Dilemma: Child safeguarding
A four year old boy is brought in by his father who is worried about his behaviour. The father mentions that when his son is particulalrly challenging he feels his temper getting out of control. There is no evidence or history of physical violence at this stage. How would you proceed in the consultation? What are the safeguarding issues, if any?
The GP needs to concentrate on listening rather than pre-judging
This is a common scenario which few parents will admit so should be taken seriously. It might be the only chance the GP has, as significant history could be hidden. The GP needs to concentrate on listening rather than pre-judging; summarising, explaining clearly what options are available and agreeing action. The situation is often complicated by the child being present. Ideally one should include a private time with the father and the child and a physical examination of the child. A four year old is often aware of the problems and could be distracted by a toy or game while the father is talking.
Suggested questions are:
- ‘Tell me about the behavioural problems.’ This is trying to explore the child’s emotional or physical issues, or conditions such as hyperactivity disorders or learning difficulties
- ‘How does your partner feel?’ Behavioural issues are often exacerbated by open disagreement between parents or partners
- ‘How much stress is in your life?’ Follow on by asking about sadness, self- harm, alcohol or drug use, and any previous mental health problems
- ‘How far does your frustration go?’ Ask particularly about hitting anyone and check for previous convictions
- Ask the child what happens.
In summarising, the GP needs to start with the agreement that we all want the child to feel safe and to grow up happy and healthy. Checking the nature and severity of the problems will clarify the next steps to take, being aware of local guidance often involving others in the primary care team, parenting or community activities. Action might be as simple as spending more time together doing something.
Dr Janice Allister is the RCGP clinical champion for child health and a GP in Peterborough
A referral into Social Care would not be indicated at this stage, but you could complete a Common Assessment Framework
There are two issues to consider in this scenario – the behavioural change in the four year old (recently challenging), and anger issues in the father.
The issue of the recent change in the child’s behaviour is usually an indication of what may be happening at home, as children may not be able to express themselves other than through a change in their behaviour. Rather than focus on the behavioural change in the child, identify what has led to that change.
A detailed family history to understand the home situation and recent changes is important, and as he is four – liaison with the Health Visitor (see children 0-5 years) is key to understanding the protective or risk factors in the boy’s life, and help in decision making.
Also in terms of the father – are there any mental health issues; use of alcohol or drugs; or any previous history of domestic violence? Other significant changes may include separation or loss.
If however the behavioural changes are indicative of impulsivity, inattention, repetitiveness, or poor social skills, the child may need a paediatric referral for an assessment to exclude ADHD or ASD spectrum, with support for the father to deal with the complex behaviour.
Unless more information with other risk factors is obtained, a referral into Social Care would not be indicated at this stage, however a CAF (Common Assessment Framework) may be completed to access support services. Follow-up would be recommended to review if situation changing.
Dr Kate Barusya is a GP in South Essex. At her practice she is the named GP for safeguarding children
The father’s admission may be a cry for help
As Dr Barusya identifies, there are two issues at stake. Both of which may give rise to concerns from a medico-legal point of view – the child’s challenging behaviour and the father’s admission that he loses his temper and feels out of control at times.
Regarding the child’s challenging behaviour, you will need to assess whether there is a medical or psychological cause which could be treated. You will need to assess whether his provocative behaviour is putting him at risk of physical or emotional abuse or neglect by his father. The child’s young age also makes him vulnerable to abuse.
The father’s admission may be a cry for help, which you should respond to by arranging any appropriate additional support for the family. You will need to consider if there are other children in the family and what involvement the child’s mother has.
While there is no evidence of physical violence, the father has intimated that he fears he might be violent. This could be an indicator for future violence, or even of emotional or sexual abuse or neglect. In considering whether the child is at risk, you may need to speak to the child’s health visitor, school nurse, school/nursery teacher to find out whether they have any concerns about the child’s behaviour or development. Ideally this should be done with the father’s consent, assuming he has parental responsibility, but if he refuses, you should act in the child’s best interests.
If you have still have concerns about the child, you may want to discuss them with the practice’s safeguarding lead or other safeguarding advisers in your area, according to your local policies and procedures.
You will need to explain your concerns to the father and that you are trying to get support for the family, in the best interests of the child, given that the child’s welfare is of paramount importance. You may need to reassure the father that you would normally not share information about him without consent, but there may be circumstances when the child’s best interests take priority and information will have to be disclosed, even without his consent.
Along with the details of any examination and history taken from the child, you should also record carefully in the child’s notes any concerns you have and why, your discussions with the father and what actions you have taken, such as who you have contacted about this and what advice they have given.
Dr Kathryn Leask is a MDU medico-legal adviser