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					The Medical Practitioner’s Role
      Child Protection

         Dr Nick van der Spek
             Consultant Paediatrician
    special interest Community Child Health
              Friday, 17th April 2009
             This is not a
mini-child protection training course
          but hopefully it
   gives you reasons to do one.
          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
    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
                   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
                  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.
              Child Abuse
•   Physical Child Abuse
•   Sexual Child Abuse
•   Neglect (most common)
•   Emotional Abuse
•   Fictitious illness by proxy (aka
    Munchausen Syndrome by proxy)
            Overview of Role

•   Identify
•   Diagnose
•   Intervention
•   Report
•   Working with other professionals in the
    interest of the child and family
             General Role
• Promote the welfare of children through
  health promotion and health surveillance
  programmes.
                 Identify
• Consider the possibility of child abuse,
  otherwise you won’t recognise it.
• Make your patient or parent feel you are
  open to receive information about child
  abuse.
                          Identify
• GP: in a special situation
   – Able to identify best because GP best aware of
      • Risk factors for child abuse like family stress
      • Family’s 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
                      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
                    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.
                     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
                  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.
                  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
                    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
                   Diagnose
• Documentation (clear and
  contemporaneous) :
  –   Date
  –   Time
  –   Location
  –   Context
  –   Other information: drawings, photographs,
      video
                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.
               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.
                       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;
                   Report
• Information from the doctor is shared with
  other professionals involved of a case, so a
  complete picture can be generated of the
  concerns;
               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.
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.
        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.
          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.
          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.
            Training needs?
• Local PCCC inquire about:
  – Foundation Child Protection course
  – Report writing courses
               References
• Children First, National guidelines for the
  protection and welfare of children – DoHC,
  1999
• The physical signs of child sexual abuse,
  RCPCH (UK) 2008