Recognition of child maltreatment in general practice

Presentations of child maltreatment in general practice are seldom, clear-cut and well-defined, and different types of abuse can overlap in the same child. The context for concerns is often more important than the identification of an 'incident'. Child protection work has been likened to a patchwork or jigsaw puzzle. Often, it is when individuals and agencies share information together that the picture is complete. This involves effective record keeping, information-sharing and communication, both internally and between agencies.

Liaising with other universal health services providers (for example, midwives, health visitors and school nurses) is invaluable as they may be the first health professionals to recognise when a child, young person or family member is in difficulty and can help to build a more complete picture. The value of universal service provision is that GPs and their staff see a multitude of presentations and behaviours in children and young people, the majority of whom will not require action to be taken to ensure their welfare. Thus, when there is a situation that 'does not feel quite right' practitioners'intuition and clinical acumen are, in our experience, usually well-founded.

Multi-disciplinary working

It is advised that every GP practice has a system that enables the GP lead for safeguarding, as well as other relevant staff, to meet with the midwife, health visitor and school nurse in a safeguarding Multi-Disciplinary Team (MDT) meeting. These meetings are invaluable for sharing information, identifying children and families who may be at risk and for discussing children who are already known to be at risk and are on child protection plans for example. These meetings could be incorporated into regular practice meetings e.g. Significant Event meetings. The suggested frequency would be to have these meetings once per month. Sometimes practitioners involved in the MDT meetings can raise concerns about a child or a family together as a group, which can be very powerful.

This template [PDF] can be used or adapted for these MDT meetings.

Some pitfalls and potential barriers

The RCGP has previously highlighted pitfalls and potential barriers to recognition and response to child maltreatment in general practice. It is helpful to revisit some of these, as they help to illustrate the challenges in safeguarding; even where practitioners' knowledge of clinical indicators is sound.

'Not seeing the child' reflects the reality that the needs of the child can easily be over shadowed by those of the parents, the needs of the child should always come first. It can be helpful to consider 'what is the daily lived experience of this child?' and act accordingly. When working with adults, it is always important to consider whether there might be any children who could be at risk of abuse or neglect as a result of the adult's health, behaviour or circumstances – see the child behind the adult. It is important to remember that the children who may be at risk may not always be within the family and may not be living locally or even in the UK.

'Not seeing the adult' - It is important to establish who is in the child's life. Practitioners need to bear in mind that there may be new adults in the child's life such as new partners of their parents or friends/family members who may be staying within the household who may pose a risk to the child – 'see the adult behind the child'.

'Not looking' reflects the fact that child maltreatment is upsetting, as well as challenging. Ignoring the problem, or seeking other, more comfortable explanations for observations, especially when, for example, feeling compassionate towards parents of a disabled child. Personal experience of abuse or neglect, including domestic violence, can also affect practitioners' ability to get involved.

'Not knowing what to do next' - Although much progress has been made, there remain gaps in procedural knowledge and contacts. Each practice should make their procedures and details of local contacts available to all staff, including non-clinical staff and locum staff, together with guidance on how to discuss and communicate concerns. If there are concerns about a child, doing nothing is never an option. Speaking to a senior colleague and/or the practice safeguarding lead or deputy can help practitioners to take forward their concerns. Advice may also be sought from Named or Designated professionals.

'Cultural relativism' - This concept describes practitioners' acceptance of different childcare practices as normal and acceptable to the culture of the family and this may influence a decision not to intervene. Culture, ethnicity, religion or any other diversity issue should not prevent action being taken to safeguard a child.

Liverpool Safeguarding Children Board - Practice Guidance: Cultural Awareness, Cultural Sensitivity & Safeguarding

The Hidden Male - From the analysis of Serious Case Reviews, the NSPCC identified two categories of 'hidden men':

  • men who posed a risk to the child which resulted in them suffering harm
  • men, for example, estranged fathers who were capable of protecting and nurturing the child but were overlooked by professionals.

This NSPCC briefing highlights the risk factors for hidden men in serious case reviews and learning for improved practice:

  • Lack of information sharing between adults' and children's services
  • Relying too much on mothers for essential information
  • Not wishing to appear judgmental about parents' personal relationships
  • Overlooking the ability of estranged fathers to provide safe care for their children

Learning for improved practice:

  • Identifying the men in the child's life
  • Involving fathers
  • Seeing men as potential protectors

Disguised compliance - This involves parents giving the appearance of co-operating with child welfare agencies to avoid raising suspicions and allay concerns. Learning from case reviews highlights that professionals need to establish the facts and gather evidence about what is actually happening, rather than accepting parent's presenting behaviour and assertions [see box below].

Practitioners should seek to establish trusting and compassionate relationships, but also remain curious, demonstrating 'respectful uncertainty' (Laming, 2003) about family life and issues that raise concern. Where families are failing to engage with services, the GP's interest will relate to the child/children's health and well-being. Clinicians must consider if health concerns have been fully and clearly explained, considering issues of language, culture, learning difficulties, disability, expectations of service provision and that parents or carers fully understand the concerns and risks of non-compliance.

It is important to remember that, for some families, services may be difficult to access and/or engage with. In these situations, it is important that health professionals consider how their service can improve access for these families.

Disguised Compliance

Adapted from Disguised Compliance: learning from case reviews. NSPCC March 2014

Risk factors for disguised compliance:

  • Missing opportunities to make interventions: Professionals reducing/downgrading a concern can allow cases to drift, leading to lost opportunities to make timely interventions.
  • Removes focus from children: Disguised compliance can lead to a focus on adults and their engagement with services rather than on achieving safer outcomes for children.
  • Over optimism about progress: Professionals can become over optimistic about progress being achieved, again delaying timely interventions.

Recognising disguised compliance:

  • Parents deflecting attention: Parents focus on engaging well with one set of professionals, for example in education, to deflect attention from their lack of engagement with other services.
  • Criticising professionals: Parents criticise other professionals to divert attention away from their own behaviour.
  • Pre-arranged home visits: Pre-arranged home visits present the home as clean and tidy with no evidence of any other adults living there.
  • Failure to engage with services: Parents promise to take up services offered but then fail to attend.
  • Avoiding contact with professionals: Parents promise to change their behaviour and then avoid contact with professionals.

Learning for improved practice:

  • Establish facts and gather evidence: Don't accept presenting behaviour, excuses or parental assertions and reassurances that they have changed or will change their behaviour. Establish the facts and gather evidence about what is actually occurring or has been achieved.
  • Build chronologies: Chronologies can be used to provide evidence of past parenting experience, including possible former instances of disguised compliance, and to analyse parenting history. The information can then be considered in relation to current parenting capacity and to gain a fully documented picture of the family environment.
  • Record the children's perspective and situation: The focus should be on recording the children's perspective and situation rather than just the adult's participation and parenting capacity. This helps to retain the focus on the child and ensure that important information does not become lost when shared between multiple agencies.
  • Identify outcomes: Focus on outcomes rather than process, so that attention cannot be deflected by good intent or an appearance of participation.
  • Use of staff supervision to challenge beliefs: Professionals can become overly optimistic about change that has occurred. Supervision needs to challenge professionals' beliefs about apparent changes and to seek evidence of actual progress.