Appendix 5 Indicators of Risk in Specific Circumstances
Part 4 of the National Guidance sets out child protection in specific circumstances. This appendix give additional information on certain circumstances of which health professionals may become aware. As stated in the National Guidance not all the indicators set out here are common, nor should their presence lead to any immediate assumptions about the level of risk for an individual child or young person. Where identified they should act as a prompt for all staff, where in an adult of child care setting to consider how they may impact on a child or young person.
Supporting the Unseen Child or Young Person
Healthcare professionals frequently have patients or carers where there is a pattern of non attendance for health appointments or where they cannot gain access to the home of the client. A patient/carer may make excuses for the professional not to see the child or young person, or refuse the service.
In such circumstances, best practice would suggest that health practitioners will review the child or young person and wider family records to find out whether there is any other information that would suggest increased vulnerability. They must inform the named person and key health professionals working with the family.
This guidance has been developed to assist practitioners in determining the most appropriate course of action to take in situations where the child or young person is "unseen", and incorporates the core components of Getting It Right for Every Child (GIRFEC).
The unseen child or young person may result from the following:
- Address unknown
- Mobile or travelling families
- Failure to attend routine appointments (e.g. immunisations, dental care)
- Failure to attend specialist appointments (e.g. diabetes clinic)
- Refusal of the service
- No access visits
- Denied access visit
Definitions regarding visits by universal services
Child or young person not seen - when the healthcare professional is granted access but does not see the child or young person (e.g. the child is said to be asleep and not to be disturbed, or is in the care of others, not in the house).
Denied access visits - when the door is opened by the carer in charge and the healthcare professional is refused access.
No access visit - when a visit has been arranged but there is no response at the door and it appears that no one is at home.
Health Boards should refer to the NHSScotland publication - "Effective Booking for NHSScotland" and develop local protocols to reduce did not attend rates to ensure these vulnerable children, young people and families receive the care and support they need.
Assessing Risk to a Child or Young Person in Secondary Care
It is often difficult to quantify the likely risk to the child/young person of a no access visit. In view of this it is preferable to discuss this with the GP referrer, parent/carer and possibly other professionals who have knowledge of the family e.g. nursery and schools. In this way more information can be obtained, allowing for a more holistic assessment of the possible impact on the child/young person resulting from no access.
At any time, where there are concerns regarding the welfare of a child/young person further advice can be sought from the line manager or child protection adviser.
Refusal or Withdrawal from Healthcare Services
It is up to those with parental responsibility to act on the behalf of a child, under the age of informed consent, to ensure that the child is a recipient of these services. In circumstances where the child is denied these services by their parents/carers, healthcare professionals including GPs must consider that it is their professional responsibility and duty to act on the child's behalf.
It is advised that professionals take into account each individual child's circumstances and the likely implications of failure to receive appropriate services. Professionals should take steps to ensure that parents are able to make informed choice and be flexible in negotiating alternative means of offering services. In non-urgent circumstances this may entail sending a letter to the parents/carers. Where services would normally be accessed in a clinic, a surgery or school, consideration should be given to home visits as an alternative means of offering services. Children who are persistently missing from school or who have been excluded may require home visits to facilitate uptake of services.
If, after all attempts to work in partnership with parents/carers are not achieved and the child's health and development may be significantly impaired as a result of this, consideration needs to be given to raising your concerns with social work.
Refusal of Prescribed Treatment
There are situations where refusal or withdrawal of prescribed medical and therapeutic treatment for children or young people may constitute neglect and it is important for staff to be aware of the following:
Where parents, the child or young person or others refuse, withdraw or actively withhold commonly available foods or fluids, or fail to co-operate with prescribed medical or therapeutic treatment such that a child or young person experiences, or is likely to experience significant harm, or neglect, a concern should be raised immediately to the social work department.
Attempts may be made to justify the above neglect on some basis (e.g. religion). However, this does not change the legal duties of all agencies to protect the child or young person's best interests.
Refusal or Withdrawal of a child from Routine Health Services
In circumstances where children or young people are denied access repeatedly to routine health services designed to promote their health and development, health professionals must ensure when writing to parents/carers that they give sufficient information about the importance of the services to the child or young person, outlining alternative means of provision and enabling them to make informed choices. It is important for professionals to demonstrate that they are seeking opportunities to work in partnership with parents in order to achieve good outcomes for the child or young person.
It is important to have written evidence to prove that you have attempted to gain co-operation with parents/carers in the routine delivery of services. A standard letter should be sent including the following key points:
- The number of home contacts attempted, including the dates and times visited and number of written "no access" communications left.
- What services are on offer at the child health clinic, surgery, health centre, at home or from the school health service.
- Why the services are important emphasising benefits to the child or young person and the implications for the child or young person of not receiving these.
- Inquire from the parent/carer whether there are particular difficulties gaining access to the services which you may be able to help them overcome (e.g. timing of clinics/sessions, transport). Consider if the family would prefer to access the services from an alternative practitioner (e.g. the GP).
- Inform parents/carers how to contact you, should they choose to have the service.
- Continue to send all appointments for routine health surveillance, immunisations and screening tests.
- If at any time you feel the withdrawal from health services is likely to result in harm for the child or young person, consult the child protection adviser or social work to decide on further action.
- Continue to monitor whether this family is registered with a named GP, in the area. If not and the whereabouts of the family are unknown, refer to "Missing Family Alert" guidance below.
Missing Family Alert
The purpose of the Missing Family Alert is to locate children who have disappeared from a known address and for whom there may be concerns of significant harm.
Each Health Board must ensure staff comply with the National Missing Family Alert guidance and process. The Lead Nurse for child protection in each Health Board has designated responsibility for this process.
Definition of Missing Family
This is a family who has disappeared from a known location within a Health Board area for whom there may be concerns of significant harm for the child or young person in respect of unmet need, vulnerability or abuse. This includes risks to unborn children.
There are several stages to the use of alerts:
It is critical to speak to any extended family and neighbours, and other significant community members, of which only the team around the child or young person are likely to be aware. It is important to communicate with the Named Person or Lead Professional.
Should the child or young person be on the Child Protection Register or is Looked After the Keeper of the Register in the authority area should be notified immediately. When this process has been followed and the family have not been located this then needs to progress to Stage 2.
NHS personnel with evidence that a family is missing should contact the child protection nurse with responsibility for their locality/area of work. All reasonable and practical efforts should continue to be undertaken to locate the family. This now needs to include discussion with other health professionals and partner agencies; and interrogation of IT systems such as Community Health Index (CHI), Standard Immunisation Recall (SIRS) and Patient Administrative System (PAS). Partner agencies may be able to assist (e.g. housing, social work, and education).
Police have a specific role to trace missing persons and they have access to numerous databases, which can assist in gathering information or intelligence, which will assist in tracing missing children, young people and families. They should be contacted as soon as there are concerns that a child/young person/family is missing.
Progress to raising a "Missing Family Alert" is reached when a child or young person or family has not been located and there are concerns of significant harm. The speed in reaching this stage is determined by the risk assessment.
This now needs to be discussed with the Lead Nurse for child protection within the Health Board. The Lead Nurse will collaborate with the Caldicott Guardian as required and agree the appropriateness of raising a NHSScotland Missing Family Alert Form.
When a Missing Child or Young Person is Found
The Lead Nurse will contact the appropriate people to ensure that the child/young person/family are in receipt of NHS services and that appropriate and relevant risk assessment and referrals are made in accordance with professional practice, information sharing protocols and child protection guidelines. This will enable appropriate planning and actions can be taken to support the child/young person and family.
High Risk Families
High Risk Families
Although child abuse and neglect can occur in any family, it is concentrated in particular sectors of society where families may be vulnerable to a combination of complex risk factors. Many of the risk factors for physical abuse are multiple, for example, domestic abuse; alcohol and drug (mis)use; and mental health issues. What is important to remember is that 'multiples matter' (Spratt, 2011) and that it is usually the accumulation of risk rather than the presence of any single risk factor that affects outcomes. Certainly the 'toxic trio' of domestic abuse, substance misuse and parental mental ill health provide a milieu of most risk, but we do not know enough about the relative weightings of each and there is a need to separate alcohol and substance dependencies. Beginning to identify risk factors, though, is not the same as being able to predict which families may harm their children (Taylor, Baldwin, & Spencer, 2008).
In the most recent analysis of SCRs (Brandon, Bailey, Belderson, Gardner, Sidebotham, Dodsworth et al., 2009), over half the children lived with current or past domestic abuse (DA), almost two thirds lived in a household where a parent or carer had a mental illness, and a substantial number of parents were misusing drugs or alcohol. Nearly three quarters of the children had lived with current or past domestic violence and/or parental mental ill health and/or substance misuse. The combination of the three problems can produce a toxic caregiving environment for the child.
Although significant attempts have been taken to end child poverty in the UK, the proportion of children living in poverty in the UK is higher as compared to a generation ago and higher than the level experienced by most European countries (Hooper, Gorin, Cabral, & Dyson, 2007). Children living in poverty are at a higher risk of a wide range of adverse experiences and unfavourable outcomes, including maltreatment and most notably physical abuse and neglect by parents (Coulton, Korbin, Su, & Chow, 1995; Garbarino & Kostelny, 1992; Waldfogel, 2007).
The main influence of poverty on parenting appears to be the stress it causes, which in turn disrupts parenting practices and styles (Katz, 2007), though this relationship is far from straightforward. Stressed parents are more likely to use harsh parenting practices and therefore increasing negative outcomes for children (Webster-Stratton, 1990).
Cycles of Abuse
Literature on the intergenerational transmission of child physical abuse suggests that individuals physically abused in childhood are at increased risk for physically abusing their own children (Coohey & Braun, 1997; Milner, Robertson, & Rogers, 1990). Individuals (and especially women) with a history of childhood physical abuse had significantly higher rates of anxiety disorders, major depression, alcoholic dependence, illicit drug use, antisocial behaviour and were more likely to have one or more such disorders than those without such a history (MacMillan, Fleming, Streiner, Lin, Boyle, Jamieson et al., 2001).
Risk taking behaviours as a result of early abuse, e.g. drug taking, can then impact on parenting behaviours and the social environment, which can then lead to further abuse. Early interventions are thus crucial given the developing brain. However, it is important to note that intergenerational cycles of abuse are not inevitable, and there are many stages where decreasing risk factors and increasing protective factors can break this kind of cycle. Much can be learned from studies where individuals have encountered severe adversity and maltreatment in childhood, yet have not repeated this in their own parenting behaviours (Harris & Dersch, 2001).
In the last national prevalence study, 26% of children and young people reported physical violence during their childhood (Cawson, Wattam, Booker, & Kelly, 2000). Results from the recent NSPCC prevalence study show that a quarter of children who live with domestic abuse experience are physically abused themselves (Radford, Corral, Bradley, Fisher, Bassett, Howat et al., 2010). It is important also to understand that the impact of domestic abuse can endure for children long after the measures have been taken to ensure their safety (Holt, Buckley, & Whelan, 2008).
We know that the rates of child abuse and neglect are 15 times higher than the national average where domestic abuse is an issue, indeed in three out of five cases of maltreatment, domestic abuse is also an issue. Not only is there a link between domestic abuse and maltreatment, domestic abuse can impact on parenting abilities; it jeopardises the developmental progress and personal abilities of children, contributing to cycles of adversity; and it disrupts broader family functioning and the home environment (Buckley, Holt, & Whelan, 2007).
The impact on their wellbeing can include a range of physical, emotional and behavioural consequences - low self esteem, depression, PTSD, aggression, running away from home and risk taking behaviour (Hester, Westmarland, Gangoli, Wilkinson, O'Kelly, Kent et al., 2006). The association between domestic abuse, harm to children's health and use of health services is not straightforward but known adverse consequences include heightened risks of under immunisation and of risk taking behaviour in adolescence (Bair-Merritt, Blackstone, & Feudtner, 2006; Webb, Shankleman, Evans, & Brooks, 2001).
Parental Mental Ill Health
Approximately one in six adults in Britain has been diagnosed with a neurotic disorder such as depression, anxiety or phobias (Office of National Statistics, 2001). In addition, approximately five in 1,000 people surveyed were assessed as having a severe mental disorder such as schizophrenia or bipolar depression. It is hard to capture the effects of mental illness as it may vary and be perceived differently from case to case.
Studies have shown some of the negative effects for children who have parents with mental illness (Aldridge, 2006; Stallard, Norman, Huline-Dickens, Salter, & Cribb, 2004; Tunnard, 2004). In addition, there have been studies that have linked parental mental illness to child abuse (Walsh, MacMillan, & Jamieson, 2002). Smith (2004) reviewed the impact of parental mental illness on children, noting how the characteristics of certain mental illness can result in physical and emotional injuries or neglect if a child is present when these symptoms are manifesting themselves. Smith also found evidence to suggest that mothers with poor mental health have a higher incidence of physically punishing their child. It is important to note, however, that most research either looks at parental mental illness from the mother's or parent's perspective, and although there are some studies addressing fathers, they are few and far between.
Approximately 30% of children under 16 years of age live with at least one binge-drinking parent (Manning, Best, Faulkner, & Titherington, 2009). Galvani (2004) interviewed 19 UK women who were victims of domestic abuse on their views of the role of alcohol on their partner's behaviour. She found that although most women found alcohol acted as a disinhibitor for aggressive behaviour, violence and abuse usually happened as a result of other factors in addition to the alcohol consumption. Alcohol misuse can affect key aspects of family life such as roles, rituals, routines, social life, finances, communication and conflict (Velleman, 1993).
It is estimated that between 200,000 and 300,000 children in England and Wales and between 41,000 and 59,000 children in Scotland have one or both parents with a serious drug problem (ACMD, 2003, 2007). Substance misuse is increasingly being regarded as one of the most problematic and challenging areas to tackle in the area of child abuse and child protection and accounts for the overwhelming majority of cases that remain open and/or are re-referred to social services (Forrester, 2007).
Drug misuse can manifest itself in a variety of ways which include physical ailments such as infections, overdoses and accidental and non-accidental injuries and psychological impairments such as being dominated by the drug and addiction, withdrawal symptoms such as erratic and irritable behaviour, psychosis and serious memory lapses (ACMD, 2003). These symptoms show how it is very likely that children living with parents who engage in drug misuse are at high risk of significant harm. Negative manifestations usually start emerging when there is a combination of other factors such as mental state, physiological impact of the substance, expectations of the individual regarding oneself and others, personality, type, dosage and method of administration.
Effects may include lack of care, neglect, growing up in an unstable and violent environment, criminality, lack of or hindered education and developmental and health problems. Not all people who use or misuse substances will be abusive or bad parents. Again, there is usually a combination of factors that may lead to one having aggressive and abusive behaviour.
Children Under One
Very young children particularly children under the age of two years are some of the most vulnerable in society. In statistics15 published by the NSPCC in December 2011 nearly half of all serious case reviews are in relation to babies under one year of age and infants aged under one year are more at risk of being killed at the hands of another person than any other age group in England and Wales. (Over 6% of all children aged under 18 years in the UK were aged under one year (2010).)
The proportion of child homicides in which the perpetrator is a parent is exceptionally high among infants.
In Ofsted's numatic evaluation report of serious case reviews in England and Wales from 1 April 2007 to 31 March 2011 "Ages of concern; learning lessons from serious case reviews" 16 key findings and recurring messages regarding babies less than one year of age were that in too many cases:
- There were shortcomings in the timeliness and quality of pre-birth assessments.
- The risks resulting from the parents only were underestimated, particularly given the vulnerability of babies.
- There had been insufficient support for young parents.
- The role of the fathers had been marginalised.
- There was a need for improved assessment of and support for parenting capacity.
- There were particular lessons for both commissioning and provider health agencies whose practitioners are often the main or the only agencies involved with family in the early months.
- Practitioners underestimated the fragility of the baby.
Of the 471 serious case reviews evaluated by Ofsted between 2007 and 2011 concerning 602 children, 210 (35%) children were babies under the age of one year.
The report states that this has been a consistent pattern across the four year period.
In Scotland, child protection figures i.e. children accessing the statutory child protection system is only available for the age category of 0-4 years old, but in Scotland in 2010 50% of all children on the child protection register were aged under four years.
The Scottish Children's Reporters Administration research report "Children aged under two years referred to the Children's Reporter" 17 is that in Scotland in recent years proportionately more children below the age of 2 years are being referred to the Reporter. In 2008 - 2009 this was almost one in 20 children under two years of age in Scotland (i.e. 5,651 children). In addition over the period of 2005 - 2009 more children under two years of age were needing to be placed on supervision requirements and on emergency measures (place of safety warrants and child protection orders) to protect them and safeguard their welfare. The research studied 50 cases of children less than two years referred to the Reporter. These children had difficult family backgrounds:
- Most parents were unemployed.
- Two thirds of the children had parents with drug and or alcohol addictions.
- Over a half of the children's parents had mental ill health.
- Three quarters of children had parents with histories of offending and 10% of fathers had been charged with sexual offences.
- 20% of children had a parent who had been in prison.
A range of services and professionals were involved with the children and their families - pre- and post-birth of the child.
However, not all parents were prepared to engage with the services being offered and that was especially the case of parents who had very chaotic lifestyles. For 20% of the cases there were serious concerns about males in the child's home due to their volatile, adverse and violent behaviour. Half of the families had housing problems with poor or inadequate accommodation, homelessness and transient lifestyles and there was evidence that parents chaotic lifestyles were impacting on their children.
Infants (i.e. children under the age of one year) may present with various potential child protection concerns as above and there must be a low threshold for raising concern and for suspicion of abuse particularly where infants present with injuries. For example "those who don't cruise, rarely bruise" (Sugar, Taylor and Feldman, 1999).
A systematic review of the international literature in infants under the age of six months suggests that any bruising on an infant under six months must be fully evaluated and a detailed history taken to ascertain the consistency with the injury. Non-mobile children should not have bruises without a clear and usually observed explanation. There are a range of physical injuries, that in their own right if presented, in an infant should immediately prompt the practitioner to ensure that full history is taken, general examination and full investigations are performed, including full photography and progression to look for internal injuries. The presence of an injury in an infant frequently indicates more severe abuse and the possibility of other internal injuries must always be considered, for example brain or abdomen or bony skeleton. Any inconsistent history for an injury must raise suspicion. Even where a potentially plausible accidental history is provided for any concerning injury in an infant the fullest information must be sought from primary, secondary and tertiary health services, as well as from social work and other agencies as appropriate, prior to discharge of a child from an inpatient or out patient health setting. Many instances have been described particularly through serious case reviews where accidental histories have been accepted from a parent or carer without attempt to validate the history via a third party or without gleaning further information. Many of these cases where this rigour has not been applied have resulted in more serious injuries occurring to those infants, sometimes within weeks and or months and some have resulted in death. These are particularly high risk cases. In light of this, some Health Boards developed or are currently developing Board-wide policy in relation specifically to the Recognition and Management of Maltreatment in Infants (Children under the age of one year).
In an infant where an injury may or may not be apparent there may be other cumulative concerns such as described earlier in this chapter and it is critical that
healthcare professionals take the utmost care and apply rigour to establishing the critical information in relation to the infant and family and communicate concerns to appropriate others to allow protection and supportive interventions at the earliest opportunity.
Much attention has been given to associations between teenage pregnancy and negative outcomes: child abuse and neglect (Burghes & Brown, 1995), poor parenting (Kotagal, 1993), high stress levels, school dropout, limited educational opportunities (Furstenberg, Brooks-Gunn, & Morgan, 1987), as well as multiple pregnancies at a young age (Britner & Reppucci, 1997). In addition, children living with single parents and stepfamilies are at greater risk than other families of physical abuse (O'Connor, Davies, Dunn, & Golding, 2000) and have poorer school performance. Unfortunately, there is a lack of national statistical data on the neglect and abuse perpetrated by teenage parents and incidence is projected only from research samples.
Children and Young People with Disabilities
There is clear evidence that disabled children are at higher risk of abuse than non-disabled children, particularly neglect and emotional abuse. For example, in a methodologically rigorous study, Sullivan and Knutson (2000), who examined the records of over 20,000 children and young people aged 0-21 in Nebraska, found a 9% incidence of child abuse among non-disabled children compared to 31% among disabled children, meaning that the latter are 3.4 times more likely to be abused. However, it is thought that the real level of abuse is higher than this, due to under-reporting. This can result from professionals' failure to identify, or report, abuse in disabled children, children's own difficulties reporting abuse, or reports of abuse from disabled children being dismissed (see for example Kvam 2004). However, the direction of casuality, and how far impairments caused by abuse contribute to the association, is not known.
A wide range of factors are likely to contribute to disabled children's increased vulnerability to abuse, although these are not always recognised. Some disabled children may have less awareness or knowledge than non-disabled children about what is acceptable and non-acceptable behaviour from others - or perpetrators may assume that is the case. Some children may be targeted because they have communication impairments making it hard for them to report abuse, or mobility difficulties making it hard to remove themselves from the abuse. Others will have personal care needs which open up opportunities for abuse. Family-related factors include the stress which can arise from caring for a disabled child, particularly if sufficient support is not available, ambivalent feelings about having a disabled child or the nature of the child/parent attachment, or parents' disciplinary approaches.
Services and systems factors can fail to protect children. Staff may not understand or communicate well with disabled children; disabled children are disproportionally represented in residential settings where risks are known to increase; having multiple carers can cause vulnerability; parents may fear losing support if they raise concerns about possible abuse, while signs of maltreatment and distress can go unrecognised in disabled children. Some professionals appear reluctant to believe that anyone would abuse a disabled child. Useful training materials produced by the NSPCC (2011) cover many of these underlying factors.
Recent research in Scotland (Stalker at al 2010) suggested that, inter alia, standard child protection procedures are not always applied to disabled children, many professionals lack the skills/confidence to communicate with disabled children, different agencies have varying views about acceptable thresholds for parental treatment of disabled children, and there is a need for better collaboration between staff working in child protection and children's disability teams.
Email: Fiona McKinlay
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