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Child Protection in Primary Care

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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) 25000 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 Category Number % of total registrations Neglect 12900 44
Physical Injury Sexual abuse Emotional abuse Other 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 Child’s 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 child’s 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 Specific Issue Order: issued where, for instance, one parent asserts their “right” to prevent child being immunised. The Court may apply an order which relates only to that immunisation.

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 Rights of the Family
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 These are hierarchical: the rights of the Child are paramount (Children Act). How that child expresses their wishes, of course, varies according to age/development and communication skills. The child’s perceptions of the abuse may, for instance, be less immediately important to them than the threat posed by someone who wants to admit them to hospital, separated from their home and family. Note that the alleged abuser also has rights: it is not for us to judge right and wrong in individual cases – that is a function of a properly-convened case conference (to decide what outcome is best for a child) or a jury trial (to decide guilt or innocence). The most challenging thing for individuals in Primary Care is the continuing relationship with other family members (including the alleged abuser). One might argue that it is beyond the reasonable expectations of society to ask a doctor to continue to serve both the victim and the culprit in sexual abuse cases (in particular).

15 Ethical concepts Utilitarianism Deontological 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 Confidentiality
“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 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 In this research general practitioners' (GPs') attitudes to child protection case conferences were explored in the belief that commonly cited practical reasons, such as inconvenient timing, fail to provide a complete explanation for poor participation. The postal survey showed that nearly half the respondents agreed there were too many other tasks of higher priority than case conference attendance, confirming that previously mentioned constraints alone did not account for poor participation. It is concluded that it may be more fruitful to concentrate on improving report submission rate and content because of GPs' priorities.

20 GP Attitudes Reasons for non-attendance Potential solutions:
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 In an NHS Primary Care arena which is almost entirely demand-led, it is difficult to undertake any activity which expends excessive amounts of time on single patients, unless backfill is provided. This is a mistake now recognised by the DoH, and most PCTs. It must also be said that Paediatricians also find it difficult to attend, but are usually better at sending apologies, and a report. This may be because each senior Paediatrician has ready access to Administrative support. To expect a GP to work an additional 2-3 hours, over and above their normal daily work commitment, is unreasonable. Equally, we must acknowledge the vital role which family doctors can play in fitting pieces of information together, to placing abuse or illness in its proper context, and to advise the Child Protection process accordingly. If society (ie Government) accepts the value of having this advice, then the work of the GP must be backfilled: and in areas such as ours, this is not merely about money – often, locum doctors simply cannot be found to do the work. Equally, GPs themselves must recognise the value and necessity of the work, and accord it higher priority, say, than the annual medical review of a boarded-out child. One form of solution would be for the keyworker (usually a Social Worker from the Children Team) to arrange a structured interview at the GPs Surgery, and thereby to prepare a report which presents the relevant information in a format useful to the Conference.

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 In Child Protection work, information may be observed by individual agencies with whom the child comes into contact, but not at a threshold enough to trigger alarm bells. Reder (1993) reports up to 72 other professionals involved Many enquiry reports (DoH 1991) comment on the “…isolation of the GP and the non-involvement in the inter-agency system”. We are used to cross-referral (not really collaborative working) to other medical colleagues, but we have difficulty trusting anyone else, and are therefore reluctant to exchange information with teachers, police, social workers etc. GMC is quite clear (Duties of a Doctor 1995): where a child may be at risk, relevant information should be shared with appropriate professionals. Use of jargon further complicates and muddies the communication between agencies: GPs often fail to understand that the statutory duty on Social Services to investigate (Section 47) is equally binding on them to comply and cooperate in response.

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
Learning Disability Team Occupational Therapy Speech Therapy Physiotherapy Audiology Optometry PHCT previous area Ambulance Service School Nurses Accident & Emergency Hospital Paediatrics Community Paediatrics Mental Health Services Education Behavioural Support Educational Psychology

24 Non-Health Agencies Social Services Education Police Probation Service
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 CPR lists those children in Lincolnshire “at risk of significant harm, and for whom there is a child protection plan” Should includes those placed there by another county (i.e transferred), but is dependent on notification by Social Services of that county (so beware the moonlight flit) CP Registrar will note your details, including reason for enquiry, and call you back (to verify your details). Each enquiry is noted.

26 Assessment Framework Developmental Parenting capacity
health education emotional Parenting capacity care/safety Family / Environment support financial housing Childs development: health, educational, emotional/behavioural, identity, relationships, social presentation, self- care skills Parent’s capacity to respond appropriately to needs basic care, ensuring safety, emotional warmth, stimulation/encouragement, guidance/boundaries, stability Family & environment context family history/functioning, wider family, support, housing, employment, income, social integration, community resources

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 child’s developmental level History of shaking Unrealistic expectation / perception of carer Inappropriate response from carer Child’s interaction with carer: “frozen watchfulness” Child’s 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 Munchausen Syndrome by Proxy (MSBP) 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 Differential Diagnoses: Bruising: clotting/bleeding disorders, birthmarks, skin disorders Burns/Scald: skin disease or infection e.g. impetigo, severe nappy rash: unusual circumstances e.g. hot metal seatbelt buckles; immobility or altered pain perception (neurological e.g. cerebral palsy)(congenital insensitivity to pain)

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 child’s emotional development may involve making the child feel: worthless / inadequate unloved valued only for meeting someone else’s 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 Always take seriously – and record verbatim if possible – a statement from child that they have been abused. It is up to other agencies to establish truth or otherwise: your prime duty of care is to believe, questioning only to establish enough detail to establish that sexual abuse is the issue. If any STD is diagnosed, abuse must be considered. Bruising in genitals, inner thighs, lower abdomen or pubic area. Useful to have an advanced plan of contact for Paediatrician: each Trust must now have Named Doctor for Child Protection – usually senior Paediatrician – who will arrange to carry out examination. It is undesirable for examination to be carried out by junior Paediatric Staff. Their subsequent reporting skills, and difficulty tolerating uncertainty, cause confusion among non-medical members of Case Conference, and often require further clarification. This is where pre-determined channels come in really useful, and where the Practice Child Protection Team pays dividends. Examination of a child where abuse is suspected should normally only be carried out once, and that by the Consultant/Senior Paediatrician.

42 Neglect the persistent failure to meet a child’s basic physical & psychological needs, possibly resulting in serious impairment of child’s 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 Deprivation hands & feet described by Glover et al (1985): deep pink (?bluish tinge) midly oedematous hands/feet seen in group of children living in families with considerable deprivation. May give rise to concern about cardiac status

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 sibling’s notes to indicate risk

48 Action following recognition
Don’t Panic Refer to LACPC Guidelines Share concerns with colleagues Senior Paediatrician Primary Care Medical Nursing Interrogate Child Protection Register

49 Professional Support Designated Doctor/Nurse Named 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 Regular meetings Channels of communication
? 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 Children’s 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 Children’s 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 GP’s Role The general practitioner’s 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 Here is the Government’s underscoring of the importance of the involvement of General Practitioners in Child Protection. If we know we have the Government’s support in this, why aren’t we going back to them to tell them what resources we need to make it happen? Like we’re doing with National Service Frameworks?

56 Reflection Quo vadis? So, how does what you’ve learned today change your practice? Is there someone who would benefit from sharing the knowledge? Is there someone already in your practice who already has some of the knowledge? Can you see benefits from using some of the knowledge we’ve discussed? Are there any simple changes you can make to adopt some of the challenges of Child Protection? What support do you think you’d need to help you take on these challenges?

57 Bibliography Lincolnshire Area Child Protection Committee (2001) Code of Practice LACPC Department of Health (1991a) The Children Act 1989:Guidance and Regulations. HMSO London Department of Health (1991b) Working Together under the Children Act. HMSO, London Department of Health (1991c) Child Abuse: a Study of Inquiry Reports HMSO, London Department of Health (1995a) Child Protection: Medical Responsibilities. HMSO London Department of Health (1995b) Child Protection: Messages from Research. HMSO, London Department of Health (1999) Working Together to Safeguard Children The Stationery Office, London Department of Health (2000) Framework for the Assessment of children in need and their families. The Stationery Office, London Government Statistical Service (2000) Children and Young People on Child Protection Registers Year Ending 31 March 2000 Government Statistical Service, London General Medical Council (1993) Professional Conduct and Discipline: Fitness to Practice General Medical Council, London General Medical Council (1995) Duties of a Doctor General Medical Council, London General Medical Council (2000) Confidentiality: Protecting and Providing Information. General Medical Council, London British Medical Association (1996) Medical Ethics Today: Its Practice and Philosophy. BMJ Publishing Group, London Hobbs CJ, Hanks HGI and Wynne JM (1999) Child Abuse and Neglect. A Clinician’s Handbook Churchill Livingstone, London 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 Reder P, Duncan S and Gray M (1993) Beyond Blame Routledge, London 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) Balliere’s Clinical Paediatrics International Practice vol. 1 no. 1, ch. 13. Balliere Tindall, London Skuse D (1997) Emotional Abuse and Neglect. In: Meadow R (ed) ABC of Child Abuse (3e). BMJ Publishing Group, London

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