Protecting Children from Abuse and Neglect in Primary Care

269 Pages·2003·9.65 MB·English

by  Michael Bannon

Protecting Children from
Abuse and Neglect in
Primary Care
Prelims.fm Page ii Tuesday, October 22, 2002 5:00 PM
Whilst every effort has been made to ensure that the contents of this book are as com-
plete, accurate and up-to-date as possible at the date of writing, Oxford University
Press is not able to give any guarantee or assurance that this is the case. Readers are
urged to take appropriately qualified medical advice in all cases. The information in
this book is intended to be useful to the general reader, but should not be used as a
means of self-diagnosis or for the prescription of medication.
Protecting Children
from Abuse and
Neglect in
Primary Care
Edited by
Michael J. Bannon
Associate Dean in Postgraduate Medicine
London Deanery
20 Guilford Street
London WC1N 1DZ
and
Yvonne H. Carter
Department of General Practice and Primary Care
Basic Medical Sciences Building
Queen Mary and Westfield College
London
Prelims.fm Page iv Tuesday, October 22, 2002 5:00 PM
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Foreword
Primary care is for everyone. People of all ages with all problems see their general
practitioners and practice nurses as their first port of call, their first contact with the
National Health Service and social care. Some people who we see are particularly
vulnerable and cannot argue for their own care without support from health profes-
sionals. In particular, those from deprived areas, the elderly and those with mental
health issues spring to mind.
However, a large group of vulnerable people are children. Where they have sup-
portive, caring parents or guardian children have a natural advocate and protector –
where such support is missing the primary care team becomes a key element in that
child’s care. Most children are not abused or neglected. However, many experience
bullying, bereavement, family break-up, movement from community to community,
and personal failures.
All children, therefore, deserve access to a carer outside their family, someone who
they can turn to for confidential help and advice, someone who has their best interests at
heart. All general practitioners, practice nurses and community nurses must understand
this need and must have the skills to fulfil the role. They require training and education.
They must recognize early signs of distress, neglect or abuse and know how to respond.
Yet this is an area in which many general practitioners feel ill at ease. Not only is there
an information and skill gap, but there are more emotional issues. Putting aside our
natural tendency to prefer not to believe that children in our area could be abused, the
exploration of suspicions has implications that are not present in normal consultations.
We try to practise medicine in the family setting. Protecting one family member
may involve distancing oneself from other family members. One doctor–patient
relationship may have to take precedence over others. The involvement of the law and
predetermined local procedures adds to the perceived difficulties.
However, this is not an area in which doctors and nurses have a choice. We have an
obligation to vulnerable children and that is an obligation we must discharge. We do
not do so alone. This is quintessentially an area in which teams come together to
ensure a holistic, sympathetic but effective response. Individual clinicians do not have
to bear responsibility alone.
This book addresses these issues. It does so with sagacity and imagination. The
reader – and all primary care team members would benefit from it – is offered facts,
skills, attitudes and insights to help in this difficult area. We can all do child protec-
tion better – let us use this book to achieve that aim.
Mike Pringle
June 2002
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Preface
Why this book was written
Child abuse and neglect seem to be always in the news, whether in the media or in
themedical press. It represents a difficult and complex subject, capable of provoking
a variety of feelings from health professionals including distaste, disbelief and perhaps
a reluctance to become involved. However, the protection of children from abuse or
neglect should represent a shared responsibility of all those who care for children and
their families.
Both of the editors have in the past been members of Area Child Protection
Committees (as designated paediatrician and GP representative). As a result, we
became aware of the issues surrounding the role of primary care and the protection of
children from abuse and neglect. In particular, we knew that the apparent reluctance
of GPs to become involved in the child protection process was a subject of concern
for Social Services. At the same time, we were conscious of the challenges faced by
primary care workers in this most difficult area of clinical practice. We could there-
fore see the argument from both sides. As clinicians with regular contact with children
and their families, we were also conscious of the devastating impact of abuse on child
development and welfare. Research undertaken by us confirmed that the involvement
of the primary health care team, particularly the GP, was complex, misunderstood
and fraught with difficulty. Having explored these issues by further research and
discussion with key informants, we have formed certain conclusions on the subject.
We thought it important to share these findings with a larger audience of primary
health care professionals.
There was a need therefore for an information resource that would enable GPs of
all levels of experience and other members of the primary health care team to gain
a greater insight with respect to their role in child protection. At the same time,
wehoped that social workers and leaders of primary care organizations would also
find this of benefit in this respect.
We have initially followed more traditional paths with respect to some of the
contents. Leading authorities have therefore contributed chapters on the following
aspects of child abuse: epidemiology, legal aspects, clinical presentation and effects of
categories of abuse, overview of the child protection process and what to do and say
when abuse presents itself to practitioners.
However, we have attempted to broaden the focus of the book:
1 In recognition of the multicultural nature of our communities, there is a chapter
that specially addresses relevant cultural issues and another compares child pro-
tection systems across different countries.
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viii PREFACE
2 As GPs provide care for all family members, we have dealt with the important
subjects of domestic violence and its relevance to child abuse, adult survivors of
abuse and looked after children.
3 Worldwide, there is a palpable move towards a primary care led health service and
the UK is no exception. Dr Bastable has explored the challenges in this context
that Primary Care Trusts will face as they attempt to address children’s needs.
4 Professor Browne and Dr Hamilton have looked to the future and consider the
frequently overlooked issue of how abuse may be prevented.
On reading these chapters together, several themes become apparent. It is of interest
that our contributors, writing independently, have identified numerous recurring
themes, the more interesting being as follows:
1 We are repeatedly reminded of children’s rights and the paramountcy principle that
requires us to place the welfare of children above all other consideration. Several
authors allude to the UN Convention on the Rights of the Child (1989) in this respect.
2 The need for training of all primary health care professionals at all levels, separately
within their own discipline and together as a team is also emphasized by several
authors. Furthermore, there is a recognized need for education (which positively
influences attitudes) as well as training (which ensures that professionals recognize
abuse and know what to do).
3 There is a palpable mood of optimism with respect to the positive impact that the
newly emerging Primary Care Trusts in England (and their equivalent in other
countries within the UK) could effect within this area. Child protection would
then be seen as part of a broader children’s agenda that would include disability
and health promotion.
On reviewing the chapters some time after they had been originally commissioned,
we are immediately aware of a number of limitations of our book. First, while it is
recognized that all GPs are part of a larger team of professionals and support staff,
there is a tendency to consider the role and challenges faced by GPs primarily.
Perhaps this is not a bad thing, as most primary health care teams are usually led by
GPs who are well placed to take a lead on this important subject. Second, rapid
change is taking place within both the NHS and health care systems worldwide.
Onesignificant development in England has been the development of Workforce
Development Confederations (WDCs). These will undoubtedly become significant
key players in the child protection process in the future. We will watch the influence
of WDCs in this area with interest.
We would like to thank all of the authors for their contributions. There are numerous
quotes which give food for thought. Perhaps, the most pervasive is that made by
TomNarducci (Chapter 16):
If we recognized our shared responsibility...we could overcome every block to effectively
protecting children that has been identified. We can do it and we should do it. The question
is will we do it?
Michael Bannon and Yvonne Carter
June 2002
Contents
List of contributors xi
1 Overview of child abuse and neglect 1
Ximena Poblete
2 The child protection process 11
Melanie Pace
3 Child abuse and primary care 22
Yvonne H. Carter and Michael J. Bannon
4 Child protection in a multicultural society 34
Geoff Debelle
5 The training needs care of primary health teams in
child protection 47
Michael J. Bannon, Yvonne H. Carter, Neil R. Jackson and Mitch Blair
6 Physical abuse 61
Chris Hobbs
7 Neglect and its impact on child welfare 72
Jocelyn Jones and Anna Gupta
8 Emotional abuse 83
Alyson Hall
9 Child sexual abuse 99
Alison Mott
10 Forgotten patients – adults abused as children 111
Christopher Cloke
11 Domestic violence and child protection: Issues for the primary
care team 126
Leslie L. Davidson and Margaret A. Lynch
12 Legal aspects of child abuse 141
Fran Clift
13 Roles and responsibilities 158
Enid Hendry