Child Protection and Non-Accidental Injury

Question 1

are there laws that allow us to protect children?

Answer 1

yes

Question 2

who is responsible for reporting any concern about child care?

Answer 2

Member of the public - See and hear aspects of child care that cause concern, Social media, Volunteering

Professional duty - General Medical Council, Contract, Public role to protect and prevent harm

When you have a concern about a child you must break confidentially if it is in the best interest of the child

It is everyone’s responsibility to safeguard against child abuse and neglect.

ALL doctors have a DUTY to act upon any concerns they have about the safety or welfare of a child or young person.

Question 3

what are the categories of abuse?

Answer 3

Physical Abuse

Sexual Abuse

Emotional Abuse

Fabricated and Induced Illness

Neglect

Question 4

what is the defintion of physical abuse?

Answer 4

To hurt or harm a child or young person on purpose IN ANY WAY. It includes: hitting with hands or objects, slapping and punching, kicking, shaking, throwing, poisoning, burning and scalding, biting and scratching, breaking bones, drowning

Question 5

How do you know when a child has been intentionally harmed? :

when a child presents, what are some alarm bells?

Answer 5

Late presentation

History changes on repeating

History inconsistent with findings

Question 6

“History inconsistent with findings”

Know what is normal and what is not - such as what?

Answer 6

Growth

Development

Common presentations of common problems, injuries and illnesses

Common presentations of NAI

Question 7

what are common sites for accidental injury and what are common sites for NAI?

Answer 7

Should always be asking questions when there is injury that isn’t overlying a bony prominence

Question 8

whats important to note when a child presents with bruising?

Answer 8

Any bruise in non mobile infant

Petechiae (See petechiae in sepsis but in the absence of sepsis you need to ask about this)

Clusters

Extensive injuries with no explanation

Injury not consistent with history or developmental level

Location of bruise

any pattern of bruising is a concern

Question 9

what is a thermal injury?

Answer 9

Burns - Dry heat

Scalds - Hot liquid

Question 10

Impetigo v. Cigarette burn - how can you tell the difference?

Answer 10

Both circular

Burns often infected

Look for distribution

Look for burnt hair

Healing

Question 11

what would oyu want to know baout fractures?

Answer 11

1/3 sustain fracture<16 yrs

Most unintentional

Most in <18 months

Mechanism

Age

Developmental status

Question 12

Abusive Head Trauma - who does it occur in and what does it result in?

Answer 12

Commonest cause of death in physical abuse

Predominantly < 2 years of age

Mortality upto 30%

Half have residual disability

Presentation variable

Retinal haemorrhages seen in 80%

Neck and cervical spine injury

Question 13

what is the defintion of neglect?

Answer 13

Neglect is the ongoing failure to meet a child’s basic needs

The most common form of child abuse

A child might be left hungry or dirty, or without proper clothing, shelter, supervision or health care. This can put children and young people in danger. And it can also have long term effects on their physical and mental wellbeing

Question 14

what are the categories of neglect?

Answer 14

Emotional

Abandonment

Medical

Nutritional/FTT

Educational

Physical

Failure to provide supervision

Question 15

how common is neglect and how commonyl is it related to FFT?

Answer 15

If you see a child with faltering growth, ask the question – could this be abuse or neglect?

Question 16

what is the definition of emotional abuse?

Answer 16

any type of abuse that involves the continual emotional mistreatment of a child

sometimes called psychological abuse

can involve deliberately trying to scare, humiliate, isolate or ignore a child

(Emotional abuse encompasses all other forms of abuse)

Question 17

how do you recognise emotional abuse?

Answer 17

There may not be any physical signs of emotional abuse

Recognition of concerning behaviours, including behavioural or developmental difficulties, wary or anxious child, placid non-demanding baby, self harm in teenagers, etc

Noting down observed harmful caregiver-child interactions

Question 18

what is the deifntion of sexual abuse?

Answer 18

When a child or young person is sexually abused, they’re forced or tricked into sexual activities

They might not understand that what’s happening is abuse or that it’s wrong. And they might be afraid to tell someone

Sexual abuse can happen anywhere – and it can happen in person or online

Question 19

how may contact sexual abuse occur?

Answer 19

sexual touching of any part of a child’s body, whether they’re clothed or no

using a body part or object to rape or penetrate a child

forcing a child to take part in sexual activities

making a child undress or touch someone else

Contact abuse can include touching, kissing and oral sex – sexual abuse isn’t just penetrative

Question 20

how many non-contact sexual abuse occur?

Answer 20

Can be in person or online

exposing or flashing

showing pornography

exposing a child to sexual acts

making them masturbate

forcing a child to make, view or share child abuse images or videos

making, viewing or distributing child abuse images or videos

forcing a child to take part in sexual activities or conversations online or through a smartphone

Question 21

what are some indicatiors that sexual abuse may be happening?

Answer 21

Disclosure

Sexualised Behaviour

STI

Pregnancy

Question 22

how is a CSA/Forensic Examination done?

Answer 22

žJoint Paediatrician/Forensic Medical Examiner

žDo not repeat interview

žVideo Colposcope - It’s a video camera, magnifying glass and a light, Don’t do internal examinations, Its an external inspection of the external genitalial and the behind

žGeneral Physical Examination

žDevelopmental Assessment

Question 23

what is the definition of FII (Fabricated or Induced Illness)

Answer 23

Fabrication: making up the symptoms of an illness

Induction: causing a child to become unwell

Question 24

Fabricated or Induced Illness - how does it occur?

Answer 24

Rare form child abuse

Spectrum

90% mother

Likely underestimated in prevalence studies

Motivation unclear

Multi-agency issue

GP must be involved if FII suspected

Question 25

so what do we do when a child presents with a child protection issue?

Answer 25

Take a history

Examine the child

Clinical investigations, if needed

Reach a preliminary opinion

Consult with other agencies

Give a revised opinion, if needed

Question 26

What happens after a referral has been made to police or social work?

Answer 26

After a referral is made the response depends on the level of risk or harm identified. An initial assessment will be made to gather information and understand the risks to the child

Can include:

• Joint Visit health , social work, police
• Child Protection Case Conference
• Immediate place of safety- Child Protection Order
• Children’s Panel may need compulsory measures of supervision
• Looked after Child - Accommodated or at home

Question 27

Summary:

Possibility of child abuse is often recognized by non-medics: we help to confirm or exclude

Paediatricians do not decide who goes on Child Protection Register or is taken into care: Social Services have statutory responsibility for child protection

Multi-agency process, including Children’s Panel and courts if necessary

Answer 27

Take Home Messages - Child Protection:

Everyone’s civil responsibility

Professional duty to child

Doctor’s role is to raise, allay or confirm concerns: “start the ball rolling”

Your action may save a life

Your inaction may lead to further harm or death