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Safeguarding children
GP trainer, Sutton Scotney, Hampshire
E-mail: dwilson155{at}aol.com
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Abstract |
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Child abuse occurs where a child is harmed or not protected from harm. Over recent years the term ‘safeguarding’, or putting measures in place to improve childrens’ safety and prevent abuse, has been introduced. Child protection is the part of the safeguarding process where it is necessary to intervene when there is a reasonable belief that a child is at risk of significant harm, and should be seen in the broader context of safeguarding and promoting the welfare of children.
In order to maximize life chance, health professionals must play their part in helping children to:
- Be healthy: enjoy good physical and mental health and live a healthy lifestyle.
- Stay safe: this means being protected from harm and neglect.
- Enjoy and achieve: by developing broad skills for adulthood.
- Make a positive contribution: to the community and society.
- Achieve economic well-being: by overcoming disadvantages to achieve their full potential.
Primary care management A GP must be able to deal effectively with the abuse of children and young people, and safeguard them from harm. Dealing effectively with abuse involves recognizing the clinical features, being familiar with local referral arrangements, having the skills required for multi-agency working, and being able to take appropriate action.
Person-centred care
Specific problem-solving skills
A comprehensive approach
Community orientation
A holistic approach
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Statistics |
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There were 4,109 reported offences of cruelty or neglect of children in England and Wales in 2002/3 and every year 730,000 children's names are added to the child protection register in England alone. However, criminal statistics, child protection registration, and referrals to social services with a child protection concern are only the tip of the iceberg as they only refer to serious and reported incidents. NSPCC research shows that about 7% of children suffer serious physical abuse at the hands of their parents or carers during childhood, 6% of children experience serious absence of care at home, 6% of children experience frequent and severe emotional maltreatment during childhood and 1% of children experience sexual abuse by a parent or carer, and another 3% by another relative during childhood.
Child death is the most severe form of child abuse. Child abuse is responsible for 1–2 deaths per week in England, but likely to be significantly higher. Most child homicide is as a result of parental or step-parental activity. Murder by a stranger is rare.
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The child protection system in the UK |
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 TOPAbstractWhat the GP curriculum...Statistics The child protection system... Relevant legislationClassificationIdentification of 'at risk'...PresentationManagementSpecial circumstancesReferences |
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Child protection in the UK is the responsibility of each individual Nation State although the principles of child protection are broadly the same across the UK. In England and Wales, child protection is the responsibility of the Department for Education and Skills (DfES). It issues statutory guidance to local authorities (which must be followed) and non-statutory guidance (which it is suggested that local authorities follow). In turn, local authorities then use this guidance to develop their own procedures tailored to local facilities and resources, that should be followed by practitioners and professionals who come into contact with children and their families in that particular area. In addition, the National Assembly for Wales has recently started producing some guidance of its own for local authorities within Wales. In Scotland, it is the Scottish Executive that issues guidance to local authorities, and in Northern Ireland the Department of Health, Social Services and Public Safety issues guidance to the four local health and social services boards.
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Relevant legislation |
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In the UK, there has been legislation in force since the 1880s to prosecute people accused of child cruelty charges. However there is no one piece of legislation that covers child protection. A number of Acts of Parliament, guidance documents, case law judgements and conclusions of inquiries into high profile child deaths (Dennis O'Neill in 1945; Maria Colwell in 1973; Jasmine Beckford in 1984; and, Victoria Climbié in 2000) constitute the UK's Child Protection legislation. Legislation covers both the rights of children and the offences that constitute child abuse. In addition, there is a raft of legislation to try to identify, monitor and prevent likely abusers working or being in close contact with children. Key pieces of legislation are listed in Box 1. Legislation does not cover how old a child should be before he or she can be left at home alone, or the minimum age that a babysitter can be deemed responsible.
Following the death of Victoria Climbié, the Laming Inquiry identified several problems with the child protection system in the UK. Victoria Climbié came into contact with several agencies, none of which acted on the warning signs. No one built up the full picture of her interactions with different services. As a result of this, ‘Every Child Matters’ was published in 2003 setting out a range of reforms to ensure the same could not happen again. These reforms include:
- Provision of training to health professionals involved in child care, including GPs
- Improving information sharing between agencies, ensuring all local authorities have a list of children in their area, a list of the services they have had contact with, and the contact details of relevant professionals
- Establishing a common assessment framework across services for all children. The aim is for core information to follow the child between services to reduce duplication
- Identifying lead professionals to take the lead on each case where children are known to more than one specialist agency
- Integrating professionals through multi-disciplinary teams responsible for identifying children at risk, and working with the child and family to ensure services are tailored to their needs
- Co-locating services in and around schools, Sure Start Children's Centres, and primary care settings
- Ensuring effective child protection procedures are in place across all organizations
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Classification |
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Child abuse is defined as depriving children of their human rights. Abuse may be physical, emotional, sexual or due to neglect (Table 1). The spectrum of abuse can vary in severity and type. In practice there is often overlap between types of abuse and more than one type of abuse may occur simultaneously.
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Identification of ‘at risk’ children |
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TOPAbstractWhat the GP curriculum...StatisticsThe child protection system...Relevant legislationClassificationIdentification of 'at risk'...PresentationManagementSpecial circumstancesReferences |
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Any child can be abused, whatever the child's background. Always have a high index of suspicion. Abuse can go unnoticed for years, may be disclosed in adulthood or may never be disclosed. There are some factors that put children into higher risk groups of abuse. These that fall into three broad categories – those relating to characteristics of the child; those relating to characteristics of the parent or carer; and, those relating to the child's environment.
Children are at risk if they have poor attachment to their parents or carers. This is particularly common if the child was the result of an unplanned pregnancy or was born prematurely. Learning, behaviour or physical health problems also increase the likelihood of abuse. Children who are looked after outside their parental home are also at particular risk of abuse.
Parents or carers are more likely to become abusers if they have been victims of abuse themselves. They are also more likely to become abusers if they have mental illness, are physically unwell themselves, have learning disabilities or are drug or alcohol abusers.
Although all kinds of abuse occur in all social classes, children living in poverty or from households where there is unemployment are more likely to be abused. Domestic violence in the home or a history of abuse of another sibling place the child in a high risk group for abuse. Finally children subject to an environment high in criticism are more likely to be abused.
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Presentation |
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Always have a high index of suspicion. There may be few or no symptoms of abuse and presentation may be subtle. Suspect abuse if:
- The child discloses it
- The story is inconsistent with injuries found
- There is late presentation after an injury or lack of concern about the injury by the parent(s) or carers
- The child has repeated attendances at A&E departments
- A sibling has been a victim of abuse
- There is reluctance to allow the child to be examined
- There are characteristic injuries - look for marks consistent with cigarette burns; scalds (especially if symmetrical or doughnut shaped on buttocks); finger mark or bite mark bruises; perineal bruising or anogenital injury; linear marks consistent with whipping; buckle or belt marks
- There are multiple injuries or old injuries co-existent with new
- Injuries are in unlikely sites, e.g. mouth, genitalia, both eyes, hidden areas such as behind ears and on soles of feet
- The behaviour of the child is suggestive, e.g. withdrawn, ‘frozen watchfulness’, sexually precocious behaviour, abnormal interaction between child and parents, unwillingness to speak about the injury, etc
- A child develops a vaginal discharge, sexually transmitted disease or recurrent UTI
- A child presents with failure to thrive, developmental delay and/or behavioural problems
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Management |
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In child protection the well-being of the child is paramount and must take precedent over anything else. There are four recognized steps in the management of child abuse (Figure 1).
Difficult issues for health professionals in child protection
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Step 1:. Recognition
Recognition occurs when health professionals either identify or suspect a situation where a child may be at risk of abuse or neglect. This is simple if the abuse is overt, but often it is difficult to decide if a child is being abused (Box 2). As a GP in training, if you suspect child abuse it is important to discuss your worries with your clinical superviser, trainer or another GP who usually sees the child or family. In primary care, not only will an experienced GP have wider knowledge of the family from previous contacts, but will also be able to provide you with useful advice and support. If you have worries but cannot justify them sufficiently to invoke child protection procedures, do not ignore them:
- Check via social services whether the child is on the ‘at risk’ register
- Check notes of siblings and other family members to see if there has been any suggestion of abuse in the family before
- Discuss your worries with the health visitor and/or other involved members of the primary health care team or other professionals involved with the child's care (such as the child's social worker, the child's school teacher).
| Box 2. Clinical case scenario Eloise is two years old. She lives with her mother, Sarah, who is a regular patient of yours. Sarah's partner left when Eloise was a small baby but still has regular contact with her. Eloise has always seemed content and well-cared for in the past when she has come to the surgery. On this day, Sarah rang to make an emergency appointment on a Monday morning. She had collected Eloise from her father's home the night before and noticed a nasty mark on the back of her right arm when she gave her a bath before she went to bed. Examining Eloise the GP finds a completely circular blister, about the size of a cigarette burn on the back of Eloise's right upper arm. Sarah is unable to provide an explanation for the mark. She has already asked her ex-partner who said he did not know how it had occurred. As the examining GP, what should you do next? Your options are:
In this case, as no explanation could be given, and it would be difficult to explain an accidental cigarette burn in that location, the GP discussed his worries with Sarah. She too had suspicions that the injury may not have been accidental and voluntarily agreed to child protection procedures being invoked. Eloise's father was contacted and informed about what was happening. After discussion with the duty social worker, Eloise was referred to the on-call paediatrician who reviewed her in the local A&E Department with both parents. In the end the lesion turned out to be a patch of impetigo that was completely innocent.
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If any of these sources increase your suspicion, you may be justified in investigating further or invoking child protection measures at that point. If you are still unsure what to do, record your worries and the reasons for them in the child's notes and alert all other involved members of the practice team. Review whenever that child is seen again in the practice.
In any situation where abuse is suspected, it is important to make sure that your records are as complete as possible as you may be asked to attend court as a professional witness at a later date. Wherever possible arrange for another healthcare professional to be present during the consultation. Take a history from any accompanying adult. If possible, and the child is old enough, take a history from the child alone too. Be careful not to ask leading questions. Examine the child and ask for an explanation for any injuries noted. In a large proportion of cases of child abuse there will be no overt physical evidence. Do not perform a forensic-type examination unless you are trained to do so. Keep thorough notes including dates and times, history given, injuries noted (diagrams can help but photographs are not necessary) and any explanation given.
Child protection issues are invariable complex and emotionally difficult. Take time to reflect on your experience of any child protection issue brought up in the course of your work with your trainer or clinical superviser. Child protection issues are also suitable topics for significant event audit.
Step 2:. Reporting
This is often the threshold at which those in Primary Care hesitate and step back from the brink because of confidentiality concerns (although suspected child abuse is one of the recognized exceptions in which breach of confidentiality may be justified), concerns about being wrong, worries about dealing with unfamiliar agencies and fear of complex paperwork. It is important that even seemingly insignificant information is shared as it may be the vital part of an overall pattern of abuse that may not be obvious to just one agency alone. Welfare of the chid is paramount. Not to report abuse is to collude with the abuser.
Once suspected abuse has been identified, further action depends on the nature of the suspected abuse, suspected abuser (e.g. if someone outside the home is suspected, the child is safe to return home, if the child is a co-victim of domestic violence all the children and the parent that is the victim of the violence may need to be moved), nature of the injuries and response of the parents. Be familiar with and follow local guidelines and practice policy. A Quality and Outcome Framework point (Management 1) is available to practices that make information on local policies relating to child protection available to individual healthcare professionals. The options are:
- Direct referral to the police if emergency action is required to protect the child
- Hospital admission - this protects the child and allows full assessment. If admission is refused, contact social services to arrange a Place of Safety Order, or the police to take the child into police protection
- Liaison with the social services child protection team (on-call 24 hours a day every day)
- Informing social services of your concerns by telephone and following the referral up within 24 hours with a written referral. You should receive a confirmation of your referral within one and certainly within three working days.
- Hospital admission - this protects the child and allows full assessment. If admission is refused, contact social services to arrange a Place of Safety Order, or the police to take the child into police protection
Step 3:. Enquiry and assessment of risk
Once worries about child abuse have been flagged, concerns and allegations must be explored. Information is gathered and the risk to the child or children is determined. This is usually done via a multi-agency approach, often led by social services.
Step 4:. Intervention
This will depend on the nature of the abuse and the identity of the abuser. The general principles are that the child must be supported and enabled to develop, wherever possible in his or her own environment.
How to safeguard children with confidence
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Special circumstances |
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Sexual abuse
The Sexual Offences Act of 2003 sets the legal age for consensual sex at 16 years. The Act is intended to protect young people under 16 years from sexual abuse or exploitation. This may include sexual activity without consent, sexual activity of an older person (over 18 years) with a child, causing or inciting a child to engage in sexual activity, causing a child to watch a sexual act, taking indecent photographs of a child, or abuse of children through prostitution or pornography. It is not intended that teenagers under 16 years who both consent to have sex together will be prosecuted, although sexual activity with a child under 13 years of age is never acceptable as children of this age cannot legally give their consent. The Sexual Offences Act does not prevent young people under 16 years having the right to confidential advice on contraception, pregnancy or abortion.
Circumcision of female children or forced marriage of children under 16 years
Circumcision of female children and forced marriage of minors are both illegal in the UK but it is not uncommon for children to be taken abroad to be circumcised or married. If you suspect that this might be going to happen to any patient of yours, inform social services and/or the police immediately.
Refugee children
Many child refugees have traumatic backgrounds. Approach children with sensitivity and consider involving specialist child psychiatric services and specialist refugee support services early.
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References |
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NSPCC Key child protection statistics Accessed via http://www.nspcc.org.uk/Inform/resourcesforprofessionals/Statistics/statistics_wda48748.html [date last accessed 28.11.07].
Walters H. An introduction to the child protection system in the UK (2007) NSPCC Accessed via http://www.nspcc.org.uk/Inform/resourcesforprofessionals/InformationBriefings/childprotectionlegislation_wda48946.html [date last accessed 28.11.07].
HM Government. Framework of Assessment of Children in Need and their families (2000) London. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4003256 [date last accessed 28.11.07].
HM Government. Working together to safeguard children: a guide to inter-agency working to safeguard and promote the welfare of children (2006) Accessed via http://www.everychildmatters.gov.uk/resources-and-practice/IG00060/ [date last accessed 28.11.07].
HM Government. What to do if you are worried that a child is being abused (2006) Accessed via http://www.everychildmatters.gov.uk/resources-and-practice/IG00182 [date last accessed 29.11.07].
Department for Education and Skills. Every Child matters (2003) Accessed via www.everychildmatters.gov.uk.
Carter YH, Bannon MJ. The Role of Primary Care in the protection of children from abuse and neglect (2003) Accessed via http://www.rcgp.org.uk/pdf/childprotection.pdf [date last accessed 29.11.07].
British Medical Association. Confidentiality and people under 16. Accessed via http://www.bma.org.uk/ap.nsf/Content/Confidentialityunder16?OpenDocument&Highlight=2,CONFIDENTIALITY,PEOPLE,UNDER,16 [date last accessed 29.11.07].
General Medical Council. Good Practice Guidance: confidentiality. Accessed via http://www.gmc-uk.org/guidance/current/library/confidentiality.asp#28 [date last accessed 29.11.07].
HM Government. Sexual Offences Act (2003) Accessed via http://www.homeoffice.gov.uk/documents/children-safer-fr-sex-crime?view=Binary [date last accessed 29.11.07]http://www.england-legislation.hmso.gov.uk/acts/acts2003/20030042.htm [date last accessed 29.11.07].
The Refugee Council. Information accessed via www.refugeecouncil.org.uk.
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