Child Protection Companion 2013 A.M Kemp, A.M Mott PATRON HRH The Princess Royal

Editorial Board Professor Alison Kemp Dr Alison Mott Dr Amanda Thomas Nick Libell (RCPCH) Laura Green (RCPCH) Anne Rusinak (RCPCH) Time scale of the project 2011-2013

Originated from a practitioner’s clinical manual produced in Leeds. History Originated from a practitioner’s clinical manual produced in Leeds. The 2006 Companion was produced by the Child Protection Special Interest Group and was based on evidence, research and practice at the time. 3

Contributing authors, reviewers and consultees Dr Folashade Alu Dr Monika Bajaj Ms Sonya Baylis Prof Nick Bishop Ms Sally Bradley Dr Rachel Brooks Dr Paul Davis Dr Geoff DeBelle Dr Margaret deJong Mr Sam Evans Dr Joanne Gifford Dr Danya Glaser Dr Lindsay Groves Dr Jenny Harris Dr Jean Herbison Dr Deborah Hodes Dr Diana Jellinek Prof Alison Kemp Mr Nick Libell Dr David Low Dr Ian Maconochie Dr Sabine Maguire Professor Jacqueline Mok Dr Alison Mott Dr Aideen Naughton Dr Sheila Paul Dr Ximena Poblete Dr Colin Powell Mr Charles Prest Dr Rosalyn Proops Dr Karen Rogstad Dr Peter Sidebotham Dr Alan Sprigg Dr Alison Steele Dr Corina The Dr Amanda Thomas Dr Elspeth Webb Dr Mike Williams Invited authors for specialist subjects and chapters Consultation groups Reviewers Sign off by College registrar 4

Aims of Child Protection Companion Primarily for UK Paediatricians 1. In their role in the multiagency safeguarding children process 2. Assist the recognition, assessment, investigation and management of suspected child maltreatment 3. To build upon and complement national guidance, policy and practice documents 5

FORMAT: RCPCH Child Protection Companion Hard copy £25 to RCPCH members £32 to non RCPCH members Online version Free to RCPCH members One year subscription £20 to non RCPCH members Online and print bundle £39 to non RCPCH members Hyperlinks to related documents Facility for regular update 6

Introduction Responsibilities of paediatricians Working Together to Safeguard Children. Children’s rights Good practice recommendations The medical assessment and admission to hospital Consent, Confidentiality and Information sharing Parental factors Recognition of Physical Abuse Child sexual abuse Neglect Emotional abuse Perplexing presentations (including FII) Abuse in special circumstances Infant and Child deaths Records and reports Photo documentation Court proceedings: giving evidence Training and support Appendices

UK wide document UK wide document Terminology is based primarily on English law, legislation and guidance. Where appropriate the differences in policy and practice in Scotland, Wales and Northern Ireland and the legal differences in Scotland are referenced Written in accordance with UNCRC 8

Landmark Documents Landmark documents Makes reference and hyperlinks to over 50 key documents e.g. Child protection legislation Children Act, Health and Social Care, Children Act Scotland Clinical Guidelines NICE guidance 2008, RCR/RCPCH Radiology guidelines Professional practice guidelines GMC publications 2012/13, RCPCH clinical competency document, BMA Toolkit Government reports Kennedy report , Munro review, Laming progress report 2009 Regional PRUDIC (Wales), Choosing to Protect 2009 (NI), A Guide for getting it Right for every Child (Scotland) 9

Evidence base Evidence base www.core-info.cf.ac.uk NICE guidance Bruising Fractures Oral injury and bites Burns and scalds Abusive head trauma Haemorrhagic retinopathy Visceral injury Emotional neglect and emotional abuse: preschool children Dental neglect NICE guidance RCPCH FII document Published systematic reviews and studies

Each chapter includes good practice recommendations aiming to set Audit standards Local and national child protection health care provision National standards

Medical assessment Communication with child and family Be sensitive to the child’s needs The child should: understand the reasons for assessment be able to express their wishes and feelings participate in decisions affecting them be given the opportunity of speaking alone Communication with multiagency team Verbal information to children’s social care and police should be followed up in writing with a formal report within 3 working days 12

Medical assessment Training The examining doctor should have level 3 training competences A trainee should be supervised by a consultant or senior paediatrician Timescales Appropriate to type of abuse and requirement for collection of evidential samples: Physical injury: within 24 hours Historic abuse and neglect: according to clinical need and child protection process. Children should not be kept waiting for more than 10 working days without clear mitigating factors agreed by all parties 13

Improved evidence base What is new? Improved evidence base Links to Core info website (www.core-info.cf.ac.uk) Integrated with NICE guidance on recognition of suspected maltreatment Detailed section on haematology investigations Vitamin D deficiency and fractures 17

Haematology assessment In consultation Geoff DeBelle Mike Williams Focus on child and family history Who to investigate? First and second line investigations

Assessment of children with occult fractures In consultation with Prof N Bishop Alan Sprigg Stress the history Explanation for injury Excluding bone fragility Investigations

Guidance for the general paediatrician on the recognition of suspected CSA and ongoing management All cases of suspected CSA must be referred to paediatrician with the appropriate training and competences Guidelines on Paediatric Forensic Examinations in Relation to Possible Child Sexual Abuse FFLM/ RCPCH 2012

Child Sexual abuse: What should you do? What should the general paediatrician do? Recognition Acute or historic? If acute Assess immediate health needs of child Examination as soon as possible The timing of the examination is essential in: Obtaining forensic evidence Risk assessment for prevention of STIs: prophylaxis for HIV has to be given within 72 hours post assault and is most effective when given as soon as possible Prevention of pregnancy: emergency contraception can be given up to 72 hours or five days post assault. Clinical signs of trauma heal rapidly and may be lost unless a child is examined within 24 hours of the assault. Evidence that can be obtained from specific forensic sampling is best obtained as quickly as possible, preferably within 24 hours, though evidence may still be present up to 72 hours and even up to one week after the assault. However, each case should be considered individually as clinical signs may be visible after 72 hours and forensic samples may not provide evidence 24 hours after the assault particularly in pre-pubertal girls 24

Any doctor who undertakes a forensic assessment of a Child Sexual Abuse Any doctor who undertakes a forensic assessment of a child who may have been sexually abused must be familiar with recent guidance. The Physical signs of child sexual abuse: an evidence based review and guidance for best practice RCPCH 2008 Currently being updated with publication expected late 2013 Need for child focused service 365 days per year with appropriate facilities

Parental risk factors: domestic abuse Children living with domestic violence are suffering significant harm (Adoption and Children Act 2002) Included in emotional abuse definition seeing or hearing the ill-treatment of another Domestic violence identified as risk factor in 34% of Serious Case Reviews (2009 -2011)

How safe are our children NSPCC 2013

Domestic abuse: Role of paediatrician Routine questioning should be part of the history taking when children are assessed for suspected child abuse and neglect Sensitivity to needs and safety of adult Multiagency process MARAC (Multi Agency Risk Assessment Committee) Indirect questions: a) Is everything ok at home? b) Is your partner supportive? c) If woman is pregnant: Are you being looked after properly? Is your partner taking care of you? Direct questions: a) Do you ever feel frightened of your partner? b) Have you ever been in a relationship where you have been hit or hurt in some way? c) Are you currently in a relationship where this is happening to you?

How safe are our children NSPCC 2013 Children at risk of abuse and neglect There are many risk factors that are associated with higher rates of abuse and neglect, but the strength of the association depends on the child and their circumstance. The presence of multiple factors increases the risk to the child DA: Children living with domestic abuse are at risk of being harmed by the impact on parenting, by living in a dangerous home and by homelessness and frequent moves. DA is frequently identified in Child Practice Reviews as being a factor when a child has suffered serious harm Mental health: The vast majority of parents with a mental health problem do not abuse their children. However in the majority of Child Practice Reviews the serious mental illness of the parents was identified as a significant risk factor Substance misuse: Children whose mothers misuse substances during pregnancy are at higher risk of impaired development. Parental misuse of drugs or alcohlol is found in more than half of parents who neglect their children Learning difficulties: Parental learning disability can impact on a parent’s ability to safeguard their children. There are no clear links between child abuse and wilful neglect: in most cases the neglect occurs by omission of action, lack of understanding of appropriate parental actions and limited support. Poverty, debt and financial pressures: Although there is no evidence that poverty causes child maltreatment, they share many similar risk factors. Impact of stress associated with poverty is the most common explanation. Parents victims of childhood abuse: Long term impact of child maltreatment on an adult may place a parent’s own children at risk. Such adults are vulnerable to lifelong psychological, behavioural and learning problems, substance misuse and mental health problems: risk factors linked to child maltreatment Children with physical/ mental impairments: From the limited evidence base deaf and disabled children are three times more likely to experience abuse than non disabled children. The key reasons for professionals not to recognise child maltreatment include lack of awareness of risk, reluctance to believe that disabled children are abused, indicators of abuse mistakenly attributed to disability and lack of effective communication with the child. Ethnicity: Children from black and mixed ethnic backgrounds are disproportionately over represented on child protection register, care system and child in need data. Children from Asian ethnic background are disproportionately under represented. Children in care: A small percentage of children remain at risk of harm suffereing additional abuse while in care. Types of abuse include targeted abuse by carers, poor standards of care, systematic abuse by staff against children, and further emotional damage caused by placement instability How safe are our children NSPCC 2013

Abuse in special circumstances Groups of children at particular risk of abuse Complex topics summarized with relevance to paediatrician Background, existing guidance, identification of key issues and responsibilities of paediatricians Themes: children living away from home eg Looked After Children children from minority groups eg Asylum seeking children focus on young people eg Sexual exploitation Complex topics summarised 33

All paediatricians require ICC Level 3 competences Training All paediatricians require ICC Level 3 competences (55 further knowledge, skills, attitudes and values) Trainees should attain ICC competences: F1/F2: Level 1 training ST1-3: Level 2 training ST4-8: Level 3 training 35

Child Protection in Practice Level 2/3: online Training Child Protection Recognition & Response  Level 2: face-to-face. Paediatricians in training (ST 1-3) Child Protection in Practice Level 2/3: online Paediatricians in training (ST 4-7) Maintaining and Updating Competences Level 3: online Consultant Paediatricians Child Protection: from examination to court Level 2/3: face-to-face. Consultant Paediatricians and senior trainees Expert witnesses in Child protection: developing excellence Level 6: face to face. Consultants 36

Peer review, supervision and support Proactive culture of learning, education and training, case supervision, service improvement including multiagency processes. Support in a non-hierarchical environment, decrease professional isolation, sharing of best practice and understand the complexities of common but uncertain situations. Assurance that case findings and report meet a measure of standard and are more reliable. Royal College of Paediatrics and Child Health (2012) Peer Review in Safeguarding

Future developments Development of standards for safeguarding children Good practice recommendations Quality assessment framework Outcomes focused standards Training competences being updated and clarified for trainees Keeping up to date 38

How safe are our children NSPCC 2013

How safe are our children NSPCC 2013

How safe are our children NSPCC 2013