Safeguarding children: Part one

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Safeguarding children is about more than brushing teeth, says Dr Caroline Fertleman in the first of a two-part article

What are the signs that a child is being abused? And what is abuse? When should the medical professional get involved and how should they proceed? All of these questions were addressed by Dr Fertleman during her fascinating presentation at Lord’s as part of the Saving Kids’ Teeth Conference, sponsored by the Dental Wellness Trust and a number of leading supporters and suppliers to the dental profession.

Child protection is not straightforward. We have a duty to flag-up concerns irrespective of a child’s ethnicity or cultural background. Even so, it can be very difficult to question a parent’s fitness to bring up their children. Dr Fertleman provided her audience with five examples of possible abuse and asked everyone to rate them from 1 to 5, 5 being acceptable and 1 not acceptable.

1. A mother hits her 8-year-old child.
2. A baby is to be circumcised for cultural reasons.
3. An 11-year-old girl with cerebral palsy cuddles her daddy in bed when she’s upset.
4. A 6-year-old boy watches his mother slapping his father.
5. A toddler’s mother drinks a bottle of white wine before noon.

How would you score these scenarios? Surely it would depend on the context? Are any of them plain examples of abuse? Dr Fertleman threw the subject open for debate with the following outcomes:

1. We are saying hitting, not slapping. This is not acceptable. There is now a trend for parents to hit a child on the back of the head because it is illegal to leave a mark. Striking a child on the back of the head leaves no marks, while smacking on the bottom or legs might bruise them and lead to an interview with the authorities.
2. The floor was divided on the subject of circumcision. Some could see the value of it; circumcision can be more painful and traumatic for a male in later life, but if the baby was a girl it would be completely unacceptable.
3. When is it acceptable for a father to cuddle his adolescent daughter in bed, and when does it cease to be appropriate? It might just be case of comforting the girl when she’s upset, but what if something else is at work? This case must be considered in context.
4. Domestic violence is always bad, so is the emotional violence the child will suffer from seeing one parent attack the other. This is a clear case of abuse.
5. The drinking situation is not black or white. What is the difference between drinking in the morning or in the evening after a long day? Does the woman continue drinking in the afternoon? At what point does she become incapable of caring for her child and with what repercussions? That is when it might become abusive for the toddler.

Dr Fertleman outlined other situations

4-year-old Lisa arrives for a routine dental examination with her father. You find a mark on the inside of Lisa’s arm that looks very like a bite. When you question the mark her father says it was caused by her 2-year-old brother who is teething. What do you do?

Proceed with caution. Note when the child has been interrupted and not allowed to speak; from the age of 3 the child should be allowed to tell their story. What size is the bite? That will indicate whether it was delivered by a 2-year-old or an adult. As soon as a case like this presents itself you have to start preparing for the fact that it might go to legal proceedings. You have to be careful not to lead the child or taint any evidence but must be aware of “red flags” when they arise.

Luke is just two and a half years old. He is brought in by his mother. He is coughing and has bruises on his chest which the mother can’t or won’t explain. What are the concerns in this case? The mother doesn’t drink.
Start by looking at where the bruises are. Children run around and collide with things, it is part of life, but these accidents leave bruises on bony prominences and foreheads. To get bruises on the chest in this way is very unlikely.
One can’t age a bruise, but are there lots and do they overlap? What shape are they? What size? Do the bruises look as if they were caused by a hand or an implement? Dr Fertleman told us that people no longer use slippers or belts to punish children – they use the wires from electrical equipment which are easily to hand. Wires leave a distinctive ‘U’ shape. She advised we look for it.

What are the risk factors?

What risk factors might lead to abuse? We must consider the family environment, the child itself, and the home environment. What if the child has special needs? They might be vulnerable for a number of reasons: Age, a young child lacking mobility is easy to abuse. They can’t run away. Was the child unwanted and resented as a burden on the household? Does it have behaviour problems such as ADHD or autism that might make it difficult to live with?

The family factors might be more obvious and throw up those red flags for danger. Are the parents’ drug or alcohol abusers? Are they in the poorer demographic and under a financial burden? Single parents can be stretched to breaking point by worry and take it out on the child.

Certain cultures and ethnic groups see strict physical abuse as part of bringing up their children correctly. What was once called ‘spare the rod and spoil the child’ is now recognised as abusive behaviour. Young parents might find their children tough to cope with and resort to violence in frustration, while others might have grown up in an abusive home and consider it natural.

Other family factors include parents with special needs such as mental health issues, a culture of domestic violence created by one or both parents, or a large family where older children might abuse younger siblings.

Environmental factors may include the family living in unsuitable housing conditions or in an area with a high crime rate. The parents’ financial situation will affect the environment in which children are brought up, poverty can lead to abuse.

It is too easy to look for abuse under these circumstances, but then ignore it when a child lives in a comfortable, financially stable home. Look for red flags under all home conditions.

In part two: Dr Fertleman continues her exploration of the causes and signs of child abuse, and discusses when and how a health professional might cross the threshold from suspicion to reporting the parents to social services.

Speaker biography
Dr Fertleman is a consultant paediatrician. She has been a consultant at the Whittington Hospital and an honorary Senior Lecturer at University College London Medical School since 2005. Caroline has a special interest in medical education. She is the UCL Medical School site sub-dean and honorary senior lecturer at the UCL Institute of Child Health. She is also honorary consultant paediatrician at Great Ormond Street Hospital.