the child’s best interest – the needs of the child are paramount
UN Convention on the Rights of the Child 1989
Age of Legal Capacity Act 1991
The Children(Scotland) Act 1995
Schedule 1 of the Criminal Procedures Act 1995.
Sex Offenders Act 1997
The Human Rights Act 1998
Protection of Children (Scotland) Act 2003
Legislative framework
UN Convention on the Rights of the Child Each Child has the right to: Protection from all forms of abuse, neglect or exploitation
Have minimum intervention in his life
A positive sense of identity
Be treated as an individual
Form a view on matters affecting
Who is a child?Who is a child?
The Children (Scotland) Act 1995
Any person under 16 years
Any person under 18 if subject to a supervision requirement or looked after by the Local Authority
The Age of Legal Capacity The Age of Legal Capacity (Scotland) Act 1991(Scotland) Act 1991
Provides that a person under 16 years shall have legal capacity to consent on his or her own behalf to any surgical, medical or dental
procedure or treatment, including psychological or psychiatric examination where, in the opinion of an attending medical
practitioner, he or she is capable of understanding the nature and possible consequences of the procedure or treatment.
Protecting Children: A Shared Responsibilty. 2000
Attitudes and ValuesAttitudes and ValuesBarriers to SharingBarriers to Sharing
InformationInformation
Exercise
8 year old who is hit by her mother
Baby whose parents ask for him to be circumcised for cultural
reasons
11 year old with cerebral palsy whose father allows her to
cuddle up to him in bed when she is upset
A 6 year old who witnesses his mother slapping his father
after an argument
A toddler whose mother usually drinks a bottle of wine before
noon
Summary of the activity
To understand that:
You often need more information Personal views differ It’s unlikely that you would all agree
Stressful circumstances commonly associated with child abuse Living in poverty
Domestic violence
Parental drug and alcohol abuse
Living in environment of high anti-social behaviour, crime, poor housing
Parental mental health disorders
Parental learning disability
Social isolation including that due to racism.
References Becker,F.,French,L(2004) Making the links: Child Abuse, animal cruelty and domestic violence Child Abuse
Review 13:399-414 Browne,K.D., Herbert,M.,(1997) .Preventing Family Violence Chichester:Wiley Lung, C. T. and D. Daro. 1996. Current trends in child abuse reporting and fatalities: The results of the 1995
annual fifty state survey. Chicago, IL: National Committee to Prevent Child Abuse. Wolfe,D.(1993) Child Abuse Prevention Child Abuse Review 2(2):153-165 Working Together to Safeguard Children 2010 Image Source www.refuge.org.uk who run a 24 hour National Domestic Violence Helpline 08082000 247
© Royal College of General Practitioners &National Society for the Prevention of Cruelty to Children, 2011
Family 10 SCR: the downward path
What is Child Abuse? “ Child abuse involves acts of commission
or omission, which result in harm to the child”
“ Abuse or neglect may occur in the family, a community or an institution (home,school,hospital,street)
Child Protection Companion – RCPCH 2006
Categories of Child Abuse Physical
Hitting, throwing, shaking, burning, scalding, poisoning, drowning, suffocating, fabricating or inducing symptoms
Neglect Failing to meet basic physical / psychological
needs Emotional
Persistent emotional ill treatment Sexual
Forcing / enticing a child to take part in sexual activities FII
Fabrication of signs and symptoms, induction of illness
Bruising - Site
Bruising to a young baby
Multiple injuries following a moderate fall
Severe head injury in baby or toddler
Rib fractures
Subdural haematoma
Multiple cigarette burns
Fracture in infants and toddlers
Patterns of injury which strongly suggest abuse
There has been delay in obtaining attention
Refusal to allow proper treatment or hospital
admission
Unprovoked aggression towards staff
Explanation inconsistent with injury.
Unusual Behaviour in ParentsUnusual Behaviour in Parents
Photographic EvidencePhotographic Evidence
Photographic EvidencePhotographic Evidence
Photographic EvidencePhotographic Evidence
Photographic EvidencePhotographic Evidence
Photographic EvidencePhotographic Evidence
Photographic EvidencePhotographic Evidence
Why do parents neglect?
Circumstantial
Poverty Relationships Lack of skill/knowledge Illness Lack of support Environmental factors
Fundamental
Lack of parenting capacity
Deep seated attitudinal/ behavioural problems Problematic substance
misuse
Neglect - Signs Dirty, poorly clothed Nappy rash, impetigo, lice, scabies Failure to thrive Untreated or under treated medical conditions Poor dental health Repeated accidents Developmental delay
Jigsaw - Jigsaw - NeglectNeglect
NCH The Bridge 2007
Why is neglect harmful?
Learning Lack of exploration Delayed speech & language Impoverished play & imagination Special educational
needs/learning disability Later educational failures Poor life skills development
Emotions Disturbed self-regulation Negative self identity Low self esteem Clinical depression Substance misuse
Bodies Fatal neglect Intra-uterine growth retardation Non-organic failure to thrive Vulnerability/susceptibility to
illness, infection & accidents Poor/delayed medical care.
Brains Lack of nutrients; reduced growth Lack of stimulation: retardation of
brain Unregulated stimulation:
disordered neural circuitry development
Sheffield Enquiry2005
How long did it take for this room to get to be like this? A week? A month? A year?
5 Children lived in here? The oldest was a girl about 10 and often cared for her twin baby brothers. Think what she might have looked like.
Why did nobody notice?
It’s not that bad really. It’s not that bad really.
They’re happy underneath it.They’re happy underneath it.
I’ve seen worse.
I’ve seen worse.
Children can be dirty but
happy.
Children can be dirty but
happy.
I mustn’t impose my
middle-class
values
I mustn’t impose my
middle-class
values
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.
Difficult to measure and prove
Not meeting developmental milestones
Timid and withdrawn
Over demanding, mood swings
Links with domestic abuse
Emotional Abuse
Emotional Abuse – psychological consequences
Low self esteem Difficulties in relationships
With peers / family / authority figures Difficulties in giving & accepting affection Often impulsive & aggressive Can be frustrated, anxious & non-
compliant
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”Working Together DoH
Vast majority of abusers are from within the family
Surrounded by secrecy
What would prompt us to investigate? Disclosure by child Concern from carer Change in behaviour Sexualised language/behaviour/drawings Medical symptoms including trauma Pregnancy Presence of STI
Children with Special NeedsChildren with Special Needs
children with disabilities are more likely to be abused than non disabled children
difficult challenging behaviour
cannot tell like other children
more anxious to have adult approval
often need intimate care
Scenario
Children in special circumstances
Homeless families Asylum seekers Young carers Children engaged in offending behaviour ‘Looked after’ children and young people Chronic disability
Vulnerable pregnancy procedures Identifying as early as possible the needs of
mother and baby and alerting services as appropriate
Developing effective care plans Ensure that no pregnant woman misusing
substances arrives at a maternity unit to give birth without support being available
Key Issues in PregnancyKey Issues in Pregnancy
Vulnerable Pregnancy Referral Pathway
Attendance of Pregnant women at ANC
Assessment of vulnerability
ANC/Midwife make referral to Interagency Liaison Meeting using
shared referral form
Comprehensive assessment agreed, contribution – CP13
Making a referral to SW
Suspicions that a child has been abused/ Neglected or is at risk of abuse/Neglect
Give reasons for your concerns. Be clear about the nature of your concern.
Clarify/ record name and status of staff receiving your call
Record date/time Clarify agreed actions
Inform relevant professionals Complete professional records
as soon as possible
All telephone referrals confirmed in writing immediately, copied and distributed
Shared Referral Form Replaces all other child
care/protection referral to SW systems
Three copies- one to SW, one for child’s record and one to CPU
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 - A guide to good practice
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?
Confidentiality
During consultations:
Do you know if your client has care /responsibility for children/young people ?
Do you consider the impact of your client’s addictions /mental health on their ability /capacity to care for their child?
How do you assess the risk to children /young people whose parents use your service
Issued of confidentiality –Are you clear? Are the limitations made clear to your clients?
Issues for Health Workers
Discussion
