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Suspected case of child abuse

Child abuse can bring several fears for the new GP, but Dr Anna Wilson advises what to do if you suspect it and how to spot its different forms

Case study

The practice nurse calls you in to ask advice about the management of a three-year-old brought in by his single teenage mother with an infected burn on the palm of his left hand.

The child appears withdrawn and his clothes are soiled. His mother says he touched the oven door while she was preparing a meal.

You have seen the mother in the past with postnatal depression and are aware that her boyfriend is a drug abuser.

What are your concerns? What should you do next?

Background

Child protection has recently received a new focus through the Laming report on the Victoria Climbié1 inquiry and with the publication of the Department of Health document 'What to do if you're worried a child is being abused'2.

Primary care has a unique role in caring for families throughout the generations and the primary health care team is able to view child development through the eyes of a variety of skilled professionals. Health visitors, school and district nurses are obvious resources but communication pathways are often fractured by a variety of geographical and record-keeping issues. Practice nurses and receptionists also have an invaluable role in picking up soft signs and may be able to supply missing parts of a jigsaw that will save a child from further abuse.

Links with secondary care – particularly A&E and paediatric services – are vital but so are those with alcohol and drug advisory and mental health services in picking up risk predictors in carers. It is important to recognise child abuse can present in different forms.

Physical abuse, neglect, emotional abuse, sexual abuse and fabricated or induced illness Remember that more than one form of abuse may be inflicted on one child.

With the publication of the children's green paper 'Every Child Matters'3 there is a new emphasis on child-friendly environments and universal raising of awareness of child protection issues, particularly in vulnerable groups such as Looked After Children.

Agencies will have to learn to work together and share information effectively through improved IT and national co-ordination and tracking systems. Primary care will therefore have an essential role in building up a holistic picture of families and children and in detecting early-warning signs that signal concern about the quality of care and possible abusive behaviour towards children. Primary care organisations have a responsibility to ensure adequate structures, quality standards and training are provided in their area.

Familiarity with the Department of Health's 'Framework of assessment for children in need and their families'4 illustrates the breadth of consideration the process requires. The framework encourages the health professional to assess the child holistically in his or her total environment in a sensitive and painstaking manner. It advises focusing on three key areas: the child's development needs, including health, education and family and social relationships; parenting capacity, including basic care, emotional warmth and stability; and family and environmental factors, including wider family, employment, income and family's social integration.

The 'paramountcy principle' in protecting a child above all other considerations, promulgated by the Children Act (1989), should be invoked when doubt arises as to whether information should be shared or certain actions should be taken in the child's interest.

The RCGP position paper 'The Role of Primary Care in the Protection of Children from Abuse and Neglect'5 identifies the child protection process in four steps (see box right).

Case study

Returning to managing the case of the three-year-old with an infected burn on the palm – as a registrar dealing with a case of suspected child abuse it is advisable to share your concerns and work in conjunction with a senior health professional who can get involved in the long-term care of this child, for example a partner at the practice or a health visitor. You would not be expected to act alone in, for example, contacting social services.

Together you could address your concerns about the child that may include:

lDelay in presentation and palmar injury rather than fingertip injury would raise your suspicions of inflicted rather than accidental injury

lWithdrawn affect suggests emotional deprivation

lDirty clothing would raise anxieties about neglect

lMental illness and substance abuse in carers are risk factors for child abuse.

What should you do?

lTake a careful history – do not ask closed or leading questions that might contaminate evidence

lInquire about home circumstances and other children

lDo a full physical examination on the child, including hidden areas of the body such as behind ears and soles of feet and measure height and weight

lLook at past medical history of child including A&E attendances

lYou may need to look at mother's and other siblings' medical records

lDiscuss the case with other professionals in your practice who may know the child

lFind out whether the child goes to a playgroup or childminder and whether there are any concerns there

lCheck whether the child is on the child protection register

lRecord your findings and concerns and whom you have contacted

lFollow the practice child protection procedures which should be readily available

lYou may wish to contact the named nurse or named or designated doctor for child protection in your area, whose name and contact details should be available in your practice and through your PCT and/or acute trust

lContact social services if your observations and discussions lead you to feel this is a child protection issue and follow up the referral in 48 hours with a written referral – you should receive confirmation of your referral within one but certainly within three working days

lYou can also refer directly to the police, particularly if you feel emergency action may be required to protect the child.

Child protection process

Recognition

When health professionals either identify or suspect a situation where a child may be at risk of abuse or neglect.

Reporting

Where suspicions are reported or discussed (social services, police, child protection agencies). This represents a critical event whereby concerns regarding a family become 'public'

– and this is often the threshold at which those of us in primary care hesitate and step back from the brink.

Inquiry and assessment of risk

Concerns and allegations are explored, information is gathered and risk to children determined. A multi-agency approach is usually employed.

Intervention

Consists of supportive and rehabilitation measures in order

to enable child development.

Difficult issues for health

professionals in child protection

lConfidentiality of medical information

lSharing information with parents and carers – should you inform them if you decide to contact social services?

lFear of damaging future relationships with the family

lFear of causing family disruption

lFear of dealing with other agencies such as police and social services

lFear of being mistaken in one's suspicions

lFear of missing abuse

lFear of attending court

lFear of negative peer review

How to deal with child protection

with confidence

lMake sure you are familiar with the practice and local child protection procedures

lShare your concerns with colleagues and try as much as possible to use shared documentation and computer templates

lMake sure you attend child protection training regularly

References

1 www.victoria-climbie-inquiry.org.uk

2 31815/What To Do if You're Worried A Child is Being Abused. Department of Health 2003

www.doh.gov.uk/safeguardingchildren/index.htm

3 'Every Child Matters' – children's green paper

www.dfes.gov.uk/everychildmatters

4 Department of Health: Framework of Assessment of Children in Need and their Families. London, The Stationery Office 2000

5 The Role of Primary Care in the Protection of Children from Abuse and Neglect. Carter and Bannon, RCGP position paper Feb 2003

• Working Together to Safeguard Children

www.doh.gov.uk/qualityprotects/work_pro/project_3htm

Anna Wilson is the named GP for child protection, Mid Hants PCT, and a

GP principal in Sutton Scotney, Winchester, Hampshire

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