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Child Protection in Primary Care Dr Andrew Mowat Named Doctor for Child Protection East Lincolnshire PCT.

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Presentation on theme: "Child Protection in Primary Care Dr Andrew Mowat Named Doctor for Child Protection East Lincolnshire PCT."— Presentation transcript:

1 Child Protection in Primary Care Dr Andrew Mowat Named Doctor for Child Protection East Lincolnshire PCT

2 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

3 Sources of Stress for Families social exclusion known domestic violence known mental health problems known drug/alcohol problems Working Together to Safeguard Children DoH 1999

4 High Risk Situations Schedule 1 Offender previous children of household on register parent who has been victim themselves concealed pregnancy

5 Prevalence Local Authority (Section 47) enquiries 160,000 per year (England) unsubstantiated 25% lead to Initial Child Protection Conference 75% of those placed on Child Protection Register percentage rising steadily Currently, 30,300 children on CPR 27 per 10,000 pop under 18 yrs Gibbons et al 1995

6 Categorising Child Abuse Child Protection Register Physical Sexual Emotional Neglect Actual Likely

7 Categories CategoryNumber% of total registrations Neglect Physical Injury Sexual abuse Emotional abuse Other6002 Source: Government Statistical Service 2000

8 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

9 Legal Milestones The Punishment of Incest Act 1908 Children & Young Persons Act 1933 Schedule 1 offences Children Act 1989 established paramountcy of the Childs 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

10 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 childs 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

11 Private Law Children Act Section 8 Residence Order Contact Order Prohibited Steps Order Specific Issue Order

12 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

13 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

14 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

15 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)

16 Ethical framework Patient Autonomy Beneficence above all, do no harm do good where possible Confidentiality Truthfulness Duty to Society

17 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)

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

19 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

20 GP Attitudes Reasons for non-attendance inconvenient timing, location sense of low priority Potential solutions: improve reporting skills keyworker to present information on GPs behalf POLNAY 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

21 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

22 Primary Healthcare Team GP GPs Partners GPs Registrar other Doctors Health Visitor Midwife Practice Nurse District Nurse Reception Staff Practice Manager Dispenser Counselling

23 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

24 Non-Health Agencies Social Services Education Secondary Primary Nursery Special Police Probation Service Parents, Family Neighbours Home Care NSPCC Youth leaders Religious Friends

25 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

26 Assessment Framework Developmental health education emotional Parenting capacity care/safety Family / Environment support financial housing

27 Child Protection in Primary Care Recognition Communication Knowledge Note keeping

28 Recognition Awareness General Characteristic Features Specific Features of: Physical Abuse Emotional Abuse Sexual Abuse Neglect

29 Characteristic Clinical Features (General)(1) Delayed presentation Changing or ill-defined accounts History not consistent with examination findings Injury not consistent with childs developmental level History of shaking Unrealistic expectation / perception of carer Inappropriate response from carer Childs interaction with carer: frozen watchfulness Childs own account

30 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

31 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

32 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

33 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

34 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

35 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

36 Emotional Abuse the persistent emotional ill-treatment of a child, such as to cause severe and persistent adverse effects on the childs emotional development may involve making the child feel: worthless / inadequate unloved valued only for meeting someone elses needs inappropriate expectations for their age/development frightened corrupted / exploited

37 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)

38 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)

39 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)

40 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

41 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

42 Neglect the persistent failure to meet a childs basic physical & psychological needs, possibly resulting in serious impairment of childs 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?)

43 Specific Features: Neglect Overlap with Emotional Abuse Inappropriate parenting physical failure to thrive poor 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

44 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?

45 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

46 Area Child Protection Committee Countywide statutory committee representing Social Services Health Education Police Probation NSPCC Armed Services County Domestic Violence Coordinator

47 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 siblings notes to indicate risk

48 Action following recognition Dont Panic 1.Refer to LACPC Guidelines 2.Share concerns with colleagues Senior Paediatrician Primary Care Medical Nursing 3.Interrogate Child Protection Register

49 Professional Support Designated Doctor/Nurse at HA level training, case reviews, management Named Doctor/Nurse at PCT level at each NHS Trust Practice colleagues

50 Practice Child Protection Team Concentration of expertise Improved response fitting together the pieces Time-consuming can we have a team for everything?

51 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

52 The Childrens 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

53 The Childrens National Service Framework External Working Group: Children in Need Co-Chairs: Professor Norman Tutt Director of Social Services, London Borough of Ealing Professor Margaret Lynch Professor in Community Paediatrics, King's Guy's and St Thomas' School of Medicine, University of London; Consultant Community Paediatrician, Community Health South London

54 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

55 The GPs Role The general practitioners 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 Hutton Minister of State for Health, January 2001

56 Reflection Quo vadis?

57 Bibliography 1.Lincolnshire Area Child Protection Committee (2001) Code of Practice LACPC 2.Department of Health (1991a) The Children Act 1989:Guidance and Regulations. HMSO London 3.Department of Health (1991b) Working Together under the Children Act. HMSO, London 4.Department of Health (1991c) Child Abuse: a Study of Inquiry Reports HMSO, London 5.Department of Health (1995a) Child Protection: Medical Responsibilities. HMSO London 6.Department of Health (1995b) Child Protection: Messages from Research. HMSO, London 7.Department of Health (1999) Working Together to Safeguard Children The Stationery Office, London 8.Department of Health (2000) Framework for the Assessment of children in need and their families. The Stationery Office, London 9.Government Statistical Service (2000) Children and Young People on Child Protection Registers Year Ending 31 March 2000 Government Statistical Service, London 10.General Medical Council (1993) Professional Conduct and Discipline: Fitness to Practice General Medical Council, London 11.General Medical Council (1995) Duties of a Doctor General Medical Council, London 12.General Medical Council (2000) Confidentiality: Protecting and Providing Information. General Medical Council, London 13.British Medical Association (1996) Medical Ethics Today: Its Practice and Philosophy. BMJ Publishing Group, London 14.Hobbs CJ, Hanks HGI and Wynne JM (1999) Child Abuse and Neglect. A Clinicians Handbook Churchill Livingstone, London 15.Polnay JC and Blair M (1999) A model programme for busy learners. Child Abuse Review. 8: Polnay JC (2000) General Practitioners and child protection case conference participation. Child Abuse Review. 8: Polnay, JC (2001) Child Protection in Primary Care Radcliffe Medical Press, Abingdon 18.Reder P, Duncan S and Gray M (1993) Beyond Blame Routledge, London 19.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: Glaser D (1993) Emotional Abuse. In Hobbs CJ and Wynne JM (eds) Ballieres Clinical Paediatrics International Practice vol. 1 no. 1, ch. 13. Balliere Tindall, London 21.Skuse D (1997) Emotional Abuse and Neglect. In: Meadow R (ed) ABC of Child Abuse (3e). BMJ Publishing Group, London

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