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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

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

12. 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

13. 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

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

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

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

23. 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

24. 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

25. 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

28. 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 ( )

29. How safe are our children NSPCC 2013

30. 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?

31. 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

33. 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

35. 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

36. 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

37. 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

38. 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

39. How safe are our children NSPCC 2013

40. How safe are our children NSPCC 2013

41. How safe are our children NSPCC 2013