Embed Size (px)
Citation preview
Child Protection -Exploring the Role of the GP
Dr Kerry MilliganGPwSI Child Protection
RCGP Child Health Strategy 2010-2015
• “The RCGP firmly believes that general practice occupies a central position in children and young people’s health, particularly in the diagnosis and management of illness and the promotion of health and wellbeing. We are concerned that unless the profession acts now to protect this important and trusted role, it will become eroded and lead to serious fragmentation of care for this vulnerable group of patients.”
RCGP Child Health Strategy 2010-2015
• The role of the GP in safeguarding is wide ranging: recognition of patterns of neglect, referring in a timely and appropriate manner to secondary health care colleagues or social care, responding to inter-agency requests, supporting families and giving context at case conferences.
• UN Convention on the Rights of the Child 1989 (Protection, Provision, Participation)
• Age of Legal Capacity Act 1991 (Enter legal commitments, give/refuse consent treatment)
• The Children(Scotland) Act 1995
• Protection of Children (Scotland) Act 2003 (list individuals unsuitable to work with children)
Legislative frameworkLegislative framework
Child Protection Unit 2012
National Guidance for Child Protection in Scotland
http://www.scotland.gov.uk/Resource/Doc/334290/0109279.pdf
National Guidance
Key Changes:
• Categories of Registration removed
• Unborn children on CPR
• Updated definitions of abuse and neglect
• Timescales for child protection processes specified
• Web based document, with links to other relevant documents
The responsibilities of all doctors
General Medical Council
Protecting children andyoung peopleShort guide for GPs
GMC-Protecting Children and Young People
• All children and young people are entitled to protection from abuse and neglect. This guidance aims to help doctors keep children and young people safe, and to support doctors in what will always be a difficult area of practice.
GMC-Protecting Children and Young People
Key points
• Be aware of risk factors that have been linked to abuse and neglect and look out for signs that a child or young person may be at risk.
• If you are treating an adult patient, consider whether your patient poses a risk to children or young people.
• Keep an open mind and be objective when making decisions. Work in partnership with families where possible.
• If you are not sure about whether a child or young person is at risk or how best to act on your concerns, ask a named or designated professional or a lead clinician or, if they are not available, an experienced colleague for advice.
Protecting children and young people
Main Themes
• Identifying children
• Working in partnership
• Confidentiality and sharing information
• Keeping records
• Child Protection Examinations
• Training and development
• Communication and support
GMC-Protecting Children and Young People
Working in partnership •Understand the roles of other professionals and agencies responsible for protecting children and young people and work in partnership with them. •Contribute to child protection procedures and provide relevant information to child protection meetings if you are not able to go to them. •Know who your named or designated professional or lead clinician is and how to contact them.
Defining the Child
• Child means person under the age of 16 years or 18 years if looked after or accommodated by social work services or subject to a supervision requirement
What is abuse?
Small group exercise
What is Child Abuse?
• “ Child abuse involves acts of commission or omission, which result in harm to the child”
• “ Abuse or neglect may occur in the family, a community or an institution (home,school,hospital,street)
• Child Protection Companion – RCPCH 2006
Adverse Childhood Events Study
• Kaiser Permanente, >17,000 subjects interviewed
• ACE (<18y) included physical/emotional/sexual abuse, growing up in household with alcoholic, substance abuser, someone imprisoned, mentally ill, mother treated violently, parents divorced or separated
• ACEs seem to account for one-half to two-thirds of serious problems with drug use. They increase the likelihood that girls will have sex before 15, and that boys or young men will impregnate a teenage girl.
Adverse Childhood Events Study
• health, social, and economic risks that result from childhood
trauma.
Adverse Childhood Events Study
The more categories of trauma experienced in childhood, the greater the likelihood as an adult of experiencing:
• alcoholism and alcohol abuse
• chronic obstructive pulmonary disease
• depression• foetal death• poor health-related
quality of life• illicit drug use• ischaemic heart disease
• liver disease• risk for intimate partner
violence• multiple sexual partners• sexually transmitted
diseases• smoking• obesity• suicide attempts• unintended pregnancies
The Hidden Epidemic: The Impact of Early Life Trauma
on Health and Disease
Types of maltreatmentMaltreatment Examples
Physical Bruising, fractures, burns, severe injuries
Sexual abuse Rape/indecent assault including sexual assault and internet abuse
Emotional Abuse
Sustained or repeated demeaning, critical and unloving behaviours, verbal abuse
Neglect Failure to thrive, missed health care and/or educational opportunities. Non Engagement / non compliance
Induced illness Suffocation, poisoning, interference with feeding tubes and IV lines
Fabricated illness
Falsifying histories, exaggerating disability, interfering with tests
Physical InjuryBruising• Prevalence, number and position of bruises is related
to increased motor development• Bruising in non independently mobile babies is very
uncommon (<1%)• Majority of school children have bruises• Common in abused children• Common sites – head (commonest site in abuse) and
neck, buttocks, genitalia, trunk and arms• Large multiple clusters or implement image “those who don’t cruise rarely bruise” Arch Pediart Adolesc Med
1999;80:363-366
Physical Injury
• ‘Those who don’t cruise, rarely bruise’ (Sugar, Taylor and Feldman 1999). A systematic review of the international literature in infants under an age of 6 months suggests that any bruise in an infant under 6 months must be fully evaluated and a detailed history taken to ascertain consistency with the injury. Non-mobile children should not have bruises without a clear and usually observed explanation. Certain areas are rarely (less than 2%) bruised accidentally at any age including neck, buttocks and hands in children less than two years.
Bruising - Site
Bruises suggestive of abuse
• More bruises in abused than non- abused children.
• Bigger bruises in abused than non-abused children
• Multiple bruises in clusters.
• Multiple bruises in uniform shape.
• Bruises carrying the imprint of an object.
Emotional Abuse
• …actual or likely severe adverse effects on the emotional and behavioural development of the child caused by persistent or severe emotional ill treatment or rejection.
Emotional Abuse
Babies• Feeding difficulties• Demanding• Irritable• In control of mother
Toddlers• Behaviour problems• Developmental delay
Adolescents• Depression• Eating disorders• DSH• Behaviour problems
School Age• Wetting / Soiling• Poor school
performance• Non-attendance /
Poor behaviour
Emotional Abuse
Child• Unwanted• Wrong sex• Disabilities• Almost always
associated with other forms of abuse
Family• Alcohol / substance
misuse• Mental health problems• Marital problems• Domestic violence
Examination• Poor growth• Observed behavioural or developmental difficulties
Emotional Abuse – psychological consequences
• Low self esteem
• Difficulties in relationships• With peers / family / authority figures
• Difficulties in giving & accepting affection
• Often impulsive & aggressive
• Can be frustrated, anxious & non-compliant
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”• Working Together DoH
• Vast majority of abusers are from within the family
• Surrounded by secrecy
Sexual Abuse
• Non Contact• Flashing, showing of pornography, taking photos
• Contact• Touching• Masturbation• Digital penetration• Vaginal or anal intercourse• Prostitution
What would prompt us to investigate?
• Disclosure by child• Concern from carer• Change in behaviour• Sexualised
language/behaviour/drawings• Medical symptoms including trauma• Pregnancy• Presence of STI
Neglect
• Practitioners do not identify and respond as well as they might - referrals concerning physical, sexual and emotional abuse are often given a higher priority than those concerning neglect (Platt 2006).
Neglect –Working Together 2006
Neglect is the persistent failure to meet a child’s basic physicaland/or psychological needs likely to result in serious impairment ofthe child’s health and development.It may involve a parent or carer failing to provide adequate food,shelter and clothing, failing to protect a child from physical harm ordanger, or the failure to ensure access to appropriate medical careor treatment. It may also include neglect of or unresponsiveness toa child’s basic emotional needs.
Why is neglect harmful?Learning• Lack of exploration
• Delayed speech & language
• Impoverished play & imagination
• Special educational needs/learning disability
• Later educational failures
• Poor life skills development
Emotions• Disturbed self-regulation
• Negative self identity
• Low self esteem
• Clinical depression
• Substance misuse NCH The Bridge 2007
Bodies• Fatal neglect• Intra-uterine growth retardation• Non-organic failure to thrive• Vulnerability/susceptibility to
illness, infection & accidents• Poor/delayed medical care.
Brains• Lack of nutrients; reduced growth• Lack of stimulation: retardation of
brain • Unregulated stimulation:
disordered neural circuitry development
Photographic EvidencePhotographic Evidence
Challenges
• Inter-agency working
• Normalisation
• Hidden children
• Over-optimistic
• ‘start again’ phenomena
• Drift
• Capacity
NICE Clinical Guideline 89Consider and Suspect:
CONSIDER means maltreatment is one possible explanation for the alerting feature or is included in the differential diagnosis.
SUSPECT means serious level of concern about the possibility of child maltreatment but not proof of it
• Listen and observe• Seek an explanation• Record
• http://www.nice.org.uk/nicemedia/live/12183/44872/44872.pdf
Stressful circumstances commonly associated with child abuse
• Living in poverty
• Domestic violence
• Parental drug and alcohol abuse
• Living in environment of high anti-social behaviour, crime, poor housing
• Parental mental health disorders
• Parental learning disability
• Social isolation including that due to racism.
References • Becker,F.,French,L(2004) Making the links: Child Abuse, animal cruelty and domestic violence
Child Abuse Review 13:399-414• Browne,K.D., Herbert,M.,(1997) .Preventing Family Violence Chichester:Wiley• Lung, C. T. and D. Daro. 1996. Current trends in child abuse reporting and fatalities: The results
of the 1995 annual fifty state survey. Chicago, IL: National Committee to Prevent Child Abuse.• Wolfe,D.(1993) Child Abuse Prevention Child Abuse Review 2(2):153-165• Working Together to Safeguard Children 2010• Image Source www.refuge.org.uk who run a 24 hour National Domestic Violence Helpline
08082000 247
© Royal College of General Practitioners &National Society for the Prevention of Cruelty to Children, 2011
Increased vulnerability: parental factors
• Alcohol and substance misuse
• Poor and unstable parental relationship
• Poor parenting skills• Parents abused as
children• Post-natal depression• Poverty and social
exclusion• Male in house-hold not
father
• Young, immature and socially isolated
• Learning disabilities• Aggression and poor
impulse control• Mental health problems
including depression, psychopathic and personality disorder
• Domestic violence
Child Protection in specific circumstances
Indicators of risk
• Domestic abuse• Parental alcohol and drug misuse• Disability• Non engaging families• Children and young people experiencing mental health problems• Children and young people affected by mental health problems• Children and young people who display harmful or problematic
sexual behaviour• Female genital mutilation• Honour based violence and forced marriage• Fabricated or induced illness• Sudden unexpected death in infants and children
Child Protection in specific circumstances
Responding to concerns about children
• Complex child abuse situations: inter-agency considerations
• Child trafficking• Historic allegations of abuse• Children who are looked after away from home• Online and mobile phone child safety• Children and young people who place themselves at risk• Children and young people who are missing• Underage sexual activity• Bullying
Domestic Abuse
• 1 in 4 women experience domestic violence in their lives (BMA 1998)
• 18% of women attending A&E (with an injury) – cause is domestic violence (BMA 1998)
• 30% of domestic violence is known to start or escalate in pregnancy (CEMD – 1994-96)
• In 60% of child abuse cases, where the father is the perpetrator, the mother is also being abused (Mullender 1998)
Parental Substance Misuse
• 1 in 10 children affected by parental substance use across UK
• 1.3 - 2 million children affected by parental alcohol misuse
• 250,000 - 350,000 children affected by parental drug misuse in UK
• 40,000 – 60,000 children affected by parental drug misuse in Scotland
Scenario
Small Group Exercise
Level 3All staff working predominately with children, young people and parents
• Be competent at level 2
• Have knowledge of the implications of key national documents/reports
• Understand the assessment of risk and harm
• Understand multi-agency framework/assessment/investigation/working
• Be able to present concerns in a CP conference
• Demonstrate ability to work with families where there are CP concerns
• Be able to advise other agencies on health management of CP concerns
• Be able to contribute to serious case reviews or equivalent process
• Where appropriate, be able to undertake forensic procedures
• Understand forensic procedures/practice
GPs have a key roleGPs have a key role:Identifying trendsCentral hub of Health info…from OOH services, EDs etcKnowledge of parents / carers healthLinks with HVs‘Each Practice should have a nominated lead & deputy lead to
promote safeguarding’ (Laming 2009)
SW Role and Responsibility
•Receive child protection referrals and investigate allegations of abuse.
•Decide whether to respond under child protection procedures.
•Discuss referrals with police.
•Joint investigation.
•Promotion of welfare and supporting families
•Organise and manage case conferences
• Who makes the call?
• To whom are you speaking?
• Be clear that you are making a child protection referral.
• Give clear details.
• Who else do you inform?
• Follow up in writing – interagency referral form
• Outcome?
Making the Referral
SW Role and Responsibility
Is there an immediate risk to the child?
• Child Protection Order (s57) • Police power to remove child (s61)
(without authorisation)• Child Assessment Order (s55)• Exclusion Order (s76)
All references are to the Children (Scotland) Act 1995
Identifying and responding to concerns about children
Child Protection Case Conferences• The CPCC should be held within 21 days of
notification of concern• Where possible participants should be given 5
days notice of decision to convene CPCC
• Reviewed in 3 months, thereafter 6 monthly• Pre birth – registration of unborn child• Minute taking• Lead Professional – Developing a plan
Safeguarding Children & Young PeopleA Toolkit for General Practice 2011
General Points for Preparing Reports for Conference
The Assessment Framework Tool recommends a triangle model of assessment. •Child’s developmental needs •Parenting capacity •Family & environmental factors
Safeguarding Children & Young PeopleA Toolkit for General Practice 2011
• Consider:
• missed appointments with GP, practice nurse and midwife
• failed immunisations
• missed hospital appointments
• education: discuss with school nurse or health visitor
• parental mental health or substance abuse
• ability of the carers to parent [disability, physical or intellectual]
• evidence of domestic violence
• cruelty to animals in the family
• are both parents registered with your practice?
• who has parental responsibility?
• sharing the report with the child if old enough and the parents where appropriate
Early Adversity has a Long Term Impact
Early Adversity has a Long Term Impact
• Research confirms the links between infant-parent attachment and psychological and behavioral development
• Attachment can be influenced by interventions
• Reflective functioning
Early Adversity has a Long Term Impact
• Maternal depression- 14% mothers
• Domestic abuse- starts or escalates in pregnancy
• Heightens maternal stress which has direct impact on foetus
Early Adversity has a Long Term Impact
Substance misuse•Majority of infants born to dependent mothers (60-90%) will show varying symptoms of neonatal abstinence syndrome
•Alcohol one of the most dangerous
neurotoxins
•Direct and indirect harm
