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Practical Paediatric Problems

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Practical Paediatric Problems

A Textbook for MRCPCH

Edited by

Dr Jim Beattie Consultant Paediatrician and Nephrologist, Royal Hospital for Sick Children, Yorkhill, Glasgow, UK

Professor Robert Carachi Head of Section of Surgical Paediatrics, Division of Paediatric Surgery, University of Glasgow, Honorary Consultant Paediatric Surgeon, Royal Hospital for Sick Children, Yorkhill, Glasgow, UK

Hodder Arnold

A MEMBER OF THE HODDER HEADLINE GROUP

Hodder Arnold A MEMBER OF THE HODDER HEADLINE GROUP

First published in Great Britain in 2005 by

Hodder Education, a member of the Hodder Headline Group

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Whilst the advice and information in this book are believed to be true and accurate at the date of going to press, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. In particular, (but without limiting the generality of the preceding disclaimer) every effort has been made to check drug dosages; however it is still possible that errors have been missed. Furthermore dosage schedules are constantly being revised and new side-effects recognized. For these reasons the reader is strongly urged to consult the drug companies’ printed instructions before administering any of the drugs recommended in this book.

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ISBN

0 340 80932 9

ISBN

0 340 80933 7 (International Students’ Edition, restricted territorial availability)

1 2 3 4 5 6 7 8 9 10

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Contents

Contents
Contents
Contents
 

Contributors

ix

Foreword

xi

Preface

xiii

1

Community child health, child development and learning difficulties David Tappin

1

2

Behavioural and emotional problems Michael Morton and Elaine Lockhart

37

3

Clinical genetics

59

 

John Tolmie

4

Acute illness, injuries, and ingestions Jack Beattie and David Hallworth

91

5

Fetal and neonatal medicine

121

J

Coutts, JH Simpson and AM Heuchan

6

Problems of infection, immunity and allergy Rosie Hague

161

7

The nervous system

213

R

McWilliam and Iain Horrocks

8

The respiratory system Neil Gibson

257

9

Cardiovascular disease Alan Houston and Trevor Richens

279

10

Gastrointestinal system, hepatic and biliary problems Peter Gillett

309

11

Nutrition Alison M Kelly, Diane M Snowdon and Lawrence T Weaver

337

12

Urinary tract problems Jim Beattie and Amir F Azmy

355

13

Diabetes Kenneth J Robertson

395

14

Endocrinology Malcolm DC Donaldson and Wendy F Paterson

405

15

Metabolic disorders

447

Peter Robinson

16

Musculoskeletal and connective tissue disorders Janet M Gardner-Medwin, Paul Galea and Roderick Duncan

485

17

Paediatric ophthalmology William Newman

519

viii

Contents

18 Dermatology Rosemary Lever and A David Burden

539

19 Haematology and oncology Brenda ES Gibson

579

20 Surgical topics

615

Robert Carachi

21 Tropical paediatric medicine Brian Coulter

629

Appendices: A. Biochemistry

649

Peter Galloway

B. Haematology Brenda Gibson

653

C. Age and gender specific blood pressure centile data

657

D. Surface area nomograms in infants and children

663

Index

665

Contributors

Contributors
Contributors
Contributors

Jack Beattie Consultant in Emergency Medicine Acute Ambulatory Assessment Unit Royal Hospital for Sick Children Yorkhill Glasgow

Jim Beattie Consultant Paediatrician and Nephrologist Royal Hospital for Sick Children Yorkhill Glasgow

Amir F Azmy Consultant Paediatric Urologist Royal Hospital for Sick Children Yorkhill Glasgow

Roderick Duncan Consultant Paediatric Orthopaedic Surgeon and Honorary Clinical Senior Lecturer Royal Hospital for Sick Children Glasgow

Paul Galea Consultant Paediatrician Royal Hospital for Sick Children Yorkhill Glasgow

Janet Gardner-Medwin Senior Lecturer in Paediatric Rheumatology and Honorary Consultant University Department of Child Health Royal Hospital for Sick Children Yorkhill Glasgow

A

David Burden

Neil Gibson

Consultant Dermatologist

Consultant in Paediatric Respiratory Medicine

Western Infirmary

Royal Hospital for Sick Children

 

Glasgow

Yorkhill Glasgow

Robert Carachi Professor, Division of Paediatric Surgery Royal Hospital for Sick Children Yorkhill Glasgow

J Brian S Coulter

Senior Lecturer in Tropical Child Health

Liverpool School of Tropical Medicine Liverpool

Jonathan Coutts Consultant Neonatalogist Queen Mother’s Hospital Yorkhill Glasgow

Malcolm DC Donaldson Senior Lecturer in Child Health University Department of Child Health Royal Hospital for Sick Children Yorkhill Glasgow

Brenda Gibson Consultant Haematologist Royal Hospital for Sick Children Yorkhill Glasgow

Peter Gillett Consultant Paediatric Gastroenterologist Royal Hospital for Sick Children Sciennes Road Edinburgh

Rosie Hague Consultant in Paediatric Infectious Disease and Immunology Royal Hospital for Sick Children Yorkhill Glasgow

David Hallworth Consultant in Anaesthesia and Intensive Care Royal Hospital for Sick Children Yorkhill Glasgow

x

Contributors

Anne Marie Heuchen Consultant Neonatologist Queen Mother’s Hospital Yorkhill Glasgow

Alan Houston Consultant Cardiologist Royal Hospital for Sick Children Yorkhill Glasgow

Iain J Horrocks Specialist Registrar in Paediatric Neurology Royal Hospital for Sick Children Yorkhill Glasgow

Alison M Kelly Specialist Registrar in Paediatric Gastroenterology, Hepatology and Nutrition Royal Hospital for Sick Children Yorkhill Glasgow

Rosemary Lever Consultant Dermatologist Royal Hospital for Sick Children Yorkhill Glasgow

Elaine Lockhart Consultant Child and Adolescent Psychiatrist Royal Hospital for Sick Children Yorkhill Glasgow

Robert McWilliam Consultant Paediatric Neurologist Royal Hospital for Sick Children Yorkhill Glasgow

Michael Morton Consultant Child and Adolescent Psychiatrist Department of Child and Family Psychiatry Royal Hospital for Sick Children Yorkhill Glasgow

William Newman Consultant Paediatric Ophthalmologist Royal Liverpool Children Hospital Alder Hey Liverpool

Wendy Paterson Auxologist Department of Child Health Royal Hospital for Sick Children Yorkhill Glasgow

Trevor Richens Consultant Cardiologist Royal Hospital for Sick Children Yorkhill Glasgow

Kenneth J Robertson Consultant Paediatrician Royal Hospital for Sick Children Yorkhill Glasgow

Peter Robinson Consultant in Paediatric Metabolic Disease Royal Hospital for Sick Children Yorkhill Glasgow

Judith H Simpson Consultant Neonatologist Queen Mother’s Hospital Yorkhill Glasgow

Diane M Snowdon Specialist Registrar in Paediatric Gastroenterology, Hepatology and Nutrition Royal Hospital for Sick Children Yorkhill Glasgow

David Tappin Senior Lecturer in Community Child Health PEACH Unit Royal Hospital for Sick Children Yorkhill Glasgow

John Tolmie Consultant in Medical Genetics Duncan Guthrie Institute Yorkhill Glasgow

Lawrence T Weaver Professor of Child Health University Department of Child Health Royal Hospital for Sick Children Yorkhill Glasgow

Foreword

Foreword
Foreword
Foreword

When Professor James Holmes Hutchison wrote his pref- ace to the first edition of Practical Paediatric Problems, published in 1964, he acknowledged ‘that a textbook by a single author on a subject as vast as paediatrics must to some extent be selective; for the author must write only of what he knows.’ There was at that time no MRCPCH but there was a requirement to pass a member- ship examination of one of the three UK Royal Colleges in general medicine before entry to training for a hospi- tal consultant post could even be contemplated. Forty years on and we, thankfully, find that there has been an exponential increase in our knowledge and understanding of childhood health problems and how best to deal with and to prevent many of them. Specialist training for a career in paediatric medicine has also changed considerably and the answer to the question ‘what is a paediatrician?’ has been well expressed in the Royal College of Paediatrics and Child Health document A Framework of Competences for Basic

Specialist Training in Paediatrics. This document is for doctors in basic specialist training in paediatrics and their tutors and educational supervisors. The authors and editors of this edition of Practical Paediatric Problems have, like Professor Hutchison, been selective and each has written only of what they know. The result is a comprehensive distillate of their know- ledge and practical experience which will not only clearly guide their readers to achieve success in Basic Specialist Training and the MRCPCH examinations, but will also give them an excellent basis for higher specialist training. It will also enable them to deal with practical paediatric problems throughout their subsequent careers as paediatricians.

Forrester Cockburn Emeritus Professor of Child Health University of Glasgow May 2005

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Preface

Preface
Preface
Preface

In

the 40 years since the publication of the first edition

recent RCPCH publication, A Framework of Competences

Jim Beattie and Robert Carachi

of

Practical Paediatric Problems, paediatrics has become

for Basic Specialist Training in Paediatrics (2004).

a large, highly developed, sophisticated and technically demanding area of health care. Advances in the under- standing of paediatric clinical physiology and patho- physiology have enabled a better understanding of disease processes resulting in radically improved outcome. Doctors undergoing General Professional or Basic Specialist Training (GPT/BST) in paediatrics have to master a considerable breadth and depth of core scien- tific and clinical knowledge along with important clin-

Major reference textbooks in paediatrics are either sys- tem or disease based; however, as in other areas of clinical medicine, patients frequently present with ill structured problems and there is therefore a need for a symptom- based text to assist in clinical problem solving. In this regard we hope that the book will be of value to practising paediatricians, paediatric surgeons, accident and emer- gency staff, general practitioners and indeed any clinician whose practice includes children and young people.

ical, technical and practical skills. In addition they must acquire appropriate attitudes in order to deal with the challenges of their chosen specialty. Although restructuring of postgraduate medical training

By necessity, this book is multi-author and all the authors in this book are experts from a broad range of disciplines within paediatrics, but we acknowledge and apologize in advance for any gaps that are inevitable in

in

the UK is planned, including the introduction of newer

a book of this size. We hope the provision of reference

methods of assessment, examinations are likely to remain

sources with each chapter will go some way in addres-

a

necessary hurdle in professional development. For

sing any deficiencies and we would welcome readers’

trainees in paediatrics, achievement of the MRCPCH is a vital step in the progress from GPT/BST to Higher Specialist Training. The aims of the MRCPCH examination are to assess the candidate’s knowledge, clinical judgement and ability to organize a management plan. We hope this book will help those preparing for both parts of the MRCPCH examination worldwide, but particularly for Part 2. We elected not to replicate the MRCPCH examination format, examples of which are available on the Royal College of Paediatrics and Child Health (RCPCH) website (www.rcpch.ac.uk) and in a number of other texts but have attempted to present a structured, contemporary and comprehensive approach modelled closely on the ‘core knowledge’ and ‘particular problems’ identified in the RCPCH publication, A Syllabus and Training Record for General Professional Training in Paediatrics and Child Health (1999). We believe the content will also help trainees achieve the required standards in the more

suggestions and criticisms. In addition, while every effort has been made to ensure accuracy of information, espe- cially with regard to drug selection and dosage, appro- priate information sources should be accessed, particularly Medicines for Children (2003). We are indebted to all the contributors for their hard work, to Joanna Koster, Sarah Burrows and Naomi Wilkinson of Hodder Arnold for their immense patience and support, to Dr Peter Galloway, Consultant in Medical Biochemistry, RHSC, Yorkhill, to our respective secretaries Lynda Lawson and Kay Byrne for their expert and will- ing help in a project that inevitably took a lot longer than planned and finally to our wives and families for their forbearance.

RHSC, Yorkhill, Glasgow May 2005

Royal College of Paediatrics and Child Health (1999) A Syllabus and Training Record for General
Royal College of Paediatrics and Child Health (1999) A Syllabus and Training Record for General
Royal College of Paediatrics and Child Health (1999) A Syllabus and Training Record for General

Royal College of Paediatrics and Child Health (1999) A Syllabus and Training Record for General Professional Training in Paediatrics and Child Health. London: RCPCH Publications Ltd. Royal College of Paediatrics and Child Health and the Neonatal Paediatric Pharmacists Group (2003) Medicines for Children, 2nd edn. London: RCPCH Publications Ltd. Royal College of Paediatrics and Child Health (2004) A Framework of Competences for Basic Specialist Training in Paediatrics. London: RCPCH Publications Ltd.

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Chapter 1

Community child health, child development and learning difficulties

David Tappin

HISTORY OF COMMUNITY CHILD HEALTH

KEY LEARNING POINT

The Court Report (1976) produced a framework for the integration of hospital, community and general practice care of children, which has slowly come about.

Before 1974, the care of children outside hospital in the UK was undertaken either by general practitioners (GPs) or by community health services, which were part of the local authority as opposed to the health authority. Reforms in 1973 (the National Health Service Reorganisation Act 1973) brought together most of the child health services under a ‘health’ umbrella. The government commissioned a review chaired by Donald Court, which reported in 1976 and set out a blueprint for the care of children. This inte- grated vision of child health care moved much of the routine work provided by community child health services – vaccination, child health surveillance, school health – to general practice under the care of a general practitioner. The more specialist paediatric aspects of the community health services – adoption and fostering, child protection, developmental paediatrics particularly in relation to spe- cial schools – were to be undertaken by consultant com- munity paediatricians. Although it has taken time, many of Court’s recommendations have come about. Consultant paediatricians, working mainly outside hospital, have gradually replaced retiring senior clinical medical officers and most have a primary general paediatric qualification (MRCP[UK] or MRCPCH). General practice paediatricians have not emerged in the UK, and vaccination and child health surveillance are now performed by health visitors and GPs. The following sections are taken from Health for All Children: Guidance on Implementation in Scotland. This document has been produced by the Scottish Executive (2004) as a consultation document, but is likely to pro- vide the framework in Scotland for preventive childcare services.

HEALTH FOR ALL CHILDREN

Parts of this section in quotes, quotation marks and boxes, are taken directly from Health for All Children: Guidance on Implementation in Scotland (Scottish Executive, 2004, © Crown copyright). Readers are referred directly to the document for further information.

In 1988, the Royal College of Paediatrics and Child Health established a multi-disciplinary working group to review routine health checks for young children. It’s [sic] report, first published in 1989, was entitled Health for All Children. In later years, the remit of the review was extended beyond routine checks to detect abnormalities or disease, to include activity designed to prevent illness and efforts by health professionals to promote good health. Sir David Hall, Professor of Paediatrics and past- President of the RCPCH, chairs the working group. The report of the most recent RCPCH review of child health screening and surveillance programmes in the UK was published in February 2003 as the fourth edition of the report Health for All Children, and is commonly referred to as Hall 4. (Scottish Executive, 2004)

There will always be a need to ensure universal provi- sion of a health promotion and surveillance programme for all children and young people to enable families to take well informed decisions about their child’s health

2

Community child health, child development, learning difficulties

and development; to identify children with particular health or developmental problems; and to recognise and respond when a child may be in need. However, each family’s circumstances and needs are different. Some parents need only information and ready access to pro- fessional advice when their child is injured or unwell or when they are worried about their child’s development or welfare. Other parents may need considerable support, guidance and help at specific times, or over a continu- ous period, perhaps because of their child’s serious ill health or disability, or because of their own personal circumstances. (Scottish Executive, 2004)

KEY LEARNING POINTS

All families with children receive the core programme of child health contacts (Figure 1.1).

The core programme includes health promotion, screening and detecting problems vaccination and child health surveillance during infancy and pre-school years (Table 1.1) as well as for school-aged children and young people (Table 1.2).

The reduction from the previous routine contacts schedule allows giving additional support to certain groups and intensive support to vulnerable families who need it.

KEY LEARNING POINT

Over 15 years, Hall reports 1, 2, 3 and 4 have sought evidence for routine child health surveil- lance. They have driven a rationalization and standardization of child health contacts in the community.

This programme adheres to the recommendations of the fourth UK report (Hall 4) from the Royal College of Paediatrics and Child Health (RCPCH), Health for All Children (Hall and Elliman, 2003).

‘TARGETING SUPPORT FOR VULNERABLE CHILDREN’ (SCOTTISH EXECUTIVE, 2004)

CORE PROGRAMME FOR CHILD HEALTH SCREENING AND SURVEILLANCE

 

‘Child health surveillance – used to describe routine child health checks and monitoring.

Vulnerable groups include:

Child health screening – the use of formal tests or examination procedures on a population basis to identify those who are apparently well, but who may have a disease or defect, so that they can be referred for a definitive diagnostic test.

‘Children at vulnerable points of transition (e.g. moving from one location to another, changing schools, moving from children’s to adult services)

Children not registered with a General Practitioner

Health promotion – used to describe planned and informed interventions that are designed to improve physical or mental health or prevent disease, disability and premature death. Health in this sense is a positive holistic state.’ (Scottish Executive,

2004)

Children living away from home

Children excluded by language barriers

Traveller families

Families living in temporary or bed and break- fast accommodation

Children of troubled, violent or disabled parents

Children who care for disabled parents

 

Children who are involved with, or whose families are involved with, substance misuse, crime or prostitution

The Core Child Health Programme begins at birth. On the labour ward, a card is completed for the Notification of Birth Acts 1907, 1915 and 1965, and sent to the local health board (health authority). All contacts are scheduled and organized centrally at health board level.

Runaways and street children

Asylum seekers and refugees, particularly if unaccompanied

Children in secure settings

Children of parents in prison’

‘Targeting support for vulnerable children’

3

Universal Core Programme All families offered core screening and surveillance programme, immunization, information,
Universal Core Programme All families offered core screening and surveillance programme, immunization, information,
Universal Core Programme All families offered core screening and surveillance programme, immunization, information,
Universal Core Programme All families offered core screening and surveillance programme, immunization, information,
Universal Core Programme All families offered core screening and surveillance programme, immunization, information,
Universal Core Programme All families offered core screening and surveillance programme, immunization, information,

Universal Core Programme All families offered core screening and surveillance programme, immunization, information, advice on services

programme, immunization, information, advice on services FAMILY HEALTH PLAN Additional support from public health
programme, immunization, information, advice on services FAMILY HEALTH PLAN Additional support from public health
programme, immunization, information, advice on services FAMILY HEALTH PLAN Additional support from public health
programme, immunization, information, advice on services FAMILY HEALTH PLAN Additional support from public health
programme, immunization, information, advice on services FAMILY HEALTH PLAN Additional support from public health
programme, immunization, information, advice on services FAMILY HEALTH PLAN Additional support from public health
FAMILY HEALTH PLAN
FAMILY HEALTH PLAN
information, advice on services FAMILY HEALTH PLAN Additional support from public health nurse as agreed with

Additional support from public health nurse as agreed with family

Structured support (e.g. first-time mother, breastfeeding problems, mental health problems)

mother, breastfeeding problems, mental health problems) Intensive support required Structured interagency support
mother, breastfeeding problems, mental health problems) Intensive support required Structured interagency support
mother, breastfeeding problems, mental health problems) Intensive support required Structured interagency support
mother, breastfeeding problems, mental health problems) Intensive support required Structured interagency support

Intensive support required

Structured interagency support for individual families or communities (e.g. child on child protection register with interagency children protection plan, looked after or disabled child, parental stresses)

Figure 1.1 Plan to target support for those who need it most (redrawn with permission from Scottish Executive (2004) Health for All Children:

Guidance on Implementation in Scotland.A draft for consultation. Edinburgh: Scottish Executive)

.A draft for consultation. Edinburgh: Scottish Executive) Universal core programme – no additional input needed

Universal core programme – no additional input needed

Contact or appointments on request

Edinburgh: Scottish Executive) Universal core programme – no additional input needed Contact or appointments on request
Edinburgh: Scottish Executive) Universal core programme – no additional input needed Contact or appointments on request

Table 1.1 The Universal Core Child Health Screening and Surveillance Programme – pre-school years

Neonate first 24 hours

Action: Child health professional – GP, midwife, junior doctor, consultant paediatrician

 

Record birth weight Record head circumference Record length (only if abnormality suspected) Record length of pregnancy in weeks Record problems during pregnancy/birth Vitamin K administration Hip test for dislocation (Ortolani and Barlow manoeuvres) Inspection of eyes and examination of red reflex Thorough check of cardiovascular system for congenital heart disease Check genitalia (undescended testes, hypospadias, other anomalies) Check femoral pulses Neonatal hearing screening – to be phased in by April 2005 Record feeding method at discharge Review any problems arising or suspected from antenatal screening, family history or labour Health promotion – discuss:

Neonatal hearing screen HDL (2001) 51, which issued in June 2001, advised the service about the introduction of universal neonatal hearing screening. The introduction of hearing tests for all neonates is also a Partnership Agreement commitment. Implementation is underway with the establishment of two pathfinder sites in Tayside and Lothian, where screening began in January 2003 and March 2003, respectively. NHS Boards are expected to implement the screening programme by April 2005

Vitamin K Each NHS Board area should have a single protocol for the administration of Vitamin K, with which every member of staff involved with maternity and neonates is familiar

Baby care

Hepatitis B and bCG vaccines

Screening Advise that no screening test is perfect. Details of signs and potential emerging problems in PCHR and who to contact if concerned

Feeding

Smoking

Jaundice

Oral health

Vitamin K

Any parental concerns

Reducing SIDS risks

Provide information about local support networks and contacts for additional advice or support when needed Identify parents who might have major problems with their infant (e.g. depression, domestic violence, substance abuse, learning difficulties, mental health problems)

 
 

(Continued)

4

Community child health, child development, learning difficulties

Table 1.1 (Continued)

Within first 10 days of life

 

Action: Lead health professional is normally the community midwife, but may be hospital midwife, GP or public health nurse in

unusual circumstances

Weight (where appropriate on clinical suspicion) Blood spot test for – phenylketonuria (PKU), hypothyroidism and cystic fibrosis Record feeding method Smokers in household Record diagnoses or concerns (coded):

Cystic fibrosis screening HDL (2001) 73, which issued in October 2001, advised about the introduction of a neonatal screening programme for cystic fibrosis using the existing blood spot test. The programme was introduced across Scotland in February 2003

Feeding

Weight

PKU and congenital hypothyroidism HDL (2001) 34, which issued in April 2001, provided guidance on the organisation of neonatal screening for PKU and congenital hypothyroidism

Illness

Sleeping

Crying

Child protection issues

Appearance

Other

 

Impairment/abnormalities in infant Mother’s health and wellbeing Discussion of birth registration Health promotion – discuss:

Haemoglobinopathies Assessment work in relation to screening for haemoglo- binopathies is currently underway. No decision has yet been taken in relation to a screening programme in Scotland

Reducing SIDS risks

Parenting skills

Immunisation schedule

Support networks and services

Screening advice Advise that no screening test is perfect. Details of signs and poten- tial emerging problems in PCHR and who to contact if concerned

Safety

Smoking

Feeding

Any parental concerns

Oral health

 

Frequency of visits Visits to the family home are usual on several occasions within the first 10 days of life. Some new parents may need to be seen more frequently than others. In particular, additional support should be provided for babies who have special needs or who needed treatment in the neonatal intensive care unit

Weight Whoever is responsible for weight measurement must be able to deal with questions about the interpretation of the weight chart

6–8 Weeks – must be completed by 8 weeks

 

Action: Lead professional is Public Health Nurse and/or GP and may be others in unusual circumstances

Immunisation – DTP-Hib, PV MenC Repeat hip test for dislocation (Ortolani and Barlow manoeuvres) Repeat inspection of eyes and examination of red reflex Repeat thorough check of cardiovascular system for congenital heart disease Repeat check of genitalia (undescended testes, hypospadias, other anomalies) Check femoral pulses Check blood spot result Weight BCG considered/been done? (for targeted population) Record smokers in household (pre-school) Feeding method Diagnoses/concerns (coded):

Immunisation Whoever is responsible for immunisation must be able to deal with questions about vaccines

Can be combined with the postnatal examination at which physical health, contraception, social support, depression, etc. can be discussed as appropriate

Weight Whoever is responsible for weight measurement must be able to deal with questions about the interpretation of the weight chart

Head circumference If no concern at this stage, no further routine measurement required

Feeding

Hearing

 

Illness

Eyes

 

(Continued)

‘Targeting support for vulnerable children’

5

Table 1.1 (Continued)

 

Crying

 

Movement

 

Appearance

Sleeping

Behaviour

 

Child protection issues

 

Weight gain

Other

Growth

 

Gross motor:

Pull to sit

Ventral suspension

 

Handling

 

Hearing and communication

 

Response to sudden sound

Response to unseen mothers voice

 

Vision and social awareness

 

Intent regard mothers face

Follow angling object past midline

 

Social smile

 

Length (only in infant who had a low birth weight, where disorder is suspected or present, or where health, growth or feeding pattern causing concern). Head circumference Parents’ health and wellbeing Enter national special needs system when clinical diagnosis recorded Health promotion – discuss:

Nutrition

 

Immunisation schedule

Development

Parenting skills

Safety

Support networks and services

Smoking

Any parental concerns

Oral health

Sleeping position

Review family’s circumstances and needs to make an initial plan with them for support and contact over the short to medium term. Identify high-risk situations and carry out a risk assessment

 

3

Months

Action: Lead professional, GP, practice nurse or public health nurse

Immunisation – DTP-Hib PV Men C Weight Health promotion – discuss:

Immunisation Whoever is responsible for immunisation must be able to deal with questions about vaccines

Nutrition

Immunisation schedule

Development

Parenting skills

Safety

Support networks and services

Weight Whoever is responsible for weight measurement must be able to deal with questions about the interpretation of the weight chart

Smoking

Any parental concerns

Oral health

4

Months

Action: Lead professional, GP, public health nurse

 

Immunisation – DTP-Hib PV Men C Weight Health promotion – discuss:

Immunisation Whoever is responsible for immunisation must be able to deal with questions about vaccines

Weaning

Oral health

Nutrition

Immunisation schedule

 

(Continued)

6

Community child health, child development, learning difficulties

Table 1.1 (Continued)

Development

Parenting skills

Weight Whoever is responsible for weight measurement must be able to

Safety

Support networks and services

Smoking

Any parental concerns

deal with questions about the interpretation of the weight chart

12–15 months

Action: Primarily GP, practice nurse or public health nurse

 

Immunisation – MMR Weight measurement Health promotion – discuss:

Immunisation Whoever is responsible for immunisation must be able to deal with questions about vaccines

Nutrition

Immunisation schedule

Development

Parenting skills

Weight Whoever is responsible for weight measurement must be able to deal with questions about the interpretation of the weight chart

Safety

Support networks and services

Smoking

Any parental concerns

Oral health

3–4 years

Action: Lead professionals could be public health nurse, GP, practice nurse or community paediatrician

Immunisation – PV MMR DTP Weight measurement Health promotion – discuss:

 

Immunisation Whoever is responsible for immunisation must be able to deal with questions about vaccines

Development

Registration with dentist

Safety

Parenting skills

Weight Whoever is responsible for weight measurement must be able to deal with questions about the interpretation of the weight chart

Nutrition

Support networks and services

Smoking

Any parental concerns

Oral health

4–5 years

Action: Orthoptist

Vision screen

Where pre-school orthoptist vision screening cannot be implemented immediately, children should instead be screened on school entry. As a minimum, training and monitoring should be provided by an orthoptist

Source: With permission from the Scottish Executive (2004) Health for All Children: Guidance on Implementation in Scotland. Edinburgh: Scottish Executive.

GP, general practitioner; NHS, National Health Service; PCHR, personal child health record; SIDS, sudden infant death syndrome.

Table 1.2 The Universal Core Child Health Screening and Surveillance Programme – school years

Entry to primary school

Action: School health service and community dental service

Height Weight Record body mass index (BMI) for public health monitoring purposes only

Height The 1990 nine-centile charts have been agreed as the standard measurement of height by the Royal College of Paediatrics and Child Health

(Continued)

‘Targeting support for vulnerable children’

7

Table 1.2 (Continued)

 

Sweep test of hearing (continue pending further review) Identify children who may not have received pre-school health

Physical examination

care programme for any reason Identify any physical, developmental or emotional problems that have been missed and initiate intervention Check that pre-school vision screening undertaken and make appropriate arrangements where not Ensure all children have access to primary health and dental care Dental check at P1 through the National Dental Inspection Programme Oral health promotion:

Dentist registration and attendance

There is no evidence to justify a full physical examination or health review based on questionnaires or interviews on school entry

Vision testing Vision testing on school entry should only be undertaken where a universal pre-school orthoptic vision screening programme is not in place

Dental checks National Dental Inspection Programme identifies children at greatest risk of oral disease and is used to inform the school health plan

Twice daily supervised brushing

 

Reducing sugary food and drink consumption

 

Primary 7

Action: School health service and community dental service

 

Dental check through the National Dental Inspection Programme Oral health promotion:

Dental checks National Dental Inspection Programme identifies children at greatest risk of oral disease and is used to inform the school health plan

Dentist registration and attendance

 

Twice daily supervised brushing

 

Reducing sugary food and drink consumption

 

Other health promotion activity should include:

Health promotion Development of an effective core programme of health promotion in schools is premised on the roll out of Health Promoting Schools

Smoking

Sexual health

Nutrition

Personal safety

Physical activity

Mental health and wellbeing

Substance use

Secondary school

Action: School health service and community dental service

 

Age 10–14 years – BCG immunisation In areas where vision is checked at 11 years old, this should continue pending further review by the National Screening Committee. If not being undertaken, it should not be introduced Age 13–18 years – PV Td immunisation Dental check at S3 through the National Dental Inspection Programme Oral health promotion:

Dentist registration and attendance

Dental checks National Dental Inspection Programme identifies children at greatest risk of oral disease and is used to inform the school health plan

Health promotion Development of an effective core programme of health promotion in schools is premised on the roll out of Health Promoting Schools

Twice daily supervised brushing

 

Reducing sugary food and drink consumption

 

Other health promotion activity should include:

Smoking

Sexual health

Nutrition

Personal safety

Physical activity

Mental health and wellbeing

Substance use

Source: with permission from the Scottish Executive (2004) Health for All Children: Guidance for Implementation in Scotland. Edinburgh: Scottish Executive.

8

Community child health, child development, learning difficulties

‘Assessing vulnerability’ (Scottish Executive, 2004)

The family’s score is reviewed approximately every three months and is recorded in the Family Health Plan. The data are also entered on the Starting Well database to enable on-going population needs assessment. Whilst recording a FNS for the family, public health nurses also indicate whether there are any special issues evident for that family in rela- tion to drugs and/or alcohol.’ (Scottish Executive,

2004)

‘Assessment of children and their needs should include consideration of:

The child’s developmental needs, including health and education, identity and family and social relationships, emotional and behavioural development, presentation and self-care.

Parenting capacity, including ability to provide good basic care, stimulation and emotional warmth, guidance and boundaries, ensuring safety and stability.

 

‘As well as assessing and targeting individual vulner- able children and families, NHS Boards should assess the level of vulnerability of communities. This will mean targeting resources such as Public Health Nurses to the most deprived communities in their population’ (Scottish Executive, 2004).

Wider family and environmental factors, including family history and functioning, support from extended family and others, financial and housing circum- stances, employment, social integration and community resources.’

No one agency can undertake a comprehensive assess- ment within and across all these domains without sup- port from colleagues in other services and sectors. But where a single agency is in touch with a child or family and identifies problems or stresses in any one of these areas, this should signal the need to involve others to accurately assess whether the child and family may be in need of additional or intensive support, and agree how this should best be provided. The universal core pro- gramme should provide information to enable health professionals to identify vulnerable children and their needs, and to ensure appropriate planning and referral for additional or intensive support when necessary. The national child health demonstration project in Scotland, Starting Well, has utilised a simple 3 point scale for community workers.

KEY LEARNING POINTS

Targeting support for vulnerable families often requires multi-agency assessment of vulnerability, which should include consideration of the child’s developmental needs, parenting capacity, and wider family and environmental factors.

Support required is likely to be from more than one agency and needs coordination to avoid duplication or omission.

‘Child protection’ (Scottish Executive, 2004)

 
 

‘Starting Well Demonstration Project – Family Need Score’

All agencies and professionals in contact with children and families have an individual and shared respon- sibility to contribute to the welfare and protection of vulnerable children and young people. This applies to services for adults working with parents to tackle prob- lems which may have a negative impact on their care of children. Preventing child abuse and neglect must be one of the key aims of the universal core programme to support child health. Where abuse and neglect has occurred, children are entitled to support and therapy to address the consequences, help them recover from the effects of abuse and neglect, and keep them safe from future harm. This is a key objective of multi-agency sup- port programmes for children at risk of significant harm. Every professional in contact with children or their families must be aware of their duty to recognise and act on concerns about child abuse.

‘The Family Need Score (FNS) is a three point scale used by Starting Well public health nurses to indi- cate the vulnerability of each Starting Well family. Based on professional judgement, public health nurses give families a Family Need Score of 1, 2 or 3:

FNS 1 – Indicates that the family requires less than routine visiting outlined in core visiting schedule.

FNS 2 – Indicates that the family requires rou- tine visiting outlined in core visiting schedule.

FNS 3 – Indicates that the family requires more than routine visiting outlined in core visiting schedule.

‘Information collection and sharing’

9

‘Induction for staff working with children in all agencies should include:

ensure they are accountable to their patient or client, to their profession and to their employing organisation or equivalent.

Training to raise awareness of child abuse and neglect and agency responsibilities for child protection.

Aggregate information about presenting conditions and problems, what was done and the outcome to assist managers and planners to assess needs and plan services.

Familiarity with child protection procedures.

The name and contact details of a designated person in their agency with lead responsibility for advising on child protection matters and local referral arrangements in the event of concern about a particular child’ (Scottish Executive, 2004).

Information for families about their child’s health status and treatment or care’ (Scottish Executive, 2004).

 

‘Domestic abuse is a serious social problem in its own right. It is now also recognised that exposure to family violence is profoundly damaging to children’s emotional and social development’ (Scottish Executive, 2004).

‘National guidance sets out the requirements for effect- ive working in partnership with parents. This depends on good information for parents from professionals’ (Scottish Executive, 2004).

‘Achieving partnerships with parents and children in

KEY LEARNING POINT

the planning and delivery of services to children requires that:

 

Child protection requires ‘All agencies and pro- fessionals in contact with children and families to have an individual and shared responsibility to contribute to the welfare and protection of vulnerable children and young people’ (Scottish Executive, 2004).

They have sufficient information at an early stage both verbally and in writing to make informed choices.

They are aware of the various consequences of the decisions they may take.

They are actively involved wherever appropriate in assessments, decision-making, care reviews and conferences.

 

They are given help to express their views and wishes and to prepare written reports and statements for meetings where necessary.

‘INFORMATION COLLECTION AND SHARING’ (SCOTTISH EXECUTIVE, 2004)

Professionals and other workers listen to and take account of parents’ and carers’ views.

All agencies gather information from children and fam- ilies to enable them to decide how best to help, and to keep records of their contact with children and families including details of their assessments, plans for inter- vention, treatment and support.

Families are able to challenge decisions taken by professionals and make a complaint if necessary.

Families have access to independent advocacy when appropriate’ (Scottish Executive, 2004).

‘Systems for recording, storing and retrieving infor- mation gathered from children and families or generated in the course of professionals work provide:

‘Health professionals should inform and advise parents and, where appropriate, children, that to provide proper care, information is recorded in written records and on computer. Sharing information between professionals and agencies should be based on parental consent unless there are concerns about a child’s welfare or safety which would override patient confidentiality’ (Scottish Executive, 2004).

A record for the clinician or practitioner of the work undertaken and the outcomes to assist their ongoing work with the family and to

10

Community child health, child development, learning difficulties

KEY LEARNING POINT

diagnosis and between diagnosis and treatment. It is important to keep under review age at diagnosis, false positive rates, waiting times at each point in the network of services and differences between age of diagnosis for high risk and low risk cases. Standardisation of records would facilitate comparisons between areas. This will be considered in the child health information strategy.

‘Sharing information between professionals and agencies should be based on parental consent unless there are concerns about a child’s welfare or safety, which would override patient confidentiality’ (Scottish Executive, 2004).

 

‘The Parent Held Child Health Record’ (Scottish Executive, 2004)

 
 

‘The Scottish Executive is working with local authority and health partners in Aberdeen, Glasgow, Dumfries and Galloway and Lanarkshire to pilot the following:

Hall 4 reviewed the use and content of the Parent Held Child Health Record (PHCHR), introduced a decade ago to facilitate partnership with parents and empower them in overseeing their child’s development and health care. Parents and primary care professionals value the record but other health professionals make more limited use of the PHCHR. Whether professionals make entries in the book or ask for it at health appointments or at contact with services such as attendance at Accident and Emergency Departments is important to parents and influences how they view the book. There is the potential to integrate the information in the PHCHR into the Family Health Plan once it comes on line. In the meantime, NHS Boards should adopt the PHCHR as a basis for recording infor- mation on child health.

An Integrated Children’s Service Record to define and develop the structures and standards for an integrated care record for children, integrating health, social work and education.

A Single Assessment Framework that will allow the sharing of assessment information between the partner agencies.

 

A Personal Care Record to provide a secure store for the records of a child from health, education, and social services and the Scottish Children’s Reporters Administration.

An Integrated Child Protection Framework to extend the technologies and processes currently used to share information on older people in Lanarkshire, to children with child protection issues’ (Scottish Executive, 2004).

SECONDARY AND TERTIARY CARE FOR CHILDREN

Secondary care for children takes place in both a hospi-

tal and a community setting. Paediatricians based in hospital have traditionally seen all acutely ill children referred from primary care, have looked after premature or ill babies after birth and have been referred ‘medical’ and ‘surgical’ paediatric problems to be seen as outpa- tients. Paediatricians based outside hospital have often dealt with ‘educational’ medicine, have looked after chil- dren ‘in care’ for fostering and adoption, have dealt with ‘developmental’ problems and have increasingly been passed the responsibility for ‘child protection’. Over the past 10 years, secondary care paediatrics has become more combined as consultant paediatricians have been appointed to replace senior clinical medical officers in the community. Future plans are based around the com- munity health partnerships (CHPs), where seven or eight consultant paediatricians (some mostly working in a hospital setting and some in the community) will look after the child health needs of a CHP area to provide an integrated service for a total population of around 150 000. Two such CHP areas would feed into one dis- trict general hospital. The eight paediatricians will be

‘Child health information’ (Scottish Executive, 2004)

 

The current child health systems are well established, though with the exception of the Scottish Immunisa- tion and Recall System (SIRS), they are not used in all NHS Board areas. They are primarily clinical systems (as opposed to being merely data collection systems) and provide useful support to clinicians dealing with children.

‘Effective monitoring’ (Scottish Executive, 2004)

Current child health information systems provide invaluable information about the uptake of screening programmes, referrals of children with development problems or disabilities, time lapses between referral and

Social paediatrics

11

trained in complementary special interests so that all common paediatric problems can be dealt with effec- tively. These special interests would be augmented by attachment to tertiary care specialist centres to provide an integrated clinical network and a seamless service for children.

SOCIAL PAEDIATRICS

The following section has been largely taken from the website of the Children’s Hearings (www.childrens- hearings.co.uk).

TERTIARY CARE FOR CHILDREN

The Children’s Hearings system and the reporter

‘Hospital’ paediatrics has become as specialized as adult medicine at a tertiary level. Paediatric tertiary specialties include respiratory disease, rheumatology, nephrology, child and family psychiatry, neurology, neonatology, emergency medicine, intensive care, infectious diseases, endocrinology, diabetes, metabolic disease, dermatology, cardiology, leukaemia and cancer care, and a number of paediatric surgical specialties. It is likely that tertiary specialties will develop within community based paedi- atrics and may include disability, social paediatrics – child protection, adoption and fostering, and looked after/vulnerable children, child mental health – which may include educational medicine and public health paediatrics.

Successive UK governments have highlighted the diffi- culty of dealing with children who offend. The need for a system different from juvenile courts is well recognized. In Scotland such a system has been in place for over 30 years. The system is not concerned with guilt or innocence but the welfare or best interests of the child. This prin- ciple is applied whether the child has offended or has been offended against or abused. One system deals with juvenile criminal justice and children’s welfare.

KEY LEARNING POINT

The Children’s Hearings system is not concerned with guilt or innocence but with the welfare and best interests of the child.

OUTREACH: HOSPITAL AT HOME/DIRECT ACCESS

How the system came about

Secondary and tertiary care paediatric problems lend themselves to outreach work. The aim is to keep children in their own environment away from hospital care when this is possible. ‘Outreach’ nurses provide specialist care, e.g. for children with cystic fibrosis. Most antibiotic ther- apy can now be given at home by parents. Intravenous access can be replaced by nurses in the child’s home. Diabetic liaison nurses provide ongoing advice and train- ing at home so that admission at diagnosis is often not necessary for the ‘walking-wounded’. Specialist nurses are a resource for schools so that teachers can learn to cope with common problems and the child is more secure in the school environment. Paediatric nephrology has been at the forefront of ‘Hospital at Home’ initiatives. Now children with chronic renal failure are treated by parents at home using overnight peritoneal dialysis. Children with asthma that is difficult to control may be granted ‘direct access’ to paediatric units so that delay in treat- ment is minimized. Initiatives will increase as technol- ogy improves so that long-term admission for chronic problems such as overnight ventilation will become a thing of the past.

In the late 1950s and early 1960s it had become increas- ingly evident that change was required in how society dealt with children and young people. To this end a com- mittee was set up under Lord Kilbrandon to investigate possible solutions. The principles underlying the Children’s Hearings system were recommended by the Committee on Children and Young Persons (the Kilbrandon Committee) which reported in 1964. The Committee found that chil- dren and young people appearing before the courts whether they had committed offences or were in need of care or protection had common needs for social and per- sonal care. The Committee considered that juvenile courts were unsuited for dealing with these problems because they had to combine the characteristics of a criminal court of law with those of a treatment agency. Separation of those functions was therefore recommended; the establish- ment of the facts where disputed was to remain with the courts, but decisions on treatment were to be the responsi- bility of a new and unique kind of hearing. The Hearings system represents one of the radical changes initiated by the Social Work (Scotland) Act 1968. On 15 April 1971 the Hearings took over from the courts most of the responsi- bility for dealing with children and young people under

12

Community child health, child development, learning difficulties

the age of 16 years who commit offences or who are in need of care or protection.

The Reporter is given a statutory discretion in decid- ing the next step in the procedure.

Why are children brought to the attention of a hearing?

The Reporter may decide that no further action is required, and the child or young person and parent or other relevant person is then informed of the decision. It is not unusual for the Reporter to convey this decision in person in offence cases when the child may be warned about their future behaviour

The Reporter may refer the child or young person to the local authority with the request that social workers arrange for such advice, guidance and

The grounds on which a child or young person may be brought before a hearing are set down in the Children (Scotland) Act 1995. These grounds include the child who is:

beyond the control of parents or other relevant person

exposed to moral danger

likely to suffer unnecessarily or suffer serious impairment to health or development through lack of parental care

the victim of an offence including physical injury or sexual abuse

assistance, on an informal basis, as may be appropriate for the child

The Reporter may arrange to bring the child to a hearing because in his or her view the child is in need of compulsory measures of supervision.

failing to attend school

indulging in solvent abuse

KEY LEARNING POINT

 

misusing alcohol or drugs or has committed an offence.

The Reporter may decide on no further action; refer for social work help for the child/family; arrange to bring the child to a hearing of a chil- dren’s panel because the Reporter is of the opinion that compulsory supervision is required.

The reporter

The reporter is an official employed by the Scottish Children’s Reporters Administration. All referrals regard- ing children and young people who may be deemed to need compulsory measures of supervision must be made to the reporter. The main source of referrals is the police, but referrals can be made by other agencies such as social work, education or health – in fact any member of the public may make a referral to the Reporter. The Reporter then has a duty to make an initial investigation before deciding what action, if any is necessary in the child’s interests. First, the Reporter must consider the sufficiency of evidence with regard to the grounds for referral and thereafter decide whether there is a case for seeking compulsory measures of supervision.

Children under 16 years are only considered for pros- ecution in court where serious offences such as murder or assault to the danger of life are in question or where they are involved in offences where disqualification from driving is possible. However, in cases of this kind it is by no means automatic that prosecution will occur, and where the public interest allows, children in these categories are referred to the Reporter by the Procurator Fiscal for decision on referral to a hearing. Where the child or young person is prosecuted in court, the court may refer the case to a hearing for advice on the best method of dealing with them. The court on receipt of that advice or in certain cases without seeking advice first, may remit the case for disposal by a hearing.

KEY LEARNING POINTS

All children and young people who may be deemed to need compulsory measures of supervision must be referred to the Reporter.

Social workers provide most referrals, health- care workers also do so, but anybody can make

Children’s panels

Members of a children’s panel volunteer to serve and come from a wide range of occupations, neighbourhood and income groups. All have experience of and interest in children and the ability to communicate with them and their families. There is an approximate balance between men and women and individuals aged between 18 and 60 years can apply to become panel members. The panel members are carefully prepared for their task through

a

referral.

The Reporter looks at the evidence and decides

if

there is a case for seeking compulsory

supervision.

 

Social paediatrics

13

initial training programmes and have continuing oppor- tunities during their period of service to develop their knowledge and skills and attend in-service training courses.

 

KEY LEARNING POINTS

 

A hearing is presided over by three children’s panel members and can only consider cases if the parents or child accept the grounds for referral stated by the Reporter. Otherwise, the Sheriff must first decide if there is ‘proof’ of grounds, in which case they are likely to pass the case back to the children’s panel hearing.

 

KEY LEARNING POINT

 

Children’s panels are made up of trained volunteers – local men and women.

SELECTION AND APPOINTMENT OF PANEL MEMBERS People are appointed or reappointed to panels by Scottish

The level of proof is on the balance of probabilities, which allows the children’s panel to act where a criminal court, which requires proof beyond reasonable doubt, could not. This allows ‘child protection’ to proceed more easily.

ministers. The task of selection is the responsibility of the Children’s Panel Advisory Committee (CPAC) for the local authority area. The selection procedure adopted by

the CPAC involves application forms, interviews and group discussions. The initial period of appointment for

 
 

panel member is up to five years and is renewable on the recommendation of the CPAC. Over Scotland as a whole, there are over 2000 panel members.

a

ATTENDANCE AT A HEARING

A

hearing is usually held at a place in the child or young

The hearings

person’s home area. The layout of the room where the Hearing takes place is informal with the participants gen- erally sitting round a table. Normally, the child or young person must attend. They have the right to attend all stages of their own Hearing. The Hearing may, however, suggest that they need not attend certain parts of the hearing or even the whole proceedings – for example, if

matters might arise that could cause distress.

The Hearing is a lay tribunal comprising three members including male and female members charged with making decisions on the needs of children and young people. The Hearing can consider cases only where the child or young person, parents or other relevant person accept the grounds for referral stated by the Reporter, or where they accept them in part and the Hearing considers it proper to proceed. Where the grounds for referral are not accepted or the child does not understand them, the Hearing must (unless it decides to discharge the referral) direct the Reporter to apply to the Sheriff to decide whether the grounds are established. The Sheriff decides if there is ‘proof’ of grounds for

referral to the Children’s Hearing. The level of proof is on the balance of probabilities, which allows the children’s panel to act where a criminal court, which requires proof beyond reasonable doubt, could not. If the Sheriff is sat- isfied that any of these grounds are established, they remit the case to the Reporter to make arrangements for

Hearing. In certain specified circumstances a child or

a

It is important that both the child’s parents or other rele- vant person are present when the Hearing considers his or her problem so that they can take part in the discussion and help the Hearing to reach a decision. Their attendance

is

compulsory by law, and failure to appear may result in

prosecution and a fine. The parents or other relevant per- son may take a representative to help them at the Hearing or each may choose a separate representative. Other persons may also be present, with the approval of the Chairman of the Hearing. No one is admitted unless

they have a legitimate concern in the case or with the panel system. The Hearing is, therefore, a small gathering able to proceed in an informal way and to give the child and his or her parents the confidence to take a full part

young person may be detained in a place of safety as defined in the Children (Scotland) Act 1995 by warrant pending a decision of a hearing for a period not exceed- ing 22 days in the first instance. The Hearing, or the Sheriff in certain court pro- ceedings, may appoint a person known as a Safeguarder. The role of the Safeguarder is to prepare a report that assists the panel in reaching a decision in the child’s best interests.

in

the discussion.

The Hearing’s task is to decide on the measures of supervision that are in the best interest of the child or young person. It receives a report on the child and his or her social background from the social work department of the local authority and, where appropriates, a report from the child’s school. Medical, psychological or psychiatric reports may also be requested. Parents are provided with copies of these reports.

14

Community child health, child development, learning difficulties

The Hearing discusses the situation fully with the par- ents, child or young person and any representatives, the social worker and the teacher, if present. As the Hearing is concerned with the wider picture and the long-term wellbeing of the child, the measures that it decides on will be based on the best interests of the child. They may not appear to relate directly to the reasons that were the immediate cause of the child’s appearance. For example, the Hearing may decide that a child or young person who has committed a relatively serious offence should not be removed from home, because their difficulties may be adequately dealt with and their need for supervision ade- quately met within the treatment resources available in their home area. In contrast, a child or young person who has come to the Hearing’s attention because of a rela- tively minor offence may be placed away from home for a time if it appears that their home background is a major cause of their difficulties and the Hearing considers that removal from home would be in their best interest.

LEGAL ADVICE AND AID Legal advice is available free or at reduced cost under the Legal Advice and Assistance Scheme to inform a child or their parents about their rights at the Hearing and to advise about acceptance of the ground for referral. Legal

aid is not available for representation at the Hearing, but may be obtained for appearances in the Sheriff Court either when the case has been referred for establishment

of

the facts or in appeal cases.

REVIEW HEARING The Hearing may suggest a review date. A supervision requirement lapses after a year unless it is reviewed earl- ier. At the Review Hearing, which is attended by the par- ents or other relevant person and normally the child, the supervision requirement may be discharged, continued or altered. A child, parent or other relevant person can request the review after three months, but the social work department may recommend a review at any time. The reporter arranges review hearings.

KEY LEARNING POINT

RESOURCES

 

In addition to funding the Scottish Children’s Reporters Administration, which costs around £14 million, the Scottish Executive contributes over £500 000 annually

The Hearing’s task is to decide on the measures of supervision that are in the best interest of the child or young person.

to

the training of panel members. This funding provides

for training organizers, who prepare and deliver training based at Aberdeen, Edinburgh, Glasgow and St Andrews universities. Responsibility for meeting the costs of this training rests with local authorities who are also respon- sible for providing appropriate facilities for the assess- ment and supervision of children and for carrying out the supervision requirements made by hearings.

SUPERVISION If the Hearing thinks compulsory measures of supervi- sion are appropriate it will impose a supervision require- ment, which may be renewed until the child is 18 years old. Most children will continue to live at home but will be under the supervision of a social worker. Sometimes, the Hearing will decide that a child should live away from their home with relatives or foster parents, or in one of sev- eral establishments managed by local authority or vol- untary organizations, such as children’s homes or other residential schools. No power has been given to a hearing to fine the child or young person or their parents. All deci-

sions made by hearings are legally binding on that child or young person.

RESEARCH AND STATISTICS

Much research has been conducted on the Hearings sys- tem; most of it has been carried out by researchers based at Scottish universities, sometimes with the support of funds from other countries. A review of the research and

a

number of other significant studies have been pub-

lished. Detailed references to recent or significant publica- tions are available from the Children’s Hearings website (www.childrens-hearings.co.uk).

APPEALS The child or young person or their parents may appeal to the Sheriff against the decision of a hearing, but must do so within 21 days. Once an appeal is lodged it must be heard within 28 days. Any Safeguarder who has been appointed also has the right of appeal against the decision of a hearing. Thereafter on a point of law only, the Sheriff’s decision may be appealed to the Sheriff Principal or the Court of Session.

Child protection

 
 
 

England and Wales

 

Children Act 1989

Social workers have a statutory duty to investi- gate reports and take appropriate action to safe- guard a child’s welfare.

Social paediatrics

15

Case conference to decide if measures of super- vision are required and if child should be put on child protection register.

Proceedings for protection of children under the Children Act take place in civil courts and are focused on the interests of the child which need proof on the balance of probabilities.

 

individual needs and stages of development and the child is, or will be, at risk through avoidable acts of commission or omission on the part of their custodian.

 

Child protection is when a child needs protection from child abuse.

(From Department of Health (1991) Working Together Under the Children Act. London: HMSO.)

Signs of abuse

A

child who has been abused or neglected may show

 
 

obvious physical signs; however, many children without

such signs signal possible abuse through their behaviour. When professionals listen to and take seriously what chil-

 

Scotland

dren say they are far more likely to detect abuse. Children with special needs are particularly vulnerable. Categories

Children (Scotland) Act 1995

of

abuse are often mixed but have been labelled physical

Social workers have a statutory duty to investi- gate reports and take appropriate action to safeguard a child’s welfare.

abuse, physical neglect, non-organic failure to thrive, sexual abuse and emotional abuse. A rare form of abuse is simulated or induced illness (factitious illness syndrome, Munchausen syndrome by proxy).

PHYSICAL INJURY POSSIBLY CAUSED BY ABUSE Bruising

Black eyes as most accidents only cause one.

Case conference to decide if measures of super- vision are required and if child should be put on child protection register.

If compulsory supervision is likely to be required the case goes to the Reporter to the Children’s panel. If after investigation he/she decides it is, the case is referred to the Children’s Hearings system for a decision on compulsory supervision required to safeguard the child. If parents contest the grounds then the Reporter takes it to a ‘proof’ hearing with the Sheriff, who examines the grounds and decides on the balance of probabilities if they are valid. If they are, he passes the case back to the Children’s Hearings to decide compulsory supervision required.

Bruising in or around the mouth, a torn frenulum.

Grasp marks on the arms or chest.

Finger marks, e.g. on each side of the face.

Symmetrical bruising, often on the ears.

Outline bruising caused by belts or a hand print.

Linear bruising particularly on the buttocks and back.

Bruising on soft tissue with no good explanation.

Bruising of different ages.

Tiny red marks on face, in or around eyes indicating constriction or shaking.

(From Scottish Office (2000) Protecting Children – A Shared Responsibility: Guidance for Health Profes- sionals. London: HMSO.)

Petechial bruising around the mouth or neck.

It is rare to have accidental bruising on the back, back of legs, buttocks, neck, mouth, cheeks, behind

 

the ear, stomach, chest, under the arm, in the genital or rectal area.

 
 

Mongolian blue spots are patches of blue-black pig- mentation classically found on the lumbar and sacral

KEY LEARNING POINTS

 

regions of Afro-Caribbean children at birth but also on children of other skin colours including white.

The Victoria Climbié report and recommendations make it clear that every professional in contact with children or their families must be aware of their duty to recognize and act on concerns about child abuse.

Bites

 

Bites leave clear impressions of the teeth.

Burns, scalds

A definition of child abuse is circumstances where a child’s basic needs are not being met in a manner which is appropriate to his or her

Burns and scalds with clear outlines are suspicious.

A child is unlikely to sit down voluntarily in a hot bath and will have scalding of the feet if they have

16

Community child health, child development, learning difficulties

 

got in themselves. They will have splash marks where they struggled to get out.

 

CASE STUDY: Fractures

Small round burns may be cigarette burns.

 

Scars

   

A 4-month-old infant was admitted with a cough and difficulty breathing with persistent crying. Routine chest radiograph showed multiple rib frac- tures confirmed by a paediatric radiologist.

Many children have scars but many of different ages,

large scars from burns that did not receive medical attention and small round scars possibly from cigarette burns should be sought.

 

Fractures

   

CASE STUDY: Fractures

These should be suspected if there is pain, swelling and discoloration over a bone or joint.

An 18-month-old was admitted after a two-month history of a limp after a fall. A healed tibial fracture was seen on radiograph. A significant gap between the event and presentation was present and there- fore non-accidental injury (NAI) suspected. Expert opinion from a paediatric orthopaedic surgeon described this as a ‘typical’ toddler’s fracture and as social workers and health visitor had no worries about the family, NAI was ruled out.

The commonest non-accidental fractures are to the long bones.

Due to lack of mobility and stage of development it

is

rare for a child under the age of 12 months to

sustain a fracture accidentally.

 

Fractures cause pain.

It

is difficult for a parent to be unaware that a child

has been hurt.

 

Genital, anal bruises

 

It

is unusual for a child to have bruising or bleeding

 

in

this area.

 

CASE STUDY: Shaken baby

 

Shaken baby

 

An infant presented after being looked after by stepfather with a history of stopping breathing and requiring mouth-to-mouth resuscitation. The infant was brought in by blue light ambulance not breath- ing. On examination there was a full fontanelle and tonic decerebrate movements. The infant was ven- tilated in the intensive care unit and had retinal haemorrhages – make sure that the most senior ophthalmologist is brought in to document the retinal haemorrhages. Post-mortem showed large subdural haematomas – make sure that early neuro- logical assessment is made so that intervention can be performed.

Subdural haemorrhages, retinal haemorrhages, fractures of ribs or long bones.

Poisoning

 

May occur in factitious illness syndrome (Munchausen by proxy).

Definition for registration Actual or attempted physical injury to a child under the age of 16 years where there is definite knowledge or rea- sonable suspicion that the injury was inflicted or know- ingly not prevented.

 

CASE STUDY: Bruising

 

A

3-year-old child was admitted with marks on the

Rib fracture in infancy should be taken as very suspi- cious of non-accidental injury (NAI) until proved other- wise. It is always important to be sure of evidence so opinion from an expert radiologist should be sought.

PHYSICAL NEGLECT The following indicators, singly or in combination should alert workers:

leg and small bruises to both sides of the face. Grandmother explained that this was how she had held her own children by the face when telling them off. The leg bruises were linear smack marks. Photo- graphs were taken. Social workers gained a place of safety order and after review it was deemed the child remained at risk and was fostered.

lack of appropriate food

 
 

inappropriate or erratic feeding

 

Social paediatrics

17

hair loss

 

Definition for registration This occurs when a child’s essential needs are not met and this is likely to cause impairment to physical health and development. Such needs include food, clothes, clean- liness, shelter and warmth. A lack of appropriate care results in persistent or severe exposure, through negli- gence, to circumstances that endanger the child.

lack of adequate clothing

circulation disorders

unhygienic home conditions

lack of protection from exposure to dangers

failure or delay in seeking appropriate medical

 

attention

 

failure to reach developmental milestones.

 

SEXUAL ABUSE Children can make statements spontaneously or in a

 
 

CASE STUDY: Neglect

 

planned way and this is often dependent on their age.

A

6-year-old child had attended with his mother for

soiling for a number of years. His mother said that she gave him his medication. The child and his brothers ran wild to the extent that when the child and mother were brought in to hospital for enemas and toilet training over a weekend, the mother was called a number of times by neighbours to inform her that the other children were running riot around the neighbourhood. The child was discharged with little improvement. Eventually he was taken into care along with his brothers for lack of parental supervision and being out of control. The child was seen three months later at clinic in the care of a fos- ter parent. She had stopped his medication but had instituted a programme of 50 pence for sitting each evening and passing a stool and £1 if he did it with- out moaning. His soiling had resolved.

The following indicators should alert workers to the pos- sibility of the child being a victim of sexual abuse.

Physical indicators These include injuries in the genital area, infections or abnormal discharge in the genital area, complaints of geni- tal itching or pain, depression or withdrawal, wetting or soiling, day or night, sleep disturbances or nightmares, chronic illnesses, especially throat infections, venereal disease which may be diagnostic, anorexia or bulimia, unexplained pregnancy, phobias or panic attacks.

 

CASE STUDY: Rectal bleeding

A 2-year-old girl was presented by grandfather with a history of bright red rectal bleeding after eating a sausage roll which grandfather said had glass in it. The child had iron-deficiency anaemia. No blood was ever seen and no sausage roll with glass. Mother was very quiet and lived with grandfather and grandmother. Grandmother was said to be bedridden, mother was 17 years old and the child’s father was not ‘in contact’. The child presented again 10 years later with abdominal pain and vomiting. Mother had eventually moved out and was living with her boyfriend. Mother and boyfriend wanted counselling about ‘issues’ before mother would agree to marry her boyfriend.

 
 

CASE STUDY: Neglect

 

A

mother who was a registered drug addict on a

methadone programme was admitted with her 6-week-old infant who was reported by her health visitor not to be gaining weight and to be a poor

feeder but very irritable. The child was irritable but fed reasonably well with the ward nurses. Mum was an infrequent visitor to the ward, and when she did

come, there were two episodes where Mum was drowsy and nearly dropped the child onto the floor.

 
 

A

further episode took place where Mum fell asleep

in

a chair, lying over the child, and the child had to

General indicators These include self-harm, excessive sexual awareness or knowledge of sexual matters inappropriate for the child’s age, acting in a sexually explicit manner, displays of affec- tion in a sexual way inappropriate to age, sudden changes in behaviour or school performance or school avoidance, tendency to cling or need constant reassurance, tendency to cry easily, regression to younger behaviour such as

be

removed from Mum’s arms. A case conference was

convened by the social work department. Nursing evidence and other concerns were enough for the social work department to obtain a place of safety order. The child was taken into foster placement and thrived.

18

Community child health, child development, learning difficulties

thumb sucking, playing with discarded toys, acting like a baby, distrust of a familiar or anxiety about being left with a relative, a babysitter or a lodger, unexplained gifts or money, secretive behaviour, eating disorders, fear of undressing for gym, phobias or panic attacks.

 

50th. No weight had been gained for a year. Parents

said that she would not eat. Family were well known

to

social services as Mum was on a methadone pro-

gramme. Food diary showed that the child was largely given fizzy juice and ate crisps. The family had no real mealtimes and just ate in front of the television. The child was allowed to run around and started each meal with a large drink of juice. Father seemed controlling and the family were very difficult to engage.

 

CASE STUDY: Overt sexualized behaviour

   
 
 

A

13-year-old presented with abnormal behaviour.

 

She did not recognize her parents or others around her. She proceeded to move into a fugue-like state where she alternated between being very active and sitting silently on her bed. The active phases included episodes where she would take all her clothes off and imitate sexual acts.

Definition for registration Children who significantly fail to reach normal growth and developmental milestones (i.e. physical growth, weight, motor skills). Organic reasons must have been medically eliminated and a diagnosis of non-organic failure to thrive established.

Definition for registration Any child below the age of 16 years may be deemed to have been sexually abused when person(s), by design or neglect exploits the child, directly or indirectly, with any activity intended to lead to sexual arousal or other forms of gratification of that person or any other person(s) including organized networks.

FACTITIOUS ILLNESS SYNDROME (MUNCHAUSEN SYNDROME BY PROXY) Parents (often mothers) report fraudulent signs and may even simulate symptoms such as bleeding and fever. Children are exposed to needless investigation and hos- pital admission.

 

CASE STUDY: Vomiting blood

 

NON-ORGANIC FAILURE TO THRIVE The following indicators should alert workers to the possibility of abuse:

diarrhoea

A

3-year-old was admitted with a history of vomit-

ing bright red blood. No further vomiting of blood took place on the ward. The parents were very wor- ried and father was upper middle class and quite aggressive. Investigation including bloods and bar- ium meal failed to show a cause. The child was sent home but one month later presented again, this time with a pillow case covered in blood. Endoscopy was performed but nothing found. Six months later, the child was seen at a tertiary referral centre for paedi-

atric gastroenterology. Eventually, a further hospital pillowcase appeared with blood on it. It was shown that the blood group of the child did not match the blood group on the pillow.

child having little interest in food

 

child thriving away from home

unresponsive child

staying frozen in one position for an unnaturally long time

 

poor skin or muscle tone

 

circulatory disorders

lethargic child

height and weight centile falling away

abnormal relationships particularly at mealtimes, e.g. persistent withholding of food as a punishment.

 

Roles of agencies in child protection

 

CASE STUDY: Non-organic failure to thrive

 

All children have the right to protection and all adults have responsibilities to ensure that children receive such protection. The welfare of children is the responsibility of the whole local authority including social work, health, police and education services. Social work services assess the needs of children and provide appropriate services.

A

2-year-old was seen in clinic with failure to thrive

below the 2nd centile having started out on the

Social paediatrics

19

They make enquiries into the circumstances of children who may require compulsory measures of supervision. The role of the police is to prevent child abuse, protect the victim(s) and detect the offender. Health profession- als may be the first to see symptoms of abuse and should share information about concerns with social workers, police or the Reporter to the Children’s Hearing system at an early stage. General practitioners, general paediatri- cians and specialist paediatricians in child protection may take referrals from social work, police, education and legal departments to assess the needs and manage- ment of a child’s health in the context of interagency concerns about abuse.

WHERE THERE IS SUSPICION OF ABUSE

 
 

Child

History, general inspection and record

 

Ensure child’s safety

 
 

Obvious child abuse

Doubt

 

1 Contact social worker for information only

Refer to social work department

2 Assess and gather all other information, e.g. from general practitioner, community doctor, health visitor, school nurse, nursery staff

Attend child protection conference

The role of health professionals in child protection:

   
 

No ongoing concern

recognizing children in need of protection

contributing to enquiries including examination of children

Ongoing concern Refer to social worker

Record all new findings Monitor and review

Figure 1.2 The steps to follow when there is suspicion of abuse

participating in child protection conferences

providing therapeutic help to abused children and their parents

the information available with each other. When doing so the paramount consideration should be the welfare of the child. It is important that a distinction be made between agency checks and referrals.

playing a part through the child protection plan in safeguarding children.

Teachers are likely to have the greatest level of routine contact with children. Educational professionals have a major responsibility in identifying cases of child abuse. Any person may refer a child to the Reporter if they have reasonable cause to believe that the child may be in need of compulsory measures of supervision, that is measures of protection, guidance, treatment or control. The Procur- ator Fiscal is the local representative of the Lord Advocate in Scotland who is responsible for the prosecution of crime. To prosecute a perpetrator in the criminal courts

KEY LEARNING POINTS

 

In all cases of suspected abuse:

 

inform senior colleague who is ultimately responsible for the case

 

inform social work department and discuss management

inform parent (unless it puts child at risk of harm)

record accurate details of history and clinical findings with diagrams

proof must be beyond reasonable doubt, but lack of this does not stop the Children’s Hearings system providing a

supervision order to protect a child when proof is at the level of balance of probabilities.

Deciding on how to respond

send report to relevant trust health professional with responsibility for child protection

send report to manager of social work depart- ment for child protection conference purposes

attend child protection case conference.

Referrals about concerns over a child’s welfare will not always require a response under child protection proced- ures. In every referral professional judgement will need to be exercised to decide upon the most appropriate response (Figure 1.2). The local authority social work service has the statutory duty to protect children, in part- nership with other agencies. It should be stressed, how- ever, that no one agency can or should work in isolation from the others. Therefore when deciding how best to respond to a referral, agencies should consult and discuss

The medical examination

 

Where abuse is suspected, a full health assessment should be carried out including a detailed medical his- tory and general physical examination including health and emotional needs. A two doctor examination should be conducted in cases of suspected child sexual abuse by doctors experienced in forensic examination at a time

20

Community child health, child development, learning difficulties

and in a place appropriate to the case to avoid duplica- tion of examination. Examinations should be sensitive, child-centred and conducive to the best outcome for the child. A medical examination may not provide evidence that child abuse has occurred, and absence of medical evidence does not automatically mean absence of abuse. Information from medical examinations should be con- sidered alongside information from social workers, police and any other relevant agency.

A child appears to be suffering from physical neglect.

Any allegation of child sexual abuse including touching over clothes, fondling, attempted or actual digital penetration, a penetrative episode.

Concern about non-organic failure to thrive.

WHO DECIDES TO ARRANGE A MEDICAL EXAMINATION? The senior social worker should discuss with police and relevant medical personnel (as above) and agreement should be reached on whether a medical examination is required and what it will achieve, type of medical required, who should conduct it, where and when it should be conducted. Whether face to face or on the telephone, dis- cussions and decisions on how to proceed should be clearly documented. If it is agreed to arrange a medical exam- ination or assessment it is important that the examining doctors have clear information about the causes of con- cern, the social background including previous instances of known or suspected abuse.

The purpose of the medical examination is:

to provide a full health assessment of the child’s needs

to establish what immediate treatment the child may require

to provide an opinion on whether or not child abuse has occurred

to provide evidence where appropriate to sup- port a referral to the Children’s Hearings system (via the Reporter) or for criminal proceedings

to secure any further medical assistance for the child if required

where appropriate to reassure the child and family that no long-term physical damage has occurred.

TIMING With physical injury, it is important to arrange a medical examination as soon as possible so that signs of injury such as bruising do not fade. With sexual abuse, if there has been any form of recent sexual assault it is imperative to arrange a medical examination within 72 hours of the last incident in order to obtain forensic evi- dence. If more than 72 hours has passed since sexual assault allegedly occurred then time could be spent plan- ning the medical. In situations where the GP is unsure whether the clinical presentation is due to abuse or illness, for example a child with unexplained severe bruising which could be due to a haematological con- dition, referral to the hospital for a paediatric opinion prior to initiating interagency discussions may be indi- cated. It is important to provide the hospital paediatri- cians with available social background that may suggest abuse.

WHERE TO ARRANGE A MEDICAL EXAMINATION AND/OR ASSESSMENT An appropriately equipped paediatric facility with experi- enced paediatric nursing staff is required. For physical injury, access to a good X-ray facility and high-quality medical photography are essential. For sexual abuse specialist video-colposcopy facilities are required.

WHEN TO ARRANGE A MEDICAL EXAMINATION FOR SUSPECTED CHILD ABUSE There should be a three-way discussion between social workers, the police and a medical practitioner (consult- ant paediatrician in child protection, general paediatric consultant, community paediatrician or a GP) to decide whether and when a medical examination is required.

Some circumstances which require a medical examination

RECORD KEEPING Records should be detailed and legible as original records may be required later for criminal proceedings. Special sheets, which include diagrams of body parts and detailed diagrams of the genitalia, should be available to aid description of injuries. Detailed measurements should be included. Details of the full names, addresses and contact

A child has physical injuries which he or she states were inflicted.

A child has injuries and the explanation is not consistent with the injuries.

Social paediatrics

21

telephone numbers of family members and friends and other professionals involved are invaluable and should be clearly documented in the notes. It is important for clin- icians to note carefully any explanations given for injuries. Records should note the date and time of any incident and the date and time the record was made. Written reports of findings should be provided at an early stage to the police and local authority (social work) if the child’s case is the subject of court proceeding or a children’s hearing. Profes- sional records may need to be made available to the police, the Reporter and the courts.

capacity, can still refuse the examination as a whole or any part of it, e.g. photography.

KEY LEARNING POINT

Child can decline examination if deemed to have legal capacity.

PHOTOGRAPHY For both physical abuse and sexual abuse, high-quality photography is an essential part of recording of injuries. This is aided by colposcopy in cases of sexual abuse.

Records should include:

 

details of any concerns about the child and family

KEY LEARNING POINT

details of contact with the family or other agencies

the findings of any assessment

A

must be present and witness medical photographs

doctor above senior house officer (SHO) level

decisions made about the case within each agency or in discussions with other agencies

to

be used in court.

a note of information shared with other agencies, with whom and when.

Referral to the Reporter of the Children’s Hearings system

 

This guidance reflects the 1998 Scottish Office guidelines Protecting Children – A Shared Responsibility. Ensuring the swift and well-informed referral of vulnerable children who require compulsory support, guidance, protection and control is the overriding consideration. The decision to refer a child to the children’s Reporter is a significant step with potentially far-reaching consequences for the child and his/her family/carers. A number of general principles should be applied when decisions are being taken.

KEY LEARNING POINT

 

Good record keeping is essential both for protect- ing the child and for evidential purposes. Take the full name, address and telephone number of every- body involved including police, social worker, the Reporter, parents, grandparents, etc. Make sure your notes are legible and detailed. Make sure if you are a junior, whoever is supervising you also writes in the notes.

The child’s welfare shall be the paramount consider- ation when deciding whether or not to refer a child

 

to

the Reporter.

Agencies are required to take into account the views

CONSENT The Age of Legal Capacity (Scotland) Act 1991 provides that a person under the age of 16 years shall have the legal capacity to consent on his or her own behalf to any surgical, medical or dental procedure or treatment, includ- ing psychological or psychiatric examination, where, in the opinion of an attending qualified medical practitioner, he or she is capable of understanding the nature and possible consequences of the procedure or treatment. If the local authority believes that a medical examination is required to find out whether concerns about a child’s safety or welfare are justified, and parents refuse con- sent, the local authority may apply to a sheriff for a Child Assessment Order. The child, if deemed to have legal

of

children and families and to work in partnership

with them.

Local authorities (e.g. social work department) have a statutory duty to safeguard and promote the welfare

of

children.

There are different statutory provisions relating to refer- ral of a child to the Reporter. The law recognizes three dis- tinct providers of such information.

The local authority (e.g. social work department) should refer to the Reporter all cases of suspected child abuse.

The police inform the Reporter of abuse cases with criminal proceeding.

22

Community child health, child development, learning difficulties

Any other person (e.g. health professionals) should refer a case to the Reporter if compulsory measures of care, protection or control may be, in their opin- ion, in the best interests of the child.

l is being provided with accommodation by a local authority under section 25, or is the subject of a parental responsibilities order obtained under section 86 of the Act and, in either case, his behaviour is such that special measures are necessary for his adequate supervision in his interest or the interest of others.

 

Grounds for referral of children to the Reporter and to the Children’s Hearings system

 

A

child may be in need of compulsory measures of

supervision if any of the following conditions is sat- isfied with respect to her or him (section 52(2) of the Children (Scotland) Act 1995).

Most referrals by health professionals are likely to arise from concerns relating to childcare and protection. They should also consider referral of children on other grounds, e.g. school-related issues or misuse of drugs, alcohol or volatile substances.

a

is

beyond control of any relevant person

b

is

falling into bad associations or is exposed

 

to

moral danger

 
   
 

c

is

likely:

 

CASE STUDY: Child with speech delay

 
 

i to suffer unnecessarily or

ii

to be impaired seriously in his health or development, due to a lack of parental care

 

A 4-year-old girl had been referred to the child development centre (CDC) with speech delay at age 2 years. The child attended the CDC once but did not attend for follow-up or for a hearing test with the educational audiologist or for blood tests or for assessment by a speech and language therapist. Every time the educational psychologist tried to see the child in the nursery placement Mum failed to arrive. The speech and language therapist made appointments with the mother to meet her at home but she was never there. The child was due to go to school, the nursery thought the child needed further help perhaps from the language unit, but nobody had managed to make a complete assessment of the child due to parental non-cooperation/neglect. After discussions at a language panel meeting this child was referred to the Reporter by the community paediatrician. Suddenly, all appointments were kept and the assessment proceeded quickly.

 

d

is

a child in respect of whom any of the offences

 

mentioned in Schedule 1 to the Criminal Procedure (Scotland) Act 1995 has been committed (Note: These are offences against children to which special provisions apply. Among the most common of these are sexual

offences against children, assault, neglect and abandonment)

 

e

is,

or is likely to become, a member of the same

 

household as a child in respect of whom any offences referred to in paragraph d above has

been committed

 

f

is, or is likely to become a member of the same household as a person who has committed any of the offences referred to in paragraph d

g

is,

or is likely to become, a member of the same

 

household as a person in respect of whom an offence under sections 1 to 3 of the Criminal Law (Consolidation) (Scotland) Act 1995 (incest and

intercourse with a child by a step-parent or person

 

in

position of trust) has been committed by a

member of that household;

When making a referral to the Children’s Reporter, agencies or individuals must not take into consideration whether they believe there is sufficient evidence for grounds for referral to be established. Considerations relat- ing to sufficiency of evidence and standard of proof are exclusively a matter for the Reporter. Referral should be made where a health professional has reasonable cause to believe that a child may be in need of compulsory meas- ures of supervision. In terms of the Children (Scotland) Act 1995, ‘supervision’ in this context may include meas- ures taken for the protection, guidance, treatment, or

 

h

has failed to attend school regularly without reasonable excuse

i

has committed an offence

j

has misused alcohol or any drug, whether or not a controlled drug within the meaning of the Misuse of Drugs Act 1971

k

has misused a volatile substance by deliberately inhaling its vapour, other than for medical purpose

Social paediatrics

23

control of the child. It is essential that sufficient and speedy referral be made. Consultation by telephone is encouraged before making a referral. Each referral should be dated and signed by the author.

a child protection plan to safeguard the child. There are four types of conference: initial, review, pre-birth and transfer (to another geographic area). Social work serv- ices are responsible for convening, chairing and minut- ing a child protection conference, but any agency can request a child protection conference by contacting the team leader for social work in the area the child resides. Parental involvement at child protection conferences should be the rule rather than the exception. It is vital that health professionals in the primary care team and any other medical or health staff involved attend to describe and interpret medical findings and relevant background information. Health professionals should normally provide written reports of their involvement and any assessment and findings.

All referrals to the Reporter should contain the fol- lowing information (if known):

full name, address (present and normal address), and date of birth of child/children being referred

any special requirements of the child or family, e.g. religion, disability, ethnic origin, language, etc.

details of all other children in the household with a clear indication of whether the agency also intends to refer them

full names and address of parents/carers

 
 

name of child’s GP and health visitor

Tasks undertaken by a child protection conference

a clear indication of whether the child is subject

to any orders or legal requirements including details of any restrictions on contact

whether or not the referral has been discussed with the family

whether or not the child is attending child and adolescent mental health services

Ensure that all relevant information is shared and collated.

Assess the degree of existing and likely future risk to the child.

Identify the child’s needs and any services required to help him or her.

a summary of the reason(s) for referral to the Reporter

a factual account of the circumstances relating to the referral and names and addresses of all parties involved, e.g. how, when and by whom the incident was discovered.

Formulate or review a child protection plan which includes a decision whether to place a child on the Child Protection Register.

 
 

CASE STUDY

Referrals to the police

Although the police have a clear role in investigating offences against children, it is the responsibility of social work services to assess the needs and possible risks to a child about whom concerns have been expressed. A referral to the police should be made when there is rea- son to believe child protection measures are required. In order to determine whether such measures are required, there is an onus on social work services to assess the situ- ation and circumstances of the child.