Safeguarding Children ED Training - PowerPoint Presentation

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Safeguarding ChildrenED Training

Emilia Wawrzkowicz

Consultant Paediatrician

Designated Doctor for Safeguarding Children

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Safeguarding in EDAll staff are aware of and follow the recommendations outlined in statutory, royal college and other key guidanceAll staff receive appropriate safeguarding training in line with the guidance document Safeguarding Children and Young People: roles and competences for health care staffAll emergency departments nominate a lead consultant and a lead nurse responsible for safeguardingAll emergency care settings have guidelines for safeguarding children and young people and include the ‘safety net’ arrangements

All staff in emergency care settings are able to access child protection advice 24 hours a day from a paediatrician with child protection expertise

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Safeguarding in EDDirect or indirect access to the Child Protection Plan is availableSystems are in place to identify children and young people who attend frequentlyThe primary care team, including GP and health visitor/school nurse, are informed, within an agreed timescale, of each attendance A review of the notes is undertaken by a senior doctor or nurse when a child or young person is not brought for a follow-up appointment, or if they leave the department without being seen When treating adults, staff must recognise the potential impact of a parent’s or carer’s physical and mental health on the wellbeing of dependents, and take appropriate action

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All Children (11 million)

Vulnerable Children

(4 million)

Children in Need

(400,000)

Children Looked After

(60,000)

Child Protection Plan (29,000)

The Protection of Children in England A Progress Report, Laming, March 2009

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Definition “ a child is considered to be abused if he / she is treated in a way that is unacceptable in a given culture at a given time”

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Child AbuseThe most important step in diagnosing non-accidental injury is to force yourself to think of it in the first place.The biggest barrier to diagnosis is the existence of emotional blocks in the minds of professionals. These can be so powerful that they prevent the diagnosis being considered in quite obvious cases.

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Forms of AbusePhysicalNeglectEmotionalSexual

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Forms of AbusePhysicalInjuries caused by:BlowsPunchesKicksShakesBitesBelts

Scalding

Burning

Suffocation

Drowning

Poisoning

Physical injuries may be:

Bruising

Burns/scalds

Lacerations

Fractures

Brain damage

Internal organ damage

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Forms of AbuseFactitious Induced IllnessMunchausen syndrome by proxyType of physical abusePoisoningSuffocation

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Forms of AbuseNEGLECTLack of FoodWarmthCleanlinessSupervisionStimulation

NEGLECT results in

Failure to grow and develop

Language and social skills

A risk of long term disability

A risk of mental health

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Newspaper…

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Forms of Abuse EMOTIONAL ABUSELack of love and securityThreatsScapegoating“You are bad, stupid, useless and I don’t love you!”

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Forms of Abuse SEXUAL ABUSEMasturbationDigital penetrationOral/anal sexRapePornographySex ringsTHINK CSE!

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Recognition of Child AbusePredisposing featuresParents themselves abused as childrenDomestic violenceSocial deprivationPrematurityMother/child separation in early infancyChild with physical or mental handicapYoung, unsupported parents

Mental illness

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Factors which should arouse suspicion of abuseHistory of injury incompatible with physical signsDelay in reporting injuryParents evasive and vague, abnormal behaviourChild – frozen watchfulness/inappropriate advances to strangersCertain patterns of bruising

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Bruises-prevalence

The prevalence and distribution of bruising in babies

Carpenter 1999, Arch Dis Child

177 babies in the community

6-12 months

22 had bruises-prevalence of 12%

All on front of body and bony prominences

Is it consistent with history, developmental stage and level

of activity?

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Bruising-accidentalOver bony prominences in 93-100%Most common on front of bodyUncommonly back, buttocks, face, abdomen, hands <1% children under 9 had bruising to neck or ear

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Bruising-accidental

Non abusive bruising-age and prevalence

<1 year 10%

2-4 years 60-90%

5-9 years 80%

10-17 years 53%

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Common sites for accidental injury

Forehead

Nose

Chin

Shoulders

Elbows

Bony spine

Forearms

Hips

Knees bruised or grazed

Shins

Hands grazed

This only applies to mobile children!

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Bruising-non accidentalPatterns of bruising in abused childrenHead commonest siteSeen over soft tissue areasOccur in clustersCan carry imprint of implementOccur amongst other injuries of different agesAre larger than non abusive bruises

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BruisingWhich should arouse suspicionSymmetricalAround the cheeks, mouth, ears and neckBlack eyesAny bruise on a child less than four months of ageLinear/ with a clear unusual outlineFinger tip

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Sites of possible non-accidental injury

Buttocks (Bruising or scalds)

Black eyes

Ears (bruises, tears)

Mouth (bruises, tears)

Abdomen

Thighs (Bruising or scalds)

Head injuries (fractures)

Bruises, grasp marks on arms, shoulders and neck

Cigarette burns

Twisting fractures

Chest bruised with grasp marks or by implements

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Can you age bruises accurately in children?

Stephenson T, Bialas Y. Estimation of the Age of Bruising.

Arch Dis Child 1996; 74(1):53-55

Bariciak ED, Plint AC, et al. Dating of Bruises in Children:

An assessment of physician accuracy. Pediatrics 2003;112(4):804-807

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Ageing Pitfalls

Different colours same bruise at one time

Ethnic differences

Depth of injury

Bruises on different parts of body age at different rates

Colours appear, disappear and reappear

Individual perception of colour is different

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Differential Diagnosis of Bruises Blue spots, haemangioma, café au lait - do not fade Bleeding disorder – ITP, leukaemia Infection - meningococcal septicaemia Allergy - periorbital swelling Skin disease - Ehlers Danlos Accident

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FracturesCan occur in any boneUnder 2 years, many fractures are non-accidental and this is even more evident under 1 yearPosterior rib and metaphyseal lesions Presentation in an infant may be non-specific or irritable and disuse of a limb.

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FracturesAccident Osteogenesis imperfecta Rickets Copper deficiency

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Fractures-ribsRib fractures (7 studies, 509 children)In absence of bony disease, birth injury or major trauma, likelihood of abuse is 84%May not be accompanied by bruising

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Metaphyseal fracturesalso known as bucket handle, chip or corner fractures-occur at growing end of the bonePredominantly seen in infants-pulling/swingingPrevalence in abuse 0.5-26%Easily missed-no outer sign of a fractureHave been described after breech delivery, physio and serial casting in neonatal period

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Humerus-any humeral fracture other than supracondylar is suspicious.A humeral fracture-20% chance of abuseSupracondylar highly likely accidentalIn non mobile child with no history of accident humeral fracture is suspiciousHumeral fractures

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Femoral FracturesFemoral fractures12% due to abuse overallnot uncommon in walking childIf not walking 42% chance of abuse

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23.5% likelihood of abuse

88% of abusive fractures in infants<1 year

If complex skull fracture 1/3 chance

Skull Fractures

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Skull FracturesA linear parietal skull fracture is commonest accidental and non accidental Other skull fractures require a greater degree of force, which should be reflected in the historyoccipital, depressed, growing, complex, wide(3.0 mm or more), associated intracranial injury

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Skull FracturesSkull Fractures (9 studies, 610 children)Require considerable forceHistory of fall less than 3 feet rarely produces a fracture

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In the following situations there should be careful

evaluation to exclude child abuse

Children under 18 months with a fracture

Children whose fracture is inconsistent with

developmental stage

Multiple fractures-especially of different ages in the

absence of an adequate explanation

Rib fractures in children with normal bones and no

history of major accidents

Fractured femur in a child who is not yet walking.

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Thermal Injuries

Scalds

Contact burns

Flames

Chemical

Electrical

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Accidental burns and Scalds

Toddlers palm of hand-reaching out to a hot object

Hair straighteners –burn on each side of hand or

ankle

Pulling flex of iron-not usually demarcated, usually

an exposed area of skin

Scalds-usually upper trunk/face/arms-irregular edge

variable depth , deepest at point of initial contact.

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Contact burnsObjects commonly causing contact burns are:Domestic ironsFire or fire surroundsCookersRadiatorsTools, pokers etc, (whether heated intentionally or not)

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NEGLECT

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SEXUAL

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Differential DiagnosisCongenitalTrauma “straddle injury”InfectionSkin diseaseBowel disease

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Case Based Discussion

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Mary Smith has attended ED with her 3 year old son and her 6 month old baby. She has brought her 3 year old as he is not drinking and has a high

temperature.You

notice the baby has a bruise on his face and Mary has a black eye and a swollen lip.

Case 1

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Mary has a black eye and swollen lip

6

month old baby has bruise on face

Case 1

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Bruising is the commonest presenting feature in physical abuse in children

The younger the child the higher the risk that the bruising is non-accidental, especially where the child is under the age of 6 months

Bruising in any child “not independently mobile” should prompt suspicion of maltreatment

Bruising in any child “not independently mobile” should prompt an immediate referral to social care and an urgent paediatric opinion

Pre-mobile babies

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Domestic Abuse & ResearchDomestic violence is an important indicator of risk of harm to children. The risk of domestic violence for women is nearly doubled where children are present Domestic violence is the most common context for child abuse

Children may experience multiple forms of abuse.

Witnessing violence to their mothers may have an abusive and detrimental impact on the children concerned

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Domestic abuse affects both adults and children within the family

Prolonged and/or regular exposure to DA can have a serious impact on children’s safety and welfare, despite efforts of parents to protect them.

DA rarely exists in isolation.

An analysis of SCR found evidence of past of present DA in over half of cases.

Domestic Abuse

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“Some of the biggest victims of domestic violence are the smallest”

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Case 2A 4 year old girl attends the ED following a referral form from OOH GP with peri-orbital oedema and some bruising on her arms. The letter says she cannot speak english.

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Case 2 2 weeks later she is brought to ED with PV bleeding.

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A teenage white male has been brought into ED with burns on his hands. He tells you he has been making fireworks. During the consultation his mother tells you she is worried “sick” about him as he is hanging out with new friends and not going to school.

Case

3

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PREVENTThe Government’s counter-terrorism strategy is known as CONTEST. Prevent is part of CONTEST, and its aim is to stop people becoming terrorists or supporting terrorism. Healthcare professionals have a key role in Prevent. Prevent focuses on working with vulnerable individuals who may be at risk of being exploited by radicalisers and subsequently drawn into terrorist-related activity. If you are concerned that a vulnerable individual is being exploited in this way, you can raise these concerns using existing safeguarding procedures for children and adults. Refer to the MASH!

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You examine a 14 year old girl in ED who has presented with a history suggestive of appendicitis. Physical examination is entirely normal. She is later discharged. Two days later you are called to see your consultant as an allegation has been made against of inappropriate “touching”.

Case

4

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Case 4LADOIf a serious allegation is made against staff and it relates to conduct towards a child, you must inform the Local Area Designated Officer (LADO) who is employed by the Local Authority. This person assumes oversight of your investigation process from beginning to end and will give you advice. They will also liaise with the police and social care if necessary. After taking any immediate action in line with your practice policy, you should inform the LADO if the staff member has, behaved in a way that has harmed, or may have harmed, a child, or possibly committed a criminal offence against or related to a child, or behaved towards a child/ren in a way that indicates unsuitability to work with children.

LADO Cambridgeshire - 01223 727967

LADO Peterborough - 01733 864038

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Debbie Brown is 12 years old and has gone to her ED asking for emergency contraception. She is accompanied by male who you note is be much older than Debbie.

Case

5

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A child under the age of 13 is not legally capable of consenting to sex (it is statutory rape)

Sexual activity with a child under 16 is also an offence

It is an offence for a person to have a sexual relationship with a 16 or 17 year old if they hold a position of trust or authority to them

Offence

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Child Sexual Exploitation (CSE)

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Sexual exploitation of children and young people

under 18

Involves exploitative situations, contexts and relationships where young people (or a third person) receive “something” as a result of them performing, and/or another or others performing on them, sexual activities.

Can occur through the use of technology without the child’s immediate recognition; Without immediate payment or gain.

In all cases, the exploiter of the has power over them by virtue of their age, gender, intellect, physical strength and/or economic or other resources.

Violence, coercion and intimidation are common,

Involvement in exploitative relationships being characterized by the child’s limited availability of choice resulting from their social, economic or emotional vulnerability

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Barnardos

Inappropriate relationship –

one perpetrator who has inappropriate power of control over a young person

‘

Boyfriend’ model and peer exploitation

–

perpetrator befriends/grooms child into a relationship them forces/coercers them to have sex with friends/associates

Organised/networked sexual exploitation

or trafficking –

Child passed through networks where forced/coerced into sexual activity with multiple men

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Vulnerabilities of children most

at risk of CSE

Living in chaotic or dysfunctional household.

History of abuse.

Recent bereavement or loss.

Gang association.

Attending school with young people who are sexually exploited.

Learning disabilities.

Unsure about sexual orientation.

Friends with young people who are sexually exploited.

Homelessness.

Lacking friends from same age group.

Living in a gang neighbourhood.

Living in residential care.

Living in hostel / B&B / foyer.

Low self esteem or self confidence.Young carers.

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Signs and symptoms of children being sexually exploitedMissing from home or care.Physical injuries.Drug or alcohol misuse.Offending.Repeat STIs / pregnancy / terminations.Absence from school.Change in physical appearance.

Evidence of sexual bullying through social networking.

Estranged from family.

Receipt of gifts from unknown sources.

Recruiting others into exploitative situations.

Poor mental health.

Self-harm.

Thoughts of or attempts at suicide.

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Fatima attends ED with her 3 year old daughter who is unwell. The child appears to have a viral illness and you are happy to discharge. Mother tells you she is travelling to Egypt for the whole summer with her children. You notice in the child’s red book that mother has been subject to FGM.

Case

6

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SummaryChild abuse is commonApproximately 200 children die of abuse and neglect each year in England and WalesMore survive but are seriously handicappedThe natural history of abuse is one of escalating violence.Physical abuse is most common in children < 4 years of age

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Take home messagesMedical examination is only one part of the jigsawIt is not always possible to be certain- balance of probabilitiesEvidence base is poorHistory is more important than physical signs

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12 months

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17 months

30 July – Mum smears chocolate to cover bruises when SW visits

1 Aug – has developmental assessment….5 months after request from CSD

2 Aug – Police tell mum she will not be prosecuted

3 Aug – Baby P found dead