VOL: 98, ISSUE: 18, PAGE NO: 34
Linda Scott, MA, RN, RM, RHV, is a senior nurse adviser for child protection, Children's Directorate, Northampton General HospitalOf the 11 million children in England in 1998, more than six million lived with their birth families and required little professional attention. Of the rest, four million (one-third) were 'vulnerable', 300,000-400,000 were 'in need', 53,000 children were 'looked after' by a local authority - either in their birth family, foster care or residential care homes - and 32,000 were on the Child Protection Register (Department of Health et al, 2000a).
Of the 11 million children in England in 1998, more than six million lived with their birth families and required little professional attention. Of the rest, four million (one-third) were 'vulnerable', 300,000-400,000 were 'in need', 53,000 children were 'looked after' by a local authority - either in their birth family, foster care or residential care homes - and 32,000 were on the Child Protection Register (Department of Health et al, 2000a).
The type of family support provided by care professionals and the methods they use to protect children must be formulated in response to the style of parenting in each case. Sensitivity is the essence of working with families who need professional support to reduce or eliminate risk to the child. In addition, professionals working with transient populations, such as refugees or travellers, may have only one opportunity to assess the health needs of family members, so effective and appropriate communication and service provision requires focused records.
Attachments underpin the parent-child relationship and can be either secure or insecure. Describing the characteristics of insecure attachments and defensive patterns of relating, Van IJzendoorn (1995) estimated that 45% of the population had insecure attachments. This percentage increases in caseloads where factors such as extreme poverty, depression, substance use and domestic violence are present.
People in disorganised patterns of attachment do not develop organised behavioural strategies to cope with stress. Patterns of helplessness recur throughout their lives, which in turn affect their children.
According to Howe et al (1999), 15% of any population is in disorganised, chaotic styles of attachment. For this reason, nurses', midwives' and health visitors' ability to recognise difficult attachments and respond to any consequent need for support or protection can make a significant difference in ensuring that a child achieves his or her full potential. To do so, each child needs safety, independence, power, intimacy, esteem and trust.
Browne et al (2000), who are based at the University of Birmingham, worked with Essex Health Authority to produce a screening programme to identify children who are most at risk of harm (Box 1).
Browne et al (2000) suggest that negative parental perceptions and insecure attachments allow professionals to distinguish families with risk factors who are truly in need from those who are not. The focus is on stressors, the vulnerabilities of the children, and parenting perceptions and abilities. The preliminary results of this work are promising in terms of helping professionals in their work with families that are at high risk.
Proactive, preventive practice and early intervention requires a knowledge of the vulnerabilities known to precipitate abuse and the stresses that each family is under. Working Together to Safeguard Children (Department of Health et al, 1999) details the types of abuse that all health care professionals need to be aware of, as well as the impact it is likely to have on the children involved.
Known abuse and known abusers are equally relevant when analysing health needs, risks and harmful environments, and any person with a conviction under the Children and Young Persons Act 1933 as a result of harming a child (Schedule 1 offender) poses a risk. Such details should be included in assessment information.
Effective interagency practice
National inquiries into child abuse and case reviews often highlight poor or ineffective communication between disciplines and agencies (Department of Health, 1991; Falkov, 1996). Ayre (1998) identified the factors that promote effective interagency practice, including a chronology of significant events. Strengths, as well as weaknesses, should be contained in such records, and Ayre suggests that this work should look at what is happening from the child's point of view.
The Crossing Bridges training pack (Falkov, 1998) explains how to share information across child care and adult mental health services. The presence of unresolved stress may precipitate violence in a family and towards primary and secondary care professionals working with the family. Working Together to Safeguard Children (Department of Health et al, 1999) covers domestic violence and stresses the importance of considering this in assessments.
Disclosures by children
Children's disclosures have informed professionals of the way abusers access and groom vulnerable children for their own sexual or emotional gratification. Prostitution among the child population is becoming more clearly understood (Department of Health et al, 2000b).
Children may be exposed to danger if professionals' responses are not made with care and sensitivity, so adequate knowledge and understanding is vital to protect the population of children and young people who have been abused. According to Howells (1974), correct assessment, combined with the right attitude from helpers, leads to effective discussions. A range of factors should be taken into account when performing an assessment (Box 2).
Recording health needs and risks
Six records are required when supporting families and protecting children from significant harm. These are:
- The personal child health record, which is retained by the child's main carer;
- The index card or base file, which is maintained by every discipline and containing basic client contact information;
- A family support and child protection document that outlines concerns, known harm, health needs, health risks and a health care plan;
- A transfer-of-records form for health visitors and school nurses, informing the records systems and professionals of changes in residence and practitioner involvement;
- A child protection supervision record, which is necessary for all staff participating in child protection supervision in health care settings;
- An end-of-year supervision opportunities record for audit purposes.
The family support and child protection document provides a structure to promote good communication and enables the sharing of information that is essential to promote a child's safety and well-being. No single discipline is expected to have all the answers, nor is a single health professional expected to 'investigate' a case to provide them.
Each professional, based on his or her practice, has a part to play in this holistic jigsaw. The records can be used by any professional - whether a neonatal nurse, a paediatric nurse, a child and adolescent mental health nurse, a drug and substance use nurse, a psychologist, a community psychiatric nurse or a learning disabilities nurse - to produce factual and focused reports for interagency use.
Few in number but comprehensive in content, records need to be written contemporaneously, dated, timed and signed, with a printed full name to identify the signature. Recorded entries must contain complete and accurate details of conversations and visits relating to the care of, or concerns for, the child. Relevant remarks or actions made by parents or carers should be indicated by direct speech in quotation marks, or a statement that the information is hearsay. Where injuries are seen, a body map should be included.
The record should state clearly where and with whom the child was seen. In the case of a child who was not seen by a professional, this should be recorded clearly.
Records of children whose names are on the Child Protection Register or who give cause for concern should be easily identifiable by other members of staff. Reports produced from the record should be used to inform statutory agencies when child abuse and neglect are identified.
A genogram - a diagram of the child's family medical history - can be used to illustrate the connections of family composition. This type of record is invaluable when working with families with a history of separation or divorce as the health care professional requires an appreciation of the child and its carers' response to these events or to cohabitation.
Further examples of observations that should be recorded are included in Box 3.
The transfer of records (by health visitors and school nurses only)
All movements of children on the Child Protection Register, and those who are not on a register but where there are serious concerns for their safety, must be relayed to the senior nurse for child protection. A contemporary transfer-of-records form should be attached to the records.
In all cases in which the forwarding address for the child is not known, this must be brought to the attention of the senior nurse for child protection.
Records of children on the Child Protection Register, and of those whose circumstances give cause for concern, need prompt transfer to the new area. The responsibility for completing this process remains with the professional. The senior nurse for child protection must be informed, as must the key social worker and custodian of the central register if the child is on the central Child Protection Register.
Child protection supervision record
Supervision, which promotes good standards of practice and supports staff members, requires a supervision record for child protection practice. This includes the names of the cases discussed and the themes discussed in the course of the supervision. Key decisions taken during the casework discussions should then be recorded in the child/family record. A record should be kept by everyone present during the supervision. The end-of-year supervision opportunities record is completed by the child protection supervisor, providing a history of the provision of child protection supervision in the previous year.
It is almost 30 years since the first national inquiry into death from child abuse. In the intervening period, many children have died or developed long-term health difficulties as a result of abuse.
Social researchers and attachment theorists have expanded the knowledge base that practitioners can draw upon and much can be done to identify and intervene before abuse occurs or escalates.
Many health care professionals work with a child, or his or her carer, yet children who access such services continue to die or be seriously harmed by abuse. All reviews on the death or serious injury of children as a result of abuse have identified written communication systems as inadequate. No system crosses professional disciplines or follows the lifeline of a child to ensure that health needs are addressed wherever the child is protected or cared for.
A personal child health record is opened for each child, but this does not contain focused information on family support or child protection issues, such as genograms, body maps and details on parenting. In this respect, it inhibits informed communication and is not used to focus on the parenting needs of a parent who is in distress or whose parenting is disorganised and chaotic.
The documentation described in this article attempts to structure and bring together focused information on families in need of support. Effective interprofessional teams require communication systems that balance the issues of confidentiality with accountability to safeguard children and support their carers. This requires a change in culture.