The Medical Practitioners Role Child Protection

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The Medical Practitioners Role Child Protection

• Dr Nick van der Spek
• Consultant Paediatrician
• special interest Community Child Health
• Friday, 17th April 2009

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• This is not a
• mini-child protection training course
• but hopefully it
• gives you reasons to do one.

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Is there a role for us?

• Yes
• Child Protection Child Abuse is not different
  from any other medical condition affecting the
  health of a child and requires the same diligent
  medical assessment.
• Aplies to any doctor who deals with a child
• aged 0 18 years
• GPs and all designated officers Senior Medical
  Officer, NCHD, Physician, Radiologist,
  Pathologist, Paediatrician, Surgeon, (General,
  Orthopaedic, Plastic), Dentist, Anaesthetist, etc

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A duty to protect children and to support
families together

• Child Abuse Guidelines DoH, 1987
• Child Care Act, 1991
• UN convention the rights of the child, 1992
• National and international Inquiries
• Protections for persons reporting child abuse,
  1998
• Children First- National Guidelines, 1999

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Two statements

• Children are vulnerable to abuse because of their
  dependency and immaturity.
• Parents or guardians have primary responsibility
  for the care and protection of their children.
• Children First, 1999

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Child?

• 0-18 years as in Children First, married
  persons excluded.
• Legislation and criminal law has variable upper
  limits (15-18), depending on the act of abuse and
  gender.

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Child Abuse

• Physical Child Abuse
• Sexual Child Abuse
• Neglect (most common)
• Emotional Abuse
• Fictitious illness by proxy (aka Munchausen
  Syndrome by proxy)

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Overview of Role

• Identify
• Diagnose
• Intervention
• Report
• Working with other professionals in the interest
  of the child and family

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General Role

• Promote the welfare of children through health
  promotion and health surveillance programmes.

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Identify

• Consider the possibility of child abuse,
  otherwise you wont recognise it.
• Make your patient or parent feel you are open to
  receive information about child abuse.

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Identify

• GP in a special situation
• Able to identify best because GP best aware of
• Risk factors for child abuse like family stress
• Familys background
• Conflict with patient being fee paying client?
• Train other in PCT to identify and how to report
• Hospital
• In any setting where children are observed and
  treated, especially E.D. and children and mental
  health wards.
• Receive information about adults abusing children

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Identify

• Beware
• Children with disabilities are more at risk for
  abuse
• Child abuse happens in all socio-economic groups,
  genders and cultures
• Neglect is as potentially fatal as physical abuse
• The severity of the sign does not necessarily
  equate with the severity of the abuse (e.g.
  shaken baby, emotional abuse is cumulative)
• Some studies suggest that 11 of all children
  have experienced child sexual abuse

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Diagnose

• Once suspicion raised or alerted, actively look
  for signs of abuse, starting with
• History
• Step-by-step find out how any injury happened
• Time delay between occurrence and presentation?
• Does the injury fit the history? Does it make
  sense
• Who else was there? etc.

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Diagnose

• History cont
• Has this happened before or to other children in
  the family?
• Are there risk factors of child abuse?
• Family stresses including poverty
• Alcohol abuse
• Domestic violence
• Other abuse/neglect in past

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Diagnose

• Interviewing
• Parents clarification match the history of the
  event with the injury observed.
• Child specialised professionals usually,
  especially for young children and more serious
  harm
• Document the langauge the child used in a
  disclosure.

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Diagnose

• Examination
• Does it need immediate treatment?
• Location, pattern of injury related to the age
  and development of the child.
• Record growth and development of the child

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Diagnose

• Examination at the request of the social worker
• If medical examination will indicate more clearly
  if the child has been physically or sexually
  abused or neglected often a Paediatrician is
  asked.
• If a child requires medical treatment
• By a doctor who has experience in the relevant
  type of child abuse examination

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Diagnose

• Documentation (clear and contemporaneous)
• Date
• Time
• Location
• Context
• Other information drawings, photographs, video

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Intervention

• Provide medical treatment or prevention
• Safety of child first, consider involvement Garda
  / section 12
• Contact Medical expert for further medical
  assessment e.g. local Paediatrician with child
  abuse examination experience or surgical
  expertise for treatment
• Support and explanation to parents
• Contact Duty Social worker to discuss concerns,
  finding and officially report concern in writing.

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Intervention

• Reporting
• Know the local procedure of contacting Child Care
  Manager or Duty Social Worker.
• Yellow forms in Cavan/Monaghan
• Be aware of the Child Protection Notification
  System.

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Report

• Writing a report for the Social worker includes a
  standard (yellow) form as well as
• a medical report detailing
• the relevant details of the history and
  examination, realising that this can be placed in
  front of a court of law

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Report

• Information from the doctor is shared with other
  professionals involved of a case, so a complete
  picture can be generated of the concerns

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Cooperation

• Working with other professionals in the interest
  of the child and family
• Joining case conference in person (or with a
  written report)
• Contribute towards a child protection plan
  re-assess child, advice on health issues
  (vaccinations), growth and developmental progress
  etc.

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Paediatrician know your locals

• Some have more experience in the assessment of
  child abuse than others
• Community Paediatricians (Community Child Health)
  and some ED Paediatricians often more training
• Some Senior Medical Officers are very
  experienced
• Most Paediatricians would have knowledge of
  common basic physical abuse but some abuse
  features require more specific knowledge.

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Paediatrician and age

• Most Paediatricians would see children until age
  14 or 15 years for child abuse concerns.
• Children aged 14-18 therefore need to be dealt
  with by adult physicians and surgeons as well as
  GPs.

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Child Sexual Abuse

• No central assessment centres
• Dublin has acute sexual abuse unit for over age
  16 years
• Southern areas have services for younger children
  to this is likely to change
• Most Paediatricians find it difficult to
  interpret signs in pubertal girls.
• Cavan/Monaghan have 0-16 yr service with
  colposcope and video.

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Child Sexual Abuse

• Small number of Paediatricians have experience in
  child sexual abuse examinations and even fewer
  have all resources to do full assessment
  (including colposcopy and video recording of
  examination)
• Number of cases is small and difficult to
  maintain skills. Cavan/Monagan approxiately
  1/month.
• No on-call rotas for child protection as seen in
  urban areas in UK.

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Training needs?

• Local PCCC inquire about
• Foundation Child Protection course
• Report writing courses

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References

• Children First, National guidelines for the
  protection and welfare of children DoHC, 1999
• The physical signs of child sexual abuse, RCPCH
  (UK) 2008