Category Archives: Child protection

Medically unexplained symptoms

Royal College of Psychiatrists and Paediatric Mental Health Association guidance on MUS – https://www.rcpsych.ac.uk/mental-health/problems-disorders/medically-unexplained-symptoms

Perplexing presentations (PP) – term is used to describe the presence of alerting signs when the actual state of the child’s physical or mental health is not yet clear and there is no perceived risk of immediate serious harm to the child’s physical health or life.

Cf Factitious or Induced Illness (FII, prev Munchausen by Proxy) –

  • Mostly associated with the mother
  • extreme end of spectrum of abnormal parenting behaviours, from ‘mild’ erroneous belief or overanxiety at one end, through manipulative fabrication to ‘severe’ imminently dangerous induction of illness at the other end.
  • Danger that effect on the child underestimated.
  • Even milder abnormal parental behaviours creates difficult relationships between family and health professionals

Features of FII

  • Unwitnessed, or at least, not independently observed
  • Poor response to treatment
  • Unexplained impairment esp school but also social
  • New symptoms, and multiple opinions sought; yet frequent WNB
  • Changes of school/clinician, complaints and demands.  Home schooled often – which also makes it harder to get independent observations

But these features are only to raise suspicion, not diagnostic! RCPCH has guidance.

Is there a risk of harm? If in doubt, discuss early with safeguarding team, rather than trying to decide alone on whether to involve  social services.

Offer a “current consensus opinion” together with at least one other professional, and ideally input from education/nursery! Continue to monitor until things improving.  No right to access parental health records however –would need explicit consent.

Chronology needs to include basis of previous diagnoses, and justification

Admission for observation – some special issues:

  • What should nursing staff be looking for?
  • Is 24/7 supervision required or possible? Can they leave the ward?
  • Where do you keep notes?

Second opinions – for specific issues, and ONLY TO HELP YOU manage the child. And necessary to provide background of concerns.

Discussing with family –

  • Bringing father, and child’s own views, into the picture helpful.  Child often defers to mother in these cases [presumably as their views are ignored]
  • reassure the parents that there is no current health concern, but emphasise that the team can/will still support and manage any condition the child has

Truancy and going missing as risk factors for sexual exploitation. Experience of conflict, threat and violence – so dealing with these as protective, along with access to safe, stable accommodation, increasing awareness of rights

Acutely – toxicology, parental responsibility, local sexual assault referral centre (SARC – but don’t wait on them), specialist police (good if hesitant). emergency contraception, post-exposure prophylaxis (PEP) incl hepatitis B vaccination.  Advice from the sexual offences examiner (SOE) or forensic medical examiner (FME).  Document if unable to get consent.

Forensics – urine samples, toilet tissue used during the admission, clothing at the time of presentation, underwear and any sanitary wear. Option for self referral for forensic exam (13+yrs) where police are not required.

General paediatrician may be required to get involved with sexual offences examiner, with view to paediatric history, consent issues, referring to social services and/or psychological support

Police protection (which can involve transport to secure location) does not confer right to consent to treatment – needs emergency protection order.

Up to 18 in some respects – Children’s act 1989 defines child as under 18.

Neglect

Type of abuse.

Neglect is not always easily recognisable in children and young people with disabilities – demonstrate emotional distress in different ways; for example, through repetitive or challenging behaviours and self-injurious or self-harming behaviours.

Usually involve neglect across not just health issues but other domains eg hygiene, stimulation, appropriate clothing, protection from harm.

If in doubt, the graded care profile (GCP) tool can help to assess the severity of neglect.

Child protection

Abusive head trauma is the most common cause of traumatic death in infants and can cause severe neurodevelopmental delay, hearing and speech problems, impaired vision and blindness in surviving infants.

Severe faltering growth is associated with neglect. During the first 2 years, a child’s brain grows rapidly, and even moderate nutritional deprivation during this period of rapid brain growth and differentiation can lead to adverse neurodevelopmental outcomes.

Neglect is associated with developmental delay, particularly delays in expressive language and imaginative play.

Several studies have reported associations between child maltreatment and ischaemic heart disease, chronic lung disease and liver disease in adulthood.

Those who have been maltreated as children are more likely to engage in smoking, drinking alcohol and engaging in risky behaviour which can give rise to physical health problems.

Child abuse is also strongly associated with obesity in later life.

Self-harm is strongly associated with sexual abuse, although not necessarily with physical abuse and neglect.

Physical abuse and sexual abuse are both associated with a doubling of the suicide risk for young people.

Children who have been physically or sexually abused are also more likely to experience intimate partner violence as adults.

Peter Connelly (also known as ‘Baby P’)

Peter died at the age of 17 months with multiple injuries including rib fractures and a fracture-dislocation of the thoracolumbar spine.

The inquiry into Peter’s death identified numerous opportunities where health and other professionals could have intervened to protect him from harm.

Training requirements

Over a 3-year period, professionals should be able to demonstrate refresher education, training and learning equivalent to:

  • a minimum of 8 hours for those requiring Level 3 core knowledge, skills and competencies
  • a minimum of 12 to 16 hours for those requiring role-specific additional knowledge, skills and competencies
  • multidisciplinary and interagency and delivered internally and externally.

It should include personal reflection and scenario-based discussion, drawing on case studies, child safeguarding practice reviews (local and national) and the lessons learned from research and audit.

Protective factors

  • Social support for mothers, safe play areas, at least one secure attachment
  • adequate income and good quality housing
  • good nutrition
  • safe play areas and appropriate learning materials
  • good quality day care (developmentally appropriate, skilled staff, attention to non-educational needs, parental engagement)
  • academic socialisation (school readiness programmes)
  • links with other adults and community networks good antenatal care have been found to promote resilience

Deaths

Child Safeguarding Practice Reviews or CSPRs (previously known as Serious Case Reviews or SCRs).

SIDS = sudden death of an infant under one year of age that remains unexplained after a thorough case investigation, including the performance of a complete autopsy, examination of the death scene and review of the clinical history

Livedo only becomes permanent around 4 hours after death, so if the infant is moved in this time period, and the livido not recorded, this information may be lost. Other marks such as those from strangulation may also fade.

Test should be down before declaration of death!

  • amino acids, newborn blood spot test, toxicology and cytogenetics
  • CSF
  • Urine (from nappy if necessary)
  • Skin biopsy for fibroblast culture

For deaths at home/community, senior police and healthcare should decide on whether there should be a visit, how soon (within 24hrs),who should attend. Routine for sudden infant death.

All child deaths in England are reviewed by a child death overview panel (CDOP) established by the local safeguarding children partnership (LSCP).

In the UK, an estimated 1 to 2 children die per week as a result of maltreatment.

National Case Review Repository website – for details of how review should be done

Purpose is establish what lessons are to be learned from a case to safeguard and promote the welfare of children

Wider cultural factors associated with increased risk include:

  • attitudes towards parental responsibility
  • attitudes towards rights of the child
  • attitudes towards violence and crime

Mental health professionals, addiction services and learning disability services  working with adults  (as well as probation, social care and police) have a duty to consider the welfare of any children dependent on those adults.

Writing Medical Reports

When writing a medical report:

  • avoid medical terms wherever possible and use common English
  • if medical terms are required, attempt to provide the common English term as well
  • conclude by stating whether the injury is consistent with the explanation provided
  • if no explanation is provided, outline the most likely explanation (where possible)

ACEs

Abuse and neglect obviously, but also family dysfunction eg divorce/separation, domestic abuse, drug/alcohol misuse.

67% of people have experienced at least one.  10% have experienced 4+

Increased risk of physical ill health – dysregulated stress? Plus unhealthy coping behaviours, of course. 

Online abuse

NSPCC (Childline) for family advice.  MindEd.org.uk https://www.minded.org.uk/Catalogue/Index?HierarchyId=0_45158_45175_45180&programmeId=45158

Report concerns to Internet watch foundation and CEOP https://www.ceop.police.uk/Safety-Centre/

Trafficking

Expensive clothes/phones?? Tattoos and specific colours can be associated with gangs.

What is the quality of the relationship with the accompanying adult?

Modern Slavery and NSPCC have helplines.

County lines = mobile phone numbers used to take drug orders. Children may be used to transport money or drugs, often across geographical boundaries. Common for properties (typically belonging to vulnerable people) to be used as bases for criminal activity.           

Financial security at home can drive attempts to get involved with activities perceived as “profitable”       

“Trauma informed care”???

LAAC

Residence orders, or guardianship order (to do with fostering), or long term placements with foster carers, take a child out of care system.

Placement order is for prospective adopter – gives rights

Information about the birth parents can be obtained without consent (for example, if it is not possible to trace a birth parent), if information is anonymised as far as possible to serve the intended purpose. [General Medical Council guidance on confidentiality] 

Unaccompanied asylum seekers –

  • hearing issues (potentially trauma-related)
  • dental and vision issues (never checked)
  • haemoglobinopathies (never screened)
  • immunisations (uncertain or incomplete)
  • malnutrition or growth issues
  • worms
  • tuberculosis or blood-borne viruses
  • female genital mutilation
  • issues with emotional health and wellbeing (these may be ongoing if still going through the asylum process)

RCPCH has guidance, as does UASChealth.org and refugee council.

Section 20 agreement is for voluntary fostering – does not give local authority parental responsibility

Foster parents do not usually have parental responsibility. 

Attachment affects positive vs negative inner working models.

Survival behaviours – lying, hypervigilance, hoarding/stealing, attention seeking

Screen time

estimates suggest that 11 to 14 year olds in the UK have an average daily screen time of 9 hours – [no idea where this comes from.  Self reporting is obviously pretty meaningless.  Lots of evidence of screen time going up post COVID esp girls, esp lower educational attainment]

Adverse Childhood Experience

Associated with range of negative outcomes.

Later lifestyle

Adverse childhood experiences increase probability of smoking in adulthood. Physical harm in Eastern European countries increases the probability of heavy drinking by about 3.4%, but not in other regions. Exposure to child neglect (little understanding) increases the probability of alcohol abuse by 2.7% in Nordic Countries but not other macro-regions. The experience of a poor relationship with parents is a strong predictor of alcohol abuse for the female subsample in Latin countries (2% higher).

While ACE does not appear to have a substantial effect on excess weight in any macro-region, childhood trauma (physical harm) appears to have a major impact on the likelihood of being obese later in life. Obesity has a more obvious impact on chronic illness than poverty, smoking or alcohol.

Contraception and sexual health

All methods with exception of condoms more than 99% effective  – if you use it as directed, of course! Combined – Rigevidon has v safe progesterone.  Evra is a patch (replace each week for 3 weeks then week free).  Nuvaring is monthly ring, less effected by GI problems but more expensive.

Contraindications for any combined product – migraine with aura, first 6 weeks breast feeding.  DVT risk related to which progesterone is in combination – risk triples with levonorgestrel (Rigevidon), norethisterone, norgestimate (Cilest) but quadruples for others.  But cf risk in pregnancy, more than 10x higher. UKMEC has risk table for family history etc.

Move towards only 4 pill free days – to avoid risk of ovulation if you miss day 1.  Ultimately going to 63-84 days continuously (3-4 packs) but potentially confusing as need to stop and start on different days of the week.

Progesterone only pills were just barrier methods, due to effect on mucus. Cerazette (desogestrel) different, inhibits ovulation without other oestrogen effects. Bleeding is quite common in early days.  Good for controlling cycle related problems eg menorrhagia, catamenial migraine. Good for young people because continuous. Depot good as lead in for implant (else weight gain as side effect).

Nexplanon is implant, under local, lasts 3 years.  But side effects include irregular bleeding. 

Enzyme inducers – cbz, phenytoin, topimarate! And st john’s wort! Rifampicin.  Lamotrigine is not an inducer, but interacts with COCP/POP so avoid unless no other option, in which case needs dose adjustment and must be continuous method.

Consent to sexual activity often confused! Under 13 cannot consent (so different from medical treatment consent).  Consent must be “free agreement” so sleep, coercion, under influence not allowed.  Disclosure of child protection concerns is tricky due to fear of disengagement with service.

Screen time

Sedentary time spent in front of screens programs metabolism and brain neurochem.  Similar to addiction.

But it’s complicated! Partly because there are so many different kinds of activity that can now be done with mobile phones and tablets, and because it’s difficult to control or randomize.

How people interact with screens is changing too. In the mid-2000s in the US, children over 8 spent an average of 6.43 hours a day on electronic media, but this was mainly watching TV.  Evidence of stress response (reduced cortisol increase) on waking after using screens for average 3 hours a day.

But now mobile devices are the centre piece of young people’s social lives.  Boys tend to spend more time gaming, girls more time on social networking.

Effect of high levels of screen time does not seem to be attenuated by equivalent exercise.

High levels of screen time (over 4 hours daily) is associated with poorer school performance. Social skills are poorer. These children tend to form cliques with shared interest, that create further social isolation.

Violent games and media are associated with aggression in children as young as pre-school. Aggression in children can be manifest physically, or verbally, or relationally (ignoring, excluding, spreading rumours). There is also significantly more hostile attribution bias, where you interpret behaviour (such as not being invited to a party) as hostile, even when it is not, or at least ambiguous.

Parental involvement matters – how frequently parents watch TV with their children, discuss content with them, and set limits on time spent playing video games.

Exposure to media violence must also be seen within a risks/resilience approach. [Gentile and Coyne, Aggressive Behaviour 2010] ]

Some evidence that some “social” games themed around cooperation and construction eg Animal crossing have benefits. Similarly, links between media and relational violence pretty weak, but that could be because relational violence content isn’t really examined! Actual content probably more important than time spent playing. Note that in that study of Animal Crossing, background mental health problems seemed to reduce benefit.

Parenting and permanence orders

Permanence order is mechanism for local authority to apply for parental rights and responsibilites to be removed from parents.

Not specifically detailed in law (2007) but “threshold test” must be satisfied:

  1. living with parent poses threat of serious detriment to welfare of child
  2. the need to safeguard and promote welfare of child is paramount consideration
  3. that it is better for the child that the order be made, than that the order not be made

Supreme Court decision In the matter of EV (A Child) (No 2) (Scotland) 2017 –

Not duty of parents to prove parenting ability, but for social work to prove lack of ability with full assessment (or adequate records and sworn evidence of non-engagement).

Also, although allegations of harm may be sufficient reason to place child in care, not sufficient for seeking “permanence order”.  Given that this may mean waiting on criminal proceedings to be completed, children may be stuck in hearing system for longer than before.

[https://andersonstrathern.co.uk/news-insight/supreme-court-permanence-order-decision-lessons-learned/]

 

Harmful parent child interactions

Emotional abuse and neglect – There is an obligation on a Local Authority to prove their case. This is important both for allegations made against a parent and for assessing the capacity of a parent to look after the child. In some cases the allegations against a parent are unsubstantiated or not proven in any other context when that decision is taken by Social Work.

The Supreme Court decision In the matter of EV (A Child) (No 2) (Scotland) puts the emphasis on meeting the threshold test- a risk of serious detriment is not sufficient in itself. The Local Authority must prove its case. Crucially the Local Authority must address the three following issues through explanation and evidence:

  1. What is the detriment to the child in staying in the care of his or her parents?
  2. Why is this detriment considered serious?
  3. Why is this detriment considered likely?

Potentially more delays in system while evidence is gathered.

The message from the Supreme Court is clear that the onus is not on a parent to show they have the necessary parenting skills to parent the child, but rather for the Local Authority to assess and prove they do not have the capacity to parent the child.

Fabricated and induced illness

Five possible causes for discrepancy between reported and observed symptoms/signs suggested in the RCPCH guidelines:

  1. Exaggeration due to anxiety, poor understanding, lack of knowledge
  2. Carer misperception of child’s illness leading to genuine belief that child is ill
  3. Carer actively promotes sick role by non-treatment or fabrication/falsification or induction of illness (‘true’ FII)
  4. Carer suffers from psychiatric condition which leads them to believe the child is ill
  5. True medical condition

It is important to keep an open mind and to carefully plan appropriate assessments for both medical causes and evidence of maltreatment, without putting the child at further risk of harm.

RCPCH National guidance supports the clinician and team in withholding concerns about FII from the parents at early stage of investiagion. This highlights the main difference in dealing with suspected FII compared to other forms of abuse. Documentation and information sharing need to be handled carefully, as alerting the parents to your concerns may put the child at greater risk of harm – concerns should not be recorded in case notes, parents should not be informed.  Important that team is united.

Gather information about the parents’ background and any known health problems, including some assessment of parenting capacity and risk factors such as domestic violence, mental health issues or drug abuse. This is essential not optional.

Chronology – given multiple attendances for multiple children with different services, helps see overall picture for a family.  Should also include significant events eg moves, bereavements etc.

It is important to feed back your findings to the parents that there appear to be no medical problems and that this is good news.  How family responds to initial assessments and management plans is key to making the diagnosis.

In-patient: clarify nursing ability to supervise 24hrs a day.  Can child leave ward with/without nurse escort?  Who gives medication/food/drink?  Where should notes be kept?

If parents demand a new consultant, you can agree to involve another consultant for a specific medical issue eg asthma/epilepsy.  You should definitely discuss with named doctor.  CAMHS could also be useful for discussing case (and supporting staff, esp if conflicting views)

Disclose to parents – if decision is made to disclose concerns, keep it positive (health of child, etc).  Bring in dad, gran etc if potentially useful.  Don’t confront or challenge, acknowledge how parents and professionals can have different perceptions and responses to a child’s problems.  Present united front, and unambiguous plan.

 

Sudden Unexpected Death in Infancy (SUDI)

Or Cot death?  Or SIDS (Sudden infant death syndrome)?

It is well recognised that some babies go to sleep apparently healthy, and then don’t wake up in the morning.  Even after a full post mortem (PM) investigation, no cause is found.  This unexplained phenomenon however has some very well recognised features eg age 2-6 months, prematurity, maternal smoking, poor socio-economic conditions, prone sleeping.

SUDI was originally defined by CESDI (Confidential Enquiry into Stillbirths and Deaths in Infancy) as death between 7 and 365 days where unexpected and unexplained at autopsy, during an acute illness that was not recognised as life-threatening, due to an acute illness of less than 24 h duration in a previously healthy infant (or death after this if life had only been prolonged by intensive medical care); definition also includes deaths from a pre-existing occult condition, and deaths from any form of accident, trauma or poisoning.

I find SUDI most useful for describing the initial situation one may find oneself in, particularly from the point of view of bereavement, need for medical and police investigation.  Interestingly, many of the same risk factors pertain to both deaths unexplained (ie SIDS, or strict SUDI) and to accidental deaths (with the exception of prone sleeping).

SIDS is the ICD recognized term, so is what is generally put on a death certificate.  However pathologists vary in their use of the terminology, some will use “Unascertained” to mean SIDS, others will use SIDS but reserve Unascertained for cases where there are additional factors that somehow cast doubt on the diagnosis.

Similarly, overlying (smothering) as a cause of SUDI is often inferred from the history, but may be specified on the death certificate to differentiate from SIDS.

PM finds a cause in about a 1/3 of cases) eg

  • Infection
  • Cardiomyopathy, anomalies of coronaries
  • Ion channelopathies
  • Metabolic disorders eg MCAD

See also Prevention, and Sudden unexpected postnatal collapse.