Safeguarding children — the need for vigilance

Posted Jun 13, 2014

Safeguarding the welfare of children is everyone’s responsibility. As practice nurses, we are involved with families, children and young people in our everyday lives and are therefore centrally placed be able to identify those at risk.

Children have a right to be protected from maltreatment, to grow and develop within a safe environment. It is our responsibility and duty to be able to recognise the signs of child maltreatment and neglect and to know how to take appropriate action on our concerns.

DEFINITIONS

Safeguarding is the umbrella term used to promote the welfare of children, of which child protection is an element. Child protection relates to the activities undertaken to protect children suffering from harm or who may be at risk of significant harm.¹Although there is no agreed single legal definition within the UK, safeguarding is defined in England as:

Protecting children from maltreatment
Preventing impairment of children’s health
Ensuring that children grow up in circumstances consistent with the provision of safe and effective care; and
Taking action to enable all children to have the best outcomes2

A child is defined as anyone under the age of 18 years of age.

Each country within the UK has specific guidance for safeguarding and the duty to protect the rights of all children, underpinned by its own legislation. The National Society for the Prevention of Cruelty to Children (NSPCC) provides a useful fact sheet into the complex laws for each of England, Northern Ireland, Scotland and Wales in relation to safeguarding3. (Box 1)

MALTREATMENT OF CHILDREN

Distressingly, there have been many high profile cases of severe and horrific abuse of children in recent years. Recommendations from the serious case reviews (SCRs) of Baby Peter, Hamzah Khan and Daniel Pelka highlight the need for greater awareness of the risks of neglect and maltreatment together with improvements in inter-agency communication and training of professionals to protect children.^4-6The NSPCC’s 2014 report ‘How safe are our children?’ states that ‘one child dies at the hands of another person every week’ with 69 child homicides recorded across the UK during 2012-13.7 The most recent NSPCC figures suggest that approximately 50,500 children are at risk of abuse and reveal the prevalence of maltreatment and neglect across the UK. The figures use the findings from studies of 11-17 year-olds to indicate the extent of child abuse today (Table 1).⁸

RISK FACTORS

Maltreatment of children occurs across all socio-economic, cultural, racial, religious and ethnic groups. There are no specific factors that can be said to directly cause the abuse and neglect of children. But there are environmental, social and contextual factors that affect the behaviour of individuals, families and communities, which may increase that risk. Factors increasing the probability of child maltreatment include:

Child Factors

Physical or mental disabilities
Born the ‘wrong’ gender
Unwanted child
Chronic long term illness
Born as a result of forced or commercial sex
Failed expectations of parents
Premature babies
Multiple births/closely spaced births

Parental Factors

Poverty
Low parental capacity
Poor interpersonal skills
Domestic violence
Learning disabilities
History of being abused themselves
Mental illness
Substance abuse
Known maltreatment of animals
Single parents
Young age of parents

Social Factors

Social isolation
‘Looked after’ children
Housing conditions
Ethnicity
Social inequality
Deprived neighbourhood
Criminal activity/gangs

FORMS OF MALTREATMENT AND NEGLECT

Children may be subject to a variety of abuse, neglect and maltreatment. Abuse may be by inflicting harm or failing to prevent harm. It can occur within families, by adults or older children, in the community, by gangs or in an institutional setting. The majority of abuse is by someone known to the child. Abuse of children can take many forms, for example: the shaking of a baby, subjecting a child to persistent ridicule and intimidation, neglecting a child’s basic physical and psychological needs, ‘honour’-based abuse and genital mutilation. Classification of abuse is separated into the following distinct areas although emotional abuse is inevitably an integral part of all types of abuse:

Physical abuse
Emotional abuse
Sexual abuse
Neglect
Non-organic failure to thrive (category in Scotland only)

In addition, other forms of harm that children can suffer from include:

Bullying
Internet abuse and cyber bullying
Living within domestic violence
Intimate partner violence
Fabricated/induced illness in children

RECOGNITION OF THE RISKS

As practice nurses, our ability to recognise signs of maltreatment and neglect in children is of paramount importance. Signs of abuse are not always easy or obvious, and nurses may have to risk affecting their professional relationship with a family if they have any concerns about the welfare of a child. The absolute priority is always the child’s safety.

Concerns may be raised because of an injury, if an explanation is implausible or if there is an unusual or inconsistent history, or if the injury isn’t consistent with the developmental age of the child. A child who seems frightened or upset by the parents, or shrinks at the approach of adults should also give rise to concern. The Government document ‘Working together to safeguard children (2013)²gives useful guidance for all professionals working with children to help with recognition of different types of maltreatment of children:

Physical abuse

May be caused by shaking, hitting, throwing, poisoning, burning or scalding
Any injury in a non-mobile baby
Bruising in children who are not independently mobile
Bruising seen away from bony prominences
Imprint bruising
Scalds and burns – especially multiple, those with a clearly demarcated edge, immersion scalds, evidence of implements used
Bite marks
Mouth injuries, torn frenulum
Bilateral eye or ear injuries
Head injuries incompatible with history
Abdominal bruising or injuries
Genital bruising or injuries
Unusual fractures (child under 18 months of age, multiple fractures, rib fractures, fractured femur in child who is not yet walking)
Fractures with a poor history or unexplained
Fabricated illness or deliberately induced illness in a child

Emotional abuse

Defined as ‘the persistent emotional maltreatment of a child such as to cause severe and persistent adverse effects on the child’s emotional development’.²

Conveying to the child they are worthless, unloved and inadequate
Denying the child opportunities to express their views
Deliberately silencing a child
Ridiculing, making fun or being critical of a child
Overprotecting a child and limiting their exploration and learning
Preventing the child participating in normal social interaction
Seeing or hearing the maltreatment of another person
Serious bullying/cyber bullying
Causing children to feel frightened or in danger
The exploitation or corruption of children

Alerting features to suspect emotional abuse

Physical, mental or emotional development delay
Low self-esteem
Unexplained changes in behaviour or emotional state
Self-harming or mutilation
Extremes of emotion, aggression, passivity
Secondary enuresis and soiling
Drug or solvent abuse
Non-attendance at school

SEXUAL ABUSE

‘Sexual abuse involves forcing or enticing a child or young person to take part in sexual activities, not necessarily involving a high level of violence, whether or not the child is aware of what is happening.’²

Alerting features

Ano-genital symptom in a child that is associated with behaviour change
Sexually transmitted infections
Pregnancy in the under 13s
Ano-genito warts
Soiling and secondary enuresis
Marked power of differential in a relationship (eg. Age difference)
Sudden changes in behaviour
Inappropriate sexual display
Secrecy, distrust of familiar adult, anxiety if left alone with a particular person
Self harm, mutilation or suicide attempt
Unexplained or concealed pregnancy
Identified in pornographic materials
Disclosure

NEGLECT

‘The persistent failure to meet a child’s basic physical and/or psychological needs that is likely to result in the serious impairment of the child’s health or development.’²

Alerting features

Substance abuse during pregnancy
Missing appointments, vaccinations and dental treatment
Hungry child, underweight
Delayed development
Poor appearance – dressed in dirty or inadequate clothing
Poor hygiene
Withdrawn and difficulty in making friendships and interacting
Antisocial behaviour
Early sexual activity or drug use
Being left alone at home, inadequate supervision
Living in an inadequate home situation
Parent indifferent to child
Acting as carer for younger siblings

FABRICATED AND INDUCED ILLNESS

Fabricated and Induced Illness (FII) is a rare form of child abuse. It is caused by a spectrum of behaviour in a carer, most commonly the child’s mother, in falsifying or over- exaggerating an illness or set of illnesses and relentlessly pursuing numerous investigations, diagnoses and treatment. The parent typically makes up symptoms and seeks multiple second opinions. At one end of the scale, the mother believes the child is genuinely ill. Extreme FII, however, can be caused by intentional drug administration, suffocating, falsifying test results and overdosing to induce symptoms in the child. For health professionals it may be difficult to distinguish between high anxiety in parents of seriously ill children and those carers who are exhibiting unusual and abnormal behaviours.¹⁰

THE PRACTICE NURSE’S ROLE

‘No single professional can have a full picture of a child’s needs and circumstances and, if children and families are to receive the right help at the right time, everyone who comes into contact with them has a role to play in identifying concerns, sharing information and taking prompt action.' ²

NMC guidance for nurses working with young people stipulates that nurses should ‘work with others to protect and promote the health and wellbeing of those in your care, their families and carers and the wider community’.¹¹Practice nurses have contact with children and young people in many ways – childhood immunisations, asthma management, minor illness and injury, sexual healthcare to name a few – and such contact enables awareness of risk. Keeping a child’s welfare central to a consultation is crucial in recognising maltreatment or neglect. The level of support required for a child and their family is in response to the level of need. It may be a question of identifying families who are vulnerable and in need of additional support or at its most serious making an urgent referral for a child who is at immediate risk.

Barriers to awareness of child maltreatment include focusing on the parent rather than the child, lacking knowledge about safeguarding issues and the ability to identify risks and indicators, underestimating the potential problem, concern for the parent/nurse relationship or not knowing how to respond. It is not the practice nurse’s sole responsibility to make a definitive judgement about maltreatment or neglect of a child. Being able to identify a potential risk, listening to a child or young person, hearing their views and acknowledging their fears and concerns, whatever their age, might be a key to detecting a potential concern. Raising concerns, made in good faith and through the correct procedures, can always be justified.¹²

It is the individual practice nurse’s responsibility to be familiar with local and national safeguarding policies and guidance, including:

Local procedures for reporting concerns about the maltreatment or neglect of a child
The name of the safeguarding lead within their own practice
How to contact children’s services both in and out of hours
How and when to contact the on-call paediatrician
How and when to contact the police
How to seek advice and further information from the named safeguarding leads
How to contact the local safeguarding children’s board (LSCB) or similar agencies
How to contact the multi-agency safeguarding hub (in some areas)
How to contact sexual assault referral centres (in some areas)

Sharing information with other professionals is paramount to the wellbeing of children we have concerns about. This may be the only opportunity to act on behalf of the child. Doing nothing can only be wrong and put a child at risk.

INFORMATION SHARING

‘You may see a child just once yet your record of that visit could help save a life’ ¹³

The key to ensuring the welfare of a child is communication. Any concerns about a child need to be reported promptly. Every GP practice should have a named safeguarding lead, with up-to-date policies and procedures for safeguarding and a clear referral pathway for reporting concerns about children. Each Clinical Commissioning Group (CCG) in England is required to have a designated safeguarding doctor and nurse, who are part of the whole multi-agency team for safeguarding. They are also an integral part of the local safeguarding children’s board (LSCB), which is responsible for developing safeguarding procedures and multiagency training. There are similar arrangements in Scotland, Wales and Northern Ireland.

It is essential to maintain concise, factual, accurate and detailed accounts of communications and actions. The failure to keep adequate records was a major criticism by Lord Laming in the Victoria Climbié Inquiry review, which in itself led to the 2004 Children Act in England and Wales.¹⁴As a result, all information about a child needs to be held in one file, accessible to all members of the multi-agency team, in line with local policy. All observations, actions, judgements, follow-up arrangements and if necessary, the use of a body map to mark injuries, need to be documented contemporaneously, with date and time. Using a tool, such as the SAFER communication guideline developed for Health Visitors, can support telephone referrals and ensures accurate information is shared appropriately.¹⁵ All verbal referrals must be followed up in writing according to local policy. The information documented and subsequent communication forms part of a jigsaw puzzle which is shared with other agencies to enable a complete picture to emerge about a child’s welfare. People who abuse children frequently seek a variety of health and social care settings in an attempt to conceal their actions. Having a system to share information between agencies is vital. Failure to maintain robust documentation and communication puts a child further at risk or allows the abuse to continue.

CONSENT AND CONFIDENTIALITY

‘A risk might only become apparent when a number of people with niggling concerns share them’ ¹²

Confidentiality is essential to professional practice.¹¹However, when a child is at risk of harm, disclosing information to appropriate agencies is imperative. The General Medical Council (GMC) booklet ‘0-18 years: guidance for all doctors’ sets out very clear principles regarding consent and confidentiality for young people and highlights professional responsibilities with regard to child protection.¹²

Consent should be sought prior to sharing information about an at-risk child. If the child has capacity they can provide the consent themselves, following an open and honest discussion (Box 2). An adult, or an adult with parental responsibility, should be asked for consent if the child does not have capacity. Disclosure of information can still be made without consent if the child is deemed to be at risk of maltreatment or neglect or, if by seeking consent, it puts a child further at risk of harm.

TRAINING

Employers have a contractual obligation to ensure that healthcare staff receive the appropriate training in safeguarding and attain competencies relevant to their role.

The 2014 intercollegiate document ‘Safeguarding children and young people: roles and competencies for healthcare staff’ sets out a framework of competencies for all staff working in the healthcare setting in their safeguarding role. It also gives guidance for the appropriate levels of training required for health professionals depending on their role and amount of contact with children.¹⁶Online training modules, such as from the e-Learning for Healthcare website, are available for practice nurses. Local policy may also incorporate team-based learning for level 3 competencies through the local Safeguarding Children’s Board and CCG.

CONCLUSION

Awareness of the signs of potential maltreatment of children is the essential first step of protecting a child. Knowledge of the key systems of referral and sharing information about children who may be at risk is paramount to the safeguarding process. Safeguarding the welfare of children is fundamental to our practice but also our responsibility in our everyday lives.

REFERENCES

1. Royal College of Paediatrics and Child Health. Child Protection [page on the internet] c2014 [updated 9 April 2013] Available from: http://www.rcpch.ac.uk/child-health/standards-care/child-protection/child-protection

2. Department for Education. Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children. London: DofE, 2013 Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/281368/Working_together_to_safeguard_children.pdf

3. NSPCC. An Introduction to child protection legislation in the UK: NSPCC Factsheet. 2014 Available at: https://www.nspcc.org.uk/Inform/policyandpublicaffairs/uk-legislation_wda100749.html

4. Local Safeguarding Children Board Haringey. Serious Case Review: Baby Peter. Executive Summary. 2009 Available at: http://www.haringeylscb.org/executive_summary_peter_final.pdf

5. Bradford Safeguarding Children Board. A Serious Case Review: Hamzah Khan. The Executive Summary. 2013 Available at: http://www.bradford-scb.org.uk

6. Coventry Safeguarding Children Board. A Serious Case Review: Daniel Pelka. Overview Report. 2013 Available at: http://www.coventrylscb.org.uk/files/SCR/FINAL%20Overview%20Report%20%20DP%20130913%20Publication%20version.pdf).

7. NSPCC. How Safe Are Our Children? 2014 Available at: http://www.nspcc.org.uk/Inform/research/findings/howsafe/how-safe-2014-report_wdf101938.pdf

8. NSPCC. Incidence and prevalence of child abuse and neglect. 2013 Available at: http://www.nspcc.org.uk/Inform/research/statistics/prevalence_and_incidence_of_child_abuse_and_neglect_wda48740.html

9. Royal College of Paediatrics and Child Health. Safeguarding Children and Young People. A Toolkit

for General Practice. 2011 Available at: http://www.rcgp.org.uk/~/media/Files/CIRC/Safeguarding%20Children%20Module%20One/Safeguarding-Children-and-Young-People-Toolkit.ashx

10. Lazenbatt A, Taylor J. Research Briefing. Fabricated or Induced Illness in Children: a rare form of child abuse? NSPCC 2011 Available at: http://www.nspcc.org.uk/Inform/research/briefings/fii_pdf_wdf83368.pdf

11. Nursing and Midwifery Council. Confidentiality. 2013 Available at:

http://www.nmc-uk.org/nurses-and-midwives/advice-by-topic/a/advice/confidentiality/

12. General Medical Council. 0-18 years: Guidance for Doctors. 2007 Available at: http://www.gmc-uk.org/guidance/ethical_guidance/children_guidance_index.asp

13. Royal College of Nursing. Safeguarding Children and Young People – every nurse’s responsibility. 2014 Available at: http://www.rcn.org.uk/__data/assets/pdf_file/0004/78583/004542.pdf

14. House of Commons Health Committee. The Victoria Climbié Inquiry Report. Sixth Report of session 2002-3. Available at: http://www.publications.parliament.uk/pa/cm200203/cmselect/cmhealth/570/570.pdf

15. Department of Health. SAFER communication guidelines. 2013 Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/208132/NHS_Safer_Leaflet_Final.pdf

16. Royal College of Paediatrics and Child Health. Safeguarding children and young people: roles and competences for health care staff. Intercollegiate document. 2014 Available at: http://www.rcpch.ac.uk

17. NSPCC. Gillick competency and Fraser guidelines: NSPCC Fact 14sheet. 2014 Available at: http://www.nspcc.org.uk/Inform/research/briefings/gillick_wda101615.html#assessment