Child Safeguarding Flashcards
GDC child safeguarding expectations
The General Dental Council expects all registrants to be aware of the procedures involved in raising concerns about the possible abuse or neglect of children and vulnerable adults.
All dental professionals have a responsibility to raise concerns about the possible abuse or neglect of children or vulnerable adults. It is your responsibility to know who to contact for further advice and how to refer to an appropriate authority (such as your local health trust or board)
child protection
Activity undertaken to protect specific children who are suffering, or are at risk of suffering, significant harm.
‘children in need’
those who require additional support or services to achieve their full potential.
safeguarding children
Measures taken to minimise the risks of harm to children.
This includes:
- protecting children from maltreatment
- preventing impairment of children’s health or development
- ensuring that children are growing up in a safe and caring environment
Working Together to Safeguard Children DfES, 2006
what is abuse and neglect
Anything which those entrusted with the care of children do, or fail to do, which damages their prospects of safe and healthy development into adulthood.
3 elements for child abuse (all need to be present)
Significant harm to child
Carer has some responsibility for that harm
Significant connection between carer’s responsibility for child and harm to child
national child protection acts (SCOTLAND)
3 main
National Guidance for Child Protection in Scotland 2014. Scottish Government
Children and Young Peoples Act 2014
Getting It Right for Every Child (GIRFEC)
For further information go to: www.scotland.gov.uk
the children and young people’s act 2014
Royal Assent on 27th March 2014
13 parts - covers a wide range of children’s policy
4 major themes
- Children’s rights (parts 1 and 2)
- Getting it Right for Every Child1 (GIRFEC) (parts 3, 4, 5 and 13)
- Early Learning and Childcare (part 6)
- ‘Looked After’ children (parts 7 to 11)
Aim of the Act, “unquestionably legitimate and benign”.
- specific proposals about information-sharing “are not within the legislative competence of the Scottish Parliament”.
aim of
the children and young people’s act 2014
“unquestionably legitimate and benign”.
- specific proposals about information-sharing “are not within the legislative competence of the Scottish Parliament”.
4 major themes of
the children and young people’s act 2014
- Children’s rights (parts 1 and 2)
- Getting it Right for Every Child1 (GIRFEC) (parts 3, 4, 5 and 13)
- Early Learning and Childcare (part 6)
- ‘Looked After’ children (parts 7 to 11)
GIRFEC in the CYPA 2014
Named person for every child as a single point of contact to provide advice and support to families and to raise and deal with concerns about a child’s wellbeing. Now voluntary schemes only not mandatory
Lead professional where particularly complex needs or where different agencies need to work together. Not legislated for, and will remain a matter of policy and guidance only.
Single child’s plan - single planning process for individual children who have wellbeing needs. Legislated for in Part 5
National practice model
- creates a shared language and approach to identifying and meeting concerns.
- the ‘well-being wheel’ (known as SHANARRI)
- ‘my world triangle’
- ‘resilience matrix’
Shared approach to:
- organising and recording information about a child
- discussing ways of addressing concerns about wellbeing.
Recommend- used by all agencies, including when recording routine information.
GIRFEC - emphasis on the way that information is shared and recorded by different professions
The SHANARRI indicators and a concept of ‘wellbeing’
- Safe, Healthy, Achieving, Nurtured, Active, Respected, Responsible, Included
SHANARRI
national practice model outlined in GIRFEC in CYPA 2014
shared language and approach to identifying and meeting concerns.
- the ‘well-being wheel’ (known as SHANARRI)
- ‘my world triangle’
- ‘resilience matrix’
The SHANARRI indicators and a concept of ‘wellbeing’
- Safe, Healthy, Achieving, Nurtured, Active, Respected, Responsible, Included
The SHANARRI indicators and a concept of ‘wellbeing’
- Safe, Healthy, Achieving, Nurtured, Active, Respected, Responsible, Included
GIRFEC emphasises
the way that information is shared and recorded by different professions
shared approach of GIRFEC
Shared approach to:
- organising and recording information about a child
- discussing ways of addressing concerns about wellbeing.
Recommend- used by all agencies, including when recording routine information.
who should use GIRFEC
Recommend- used by all agencies, including when recording routine information.
CYPA 2014 and information sharing
Information can be shared when safety is at risk, or where the benefits of sharing the information outweigh the public and individual’s interest in keeping info confidential.
- Good practice to get consent where possible and safe to do so
Share what you need to and keep a note of what and why you have shared the info.
international child safeguarding acts
Children and Young Peoples Charter
The UN Convention on the Rights of the Child UNCRC. They are based on the NEEDS of children
- The right to respect
- The right to information about yourself
- The right to be protected from harm
- The right to have a say in your life
- The right to a good start in life
- The right to be and feel secure
NEEDS of the child in UN Convention on Rights of Child (6)
- The right to respect
- The right to information about yourself
- The right to be protected from harm
- The right to have a say in your life
- The right to a good start in life
- The right to be and feel secure
UNRC criticised UK on which 3 areas
Protection
- against physical abuse and violence (art 19). Continued use of ‘reasonable chastisement’ defence to corporal punishment in the home - smack
- teenagers in the penal system (arts, 37, 40). without access to health care, education or child protection
- lack of benefits and access to health care from asylum seeker children
Participation
- full participation for disabled children (art 23)
- access to information (art 17). Lack of recognition for the need to respect children’s rights in government documents.
Provision
- standard of living adequate for physical, mental, spiritual, moral, and social development (art 27). Nearly one in three children living in poverty
aetiology and contributing factors for child abuse in adults
drugs, alcohol, poverty, unemployment, marital stress, mental illness, disabled, domestic violence, stepparents, isolation, abused as a child, unrealistic expectations
aetiology and contributing factors for child abuse in children
crying, soiling, disability, unwanted pregnancy (born at wrong time), failed expectations, wrong gender, product of forced, coercive or commercial sex
aetiology and contributing factors for child abuse in community/environment
Dwelling place and housing conditions, Neighbourhood
aetiology and contributing factors for child abuse through family (violence/dysfunctional)
Intergenerational cycle, Violence toward pets, Social isolation, Poverty
the big 3 concerns in parenting capacity
Domestic violence
Drug and alcohol misuse
Mental health problems
Cumulative problems increase the likelihood of a negative outcome
child abuse volume
2599 children on Child protection register in Scotland 2019
80% new registrations (never registered before)
20% previously registered
49% have been on register for less than 6 months, 34% 6 months to 1 year
Only 2% on register for 2 or more years
14015 children “looked after”
registration rate for child abuse in differing scottish local authorities
Glasgow city 4.1%
East Ren 0.8%
East Dun 2.9%
East Ayrshire 4.6%
North Lanarkshire 2.6%
Scotland overall 2.8% (lower than rest of U.K)
Scotland Vs UK child abuse level
Scotland overall 2.8% (lower than rest of U.K)
ratio of children facing severe maltreatment
Data suggests 1 in 5 children experience severe maltreatment
issue with data on child abuse
no data on child protection referrals collected since 2011
child abuse categories (5)
Physical
Emotional
Neglect
Sexual
(Non-organic Failure to thrive)
vulnerable children are (3 classes)
Under 5s
- Not at school yet – so predominately family care
Irregular attenders
- repeatedly DNA, return in pain, exposed to risks of GA
Medical problems and disabilities
- more at risk of experiencing abuse of all kinds
- serious impairment of health or development is more likely as a result of untreated dental disease
- ‘looked after’ children
how are under 5s vulnerable children
Not at school yet – so predominately family care
how are irregular attenders vulnerable children
- repeatedly DNA, return in pain, exposed to risks of GA
how are children with medical problems and disabilities vulnerable
- more at risk of experiencing abuse of all kinds
- serious impairment of health or development is more likely as a result of untreated dental disease
- ‘looked after’ children
child deaths
UK Vs USA Vs Scotland
In UK 1-2 children per week
In the USA 80 children per month
In Scotland each year, about ten children are killed by a parent or parent substitute.
dental team role in child protection
We too have a responsibility to contribute to the wider picture.
If opportunities are missed that may not arise again for some time, the consequences of this can be very damaging
neglect
significant and under-recognised problem which affects the wellbeing of many children; agencies and their staff need additional professional support in the assessment and intervention with such children and young people.
A centre for children’s wellbeing should include a focus on research and on developing a range of interventions that will be effective.
5 Child’s needs that can be used as markers of general neglect
nutrition
warmth, clothing, shelter
hygiene and health care
stimulation and education
affection
effect on child of neglect
- nutrition
failure to thrive/ short stature
effect on child of neglect
- warmth, clothing, shelter
inappropriate clothing, cold injury, sunburn
effect on child of neglect
- hygiene and health care
ingrained dirt (finger nails)
head lice
dental caries
effect on child of neglect
- stimulation and education
development delay
effect on child of neglect
- affection
withdrawn or attention seeking behaviour
‘neglect of neglect’
Possible that ‘neglect of neglect’ will occur because neglect is less incident focused or because there is less shared understanding of what is meant by neglect and how it should be responded to.
Neglect is common TODAY
Neglect damages children
Neglect can kill
ultimate effect of neglect
Neglect is common TODAY
Neglect damages children
Neglect can kill
typical neglect victims e.g.s (2)
Child under 1yr deprived of food and drink
Older independently mobile child inadequately supervised
short term damage of neglect (4)
Physical health
Emotional health
Social development
Cognitive development
long term damage of neglect (5)
Adults neglected as children-higher incidence of:
- Arrest
- Suicide attempts
- Major depression
- Diabetes
- Heart disease
Strain on health service – so tackle child abuse to help benefit the community for future generations
dental neglect
…is wilful failure of parent or guardian to seek and follow through with treatment necessary to ensure a level of oral health essential for adequate function and freedom from pain and infection
…the persistent failure to meet a child’s basic oral health needs, likely to result in the serious impairment of a child’s oral or general health or development
resist erroneous assumptions for dental neglect
multi-factorial aetiology of dental caries
variation in individual susceptibility
inequalities in dental health e.g. regional, social class
inequalities in access to dental treatment
differences in treatment philosophies
dental neglect can cause
severe dental disease
effects of severe dental disease on child (4)
Toothache
Disturbed sleep
Difficulty eating/ change in food preferences
Absence from school
what can dental disease put child at risk of (4)
Teasing due to poor dental appearance
Repeated antibiotics
Repeated general aesthetic extractions
Severe infection
wilful dental neglect is when
After dental problems have been pointed out:
- Irregular attendance, repeated failed appointments, repeated late cancellations
- Failure to complete treatment
- Returning in pain at repeated intervals
- Repeated GA for dental extractions – despite preventative measure/advices
indicators of dental neglect (3)
Obvious dental disease
Impact on the child – school, eating, confidence etc
Practical care has been offered, yet the child has not returned for treatment
managing dental neglect - guidance from
Current guidance from child protection and the dental team
- a handbook or open-access website www.cpdt.org.uk or https://www.bda.org/childprotection
- for the primary dental care team
3 stages of managing dental neglect
Preventive dental team management
Preventive multi-agency management
Child protection referral
what may occur in stage 1 of dental neglect management
PREVENTATIVE DENTAL TEAM MANAGEMENT
raise concerns with parents, offer support, set targets, keep records and monitor progress.
- Patient/carer offered treatment and sent reminder.
what may occur in stage 2 of dental neglect management
PREVENTATIVE MULTI-AGENCY MANAGEMENT
liaise with other professionals (e.g. health visitor, school nurse, general medical practitioner, social worker) to see if concerns are shared
A child may be the subject of a CAF (Common Assessment Framework) at this level.
Check if child is subject to a child protection plan (which replaced the child protection register)
Agree joint plan of action, review at agreed intervals
Letter to HV of children < 5 who fail appointments and have failed to respond to letter from dental practice
- “If this family is known to you, we would welcome working together to promote their oral health.”
(standard letter)
what may occur in stage 3 dental neglect management
CHILD PROTECTION REFERRAL
In complex or deteriorating situations
Follow local guidelines
Referral is to social services
- Usually by telephone followed up in writing
dental neglect case example
3-year-old child
Dentist refers to dental hospital as child has multiple grossly carious teeth and is in pain
Family cancel first assessment appointment, then fail to attend next 2 appointments
Dental hospital try and contact family- no response
Dental hospital contact GDP to alert and ask re attendance
GDP has GMP details, contacts GMP and asks for health visitor details
Letter to health visitor
Health visitor visits and contacts GDP and dental hospital to arrange new appt, health visitor given details of appt.
assessment framework for child neglect
triangle sides
child’s developmental need
- health
- education
- emotional and behavioural development
- identity
- family and social relationships
- social presentation
- selfcare skills
Parenting Capacity
- basic care
- ensuring safety
- emotional warmth
- stimulation
- guidance and boundaries
- stability
family and environmental factors
- family history and functioning
- wider family
- housing
- employment
- family’s social intergration
- community resources
learning points from this scenario (7)
You are examining a family of 3 siblings aged 8 years old, 6 years old and 6 months old. The older siblings have previously been registered with another dentist in your practice but have transferred to your list. This is the first dental visit for the 6-month-old. The children have had a social worker appointed to them because of concerns about their care and the family give you their contact details.
You note that both older siblings have obvious ingrained dirt on their school uniforms, their skin and hair is visibly dirty, and they smell bad. During the intra-oral examination, you note active dental caries in both the older siblings. The 6-year-old has generally poor oral hygiene. The 8-year-old has good oral hygiene round their anterior teeth but plaque deposits on their posterior teeth. The 6-month-old has clean freshly laundered clothes, their hair and skin appear clean and they have 2 lower incisors present and good oral hygiene. All the children are b for examination. You raise your concerns about the oral health of the children with their father who blames the children saying, “they never brush their teeth when I tell them to”. You make their father aware of the children’s dental needs and the family elects to return for treatment. When you talk to the children’s previous GDP they confirm that the older children were always compliant but they failed to complete treatment and were irregular attenders. A few weeks later the older siblings are not brought to their agreed treatment appointments.
Extra oral appearance is important
Children need assistance with toothbrushing until approximately 7 years of age
It may be not all children in a family who are abused/ neglected
Irregular attendance and failure to complete treatment are alerting features
Dentists hold key information other professionals do not
Information sharing essential
Sharing Information
outcome from this scenario
You are examining a family of 3 siblings aged 8 years old, 6 years old and 6 months old. The older siblings have previously been registered with another dentist in your practice but have transferred to your list. This is the first dental visit for the 6-month-old. The children have had a social worker appointed to them because of concerns about their care and the family give you their contact details.
You note that both older siblings have obvious ingrained dirt on their school uniforms, their skin and hair is visibly dirty, and they smell bad. During the intra-oral examination, you note active dental caries in both the older siblings. The 6-year-old has generally poor oral hygiene. The 8-year-old has good oral hygiene round their anterior teeth but plaque deposits on their posterior teeth. The 6-month-old has clean freshly laundered clothes, their hair and skin appear clean and they have 2 lower incisors present and good oral hygiene. All the children are b for examination. You raise your concerns about the oral health of the children with their father who blames the children saying, “they never brush their teeth when I tell them to”. You make their father aware of the children’s dental needs and the family elects to return for treatment. When you talk to the children’s previous GDP they confirm that the older children were always compliant but they failed to complete treatment and were irregular attenders. A few weeks later the older siblings are not brought to their agreed treatment appointments.
Children’s social worker contacted re failure to attend subsequent dental appts
Social worker reports children have been accommodated in different health board and requests a letter from you and permission to share dental details with new GDP
any concerns about this scenario
You are examining a family of 3 siblings aged 8 years old, 6 years old and 6 months old. The older siblings have previously been registered with another dentist in your practice but have transferred to your list. This is the first dental visit for the 6-month-old. The children have had a social worker appointed to them because of concerns about their care and the family give you their contact details.
You note that both older siblings have obvious ingrained dirt on their school uniforms, their skin and hair is visibly dirty, and they smell bad. During the intra-oral examination, you note active dental caries in both the older siblings. The 6-year-old has generally poor oral hygiene. The 8-year-old has good oral hygiene round their anterior teeth but plaque deposits on their posterior teeth. The 6-month-old has clean freshly laundered clothes, their hair and skin appear clean and they have 2 lower incisors present and good oral hygiene. All the children are b for examination. You raise your concerns about the oral health of the children with their father who blames the children saying, “they never brush their teeth when I tell them to”. You make their father aware of the children’s dental needs and the family elects to return for treatment. When you talk to the children’s previous GDP they confirm that the older children were always compliant but they failed to complete treatment and were irregular attenders. A few weeks later the older siblings are not brought to their agreed treatment appointments.
That the older siblings will continually be missed from treatment if moving around health boards and treatment not being completed
Younger sibling grows to have similar level of neglect
Impacts on childrens’ life in long term
who would you contact about this scenario
You are examining a family of 3 siblings aged 8 years old, 6 years old and 6 months old. The older siblings have previously been registered with another dentist in your practice but have transferred to your list. This is the first dental visit for the 6-month-old. The children have had a social worker appointed to them because of concerns about their care and the family give you their contact details.
You note that both older siblings have obvious ingrained dirt on their school uniforms, their skin and hair is visibly dirty, and they smell bad. During the intra-oral examination, you note active dental caries in both the older siblings. The 6-year-old has generally poor oral hygiene. The 8-year-old has good oral hygiene round their anterior teeth but plaque deposits on their posterior teeth. The 6-month-old has clean freshly laundered clothes, their hair and skin appear clean and they have 2 lower incisors present and good oral hygiene. All the children are b for examination. You raise your concerns about the oral health of the children with their father who blames the children saying, “they never brush their teeth when I tell them to”. You make their father aware of the children’s dental needs and the family elects to return for treatment. When you talk to the children’s previous GDP they confirm that the older children were always compliant but they failed to complete treatment and were irregular attenders. A few weeks later the older siblings are not brought to their agreed treatment appointments.
Social worker – still in contact with the family. Potentially GP or school of older siblings
physical abuse (3 categories)
Over chastisement (cultural)
Acute/ compassionate (shaking)
- Spontaneous uncalculated reaction
- Remorse, take appropriate action
- Child’s needs are priority
Chronic/ pathological (way of life)
- Help sought but not actively
- No remorse
- Child’s needs not a priority
Chronic/ pathological (way of life) physical child abuse
- Help sought but not actively
- No remorse
- Child’s needs not a priority
Acute/ compassionate (shaking) physical child abuse
- Spontaneous uncalculated reaction
- Remorse, take appropriate action
- Child’s needs are prioritys
scotland laws on physical child abuse
Already illegal to hit a child with an object or to hit them anywhere on head
In 2019 the CHILDREN (EQUAL PROTECTION FROM ASSAULT)(SCOTLAND) BILL was passed which removes the “reasonable chastisement” excuse from law
- From 7th November 2020 it is illegal to physically punish a child
types of injuries from child abuse
Head - 95% of serious head injuries in first year of life not accidental
Body - 10% of 5 year olds attending A&E not accidental
10-12% of childhood burns are non-accidental
how many physical abuse injuries are on head and neck
approx 60%
accidental injuries indicators
on prominences of body (stick out)
- forehead, nose, chil, palm, parietal or occiptal areas of head, elbows, knees, shins
match history
are in keeping with child development
non accidental injuries indicators
injuries to both sides of body
injuries to soft tissue
injuries with particular patterns
any injury that doesn’t fit explanation
delays in presentation
untreated injuries
harder to hit areas
- triangle of safety of neck , ears, inner arms and thighs, back, eyes, in mouth , chest, forearms, soles
orofacial signs of physical abuse
extra oral
Bruising of face - punch, slap, pinch
Bruising of ears - pinch, pull
Abrasions and lacerations
Burns and bites
Neck - choke or cord marks
Eye injuries
Hair pulling
Fractures (nose>mandible>zygoma)
major clinical signs of physical abuse (4 categories)
Skin lesions
Bone lesions
Intracranial lesions
Visceral lesions
physical abuse skin lesions
- Bruises, burns, bites, lacerations, pinch marks
Different stages of healing – less likely to be accidental - Tattoo - matches the object hit with
physical abuse bone lesions
fractures
nose>mandible>zygoma
physical abuse intracranial lesions
From shaking
physical abuse visceral lesions
(intra-abdominal)- blunt trauma
intra oral signs of physical abuse
Contusions
Bruises
Abrasions and lacerations
Burns
Tooth trauma
Frenal injuries
- Non mobile children is suspicious as not like fell in attempt to walk
medical equivalent explanation of physical abuse signs
similar appearance to cigarette burns
impetigo
medical equivalent explanation of physical abuse signs
mistaken for bruises
birthmarks
medical equivalent explanation of physical abuse signs
mistaken for trauma
facial infection
medical equivalent explanation of physical abuse signs
coagulation problem
bruise easily
index of suspicion (9)
Delay in seeking help
Story vague, lacking in detail, vary with each telling and person to person
Account not compatible with injury
Parents mood abnormal. Preoccupied.
Parents behaviour gives cause for concern
Child’s appearance and interaction with parents is abnormal
Child may say something contradictory
History of previous injury
History of violence within the family
final check list questions for physical abuse
Could the injury have been caused accidentally and if so how?
Does the explanation for the injury fit the age and the clinical findings?
- E.g. alcohol at young age
If the explanation is consistent with the injury, is this itself within normally acceptable limits of behaviour?
If there has been delay in seeking advice, are there good reasons for this?
final check list observations for physical abuse
The general demeanour of the child
The nature of the relationship between guardian and child
The child’s reactions to other people
The reaction of the child to any medical or dental examination
Any comments by the child and or guardian that give concern about the child’s upbringing or lifestyle
what to do here
You are at the reception desk of the practice you work in and in the waiting room you see one of the patients shout at her 7-year-old son (who is not a registered patient at the practice). Shortly after this she slaps him across the face in front of the whole waiting room.
witnessed a CRIME
- report to police
role of dental team in neglect and physical injuy cases
contribute a vital piece of the jigsaw to prevent the death of a child
- by referral
be the first link in the chain to offer support to a family in crisis
dental team expected to for physical abuse and neglect cases (4)
Observe
Record
Communicate
Refer for assessment
NOT expected to diagnose
how can dental team help in child safeguarding
Share concerns- Named Person
Know where to go for help and advice:
- Experienced colleague
- Named Safeguarding Nurse
- Child Protection Adviser
- Named Doctor for Safeguarding
- Social work / social services(e.g Social care direct)
- Children’s Services Department (e.g First Contact)
- NSPCC Helpline 0808 800 5000
Know the contact names and numbers
https://www.mygov.scot/report-child-abuse/
The Dental Team IS part of THE team
- Know what to do if you still have concerns following initial discussion
how to refer/share concerns
for child safeguarding concerns
By telephone initially, follow up in writing
Facts
Statement of concerns
what form for child safeguaring
notification of concern form/ shared referral form
when would you not inform child and parent/carer that you are doing a referral
only when Unable to get in touch with or risk to child
“agreed actions” when filling in shared referral form
Form filled in and sent - referral sent
Arranged an appointment with child in X days
after the referral if the child is in immediate danger (4)
e.g. crime/hit witnessed
- Child Protection order
- Exclusion order
- Child assessment order
- Removal by police or authority of a JP
if child not in immediate danger, after referral …
Otherwise- investigation, initial assessment, discussion
- Begin to decide if child is at risk of significant harm
Then;
- No further CP action, may get additional support (Eng/ Wales/ N.I/ Scot)
- Joint investigation (Scotland)
