Does Child Protection Matter?W

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Overview

Why is child protection important?

What are the Obstacles to overcome?

Categories of Child Maltreatment

The Risk Group

Parent-child interaction

What do I do when I have concerns?

Whom do I speak to locally?

What can happen to you if you refer?

What will happen to the child if you do not refer?

How to reduce Your Risk

Assessment Questionnaire

Statastics

Reporting Sources of Abuse

Educational PersonnelLegal, Criminal, Law enforcement

Social ServiceMedical Professionals

Mental HealthChild Daycares

Foster careAnonymous

OthersRelatives

ParentsNeighbours & Friends

Un-Known

0 2 4 6 8 10 12 14 16 18

Child Maltreatment

Physical and psychological symptoms &

signs

May present with more than one type of

abuse

May be observed in child-carer

interactions

Concerns may arise before child is born

Categories of Child Maltreatment

Physical abuse

Sexual abuse

Neglect

Emotional abuse

Fabricated illness (“Munchausen's by Proxy”)

Mixture of the above

Abuse Cycle

Tension BuildingCommunication breakdown, victim becomes fearful & feels the need to placate the abuser

IncidentVerbal, emotional, physical abuse, anger, blaming, arguing, threats and intimidation

ReconciliationAbuser apologise, give excuses, blames the victim, denies abuse occurred, say it wasn’t as bad as the victim claims

Honeymoon PeriodIncident is “Forgotten” and no abuse occur. The calm phase

Perpetrators by Relationship to Victims

Parents74%

Other Rel-atives

Foster ParentsLegal Gardian

Residential Staff

Chid Daycare Centre

Unmarried Partner

Other Pro-fessionals

Friends & Neighbours Others

Unkown or Missing

Who Are At Risk?

History of physical or sexual abuse (as a child)

Teen parents Single parents Emotional immaturity Poor coping skills Low self-esteem Substance abuse Known past history of child abuse Lack of social support (community) Extended family Domestic violence MOD Personals Lack of parenting skills Lack of preparation for the stress of a new

infant Depression or other mental illnesses Multiple young children Unwanted pregnancy Denial of pregnancy Prematurity of child

Effects – Short & Long term

Obstacles to identify maltreatment

Concern about missing a treatable disorder

Fear of losing positive relationship with

family

Wrongly blaming a carer

Divided loyalties to adult and child

Breaching confidentiality

Personal safety

Complaints

Features of Physical Maltreatment

Unexplained bruising or petechiae

• Pattern of bruising

Human bite mark

Unexplained lacerations, abrasions or scars

Unexplained burns or scalds

Unexplained Oral, facial & head injuries

Cold injuries / hypothermia

One or more unexplained fractures

Non-Accidental : Accidental Injury

Suspicious Bruising

In a non mobile child

Shape of a hand, grip, stick, ligature,

specific implement, etc

Multiple or in clusters

On non-bony parts of the body

Around the neck, wrists & ankles

Facial bruising or retinal haemorrhages

Pattern of Bruising

Accidental bruising patterns Abusive bruising patterns

©2010 by BMJ Publishing Group Ltd and Royal College of Paediatrics and Child Health

Maguire S; Arch Dis Child Educ Pract Ed 2010;95:170-177

Think & Ask Why?

Suspicious Burns or Scalds

Absent or unsuitable explanation

Burns in a child who is not mobile

On the back of hands, soles, buttocks or

back

Cigarette burns (usually on exposed areas)

Solid object burns (iron, electric fire)

Immersion burns of buttocks & legs

Pattern of Scalding

Accidental Scald Abusive scald ‘glove and stocking’ pattern

©2010 by BMJ Publishing Group Ltd and Royal College of Paediatrics and Child Health

Maguire S; Arch Dis Child Educ Pract Ed 2010;95:170-177

Cigarette Burns

Suspicious Fractures

Absent or unsuitable explanation

Fractures in non-mobile children

Multiple fractures at presentation Spiral or metaphyseal fractures Fractures of different ages (including occult)

Skull fractures in infants (boggy scalp

swelling)

Facial fractures

Other suspicious physical injuries

Head injuries

▪ Intracranial (particularly < 3 years)

▪ Chronic or multiple sub-dural haematomas

Eye injuries & retinal haemorrhages

Oral injuries

▪ teeth, torn frenulum

Signs of spinal injury

Unexplained Intra-abdominal injuries

Features of Sexual Abuse

Unusual sexualised behaviour pre-pubertal

Persistent / recurrent genital & anal

symptoms

▪ Anogenital warts (no vertical transmission)

▪ Genital, anal or perineal injuries & FB’s

Persistent abdominal pain

Constipation without medical cause

STD in a child younger than 13 years

▪ Hep B, HIV (no vertical transmission)

Pregnancy in a child under 13 years

Features of Neglect

Personal Hygiene Severe & persistent infestations

Nutrition Failure to Thrive Anaemia

Failure to seek medical advice Failure to administer prescribed medications

Lack of supervision Child being left in unsafe living environment Injuries

Features of Emotional Maltreatment

Fearful or withdrawn

Low self-esteem and severe

mood changes

Aggressive or oppositional

behaviour

Over-friendliness to strangers

Parent-Child Interactions - Potential causes for concern

Domestic Violence (including substance abuse)

Negativity or hostility towards the child

Rejection or scapegoat of the child

Emotional unresponsiveness towards the child

Inappropriate threats or disciplining

Exposure to frightening or traumatic

experiences

Manipulating child to fulfil adult’s needs

Carer consistently prevents access to the child

When to suspect child maltreatment

Absent or unsuitable explanation for injury

Changing explanations with time and/or carer

Seeking medical attention▪ Delay

▪ Multiple A&E attendances

Multiple injuries of different ages▪ Injuries in a non-mobile child

▪ Particular pattern

Child’s behaviour▪ Inappropriate sexual activity or STD

Features of neglect present

What to do if you suspect child abuse

Seek an explanation

Look for supporting evidence of abuse

Discuss with a colleague

Gather collateral information from others

Record in detail all actions taken &

outcomes

Implement local Safeguarding procedures

Who to talk to at a local level

Share information with other

professionals!

Paediatric Consultant of the Week (COW)

Named Doctor for Safeguarding Children

Named Nurse or Midwife for Safeguarding

Community Paediatricians

Paediatric Liaison Health Visitor

Paediatric Social worker (Intranet: Safeguarding Children Policy

page 19-21)

What Happens if You Report

Parent’s will be angry , abusive and complaint to PCT

Pray you don’t see meet the parents in the town centre

Never tell any patient where you live (your life is at risk)

SHO in the hospital will not listen to your concern and suggest you to call

Registrar

Nurse taking the call not helpful, will ask you to call back

Community Paediatricians often are not available or will not defend your action

Community Paediatricians don’t have any power to stop you vindicated /

criticised

Paediatric Liaison HV ask too many questions but will offer no solution

Attending social service meeting is simply a waste of time

Paediatric Social worker telephone is busy and you won’t get any help either

If you refer a child of an army personal (MOD) – you may be court marshalled

Don’t waste time informing GMC they are too busy chasing Registration fee

Be prepared to be terminated from locum job contract if the parents complaint.

Make sure you have MPS / MDU cover in case your suspicion was wrong

What Will Happen If You Ignore

What Happens if you Ignore?

The child will suffer for a long time, “its not fair” Family may break-up and the child will be neglected Child may die and then the media will hound you The child may sue you for ignoring when he/she grows

up Your colleagues will criticise you for ignoring You will be haunted with a memory for ignoring Your partner will hate you if they hear what you did

I have been through all the trauma for referring a child to Paediatric assessment but I will do it again if I see a child with a history of ? abuse

If you have information that is important in ensuring a child’s welfare and to protect them from harm, ”You Have A DUTY To Share This”

How To Reduce Your Risk

Ask another doctor, staff or nurse to see the child and document their comments.

Document spots, scratches and bruising in the notes and ask the witness to initialize

Never tell parents that you need 2nd opinion or mention social service

Never take a picture using your mobile phone Ask Paediatric Registrar in the hospital to review (never ask SHOs) If the switchboard puts the call through to SHO, just disconnect and

call back. Never call hospital when the patient is in your room & send letter to

hospial by fax or Make sure the parents address and telephone numbers are updated

& correct Do-not examine teenagers without a chaperone (they may complaint

against you) Never believe the story from parents if the clinical feature are

consistent with abuse Please document time and duration of the consultation. If you are working in MOD, make sure you read their protocol (often

they don’t have one) Don’t bother calling Social service, they will know less than you Remember to call Paediatric registrar and ask what they did before

you leave surgery.

Assessment Questionnaire

IS THE CHILD:

1. aggressive, defensive or oppositional?2. cover around adults or otherwise show fear of adults?3. act out, displaying aggressive or disruptive behaviour?4. destructive to themselves or others?5. show fear of going home, possibly by coming to school too early or not waiting to

leave school?6. fearless, in some cases taking extreme risk?7. described as “accident prone”?8. cheat, steal or lie (possibly indicating expectations at home are too high?9. a low achiever and unable to expend the energy required to learn?10. have difficulty making good friends their own age?11. child wear cloths that cover their body even when the weather is warm (not

cultural reason)?12. behave immature or regressive manner?13. Dislike or shrink from physical contact (such as pat on the back while offering

praise)?

If The Score >10 : Does not indicate abuse but will need referral to Paediatrics for assessment