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At the heart of general practice since 1960

August 2008: GPs have a vital role in recognising child abuse

What symptoms and signs might indicate child abuse or neglect?

What are the referral pathways for child abuse?

When should social services be involved?

What symptoms and signs might indicate child abuse or neglect?

What are the referral pathways for child abuse?

When should social services be involved?

GPs and the primary healthcare team are the cornerstone of family healthcare for the vast majority of children. Therefore, children who are victims of abuse and neglect may already be known to the practice.1

Adult survivors of abuse are four times more likely to consult their GP2 and much more likely to suffer pelvic pain, bladder problems, premenstrual and breast problems, gastrointestinal problems, pseudoseizures and mental health problems.3,4

The average GP, with 2,000 patients, 400 of whom will be children or young people, might have 28 children on their list suffering physical abuse; 24 emotional abuse; 24 neglect and up to 60 sexual abuse. In 2000, an NSPCC survey of 2,869 children revealed that 7% suffer ‘serious physical abuse', 6% ‘frequent and severe emotional maltreatment' and 6% ‘serious absence of care'. Around 1% of children in the UK suffer sexual abuse by a parent or carer, 3% by a relative and 11% by someone else they know.5

Abuse is the commission of an act – physical, emotional or sexual – from which a child suffers actual harm; neglect is the withdrawal of the normal things that sustain us: physical and emotional warmth, love, clothing, shelter and nourishment.

Identification

Children who are born prematurely or have low birthweight, disability, chronic ill health or looked after children (previously termed children in care) are at increased risk of child abuse. Certain family circumstances are also associated with an increased risk of abuse:
• Domestic violence
• Substance misuse
• Parents are offenders
• Parents have mental health issues
• Parents themselves victims
• Child shouldering adult responsibilities
• Concealed pregnancy
• Unplanned pregnancy
• Mobile families
• Financial difficulty
• Abuse of animals
• Frequent A&E attendances.

General indicators of abuse and neglect include:
• Delayed presentation
• Changing history
• Contradictory accounts by child and carer
• History inconsistent with injury pattern
• Frozen watchfulness
• Disinterested carer
• Child's injuries inconsistent with developmental level
• History of shaking
• Extensive bruising
• Injuries of varying age
• Injuries in unusual sites: in mouth, behind ear, on buttocks
• Previous suspicion of abuse.

Table 1, attached, lists specific indicators of physical, emotional and sexual abuse and neglect.

In Scotland, a further category of abuse – non-organic failure to thrive – is recognised. Its features mainly reflect those of neglect and emotional abuse.

Many of the presenting features of abuse are particularly common in primary care; the presence of multiple symptoms or signs should increase suspicion, but no individual sign or symptom should be necessarily seen as diagnostic in its own right.

Consultation

It can be difficult to conduct a consultation in which the GP has suspicions about the nature of injury to a child. Above all, the GP has a duty to make the child safe: it is not for GPs to investigate (that is the role of children's social services) but to put the needs of the child first. Phrases like ‘We need to check this in more detail than I can do here', ‘I can't yet be sure this isn't due to some other unseen cause', or ‘Further tests may help to reassure us as to the exact cause of this problem' may help to soothe some of the inherent tensions in such a consultation. Children's services and the police may undertake single or joint agency investigations to establish causes and gather evidence.

Referral

If a GP suspects abuse or neglect, further information is usually required before any diagnosis is made. Other health colleagues such as health visitors, school nurses, practice nurses and other doctors may have information to add to the picture. These colleagues should be encouraged to share their information in the GP record as the central single site record of choice.6

GPs should consider sharing their concerns with a colleague in the practice, possibly the practice lead for safeguarding/child protection. At the same time, a check should be carried out to see if the child is subject to a Child Protection Plan (previously the Child Protection Register).

If the GP still has concerns, they should phone the local children's services team to agree a plan of how to proceed. This may involve completion of a Common Assessment Framework tool by the GP or another member of the primary care team.

The child may need immediate medical attention, perhaps because of injury, and referral to hospital paediatric services may be necessary. It is essential that children suspected of being victims of physical abuse have a radiological skeletal survey carried out to look for evidence of older injuries. Above all, if the child is still in a vulnerable setting, they should be taken to a place of safety.

In other situations, it may be felt that the risk to the child has already been removed and the assessment is less urgent. See figure 1, attached, for guidance on referral and investigation in primary care.

RCGP/NSPCC Toolkit

RCGP/NSPCC toolkit for safeguarding children and young people in general practice6 is a framework into which local safeguarding children policies and procedures can be integrated7 with information about symptoms and signs of abuse and neglect to form a training tool for practices.

Key telephone numbers should be available for professionals, allowing access to emergency children's social services. PCTs must also have named doctors and nurses in post, and these personnel may provide useful anonymous advice on protecting a child.

Confidentiality

Many GPs express concern about potentially breaching confidentiality when safeguarding children. The GMC has recently revised its guidance.8 In it, GPs are reminded of the importance of confidentiality and advised to try and seek consent before sharing information. However, sharing information is justified where there is a public interest, such as where a child is at risk of neglect or physical, sexual or emotional abuse, or where the information would help in the prevention, detection or prosecution of serious crime. The reasons for disclosure, or for deciding not to disclose, should always be recorded.

Supporting the family

GPs may have difficulty engaging in child protection processes9,10 because of the tension that exists between addressing the needs of the child and maintaining the continuing relationship with other members of the family, who are likely to be registered with the practice.

Being open and honest about the situation is often the best approach. It may also be wise for another GP in the practice to look after other family members, who may be confused and angry as a result of the GP's actions.

It is well recognised that children often move in and out of situations in which they are at risk of abuse and neglect,11 and that support from primary care teams may ameliorate this at a much earlier stage. Many children who would be at low risk of abuse or neglect most of the time may find themselves at higher risk because of parental mental health problems, housing problems, substance misuse or financial difficulty in the family. Prompt referral at this time to housing agencies, involvement of children's services, family support and referral for, or treatment of, behavioural problems may all help to reduce the risk to children.

Child protection conferences

Child protection conferences present an invaluable opportunity for GPs and their teams to contribute to the safety of a child. GPs are uniquely placed to comment and guide colleagues who are not health professionals on issues to do with child health and development. Having the GP at the conference helps other parties involved understand health information: if you are unable to attend in person, you should always try to send a report, expressing what is known.

The contribution of good GP records is regularly emphasised by reports of serious case reviews. Training courses are run regularly by Local Safeguarding Children Boards and GPs should remain up to date with changes to local procedures. Training courses are also a vital way of meeting colleagues from other sectors, creating networks and understanding needs.

Conclusion

GPs and the primary care team are well placed to recognise, record and manage child abuse. New tools are becoming available to improve both knowledge and skills in this area. It is hoped that children and young people in the UK will be safer as a result.

Key points Author

Dr Andrew Mowat
MBChB FRCGP
GP, Lincolnshire,
Chair, Primary Care Forum, and Child Health Lead, RCGP

Figure 1: What to do if you are worried a child is being abused Table 1: Specific indicators of abuse/neglect

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