Child Protection -Exploring the
Role of the GP
Dr Kerry Milligan
GPwSI Child Protection
RCGP Child Health Strategy 20102015
• “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 20102015
• 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.
Legislative framework
• 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)
National Guidance for Child
Protection in Scotland
http://www.scotland.gov.uk/Resource/Doc/334290/0109279.pdf
Child Protection Unit 2012
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 and
young people
Short 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
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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 twothirds 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
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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 maltreatment
Maltreatment
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 Injury
Bruising
• 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. Nonmobile 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
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Feeding difficulties
Demanding
Irritable
In control of mother
Toddlers
• Behaviour problems
• Developmental delay
Adolescents
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Depression
Eating disorders
DSH
Behaviour problems
School Age
• Wetting / Soiling
• Poor school
performance
• Non-attendance /
Poor behaviour
Emotional Abuse
Examination
• Poor growth
• Observed behavioural or developmental difficulties
Child
• Unwanted
• Wrong sex
• Disabilities
• Almost always
associated with other
forms of abuse
Family
• Alcohol / substance
misuse
• Mental health problems
• Marital problems
• Domestic violence
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 & noncompliant
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
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Touching
Masturbation
Digital penetration
Vaginal or anal intercourse
Prostitution
What would prompt us to
investigate?
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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 physical
and/or psychological needs likely to result in serious impairment of
the 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 or
danger, or the failure to ensure access to appropriate medical care
or treatment. It may also include neglect of or unresponsiveness to
a child’s basic emotional needs.
Why is neglect harmful?
Learning
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Lack of exploration
Delayed speech & language
Impoverished play &
imagination
Special educational
needs/learning disability
Later educational failures
Poor life skills development
Emotions
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Disturbed self-regulation
Negative self identity
Low self esteem
Clinical depression
Substance misuse
NCH The Bridge 2007
Bodies
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Fatal neglect
Intra-uterine growth retardation
Non-organic failure to thrive
Vulnerability/susceptibility to
illness, infection & accidents
Poor/delayed medical care.
Brains
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Lack of nutrients; reduced growth
Lack of stimulation: retardation of
brain
Unregulated stimulation:
disordered neural circuitry
development
Photographic Evidence
Challenges
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Inter-agency working
Normalisation
Hidden children
Over-optimistic
‘start again’ phenomena
Drift
Capacity
NICE Clinical Guideline 89
Consider 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
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Living in poverty
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Domestic violence
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Parental drug and alcohol abuse
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Living in environment of high
anti-social behaviour, crime, poor
housing
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Parental mental health disorders
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Parental learning disability
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Social isolation including that due
to racism.
References
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Becker,F.,French,L(2004) Making the links: Child Abuse, animal cruelty and domestic violence
Child Abuse Review 13:399-414
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Browne,K.D., Herbert,M.,(1997) .Preventing Family Violence Chichester:Wiley
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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.
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Wolfe,D.(1993) Child Abuse Prevention Child Abuse Review 2(2):153-165
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Working Together to Safeguard Children 2010
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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
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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 3
All 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
Safeguarding Children &
Young People
A Toolkit for General Practice
2011
Safeguarding Children &
GPs have a key role:
Young
People
Identifying
trends
A Toolkit
General
Practice
Central hub
of Health for
info…from
OOH services,
EDs etc
Knowledge
of parents / carers health
2011
Links 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
Making the Referral
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Who makes the call?
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To whom are you speaking?
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Be clear that you are making a child protection referral.
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Give clear details.
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Who else do you inform?
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Follow up in writing – interagency referral form
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Outcome?
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
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Reviewed in 3 months, thereafter 6 monthly
Pre birth – registration of unborn child
Minute taking
Lead Professional – Developing a plan
Safeguarding Children & Young People
A 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 People
A Toolkit for General Practice 2011
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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
Questions?
kerrymilligan@nhs.net
www.nhsggc.org.uk/childprotectionunit
Advice Line 0141 201 9225