Red flags in child safeguarding

In the latest in our series from Pulse Live talks, GP and safeguarding consultant  Dr Vimal Tiwari explains what red flags GPs need to look out for. For more on setting up your practice to support child safeguarding, click here

What is child safeguarding? 

The NSPCC defines safeguarding as ‘action that is taken to promote the welfare of children and protect them from harm’. Child protection is part of safeguarding practice and refers to activity undertaken to protect children who are likely to suffer or are already suffering harm. Safeguarding is about preventing harm, while child protection is about how we respond to harm.

The context

There are around 14 million children in the UK. Around one third of these children are said to be vulnerable when those living in poverty are taken into consideration.¹ The reasons can for vulnerability include:

• Known safeguarding concerns or being in local authority care 
• Chronic long-term health conditions or disability 
• Adverse economic circumstances, family circumstances and characteristics, including parental physical and mental health
• Educational non-engagement 
• Involvement in offending and/or antisocial behaviour 
• Experience of abuse and exploitation 
• Missing and absent children and minority populations 

These children are more likely to face adverse childhood experiences (ACEs), which influence brain development, immune and hormone systems, and genetic expression. An average of 62 children are referred to protective agencies every day but the extent of undisclosed abuse is unknown.² There is at least one child death each week linked to maltreatment, although this is likely to be an underestimate.

ACEs have a profound effect on the developing brain. Children growing up in toxically stressful situations have elevated levels of stress hormones.  Brain changes include reduced global volume, alterations in circuitry of the amygdala and hippocampus (responsible for emotion) and alterations in prefrontal cortex development (responsible for attention, executive function and self-regulation).

There is substantial evidence for a dose-response relationship between childhood adversity and health-risk behaviours such as substance abuse, physical inactivity and high-risk sex behaviours, as well ischemic heart disease, cancer, stroke, chronic obstructive pulmonary disease, diabetes and suicide.^3,4

These are compelling reasons for early identification and prevention of child maltreatment.

The role of general practice

Staff in general practice may be a patient’s first point of contact with healthcare and so play a key role in child protection, both in identifying children in need of safeguarding and in supporting families at risk. GPs are holders of the primary healthcare records, which can act as a comprehensive source of information about a family.  

Child maltreatment is common and often longstanding but affected children may never reach the threshold for investigation or intervention by child protection services. The GP’s role includes:

• Documenting concerns in the patient’s record 
• Reflection and discussion with colleagues 
• Monitoring, information gathering and regular practice meetings to discuss management of vulnerable families
• Involving other agencies such as social services as appropriate 

Consistent, accurate data recording, coding and summarising is crucial to support continuity of care and build a cumulative picture of any family difficulties or concerns. This is essential when patients may see a multiplicity of personnel from a variety of disciplines.

Recognising patients at risk of abuse and/or neglect

Within the constraints of the 10-minute consultation this can be challenging, as the signs may be small and subtle. Accurate, comprehensive coding and summarising are invaluable in identifying vulnerability because in this sphere of human suffering, familial risk factors and past history can be reliable predictors. 

NICE guidance Child maltreatment: when to suspect maltreatment in under 18s gives helpful information on physical symptoms and signs of abuse.⁵ NICE guidance Child abuse and neglect describes the ‘softer’ signs more likely to present in general practice.⁶

Identifying complex families and potential difficulties

At the time of registration, check family details, who the child is living with and the relationships to the child. Where parents live at different addresses, try to find a way of linking family members. It is particularly important to make regular enquiries about male partners of sole mothers who may have contact with the children. If the child is looked-after, place an alert on their records so that staff are aware of their extra vulnerability.

Harm prevention starts before pregnancy by identifying people who will be vulnerable when they become parents and considering how they may be supported before a pregnancy occurs. This group includes survivors of abuse, people with mental health or neurodevelopmental disorders or learning difficulties, people with long-term chronic conditions or disabilities and people who are vulnerable to becoming parents before age 18, for example care-leavers.

When seeing parents and carers of children, make routine enquiries about drug and alcohol use and domestic abuse. Always ask patients with significant childcare responsibilities if they have mental health difficulties, learning difficulties or drug and alcohol misuse. Consider if these might impact on their capacity to care for children safely. Record this information and emphasise it in any referrals and correspondence. 

GPs who work with different members of the same family will need to share information with each other on a regular basis when there are concerns about child safety.

Babies and immobile children

Babies are the most vulnerable members of our society, being totally dependent on their carers for 24-hour attention to nutrition, hygiene, emotional warmth and stimulation. Always be aware of the significance of bruising on babies and children who cannot move around by themselves. 

Familiarise yourself with the local policy on bruising/unusual marks and refer such cases urgently to children’s social care with full and accurate information, which includes a medical and social history, the child’s developmental stage and the explanation given by the parent. A tiny bruise may be the only surface marker for serious and possibly life-threatening internal injuries. The risk of homicide in infants under 12 months is greater than at any other time of life.

Adolescent risk 

One in seven 14- to 15-year-olds is living with parents who neglect them in one or more ways.⁷ This may include a lack of emotional care, warmth and encouragement, a lack of adequate supervision, insufficient physical care to preserve their health and little or no interest shown in their education. 

Adolescents can make poor decisions that leave them vulnerable to physical or psychological harm and consequent negative impacts on their long-term health and viability. Some suffer from internet and media dependency, gender uncertainty, mental health issues, neurodevelopmental disorders or chronic long-term physical conditions. The incidence of physical abuse in adolescents is higher than in younger age groups, while the incidence of sexual violence and domestic abuse is higher in people under 18 than in older age groups. Be aware that this age group may present with sudden behaviour change or development of mental health symptoms because of abuse.

Missed and unscheduled appointments

Children are dependent on adults to take them to appointments. Missed appointments may be a feature of neglect. Use the code ‘Child not brought’ and carry out regular records searches to pick up failures of attendance at necessary scheduled appointments, especially for children with chronic long-term conditions requiring regular monitoring. 

Frequent attendance at out-of-hours services or A&E departments may be indicators of non-accidental injury or family chaos. Such attendances should be appropriately coded and monitored. Consider routine follow-up of under-fives following such attendances and of older children if more than four in a year.

Seeing and hearing children

It is important to confirm the identity of the person who brings the child to the consultation and document their name (if not a parent) and relationship to the child. The child’s appearance, demeanour and attitude to the accompanying adult provide useful clues. Check hygiene, including oral hygiene and dental health when possible, and whether clothing is appropriate for the child’s age and the weather. 

Try not to accept a parent’s or carer’s history without observing and talking to the child. If the child is very young, observe and interpret their presentation and behaviour. Do not refer a child to a specialist without seeing and examining the child and checking your findings against the parent’s history. 

Repeat prescriptions issued to children should always be regularly monitored. This includes checking for drug efficacy, adverse effects, and measuring the child’s weight and height. Consider implementing an alert system to identify the over- or under-prescription of drugs to a child.

Managing safeguarding concerns

Try to develop and maintain a relationship with your local public health nurses (health visitors and school nurses) and if possible have regular meetings to facilitate sharing of information when you are worried about a child or family.

The concerns may not require a child protection referral, but the family might benefit from other forms of support, such as parenting support, financial advice, signposting to a food bank, encouraging improved management of physical or mental health conditions in parents, referral to drug and alcohol services and assistance in attending appointments. It is helpful to familiarise yourself with local services for families in general as well as the most vulnerable families. Check on the local authority’s website for child protection processes and referral mechanisms because these vary by locality.

GPs may be anxious about breaking confidentiality, being criticised or being subject to litigation. Talk to your practice safeguarding lead for advice. If you are worried, and the situation appears non-urgent, try to discuss your concerns with the parent or carer to gain their consent and collaboration with further action. This may be difficult or even impossible in instances where a child is at risk of harm or has already been harmed and you suspect parental or carer involvement. In that case a referral to social services may be made without parental consent. Information sharing without consent should be made explicit in all communication and clearly documented. 

When making referrals to social care, make sure that the concerns are worded clearly and do not understate severity or the urgency of the referral, without using jargon or technical language. Be clear about what action you would like in response. If there are medical issues, explain the impact on the child’s wellbeing. Make sure the practice policies and procedures give guidance for challenging professionals in other agencies who are not responding adequately to concerns about a child. You may need tenacity in such situations and usually your local health safeguarding team will be willing to help with escalation. 

If a child requires urgent treatment and you suspect abuse, tell the admitting paediatricians of your suspicions and make an urgent referral to social services.

If uncertain about what to do, consult colleagues such as the practice safeguarding lead or your local safeguarding team but remember the GP role in safeguarding is to identify and act upon concerns. Social services, the police and the NSPCC have a duty to investigate incidents. 

References

1. Joseph Rowntree Foundation. UK Poverty 2023: The essential guide to understanding poverty in the UK. Link
2. NSPCC 2022. Half a million children suffer abuse in the UK every year. Link
3. Bellis M et al. Measuring mortality and the burden of disease associated with adverse childhood experiences in England: a national survey. J Public Health (Oxf). 2013;37:445-454. Link
4. Felitti V et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults.  Am J Prev Med . 1998;14:245-258. Link
5. NICE CG89. Child maltreatment: when to suspect maltreatment in under 18s. Link
6. NICE NG76. Child abuse and neglect.  Link
7. Raws, P. Thinking about adolescent neglect: A review of research on identification, assessment and intervention. 2018. Link

Resource

The NSPCC Learning Hub: Training and resources in safeguarding and child protection. Link