Presentation on theme: "Child Protection in Primary Care"— Presentation transcript:
1 Child Protection in Primary Care Dr Andrew MowatNamed Doctor for Child ProtectionEast Lincolnshire PCT
2 “Child Protection in Primary Care” Radcliffe Medical Press Ltd 2001 Dr Janet C Polnay MB BS BSc(Hons) MAAssociate Specialist in PaediatricsNamed Doctor for Child Protection, Nottingham City Hospital NHS TrustSenior Doctor in Child Protection (Primary Care), Nottingham Community Health NHS TrustMedical Advisor, Nottingham Health AuthorityFormerly, GP Principal, Nottingham
3 Sources of Stress for Families social exclusionknown domestic violenceknown mental health problemsknown drug/alcohol problemsWorking Together to Safeguard ChildrenDoH 1999
4 High Risk Situations Schedule 1 Offender previous children of household on registerparent who has been victim themselvesconcealed pregnancy
5 Prevalence Local Authority (Section 47) enquiries 160,000 per year (England)25000 unsubstantiated25% lead to Initial Child Protection Conference75% of those placed on Child Protection Registerpercentage rising steadilyCurrently, 30,300 children on CPR27 per 10,000 pop under 18 yrsGibbons et al 1995
7 Categories Category Number % of total registrations Neglect 12900 44 Physical InjurySexual abuseEmotional abuseOtherSource: Government Statistical Service 2000
8 Historical Context Children as possessions of parents Corporal punishment “necessary”children inherently badNSPCC 1890BSCC Liverpool 1883Battered Child Syndrome (Kempe, 1962)First UK Government guidance 1970Cleveland enquiryButler-Schloss, 1988
9 Legal Milestones The Punishment of Incest Act 1908 Children & Young Persons Act 1933Schedule 1 offencesChildren Act 1989established paramountcy of the Child’s interestsestablished ACPCsWorking Together under the Children Act 1989Working Together to Safeguard Children 1999Human Rights Act 1998New 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 orderresidence/adoption ordercare order
11 Private Law Children Act Section 8 Residence Order Contact Order Prohibited Steps OrderSpecific Issue OrderSpecific 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 OrderPolice Protectionremove to “suitable accommodation” for 72 hrsChildren Act Section 31Care & Supervision Orders
13 Domestic Violence100 women per year in England & Wales killed by present/former partnersFamily Law Act 1996: provides forOccupation OrdersNon-molestation OrdersPowers of ArrestAmended 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 careconfidentialityRights of the Familybest place to care for a child is in their own familyRights of the (alleged) Abuserinnocent until proven guiltyDuty to SocietyRights of the Doctor / NurseThese 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 outcomesapplies to large populationse.g. “the greatest good for the greatest number”Deontologicalapplies to individualsbased 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”ConfidentialityTruthfulnessDuty 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 enquiryCase Conferences: reports & attendanceCase Reviews (Part 8)(or managerial)
19 The GPs Role Opportunities already exist: awareness that child abuse occurscommunication systems which allow information exchange between professionalsTraining Needs/ResponsibilitiesGP TrainingStaff TrainingPOLNAY 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, locationsense of low priorityPotential solutions:improve reporting skillskeyworker to present information on GPs behalfPOLNAY 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, ppIn 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 WorkingWide range of other agencies involved in care of child (see next slides)Most used to inter-agency cooperationIsolated GPtoo many competing priorities?lack of trust of other agencies?absence of any organisation within GP?“Confidentiality” often used as an excuseGPs have no knowledge of other agencies’ agendaIn 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 involvedMany 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.
24 Non-Health Agencies Social Services Education Police Probation Service SecondaryPrimaryNurserySpecialPoliceProbation ServiceParents, FamilyNeighboursHome CareNSPCCYouth leadersReligiousFriends
25 Child Protection Register Maintained by LACPCLists all children considered to be at riskReceives enquiries from any health professionalwill ask for your details, including reason for enquiry, and call you backCPR 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 healtheducationemotionalParenting capacitycare/safetyFamily / EnvironmentsupportfinancialhousingChilds development:health, educational, emotional/behavioural, identity, relationships, social presentation, self- care skillsParent’s capacity to respond appropriately to needsbasic care, ensuring safety, emotional warmth, stimulation/encouragement, guidance/boundaries, stabilityFamily & environment contextfamily history/functioning, wider family, support, housing, employment, income, social integration, community resources
27 Child Protection in Primary Care RecognitionCommunicationKnowledgeNote keeping
28 Recognition Awareness General Characteristic Features Specific Features of:Physical AbuseEmotional AbuseSexual AbuseNeglect
29 Characteristic Clinical Features (General)(1) Delayed presentationChanging or ill-defined accountsHistory not consistent with examination findingsInjury not consistent with child’s developmental levelHistory of shakingUnrealistic expectation / perception of carerInappropriate response from carerChild’s interaction with carer:“frozen watchfulness”Child’s own account
30 Characteristic Clinical Features (General)(2) Unusual site of injurybehind the earin the hairin the mouthsoft tissue e.g. buttocksExtensive bruisingBruises / Scars of different agesPrevious suspicion or record of abuse (consider multi-generational abuse)Indication of Domestic ViolenceUnexplained injury / illness of recurring pattern
31 Physical Abuse Munchausen Syndrome by Proxy (MSBP) May involve: hittingshakingthrowingpoisoningburning/scaldingdrowningsuffocatingor otherwise causing physical harm to a childMunchausen 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) Bruisesface (baby)mouth (frenulum)grasp marks or fingertip bruisingunusual sites (ears, genitals, back, abdomen)outline (handprint, shoe or belt mark)extent / type of bruiseDifferential DiagnosesBurns/Scaldssite (perineum, face & head, genitalia, hands, feet, legs)“glove or stocking”look for splash marksregular edgesdepth on injury“hole in the doughnut” scald on buttockscigarette burnsDifferential DiagnosesDifferential Diagnoses:Bruising: clotting/bleeding disorders, birthmarks, skin disordersBurns/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) BitesHuman or Animal?Animal: puncture, cut and tear skinHuman: bruise, usually crescent shape, ?individual teeth seen: breaking of skin unusualdifficult to distinguish child or adult biteFractures?presenting feature or incidental findingmay only be detected by Radiologymay present as:reluctance to move limblimpswelling / pain
34 Specific Features: Physical Abuse (3) Poisoningchildren ingest harmful substances because:lack of supervisiondeliberate self-harmadministration by carernon-accidental poisoning often present “fits, faints or funny turns”Suffocation/Submersionnon-accidental suffocation may present as cot death, or “fits, faints or funny turns”non-accidental submersion difficult to identifyusually toddlerssometimes left with inappropriate carer
35 Munchausen Syndrome by Proxy presentation (often repeated) with illness fabricated by carercarer denies any idea of causesigns improve on separation from carersymptoms/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 Abusethe persistent emotional ill-treatment of a child, such as to cause severe and persistent adverse effects on the child’s emotional developmentmay involve making the child feel:worthless / inadequateunlovedvalued only for meeting someone else’s needsinappropriate expectations for their age/developmentfrightenedcorrupted / exploited
37 Specific Features: Emotional Abuse (1) Relationship CharacteristicsNegative Attitudes of parent to childConditional ParentingEmotional unavailabilityInappropriate expectationsFailure recognise individualityInconsistency of expectation/responseSomatic symptoms (see below)Glaser (1993)
39 Specific Features: Emotional Abuse (3) Schoolphysical (short/light, poor hygiene, unkempt)developmental (learning difficulties, low self-esteem, immaturity)behavioural (poor relationships, aggressive, destructive, soiling)Teenagerphysical (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 AbuseSexual 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 happeningThe activities may involve:physical contact, including penetrative (e.g. rape or buggery) or non-penetrative actsnon-contact activities, such as involving children in looking at, or in the production of, pornographic material or watching sexual activitiesencouraging children to behave in sexually inappropriate ways
41 Specific Features: Sexual Abuse Strong AssociationsStatement from ChildSTDPregnancySexualised behaviourGenital Bruising“love bites” of concernMild AssociationsGenital trauma or infectionOther less specificenuresisdepressive somaticheadache, abdo pain, sleep disturbance, loss of appetiteself-harmAlways 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 Neglectthe persistent failure to meet a child’s basic physical & psychological needs, possibly resulting in serious impairment of child’s health or developmentMay involvefailure to provide adequate food, clothing, shelterfailure to protect from danger / physical harmfailure to ensure access to appropriate medical care / treatmentfailure to meet basic emotional needs (overlap emotional abuse?)
43 Specific Features: Neglect Overlap with Emotional AbuseInappropriate parentingphysicalfailure to thrivepoor hygiene“deprivation hands/feet”Refusal to seek / accept medical adviceovertwhere harm fairly obvious as sequel e.g. withholding insulin for diabetescovertwhere harm not immediately obvious eg persistent non-attendance at appointmentsDeprivation 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 possibleLook to improve GP ⇆ A&E/Hospital channelsSharing Relevant information within PHCTregular 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 abuseUnless this is regularly updated, will quickly become unfamiliar and frighteningMembers within PHCT may develop special interest and awarenessClinical Governance issue
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 contextTagging of sibling’s notes to indicate risk
48 Action following recognition Don’t PanicRefer to LACPC GuidelinesShare concerns with colleaguesSenior PaediatricianPrimary CareMedicalNursingInterrogate Child Protection Register
49 Professional Support Designated Doctor/Nurse Named Doctor/Nurse at HA leveltraining, case reviews, managementNamed Doctor/Nurseat PCT levelat each NHS TrustPractice colleagues
50 Practice Child Protection Team Concentration of expertiseImproved responsefitting together the piecesTime-consumingcan we have a team for everything?
51 Organisation Practice Lead Regular meetings Channels of communication ? Doctor ?Health VisitorRegular meetingsallows sharing of information/concernsallows monitoring of children in needChannels of communicationwhen urgent need arises, links already made
52 The Children’s National Service Framework The general themes of the NSF will be::inequalities/accesschildren with disabilitiesinvolving parents/children in choicesintegration and partnershiptransition to adult services
53 The Children’s National Service Framework External Working Group: Children in NeedCo-Chairs:Professor Norman Tutt Director of Social Services, London Borough of EalingProfessor 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/skillsTraining and support are readily availablePractices may benefit by developing a smaller team with more expertise
55 The GP’s RoleThe 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 HuttonMinister of State for Health, January 2001Here 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 ReflectionQuo 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 BibliographyLincolnshire Area Child Protection Committee (2001) Code of Practice LACPCDepartment of Health (1991a) The Children Act 1989:Guidance and Regulations. HMSO LondonDepartment of Health (1991b) Working Together under the Children Act. HMSO, LondonDepartment of Health (1991c) Child Abuse: a Study of Inquiry Reports HMSO, LondonDepartment of Health (1995a) Child Protection: Medical Responsibilities. HMSO LondonDepartment of Health (1995b) Child Protection: Messages from Research. HMSO, LondonDepartment of Health (1999) Working Together to Safeguard Children The Stationery Office, LondonDepartment of Health (2000) Framework for the Assessment of children in need and their families. The Stationery Office, LondonGovernment Statistical Service (2000) Children and Young People on Child Protection Registers Year Ending 31 March 2000 Government Statistical Service, LondonGeneral Medical Council (1993) Professional Conduct and Discipline: Fitness to Practice General Medical Council, LondonGeneral Medical Council (1995) Duties of a Doctor General Medical Council, LondonGeneral Medical Council (2000) Confidentiality: Protecting and Providing Information. General Medical Council, LondonBritish Medical Association (1996) Medical Ethics Today: Its Practice and Philosophy. BMJ Publishing Group, LondonHobbs CJ, Hanks HGI and Wynne JM (1999) Child Abuse and Neglect. A Clinician’s Handbook Churchill Livingstone, LondonPolnay 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, AbingdonReder P, Duncan S and Gray M (1993) Beyond Blame Routledge, LondonSimpson 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, LondonSkuse D (1997) Emotional Abuse and Neglect. In: Meadow R (ed) ABC of Child Abuse (3e). BMJ Publishing Group, London