Ebook Practical paediatric problems: Part 1

(BQ) Part 1 book “Practical paediatric problems” has contents: Community child health, child development and learning difficulties, behavioural and emotional problems, clinical genetics, acute illness, injuries, and ingestions, fetal and neonatal medicine, problems of infection, immunity and allergy,… and other contents.

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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

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issued by the Copyright Licensing Agency In the United Kingdom such

licences are issued by the Copyright Licensing Agency: 90 Tottenham

Court Road, London W1T 4LP.

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.

British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library

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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

Commissioning Editor: Sarah Burrows

Project Editor: Naomi Wilkinson

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To Wilma and Annette, for their patience while

this book was being written.

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Michael Morton and Elaine Lockhart

John Tolmie

Jack Beattie and David Hallworth

J Coutts, JH Simpson and AM Heuchan

6 Problems of infection, immunity and allergy 161

Rosie Hague

R McWilliam and Iain Horrocks

Neil Gibson

Alan Houston and Trevor Richens

10 Gastrointestinal system, hepatic and biliary problems 309

Peter Gillett

Alison M Kelly, Diane M Snowdon and Lawrence T Weaver

Jim Beattie and Amir F Azmy

16 Musculoskeletal and connective tissue disorders 485

Janet M Gardner-Medwin, Paul Galea and Roderick Duncan

William Newman

Contents

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18 Dermatology 539

Rosemary Lever and A David Burden

C Age and gender speciﬁc blood pressure centile data 657

D Surface area nomograms in infants and children 663

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Jack Beattie

Consultant in Emergency Medicine

Acute Ambulatory Assessment Unit

Royal Hospital for Sick Children

Yorkhill

Glasgow

Jim Beattie

Consultant Paediatrician and Nephrologist

Yorkhill

Glasgow

Amir F Azmy

Consultant Paediatric Urologist

Professor, Division of Paediatric Surgery

Yorkhill

Glasgow

J Brian S Coulter

Senior Lecturer in Tropical Child Health

Liverpool School of Tropical Medicine

Senior Lecturer in Child Health

University Department of Child Health

Brenda Gibson

Consultant HaematologistRoyal Hospital for Sick ChildrenYorkhill

Glasgow

Peter Gillett

Consultant Paediatric GastroenterologistRoyal Hospital for Sick ChildrenSciennes Road

David Hallworth

Consultant in Anaesthesia and Intensive CareRoyal Hospital for Sick Children

YorkhillGlasgow

Contributors

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Anne Marie Heuchen

Specialist Registrar in Paediatric Neurology

Yorkhill

Glasgow

Alison M Kelly

Specialist Registrar in Paediatric Gastroenterology,

Hepatology and Nutrition

Consultant Child and Adolescent Psychiatrist

Yorkhill

Glasgow

Robert McWilliam

Consultant Paediatric Neurologist

Yorkhill

Glasgow

Michael Morton

Consultant Child and Adolescent Psychiatrist

Department of Child and Family Psychiatry

Yorkhill

Glasgow

William Newman

Consultant Paediatric Ophthalmologist

Royal Liverpool Children Hospital

Alder Hey

Liverpool

Wendy Paterson

AuxologistDepartment of Child HealthRoyal Hospital for Sick ChildrenYorkhill

Glasgow

Trevor Richens

Consultant CardiologistRoyal Hospital for Sick ChildrenYorkhill

Glasgow

Kenneth J Robertson

Consultant PaediatricianRoyal Hospital for Sick ChildrenYorkhill

Judith H Simpson

Consultant NeonatologistQueen Mother’s HospitalYorkhill

Glasgow

Lawrence T Weaver

Professor of Child HealthUniversity Department of Child HealthRoyal Hospital for Sick ChildrenYorkhill

Glasgow

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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 andtheir 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 onlyclearly guide their readers to achieve success in BasicSpecialist Training and the MRCPCH examinations, butwill also give them an excellent basis for higher specialisttraining It will also enable them to deal with practicalpaediatric problems throughout their subsequent careers

as paediatricians

Forrester CockburnEmeritus Professor of Child Health

University of Glasgow

May 2005

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In the 40 years since the publication of the ﬁrst edition

of Practical Paediatric Problems, paediatrics has become

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-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

in the UK is planned, including the introduction of newer

methods of assessment, examinations are likely to remain

a necessary hurdle in professional development For

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

recent RCPCH publication, A Framework of Competences

for Basic Specialist Training in Paediatrics (2004).

Major reference textbooks in paediatrics are either tem or disease based; however, as in other areas of clinicalmedicine, patients frequently present with ill structuredproblems and there is therefore a need for a symptom-based text to assist in clinical problem solving In thisregard we hope that the book will be of value to practisingpaediatricians, paediatric surgeons, accident and emer-gency staff, general practitioners and indeed any clinicianwhose practice includes children and young people

sys-By necessity, this book is multi-author and all theauthors in this book are experts from a broad range ofdisciplines within paediatrics, but we acknowledge andapologize in advance for any gaps that are inevitable in

a book of this size We hope the provision of referencesources with each chapter will go some way in addres-sing any deﬁciencies and we would welcome readers’suggestions and criticisms In addition, while every efforthas 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 hardwork, to Joanna Koster, Sarah Burrows and NaomiWilkinson of Hodder Arnold for their immense patienceand support, to Dr Peter Galloway, Consultant in MedicalBiochemistry, RHSC, Yorkhill, to our respective secretariesLynda Lawson and Kay Byrne for their expert and will-ing help in a project that inevitably took a lot longerthan planned and ﬁnally to our wives and families fortheir forbearance

Jim Beattie and Robert CarachiRHSC, Yorkhill, Glasgow

May 2005

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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HISTORY OF COMMUNITY CHILD

HEALTH

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 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

provi-Community child health, child development and learning difﬁculties

David Tappin

Chapter 1

The Court Report (1976) produced a framework for the integration of hospital, community andgeneral practice care of children, which has slowlycome about

K E Y L E A R N I N G P O I N T

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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 sericontinu-ous ill

health or disability, or because of their own personal

circumstances (Scottish Executive, 2004)

CORE PROGRAMME FOR CHILD HEALTH

SCREENING AND SURVEILLANCE

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

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)

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

‘Child health surveillance – used to describe routine

child health checks and monitoring

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

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,

as well as for school-aged children and youngpeople (Table 1.2)

● The reduction from the previous routinecontacts schedule allows giving additionalsupport to certain groups and intensive support

to vulnerable families who need it

K E Y L E A R N I N G P O I N T S

Vulnerable groups include:

● ‘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

● Children living away from home

● Children excluded by language barriers

● Traveller families

● Families living in temporary or bed and fast accommodation

break-● 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

● Runaways and street children

● Asylum seekers and refugees, particularly if unaccompanied

● Children in secure settings

● Children of parents in prison’

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‘Targeting support for vulnerable children’ 3

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

immunization, information, advice on services

FAMILY HEALTH PLAN

Additional support from public health nurse as agreed with family Structured support (e.g first-time mother, breastfeeding problems, mental health problems)

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)

Health for All Children: Guidance on Implementation in Scotland A draft for consultation.

Edinburgh: Scottish Executive)

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 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:

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)

Vitamin KEach 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

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

HDL (2001) 51, which issued in June 2001, advised theservice about the introduction of universal neonatal hearingscreening The introduction of hearing tests for all neonates isalso a Partnership Agreement commitment Implementation isunderway with the establishment of two pathﬁnder sites inTayside and Lothian, where screening began in January 2003and March 2003, respectively NHS Boards are expected toimplement the screening programme by April 2005

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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

Blood spot test for – phenylketonuria (PKU), hypothyroidism and

Mother’s health and wellbeing

Discussion of birth registration

● Oral health

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

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)

Advise that no screening test is perfect Details of signs and tial emerging problems in PCHR and who to contact if concernedFrequency of visits

poten-Visits to the family home are usual on several occasions withinthe ﬁrst 10 days of life Some new parents may need to be seenmore frequently than others In particular, additional supportshould be provided for babies who have special needs or whoneeded treatment in the neonatal intensive care unit

WeightWhoever is responsible for weight measurement must be able todeal with questions about the interpretation of the weight chart

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

WeightWhoever is responsible for weight measurement must be able todeal with questions about the interpretation of the weight chartHead circumference

If no concern at this stage, no further routine measurementrequired

HDL (2001) 73, which issued in October 2001, advised aboutthe introduction of a neonatal screening programme for cysticﬁbrosis using the existing blood spot test The programme wasintroduced across Scotland in February 2003

Whoever is responsible for immunisation must be able to dealwith questions about vaccines

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Hearing and communication

Vision and social awareness

● Follow angling object past midline

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

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

4 Months

Action: Lead professional, GP, public health nurse

Weight

(Continued)

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12–15 months

Action: Primarily GP, practice nurse or public health nurse

Weight measurement

● Oral health

4–5 years

Action: Orthoptist

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

Whoever is responsible for immunisation must be able todeal with questions about vaccines

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

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Sweep test of hearing (continue pending further review)

Identify children who may not have received pre-school health

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:

Primary 7

Other health promotion activity should include:

Secondary school

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

Dental check at S3 through the National Dental Inspection

Programme

Other health promotion activity should include:

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

Edinburgh: Scottish Executive

Vision testingVision testing on school entry should only be undertaken where

a universal pre-school orthoptic vision screening programme isnot in place

Dental checksNational Dental Inspection Programme identiﬁes children atgreatest risk of oral disease and is used to inform the schoolhealth plan

National Dental Inspection Programme identiﬁes children atgreatest risk of oral disease and is used to inform the schoolhealth plan

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

Physical examinationThere is no evidence to justify a full physical examination or healthreview based on questionnaires or interviews on school entry

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

National Dental Inspection Programme identiﬁes children atgreatest risk of oral disease and is used to inform the schoolhealth plan

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‘Assessing vulnerability’ (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

● 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.

‘As well as assessing and targeting individual able children and families, NHS Boards should assess thelevel of vulnerability of communities This will meantargeting resources such as Public Health Nurses to themost deprived communities in their population’ (ScottishExecutive, 2004)

vulner-‘Child protection’ (Scottish Executive, 2004)

All agencies and professionals in contact with children and families have an individual and shared responsibility to contribute to the welfare and protection of vulnerable children and young people This applies to services for adults working with parents to tackle problems 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 support 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.

‘Starting Well Demonstration Project – Family

Need Score’

‘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

The family’s score is reviewed approximately everythree months and is recorded in the Family HealthPlan The data are also entered on the Starting Welldatabase to enable on-going population needsassessment 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)

● Targeting support for vulnerable families often requires multi-agency assessment ofvulnerability, which should includeconsideration of the child’s developmentalneeds, parenting capacity, and wider familyand environmental factors

● Support required is likely to be from more thanone agency and needs coordination to avoidduplication or omission

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‘Information collection and sharing’ 9

‘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)

‘INFORMATION COLLECTION

AND SHARING’ (SCOTTISH

EXECUTIVE, 2004)

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.

‘National guidance sets out the requirements for ive working in partnership with parents This depends

effect-on good informatieffect-on for parents from professieffect-onals’(Scottish Executive, 2004)

‘Health professionals should inform and advise parentsand, where appropriate, children, that to provide propercare, information is recorded in written records and oncomputer Sharing information between professionalsand agencies should be based on parental consent unlessthere are concerns about a child’s welfare or safetywhich would override patient conﬁdentiality’ (ScottishExecutive, 2004)

‘Induction for staff working with children in all

agencies should include:

● Training to raise awareness of child abuse and

neglect and agency responsibilities for child

protection

● 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)

‘Systems for recording, storing and retrieving

infor-mation gathered from children and families or

generated in the course of professionals work

provide:

● A record for the clinician or practitioner of the

work undertaken and the outcomes to assist

their ongoing work with the family and to

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)

ensure they are accountable to their patient orclient, to their profession and to their employingorganisation or equivalent

● Aggregate information about presentingconditions and problems, what was done and the outcome to assist managers and planners

to assess needs and plan services

● Information for families about their child’s health status and treatment or care’ (ScottishExecutive, 2004)

‘Achieving partnerships with parents and children inthe planning and delivery of services to childrenrequires that:

● They have sufﬁcient information at an earlystage both verbally and in writing to makeinformed 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 andstatements for meetings where necessary

● Professionals and other workers listen to andtake account of parents’ and carers’ views

● Families are able to challenge decisions taken

by professionals and make a complaint if necessary

● Families have access to independent advocacywhen appropriate’ (Scottish Executive, 2004)

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‘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

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.

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

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 information on child health.

SECONDARY AND TERTIARY CARE FOR CHILDREN

Secondary care for children takes place in both a tal and a community setting Paediatricians based inhospital have traditionally seen all acutely ill childrenreferred from primary care, have looked after premature

hospi-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 oftendealt with ‘educational’ medicine, have looked after chil-dren ‘in care’ for fostering and adoption, have dealt with

‘developmental’ problems and have increasingly beenpassed the responsibility for ‘child protection’ Over thepast 10 years, secondary care paediatrics has become

more combined as consultant paediatricians have been

appointed to replace senior clinical medical ofﬁcers inthe community Future plans are based around the com-munity health partnerships (CHPs), where seven or eightconsultant paediatricians (some mostly working in ahospital setting and some in the community) will lookafter 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 trict general hospital The eight paediatricians will be

dis-‘The Scottish Executive is working with local

authority and health partners in Aberdeen, Glasgow,

Dumfries and Galloway and Lanarkshire to pilot the

following:

● 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)

‘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)

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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

TERTIARY CARE FOR CHILDREN

‘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 paedipaedi-atrics –

child protection, adoption and fostering, and looked

after/vulnerable children, child mental health – which

may include educational medicine and public health

paediatrics

OUTREACH: HOSPITAL AT

HOME/DIRECT ACCESS

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

SOCIAL PAEDIATRICS

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

The Children’s Hearings system and the reporter

Successive UK governments have highlighted the culty of dealing with children who offend The need for asystem different from juvenile courts is well recognized

difﬁ-In Scotland such a system has been in place for over 30years The system is not concerned with guilt or innocencebut the welfare or best interests of the child This prin-ciple is applied whether the child has offended or has beenoffended against or abused One system deals with juvenilecriminal justice and children’s welfare

How the system came about

In the late 1950s and early 1960s it had become ingly evident that change was required in how societydealt with children and young people To this end a com-mittee was set up under Lord Kilbrandon to investigatepossible solutions The principles underlying the Children’sHearings system were recommended by the Committee onChildren and Young Persons (the Kilbrandon Committee)which reported in 1964 The Committee found that chil-dren and young people appearing before the courtswhether they had committed offences or were in need ofcare or protection had common needs for social and per-sonal care The Committee considered that juvenile courtswere unsuited for dealing with these problems becausethey had to combine the characteristics of a criminal court

increas-of law with those increas-of a treatment agency Separation increas-ofthose functions was therefore recommended; the establish-ment of the facts where disputed was to remain with thecourts, but decisions on treatment were to be the responsi-bility of a new and unique kind of hearing The Hearingssystem represents one of the radical changes initiated bythe Social Work (Scotland) Act 1968 On 15 April 1971 theHearings took over from the courts most of the responsi-bility for dealing with children and young people under

Social paediatrics 11

The Children’s Hearings system is not concerned withguilt or innocence but with the welfare and bestinterests of the child

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the age of 16 years who commit offences or who are in

need of care or protection

Why are children brought to the attention

of a hearing?

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

● failing to attend school

● indulging in solvent abuse

● misusing alcohol or drugs or has committed an

offence

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

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

decid-● The Reporter may decide that no further action isrequired, and the child or young person and parent

or other relevant person is then informed of thedecision It is not unusual for the Reporter to conveythis decision in person in offence cases when thechild may be warned about their future behaviour

● The Reporter may refer the child or young person tothe local authority with the request that socialworkers arrange for such advice, guidance andassistance, on an informal basis, as may beappropriate for the child

● The Reporter may arrange to bring the child to ahearing because in his or her view the child is inneed of compulsory measures of supervision

Children under 16 years are only considered for ecution in court where serious offences such as murder

pros-or assault to the danger of life are in question pros-or wherethey are involved in offences where disqualiﬁcation fromdriving is possible However, in cases of this kind it is by

no means automatic that prosecution will occur, and wherethe public interest allows, children in these categoriesare referred to the Reporter by the Procurator Fiscal fordecision on referral to a hearing Where the child oryoung person is prosecuted in court, the court may referthe case to a hearing for advice on the best method ofdealing with them The court on receipt of that advice or

in certain cases without seeking advice ﬁrst, may remitthe case for disposal by a hearing

Children’s panelsMembers of a children’s panel volunteer to serve andcome from a wide range of occupations, neighbourhoodand income groups All have experience of and interest inchildren and the ability to communicate with them andtheir families There is an approximate balance betweenmen and women and individuals aged between 18 and 60years can apply to become panel members The panelmembers are carefully prepared for their task through

● 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

a referral

● The Reporter looks at the evidence and decides

if there is a case for seeking compulsory

supervision

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 opinionthat compulsory supervision is required

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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

SELECTION AND APPOINTMENT OF PANEL MEMBERS

People are appointed or reappointed to panels by Scottish

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

a 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

The hearings

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

a Hearing In certain speciﬁed circumstances a child or

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

ATTENDANCE AT A HEARING

A hearing is usually held at a place in the child or youngperson’s home area The layout of the room where theHearing takes place is informal with the participants gen-erally sitting round a table Normally, the child or youngperson must attend They have the right to attend allstages of their own Hearing The Hearing may, however,suggest that they need not attend certain parts of thehearing or even the whole proceedings – for example, ifmatters might arise that could cause distress

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

rele-is compulsory by law, and failure to appear may result inprosecution 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 ofthe Chairman of the Hearing No one is admitted unlessthey have a legitimate concern in the case or with thepanel system The Hearing is, therefore, a small gatheringable to proceed in an informal way and to give the childand his or her parents the conﬁdence to take a full part

in the discussion

The Hearing’s task is to decide on the measures ofsupervision that are in the best interest of the child oryoung person It receives a report on the child and his orher social background from the social work department

of the local authority and, where appropriates, a reportfrom the child’s school Medical, psychological or psychiatric reports may also be requested Parents areprovided with copies of these reports

Children’s panels are made up of trained

volunteers – local men and women

of grounds, in which case they are likely topass the case back to the children’s panelhearing

● 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 proceedmore easily

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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

SUPERVISION

If the Hearing thinks compulsory measures of

supervi-sion are appropriate it will impose a supervisupervi-sion

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

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

LEGAL ADVICE AND AID

Legal advice is available free or at reduced cost under theLegal Advice and Assistance Scheme to inform a child ortheir parents about their rights at the Hearing and toadvise about acceptance of the ground for referral Legalaid is not available for representation at the Hearing, butmay be obtained for appearances in the Sheriff Courteither 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 supervisionrequirement 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, thesupervision requirement may be discharged, continued oraltered A child, parent or other relevant person canrequest the review after three months, but the social workdepartment may recommend a review at any time Thereporter arranges review hearings

RESOURCES

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

to the training of panel members This funding providesfor training organizers, who prepare and deliver trainingbased at Aberdeen, Edinburgh, Glasgow and St Andrewsuniversities Responsibility for meeting the costs of thistraining 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 thesupervision requirements made by hearings

RESEARCH AND STATISTICS

Much research has been conducted on the Hearings tem; most of it has been carried out by researchers based

sys-at Scottish universities, sometimes with the support offunds from other countries A review of the research and

a number of other signiﬁcant studies have been lished Detailed references to recent or signiﬁcant publica-tions are available from the Children’s Hearings website(www.childrens-hearings.co.uk)

pub-Child protection

The Hearing’s task is to decide on the measures of

supervision that are in the best interest of the child

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investi-Social paediatrics 15

Signs of abuse

A child who has been abused or neglected may showobvious physical signs; however, many children withoutsuch signs signal possible abuse through their behaviour.When professionals listen to and take seriously what chil-dren say they are far more likely to detect abuse Childrenwith special needs are particularly vulnerable Categories

of abuse are often mixed but have been labelled physicalabuse, physical neglect, non-organic failure to thrive, sexual abuse and emotional abuse A rare form of abuse issimulated or induced illness (factitious illness syndrome,Munchausen syndrome by proxy)

PHYSICAL INJURY POSSIBLY CAUSED BY ABUSE

B r u i s i n g

● Black eyes as most accidents only cause one

● 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 indicatingconstriction or shaking

● Petechial bruising around the mouth or neck

● It is rare to have accidental bruising on the back,back of legs, buttocks, neck, mouth, cheeks, behindthe ear, stomach, chest, under the arm, in the genital

or rectal area

● Mongolian blue spots are patches of blue-black mentation classically found on the lumbar and sacralregions of Afro-Caribbean children at birth but also

pig-on children of other skin colours including white

B i t e s

● Bites leave clear impressions of the teeth

B u r n s , s c a l d s

● Burns and scalds with clear outlines are suspicious

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

Scotland

Children (Scotland) Act 1995

● Social workers have a statutory duty to

investi-gate reports and take appropriate action to

safeguard a child’s welfare

● 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

(From Scottish Ofﬁce (2000) Protecting Children – A

Shared Responsibility: Guidance for Health

Profes-sionals London: HMSO.)

● 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

● 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

individual needs and stages of development andthe child is, or will be, at risk through avoidableacts of commission or omission on the part oftheir custodian

● Child protection is when a child needs protectionfrom child abuse

● 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.

(From Department of Health (1991) Working Together

Under the Children Act London: HMSO.)

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got in themselves They will have splash marks

where they struggled to get out

● Small round burns may be cigarette burns

S c a r s

● 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

Fr a c t u r e s

● These should be suspected if there is pain, swelling

and discoloration over a bone or joint

● 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

G e n i t a l , a n a l b r u i s e s

● It is unusual for a child to have bruising or bleeding

in this area

S h a k e n b a b y

● Subdural haemorrhages, retinal haemorrhages,

fractures of ribs or long bones

P o i s o n i n g

● May occur in factitious illness syndrome

(Munchausen by proxy)

D e f i n i t i o n f o r r e g i s t r a t i o n

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

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

suspi-PHYSICAL NEGLECT

The following indicators, singly or in combination shouldalert workers:

● lack of appropriate food

● inappropriate or erratic feeding

CASE STUDY: Bruising

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

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

CASE STUDY: Fractures

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

CASE STUDY: Fractures

An 18-month-old was admitted after a two-monthhistory of a limp after a fall A healed tibial fracturewas seen on radiograph A signiﬁcant gap betweenthe event and presentation was present and there-fore non-accidental injury (NAI) suspected Expertopinion from a paediatric orthopaedic surgeondescribed this as a ‘typical’ toddler’s fracture and associal workers and health visitor had no worriesabout the family, NAI was ruled out

CASE STUDY: Shaken baby

An infant presented after being looked after bystepfather with a history of stopping breathing andrequiring mouth-to-mouth resuscitation The infantwas brought in by blue light ambulance not breath-ing On examination there was a full fontanelle andtonic 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 neurological assessment is made so that intervention

can be performed.

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● hair loss

● lack of adequate clothing

● circulation disorders

● unhygienic home conditions

● lack of protection from exposure to dangers

● failure or delay in seeking appropriate medical

SEXUAL ABUSE

Children can make statements spontaneously or in aplanned way and this is often dependent on their age.The following indicators should alert workers to the pos-sibility of the child being a victim of sexual abuse

P h y s i c a l i n d i c a t o r s

These include injuries in the genital area, infections orabnormal discharge in the genital area, complaints of geni-tal itching or pain, depression or withdrawal, wetting orsoiling, 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

G e n e r a l i n d i c a t o r s

These include self-harm, excessive sexual awareness orknowledge of sexual matters inappropriate for the child’sage, 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

CASE STUDY: Neglect

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

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

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

CASE STUDY: Rectal bleeding

A 2-year-old girl was presented by grandfather with

a history of bright red rectal bleeding after eating asausage roll which grandfather said had glass in it.The child had iron-deﬁciency anaemia No bloodwas ever seen and no sausage roll with glass Motherwas very quiet and lived with grandfather andgrandmother Grandmother was said to be bedridden,mother was 17 years old and the child’s father wasnot ‘in contact’ The child presented again 10 yearslater with abdominal pain and vomiting Motherhad eventually moved out and was living with herboyfriend Mother and boyfriend wanted counsellingabout ‘issues’ before mother would agree to marryher boyfriend

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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

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

NON-ORGANIC FAILURE TO THRIVE

The following indicators should alert workers to the

possibility of abuse:

● diarrhoea

● child having little interest in food

● child thriving away from home

● height and weight centile falling away

● abnormal relationships particularly at mealtimes,

e.g persistent withholding of food as a punishment

Children who signiﬁcantly fail to reach normal growth anddevelopmental milestones (i.e physical growth, weight,motor skills) Organic reasons must have been medicallyeliminated and a diagnosis of non-organic failure to thriveestablished

FACTITIOUS ILLNESS SYNDROME (MUNCHAUSENSYNDROME BY PROXY)

Parents (often mothers) report fraudulent signs and mayeven simulate symptoms such as bleeding and fever Children are exposed to needless investigation and hos-pital admission

Roles of agencies in child protectionAll children have the right to protection and all adultshave 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

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

50th No weight had been gained for a year Parentssaid that she would not eat Family were well known

to social services as Mum was on a methadone gramme Food diary showed that the child waslargely given ﬁzzy juice and ate crisps The familyhad no real mealtimes and just ate in front of thetelevision The child was allowed to run aroundand started each meal with a large drink of juice.Father seemed controlling and the family were verydifﬁcult to engage

pro-CASE STUDY: Non-organic failure

to thrive

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

below the 2nd centile having started out on the

CASE STUDY: Vomiting blood

A 3-year-old was admitted with a history of ing bright red blood No further vomiting of bloodtook place on the ward The parents were very wor-ried and father was upper middle class and quiteaggressive Investigation including bloods and bar-ium meal failed to show a cause The child was senthome but one month later presented again, this timewith a pillow case covered in blood Endoscopy wasperformed but nothing found Six months later, thechild was seen at a tertiary referral centre for paedi-atric gastroenterology Eventually, a further hospitalpillowcase appeared with blood on it It was shownthat the blood group of the child did not match theblood group on the pillow

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vomit-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 paediatripaediatri-cians 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

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

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

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 information available with each other When doing

so the paramount consideration should be the welfare ofthe child It is important that a distinction be madebetween agency checks and referrals

The medical examinationWhere abuse is suspected, a full health assessmentshould be carried out including a detailed medical his-tory and general physical examination including healthand emotional needs A two doctor examination should

be conducted in cases of suspected child sexual abuse bydoctors experienced in forensic examination at a time

The role of health professionals in child protection:

● recognizing children in need of protection

● contributing to enquiries including examination

of children

● participating in child protection conferences

● providing therapeutic help to abused children

and their parents

● playing a part through the child protection plan

in safeguarding children

WHERE THERE IS SUSPICION OF ABUSE

Child

History, general inspection and record

Ensure child’s safety

1 Contact social worker for information only

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

Refer to social work department

Attend child protection conference

Ongoing concern Refer to social worker

No ongoing concern Record all new findings Monitor and review

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

In all cases of suspected abuse:

● inform senior colleague who is ultimatelyresponsible for the case

● inform social work department and discussmanagement

● inform parent (unless it puts child at risk ofharm)

● record accurate details of history and clinicalﬁndings with diagrams

● send report to relevant trust health professionalwith responsibility for child protection

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

depart-● attend child protection case conference

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and in a place appropriate to the case to avoid

duplica-tion of examinaduplica-tion Examinaduplica-tions 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

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

WHO DECIDES TO ARRANGE A MEDICALEXAMINATION?

The senior social worker should discuss with police andrelevant medical personnel (as above) and agreementshould be reached on whether a medical examination isrequired and what it will achieve, type of medical required,who should conduct it, where and when it should beconducted Whether face to face or on the telephone, dis-cussions and decisions on how to proceed should be clearlydocumented If it is agreed to arrange a medical exam-ination or assessment it is important that the examiningdoctors have clear information about the causes of con-cern, the social background including previous instances

of known or suspected abuse

TIMING

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

RECORD KEEPING

Records should be detailed and legible as original recordsmay be required later for criminal proceedings Specialsheets, which include diagrams of body parts and detaileddiagrams of the genitalia, should be available to aiddescription of injuries Detailed measurements should beincluded Details of the full names, addresses and contact

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

Some circumstances which require a medical

examination

● 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

● A child appears to be suffering from physical neglect

● Any allegation of child sexual abuse includingtouching over clothes, fondling, attempted oractual digital penetration, a penetrative episode

● Concern about non-organic failure to thrive

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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

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

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

PHOTOGRAPHY

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

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 childrenwho require compulsory support, guidance, protection andcontrol is the overriding consideration The decision torefer a child to the children’s Reporter is a signiﬁcant stepwith potentially far-reaching consequences for the childand his/her family/carers A number of general principlesshould be applied when decisions are being taken

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

consider-to the Reporter

● Agencies are required to take into account the views

of children and families and to work in partnershipwith them

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

of children

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

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

● The police inform the Reporter of abuse cases withcriminal proceeding

Records should include:

● details of any concerns about the child and family

● details of contact with the family or other agencies

● the ﬁndings of any assessment

● decisions made about the case within each agency

or in discussions with other agencies

● a note of information shared with other

agencies, with whom and when

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

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● 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

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

When making a referral to the Children’s Reporter,

agencies or individuals must not take into consideration

whether they believe there is sufﬁcient evidence forgrounds for referral to be established Considerations relat-ing to sufﬁciency of evidence and standard of proof areexclusively a matter for the Reporter Referral should bemade where a health professional has reasonable cause

to believe that a child may be in need of compulsory 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

meas-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)

a is beyond control of any relevant person

b is falling into bad associations or is exposed

to moral danger

c is likely:

i to suffer unnecessarily or

ii to be impaired seriously in his health or

development, due to a lack of parental care

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;

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

l is being provided with accommodation by a localauthority under section 25, or is the subject of aparental responsibilities order obtained undersection 86 of the Act and, in either case, hisbehaviour is such that special measures arenecessary for his adequate supervision in hisinterest or the interest of others

CASE STUDY: Child with speech delay

A 4-year-old girl had been referred to the childdevelopment centre (CDC) with speech delay at age

2 years The child attended the CDC once but didnot attend for follow-up or for a hearing test withthe educational audiologist or for blood tests or forassessment by a speech and language therapist.Every time the educational psychologist tried to seethe child in the nursery placement Mum failed toarrive The speech and language therapist madeappointments with the mother to meet her at homebut she was never there The child was due to go toschool, the nursery thought the child needed furtherhelp perhaps from the language unit, but nobodyhad managed to make a complete assessment of thechild due to parental non-cooperation/neglect Afterdiscussions at a language panel meeting this childwas referred to the Reporter by the communitypaediatrician Suddenly, all appointments were keptand the assessment proceeded quickly

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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

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

Child protection conference

Child protection conferences are an important stage in the

child protection process and provide a forum for

profes-sionals to share information and make plans to protect

children A key function is to consider the need for

regis-tration but equal emphasis should be placed on identifying

a child protection plan to safeguard the child There arefour types of conference: initial, review, pre-birth andtransfer (to another geographic area) Social work serv-ices are responsible for convening, chairing and minut-ing a child protection conference, but any agency canrequest a child protection conference by contacting theteam leader for social work in the area the child resides.Parental involvement at child protection conferencesshould be the rule rather than the exception It is vitalthat health professionals in the primary care team andany other medical or health staff involved attend todescribe and interpret medical ﬁndings and relevantbackground information Health professionals shouldnormally provide written reports of their involvementand 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

● 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

● 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

Tasks undertaken by a child protection conference

● Ensure that all relevant information is sharedand collated

● Assess the degree of existing and likely futurerisk to the child

● Identify the child’s needs and any servicesrequired to help him or her

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

CASE STUDY

A 6-year-old child arrived at school with a black eye When asked by a teacher how he hadbruised his eye, he said that his stepfather punchedhim At the case conference the community policeofﬁcer, social worker, school teacher, probationofﬁcer for stepfather, hospital doctor and motherwere present Mother said that the stepfather was

no longer living in the house However, it becameclear that she did not believe the boy’s story andshe was therefore deemed unable to protect him Hewas put on the ‘at-risk register’ and the mother wastold that if evidence came to light from communitypolice or elsewhere that the stepfather was still

in the house, a Child Protection Order would besought and the boy would be taken into the care ofthe local authority

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In some cases of child abuse, problems have arisen when

professionals fail to communicate effectively and share

information both vertically within a professional

struc-ture and between professional agencies involved with

the child and family It is crucial for the beneﬁt of the child

that key people communicate effectively across

profes-sional boundaries in an atmosphere of trust

Child Protection Register

The purpose of the Register is to provide a record of

chil-dren who are in need of protection by means of an

inter-agency child protection plan The Register can provide a

central point for enquiry for professional staff who are

concerned about a child The management and upkeep of

the Child Protection Register is the responsibility of social

work services The Child Protection Register is not a legal

order but rather an interagency internal ‘highlighter’ to ﬂag

up children who are felt to be at risk of abuse or in need of

protection Enquiries are made via the social work area

team or standby out of hours The decision to place a child’s

name on or take it off the Child Protection Register is taken

at the child protection conference There are ﬁve categories

of registration corresponding to the different forms of child

abuse: physical injury, sexual abuse, non-organic failure to

thrive, emotional abuse and physical neglect

The Children’s Hearings system in child

protection in Scotland

Important measures are available to protect children who

have been the victims of offences whether or not there is

a prosecution or conviction maintained beyond reasonable

doubt in a criminal court Such offences can be established

within the Children’s Hearings system by proof (deemed

sufﬁcient at a sheriff’s proof hearing) on the balance of

probabilities Children, who are not themselves victims,

but are at risk of abuse through their contact with the

per-son responsible, can also be protected

Orders

An application for a Child Protection Order can be made

by any person to a sheriff who must be satisﬁed thatthere are reasonable grounds to believe that the child isbeing treated in a manner to cause signiﬁcant harm orwill suffer such harm if not removed to a place of safety

A 24-hour Emergency Order can be made to a Justice ofthe Peace or a police constable can remove a child for

24 hours if a sheriff is not available A Child AssessmentOrder from a sheriff is intended to enable an assessment

of a child’s health or development to be made A localauthority may apply to a sheriff for an Exclusion Order toexclude a ‘named person’ from the house of a particularchild or children

THE LOCAL CHILD PROTECTION COMMITTEE

The committee is an interagency forum for developing,monitoring and reviewing child protection policies Themembership includes representatives of social work, education and health services (managerial and profes-sional including the designated doctor and nurse, a GPfor primary care), the police, the National Society for thePrevention of Cruelty for Children (NSPCC), the probation

CASE STUDY: An infant hit by a parent

A mother was at a bus stop at 10 pm on a Saturdaynight with her 9-month-old infant in a pram A busstopped and passengers witnessed the mother hit-ting the child who was crying The bus driver sep-arated the mother from the child with the help ofsome passengers and a passing police car stopped

An Emergency Child Protection Order was takenout by the police ofﬁcer who brought the child tothe hospital as a place of safety The sheriff granted

a Child Protection Order to the social work ment the next day

depart-The Children’s Hearings system can protect childreneven if criminal proceedings do not succeed By

working on proof at the level of the balance of

prob-abilities, compulsory supervision, which may include

care outside the home, can still be invoked

K E Y L E A R N I N G P O I N TThe child protection conference has an important

role to formulate a child protection plan to protect

a child from further abuse It is important for all

pro-fessionals and parents to be there as together they

are likely to have all the information to achieve a

competent plan If part of the picture is missing then

a competent plan may not be achieved and the child

may remain at risk

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service, and may include a lawyer, the Procurator Fiscal

and other voluntary agencies Members are accountable

to their own agencies and have authority to speak on

their agency’s behalf Committees produce written

guide-lines for the management of child abuse in their area to

foster close interagency cooperation

Fostering and adoption: the role of the

community paediatrician

There is obviously a close link between child protection

and fostering and adoption, as many children who are

fostered and adopted have been the subject of some kind

of abuse In Glasgow, community paediatricians have

taken on the task of tracking children who are looked

after by the local authority, fostered and eventually

adopted Over 1000 children are in the care of the local

authority at any one time in Glasgow with 300 new

‘receipts into care’ each year A database of children

received into care has been established over the past 10

years The aim is to improve the healthcare provision for

this transient group of children Each child requires a

medical examination by a doctor before or soon after

being received into care This contact allows a health

appraisal to be undertaken and appropriate management

to be implemented

Adoption panels decide on the placement of a child

who either voluntarily or by the order of the court has

been ‘freed’ from parental responsibility and requires

and is willing to be permanently placed with new

per-manent carers who will assume parental responsibility

Each adoption panel has at least one medical adviser

The role of the medical adviser is to provide the panel

and the prospective adopters with a full detailed account

of the child’s medical background and what may be

required in the future including operations and

outpa-tient attendance This may require full assessment of

the child by the panel adviser with the help of other

spe-cialists A separate medical adviser may be employed

for the health of prospective adopters The panel needs to

be sure that adopters will be able and healthy until the

child is able to achieve an independent life The medical

adviser has to attend adoption panel meetings and is an

important person to advocate for the best interests of the

child

CHILD DEVELOPMENT AND

LEARNING DIFFICULTIES

Child disability services are a core part of community

child health All children deserve access to a range of

high-quality services that will help them attain optimalhealth and wellbeing and to become healthy and well-adjusted adults Children with physical or mental illness

or disability with often economic and social vantage require additional help and support to reachtheir potential Although many chronic illnesses causechildren to have disability and consequent special needs,

disad-90 per cent are caused by impaired function of the ous system

nerv-These children require a different service to simplehospital inpatient and outpatient care A child with mul-tiple disabilities including complex neurological problemscompounded by psychological and behavioural difﬁ-

culties needs a dedicated multidisciplinary interagency

approach Child development teams may include a cialist health visitor, a clinical psychologist, a speechtherapist, a physiotherapist, an occupational therapist, asocial work resource worker and a community paediatri-cian The social work resource worker is especiallyimportant for families of disabled children who often are

spe-in need of extra beneﬁts, particularly Disability Livspe-ingAllowance, which is not means tested

Educational input will be coordinated by an tional psychologist and may include assessments by aneducational audiologist, a home visiting teacher andteachers and nurses within the nursery and school sys-tem Parent support groups can help ‘new’ parents tocome to terms with their child’s disability by seeing howother families have coped Disabled children often requireinput from other specialties particularly neurology, oph-thalmology, genetics, ENT, orthopaedics and child andfamily psychiatry The primary care team needs to beclosely involved There is a changing population of dis-abled children with increasing numbers who have morecomplex difﬁculties Children with cerebral palsy experi-ence greater impairment than previously

educa-Over recent years there have been increasing referrals

to disability services, with public awareness and ledge particularly with regard to conditions such as autismand attention deﬁcit hyperactivity disorder

differ-K E Y L E A R N I N G P O I N T

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