National Guidance for Child Protection in Scotland: Consultation

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PART 4 - CHILD PROTECTION IN SPECIFIC CIRCUMSTANCES

INDICATORS OF RISK

426. This section gives additional information for dealing with specific conditions that may impact adversely on children as well as addressing operational considerations in certain circumstances. It should be noted that whilst a range of special or specific circumstances have been included in this part, the national guidance does not provide detailed guidelines on areas of practice/policy that are contained elsewhere; but rather, where appropriate, signposts to relevant policies and materials or provides a framework of standards that local policies will need to consider.

427. In making practitioner judgements about the risks and needs of child, there are a range of indicators that should 'trigger' assessment and, where appropriate, action. Not all the indicators set out here are common, nor should their presence lead to any immediate assumptions about the levels of risk for an individual child, but where identified, they should act as a prompt for all staff, whether in an adult or child care setting, to consider how they may impact on child. In the sections below, the indicators of potential risk are considered separately, but in many cases, and very often for children in vulnerable circumstances, combinations of these indicators will be present. Consequently, when considering these indicators of risk, they should not be considered in isolation but in relation to all the relevant factors of a child's and family's circumstances. Where there are a number of risk factors in a child's life, practitioners should pay particular attention to the accumulative impact on the child. In addition, where there are a number of risk factors co-existing, this may result in an increasing range of different services involved and it is especially important that the focus on the child's needs is maintained.

428. The sections below provide summaries of key aspects of the different indicators or risk. More detail on specific indicators may be required, and for that reason, the further information sections provide links to important resources that will support practitioner judgements.

Domestic Abuse

429. Children and young people living with domestic abuse are at increased risk of significant harm, potentially as a result of direct abuse from the perpetrator as well as from witnessing harm to other members of the family. It is not necessary, however, for children to witness directly or be subject to abuse to be affected by it. Domestic abuse can profoundly disrupt a child's stable and nurturing environment and affect their physical, mental and emotional health.

430. The impact of domestic abuse on any one child will vary, depending on a number of factors, including the frequency, severity and length of exposure to abuse and the ability of others in the household (particularly the non-abusive parent/carer) to provide parenting support under such adverse. If the non-abusive parent/carer - most frequently the mother - is not safe, it is unlikely that the children will be. Indeed, children frequently come to the attention of practitioners at a point when the severity and length of exposure to abuse has compromised the non-abusing parent's/carer's ability to nurture and care for the children.

431. The best way to keep both children and the non-abusive parent/carer safe is to focus on early identification, assessment and intervention through skilled and attentive staff in universal services. Domestic abuse is widely under-reported to the police. Given the reticence of victims to come forward unless directly questioned, it is crucial that staff routinely are aware of any indications of domestic abuse and make appropriate enquiries.

432. When undertaking assessment or planning for any child affected by domestic abuse, it is crucial that practitioners recognise that domestic abuse involves both an adult and a child victim. The impact of domestic abuse on a child should be understood as a consequence of the perpetrator choosing to use violence in the environment of the child, rather than of the non-abusing parent's/carer's failure to protect. Whilst support to the non-abusing parent/carer is essential to re-establishing a stable and nurturing home for the child in the longer term, there may be occasions when, as a consequence of domestic abuse, they are unable to provide this in the present. Appropriate steps may need to be taken to protect the child, which can mean the child living apart from the non-abusing parent/carer for a period of time. In such circumstances, placement within the wider family network should always be the first option as this will provide some degree of continuity and stability for the child. Agencies should always work to ensure that they address the protection of children in parallel to the protection of their non-abusing parents/carers.

433. Protection needs to be long-term and should not cease after separation between the abuser and the non-abusing parent/carer. Indeed, separation is frequently a time of increased risk for children and their non-abusing parent/carer, when violence may escalate rather than abate. One area of critical concern is the child's contact with the perpetrator, which can be used to continue the domestic abuse. Any decisions made in regard to contact by both social work services and the civil courts should be based on an appropriate risk assessment of the potential danger to both the non-abusing parent/carer and the children.

Further Information

434. More detailed information about the impact of domestic abuse on children and young people and the need to address this from a child protection perspective can be found in the following documents:

Parental Substance Misuse

435. Substance misuse can involve either alcohol or drug misuse (which can include prescription as well as illegal drugs). The risks and impacts on children of substance-misusing parents and carers are known and well-researched. Substance misuse during pregnancy can have significant health impacts on the unborn child. Parental substance misuse can also result in the sustained abuse, neglect, maltreatment, behavioural problems, disruption in primary care-giving, social isolation and stigma of children. Substance-misusing parents/carers often lack the ability to provide structure or discipline in family life. Poor parenting can impede child development through poor attachment and the long-term effect of maltreatment can be complex. The capability of parents/carers to be consistent, warm and emotionally responsive to their children can be overwhelmed by the preoccupation of substance misuse.

436. It is important that all practitioners working with drug- or alcohol-abusing parents/carers know the potential effects that substance misuse can have on a child, both in terms of the indirect impact on the care environment as well as direct exposure to the use of these substances. Planning around these children is vital, particularly in pre-birth situations, and will often include input from agencies that do not have a frontline childcare role. The best interests of the child should always be the principal concern.

437. Local areas should ensure there are robust policies and guidance in place for the identification, assessment and management of children affected by substance misuse. These should reflect the multi-agency and single agency roles and responsibilities for this complex area of work. These will be framed by local CAPSM strategies, whose development should be led by ADPs working in conjunction with Child Protection Committees, that cover partnership working, commissioning of services, training to ensure that the skills set for dealing with adult- and child-specific issues are known by all relevant staff, and a performance monitoring framework.

438. Below these strategies, local guidance should be developed to refer to the key wider national change programmes and frameworks which are relevant to children affected by parental substance misuse - currently the National Drug Strategy, The Road to Recovery, and the National Alcohol Framework, Changing Scotland's Relationship with Alcohol: a Framework for Action, as well as GIRFEC. In addition, it is important that local guidance should include the following.

  • Reference to the evidence base on the impact of parental substance misuse on children. This should include specific reference to Fetal Alcohol Syndrome and Neo-natal Alcohol Syndrome as well as best practice guidance on blood-borne viruses - for example, in relation to breast-feeding, testing, immunisation of mothers and infants, and treatment and care of affected children. Local guidance should also include an evidence base for effective interventions with parents, carers and families affected by problem drug and alcohol use. This should include ante-natal and post-natal care pathways for parents/carers where there are substance misuse issues. Separate guidance on the management of young people with problem substance use and families affected by young peoples substance use should also be in place.
  • A clear statement about partnership working, roles and responsibilities of practitioners and agencies involved with families at key stages. Effective intervention is dependent on robust working relationships between practitioners within both a child and adult care setting. When identifying and responding to concerns about a child, expertise in child protection and addiction services should be brought together to ensure the child receives a robust, joined-up service. Particular attention should be paid to information-sharing (including resolution of disputes on information-sharing) and best practice for consent to share information.
  • Advice on how to include a family support plan element within the planning for children, taking account of the issues affected not just mothers and children, but parents and carers more generally. In particular, the Family Support Plan model can be useful when dealing with families affected by problems substance misuse.

439. A Lead Professional should be identified in cases where several services are involved. In child protection cases, this role should be assigned to a social worker but in other scenarios, local guidance should provide direction on:

  • the practitioners and agencies who should undertake this role;
  • at what stage in the process of assessing an individual child's needs that a Lead Professional should be appointed; and
  • the relevant governance arrangements and accountability.

440. Local services should have an agreed risk assessment framework for CAPSM. In addition, there should be in place a strategy for the training and education of staff involved in this area of work. This should encompass staff in addiction services who need to know about child development/maltreatment, as well as social worker/health staff who will require training on drug and alcohol problems.

441. There are particular issues regarding kinship care and the impact of parental substance misuse that should be highlighted. Regulation 10 of the Looked After Children (Scotland) Regulations 2009, provides that a local authority may make a decision to approve a 'kinship carer' as a suitable carer for a child who is looked after by that authority in terms of section 17(6) of the Children (Scotland) Act 1995. It should be recognised that CAPSM is a significant driver in the number of kinship care cases and local authorities must recognise kinship carers and make adequate provision at a local level. Many children are living apart from their birth parents because of parental substance misuse. Preventative and protective work is necessary to support carers, especially kinship carers who face added challenges. Particular issues for kinship carers in these circumstances include the potential risks posed by parents and how the kinship carers (for example, a grandparent) feel about protecting their grandchild or grandchildren, from their own child. Kinship carers may have a number of ambivalent feelings about the circumstances that has resulted in them having to care for a child or young person and services need to be sensitive to these issues and offer support wherever possible.

Further Information

442. More detailed information about the impact of parental substance misuse on children and young people and the need to address this from a child protection perspective can be found in the following documents:

Disability

443. Disabled children are not only vulnerable to the same types of abuse as their typically developing peers, but there are some forms of abuse to which they are more vulnerable . The definition of 'disabled children' includes children and young people with a comprehensive range of impairments with physical, emotional, developmental, learning, communication and health care needs. Disabled children are defined as a child in need under section 93(4) of the Children (Scotland) Act 1995.

444. There is a strong association between childhood disability and maltreatment. Abuse of disabled children is significantly under-reported. Local services need to ensure their systems for collecting information about disabled children are sufficiently robust.

445. Disabled children are more likely to be dependent on support for communication, mobility, manual handling, intimate care, feeding and/or invasive procedures. There may be increased parental stress, multiple carers, care in different settings (including residential) and often reluctance among adults to believe that disabled children are abused. Disabled children are also likely to be less able to protect themselves from abuse and limited mobility can add to their vulnerability. In addition, the network of carers around the child is likely to be larger than for a non-disabled child, which can be a risk factor in itself. While the majority of parents/carers who are part of such a team demonstrate the highest standard of care for their child, some could themselves be perpetrators. Particularly vulnerable are those children with communication or sensory impairments, behavioural disorders or learning disabilities. Abuse of disabled children is more likely to start at an earlier age and repeated multiple abuses are evident. Neglect is most frequently reported, followed by emotional abuse.

446. Children looked after by parents/carers in the community can have complex health care needs which include life-threatening conditions. The caring responsibilities, which can involve complex clinical procedures, can cause considerable pressure on families. Reliance on physical, mechanical and chemical interventions to manage health and behaviour can leave these children particularly vulnerable to harm. This can be through lack of awareness, knowledge or support. In addition, dependence on medication may leave disabled children further exposed to abuse from purposeful manipulation of medication or from lack of understanding resulting in failure to administer the medication as prescribed.

447. Disabled children are often highly dependent on their carers. They may be less resilient and non-treatment of even minor ailments can have serious consequences. Practitioners' expectations of the ability of parents/carers to cope in managing the care needs may be over-estimated. The latter can fear failing or admitting they cannot cope. To protect disabled children, it is crucial for assessments to include the ability and capacity of parents/carers to cope with the demands required.

448. When responding to concerns about a disabled child, expertise in child protection and disability should be brought together to ensure the child receives the same standard of service as a non-disabled child. Practitioners experienced in working with disabled children, such as speech and language therapists or residential workers, may be helpful to participate in the investigative process. Local guidance should set out processes and available support and be sensitive to the particular needs of disabled children during the conduct of child protection investigations, such as when children with disabilities need to be examined, give consent or communicate evidence. For example, where a disabled child has communication impairments or learning disabilities, special attention should be paid to the child's communication needs, and ascertaining the child's perception of events, and their wishes and feelings. Practitioners responsible for making enquiries into a child protection concern should be aware of non-verbal communication systems, when they might be useful and how to access them, and should know how to contact suitable interpreters or facilitators. Assumptions should not be made about the inability of a disabled child to give credible evidence or withstand the rigours of the court process. Each child should be assessed carefully and supported to participate in the process when this is in the child's best interest.

449. Local services need to provide training for those involved in child protection work on the particular vulnerability of disabled children. Local guidelines should promote early contact with key workers as crucial for advice on the child's impairment, how this is likely to impact on the investigation and what support is needed for the child in order to progress any enquiry. Specialist advice should be sought at an early stage to help inform decision-making and any investigation planning should include: providing support to the child, such as a preferred support worker and someone who is able to communicate with, and for, the child; identifying a location suited to the sensory or communication needs of the child, including any communication boards/loop system as required; and additional time allowed to conduct the inquiry, including time before to brief the support staff and time for breaks to suit the child's needs.

450. Disabled children can progress into adult protection. The Protection of Vulnerable Groups (Scotland) Act 2007 recognises the vulnerability of disabled adults. Transition to adult services for disabled children may be a traumatic time for them and their families. Local services should consider the development of transition plans that reflect the complexity of transition from child to adult services.

Disabled Parents and Carers

451. Children can also be affected by the disability of those caring for them. Disabled parents/carers/siblings may have additional support needs relating to physical and or sensory impairments, mental illness, learning disabilities, serious or terminal illness, or degenerative conditions. These may impact on the safety and well-being of their children, resulting in delay to their education, physical and emotional development. Further information on mental health issues and the impact on children can be found in this chapter.

Further Information

452. Further helpful information can be found in the following publications or on the links noted below.

Non-engaging Families

453. Practice and child protection inquiries in the past 20 years 14 have identified that some adults deliberately evade practitioner intervention to protect a child. This is a clear and deliberate strategy in many cases of child abuse, employed by one or more of the adults with responsibility for the care of a child. It is also the case that the nature of child protection work can result in parents and carers feeling and demonstrating a range of emotions and behaviour. Accordingly, they will, at times, react in an apparently negative or hostile way towards practitioners who are involved with their family, and practitioners should be aware that this behaviour can be misinterpreted.

454. The terms 'non-engagement' and 'non-compliance' are used to describe a range of deliberate behaviour and attitudes, such as:

  • failure to enable necessary contact, such as keeping appointments, or refusal to allow access to the child or to the home;
  • active non-compliance with the actions within the child's plan (or child protection plan);
  • disguised non-compliance, for example, making their behaviour or verbal agreement look like apparent co-operation, without actually carrying out actions or enabling them to be effective; and
  • threats of violence or other intimidation towards practitioners.

455. Consideration needs to be given to explicitly who within the family is reluctant for engagement to take place. In some families, it may be important to recognise that one partner may be 'silencing' the other and domestic abuse may be a factor.

456. Further, some children and families may have genuine difficulties accessing some services. Account should always be taken of diversity and equality issues. For example adults with a learning disability, gypsy travellers, or people from minority ethnic communities may have specific communication needs and require flexible approaches by staff to engage with them. Some people find it easier to work with some practitioners; for example, young parents may agree to work with the health visitor but not the social worker.

457. Accordingly, when considering non-engagement by a parent or carer, practitioners must consider if the child protection concerns and necessary actions have been explained clearly, taking into account issues of language, culture and disability, so that parents or carers fully understand the concerns and the impact on their care and needs of the child.

458. If there are risk factors associated with the care of children, where any of the responsible adults with caring responsibilities do not engage or comply with child protection services, risk is likely to be increased. 15 Non-engagement and non-compliance, including disguised compliance, must be taken account of in information collection and assessment. Non-engagement and non-compliance are likely to be indicators of the need for compulsory or emergency measures. As these are often challenging situations, staff may need access to additional or specialist advice to inform their assessments and plans.

459. There is danger in 'drift' setting in, before non-engagement is identified. If letters are ignored, or appointments not kept, weeks can pass without practitioner contact with the child. If carers fail to undertake or support necessary actions, this should be monitored and the impact regularly evaluated. Good record-keeping in relation to families, such as contacts and whether they are successful or not, should be maintained, taking particular account of high risk periods when children would not be in nursery or school, for example, Christmas and summer holidays.

460. Core groups need to work effectively and collaboratively to deal with and counter non-engagement. It should, though, be recognised that different agencies and practitioners have different responsibilities. The plan for the child should include recognition of the protocols for different agencies and make sure that these result in a coherent overall approach to the risks.

461. Effective multi-agency approaches can offer flexibility about the best person to engage with the family and carers. This may include giving greater responsibility for certain actions to those practitioners or agencies that are more likely to be successful in achieving positive engagement. The use of all children's services should be flexible.

462. Given the nature of child protection work, non-engagement can sometimes involve direct hostility and threats or actual violence towards staff. All agencies should have protocols to deal with this, including practical measures that promote the safety of staff who have direct contact with families. In addition, staff should have the opportunity for 'critical stress debriefing' after any incidents.

463. Families or carers who are directly hostile are very challenging to practitioners, however withdrawing a service to a child without other protective measures in place would not be justifiable. Local child protection guidance should state that key safeguards and services should be maintained for children who are at risk of harm

Children and Young People Experiencing Mental Health Problems

464. There are two separate but not unconnected issues which should be considered within the context of identifying, assessing and managing the risks faced by children affected by mental health problems:

  • children and young people who themselves are experiencing mental health problems; and
  • children and young people whose lives are affected by parental mental illness or mental health problems.

This section deals with the first of these issues, while the following section covers children affected by parental mental illness.

465. There are strong links and similarities to issues for children with disabilities, children affected by substance misuse, families who do not access services and children affected by domestic abuse. Stigma is a particular issue causing many people not to admit to experiencing mental health problems or seeking help for themselves or their children.

466. The emotional well-being of children and young people is just as important as their physical health. Most children grow up mentally healthy, but certain risk factors make some more likely to experience problems than others. Evidence also suggests that more children and young people have problems with their mental health today than 30 years ago. The things that happen to children will not usually lead to problems with their mental health on their own, but traumatic events can trigger problems for children and young people whose mental health is not already robust.

467. Changes can act as triggers, such as moving home or school. Teenagers often experience emotional turmoil as their minds and bodies change and develop. An important part of growing up is working out and accepting who you are: some young people find it hard to cope and may experiment with alcohol, drugs or other substances that can alter how they feel. Self-harm and suicide has increased amongst young people over the last 15 years.

468. For some young people, this will not be a transitory issue and mental health problems will severely limit their capacity to participate actively in everyday life and will continue into adulthood. Some will develop severe difficulties and behaviour that challenges families and services, including personality disorders and sexually-predatory behaviour. A small number of children with mental health problems may pose risks to themselves and others. For some, their vulnerability, suggestibility and risk levels may be heightened as a result of their mental illness. For others, their need to control, coupled with lack of insight or regard for others, feelings and needs, may lead to them preying on the vulnerabilities of other children. It is imperative that services work in close partnership to address the difficulties and mitigate the risks for these children and for others.

Risk Factors

469. There are certain risk factors that make some children and young people more likely to experience problems than other children, but they do not necessarily mean difficulties are bound to come up or are even probable. Some of these factors include:

  • having a long-term physical illness;
  • having a parent or carer who has had mental health problems, problems with alcohol or been in trouble with the law;
  • experiencing the death of someone close to them;
  • having parents who separate or divorce;
  • having been severely bullied or physically or sexually abused;
  • living in poverty or being homeless;
  • experiencing discrimination, perhaps because of their race, sexuality or religion;
  • acting as a carer for a relative, taking on adult responsibilities;
  • having long-standing educational difficulties; and
  • insecure attachments with primary carer.

Service Responses and Practice Issues

470. There is a range of mental health problems that children and young people can experience, from depression and anxiety through to psychosis, and while most recover from these, many are left with unresolved difficulties or undiagnosed illnesses that can follow them into adult life. In addition child protection is a crucial component of the service response to children and young people experiencing mental health problems. A greater awareness of the issues is required.

471. For children and young people experiencing such difficulties, it is extremely important that they are able to access the right support and services and that their issues are taken seriously. The same is true for parents and carers who may be bewildered or frightened by their child's behaviour or concerned that they are the cause of such behaviour.

472. A focus on children's welfare is paramount. The need to work collaboratively across services to ensure effective responses that take account of the child's or young person's family and wider social circumstances is fundamentally important. This is particularly important where child protection concerns have been identified. Effective risk assessment is required as part of this response. Child and adolescent mental health services can provide an important resource in helping children and young people overcome the emotional and psychological effects of abuse and neglect. In some parts of the country, there are long waiting lists for children and young people to see mental health specialists or have a talking therapy on the NHS. It is important that children and young people's mental health is not seen as only the preserve of psychiatric services, as the causes of mental ill-health are bound up with a range of environmental, social, educational and biological factors. Long waiting times for access to these services should not be a reason for inactivity on the part of other agencies.

Further Information

473. Further helpful information can be found in the following publications or on the links noted below.

  • The National Patient Safety Agency Rapid response report on preventing harm to children from parents with mental needs has made a number of recommendations for practice and NHS Boards in Scotland have been asked to consider and review their local arrangements in light of these recommendations.
  • The SCIE Report, Think child, think parent, think family (published July 2009) identifies the need for a multi-agency approach with senior level commitment to this strategy and includes recommendations for practice in relation to assessment, care planning /provision and reviewing this at a practitioner, organisational and strategic level. This guidance relates to circumstances in England and Wales and will require some amendments to take account of the situation in Scotland. However, it establishes a useful and positive perspective.
  • See Me - Scotland's national campaign to end the stigma and discrimination of mental ill-health.
  • Scottish Good practice Guidelines for Supporting Parents with Learning Disabilities is aimed at providing practical guidance to agencies that support people with learning disabilities who become parents.

Parental Mental Illness

474. It is not inevitable that living with a parent or carer who experiences mental ill health will have a detrimental impact on a child's development and many adults who experience mental health problems are good parents. However, there is evidence to suggest that many families in this situation are more vulnerable.

475. A number of features can contribute to the risk experienced by a child or young person living with a parent or carer who has mental health problems including that:

  • they may be involved in parent's/carer's delusional system or obsessional compulsive behaviour;
  • the child may have become the focus for parental aggression or rejection;
  • the child may witness disturbing behaviour arising from the mental illness (often with little or no explanation);
  • the child may have caring responsibilities which are inappropriate for his/her age; and
  • the parent/carer is unable to anticipate the needs of the child or put the needs of the child before their own.

476. There are also factors which may impact on parenting capacity including:

  • maladaptive coping strategies or misuse of alcohol and/or drugs;
  • lack of insight into the impact of the illness (on both the parent/carer and child); and
  • poor engagement with services or non-compliance with treatment.

477. This list is not exhaustive and a number of other factors can also impact on these situations, for example, issues impacting on the attachment relationship or domestic abuse.

478. Parental mental illness requires effective partnership working and, at times, it must be acknowledged that the needs of the child and their parents may conflict. The importance of a holistic perspective on family assessment is fundamental to providing appropriate services to both parents/carers and children in families dealing with mental health problems. However, it must be recognised that this work cannot be limited to specialist services and universal services must also be aware of the potential impact of adult mental illness on children and young people and

479. parenting capacity. Practitioners must develop a sound knowledge about, and relationship with, other services which will facilitate joint working and shared case management.

480. The stigma associated with mental health problems means that many families are reluctant to access services because of a fear about what will happen next. Whilst this fear may also be present in other families, many parents/carers with mental health problems are worried that they will be judged because of their problems and this alone will be considered in terms of the care of their children. Therefore, for many of them, identifying a need for services or support is viewed as a high risk strategy.

Problem Sexual Behaviour in Children and Young People

481. Boundaries between what is abusive, what is inappropriate and what is part of normal childhood or adolescent experimentation can cause confusion. Practitioners' ability to determine if a child's sexual behaviour is developmentally normal, inappropriate or abusive will be based on healthy and problematic behaviour and issues of informed consent, power imbalance and exploitation.

482. Where abuse of a child is alleged to have been carried out by another child or young person, such behaviour should always be treated seriously and be subject of a referral to relevant agencies, both in respect of the victim and the perpetrator. In all cases where a child or young person presents problem sexual behaviour, immediate consideration should be given to whether action requires to be taken under child protection procedures, either to protect the victim or because there is concern about what has caused the child/young person to behave this way.

483. Identifying children and young people with problem sexual behaviour raises a number of dilemmas and issues for the practitioners working with them. They will normally require input from youth justice workers as well as health and education services, but they may also involve other practitioners such as criminal justice workers, including MAPPA on some occasions. The interface with child protection processes, and occasionally with adult protection, also needs to be considered.

484. All Child Protection Committees should have clear guidance in place to support staff working in such situations and should ensure that appropriate training is provided, including youth justice workers who will often be the practitioners undertaking the risk assessment and ongoing risk management tasks with the child or young person and their family. A risk assessment should be carried out to determine whether the child or young person should remain within the family home if this is an appropriate option, or to inform the decision about what might be an appropriate alternative placement. In the event that an alternative placement requires to be identified, residential staff or foster carers need to be fully informed about the problem sexual behaviour and a risk management plan must be drawn up to support the placement. In most instances, it will be appropriate that a referral is made to the Children's Reporter so that the need for compulsory measures of supervision can be considered where these are not already in place.

485. The two key tasks involved in effectively addressing problem sexual behaviour are risk management and risk reduction . While both are linked and one informs the other, it is helpful to make some distinctions.

486. Risk management is the action take to reduce opportunities for the problem sexual behaviour to happen again. A good risk management process should identify those children and young people who are most likely to commit further sexually abusive behaviour and require high levels of supervision. It should provide a robust mechanism through which concerns about a young person's problematic behaviour can be shared with relevant agencies in order that appropriate measures in risk management can be taken.

487. To manage risk effectively it is essential that:

  • multi-agency risk management framework and protocols are in place and being used effectively;
  • staff are trained to understand this area of work;
  • there is clarity about the roles and tasks of all the systems involved in risk management;
  • internal and external static and dynamic factors that impact on risk are identified;
  • safety plans are drawn up in the relevant environments, for example, home, schools, communities and residential units; and
  • a comprehensive assessment framework informs ongoing risk management.

488. Risk reduction is a planned programme of work that helps them develop appropriate skills and insights to reduce their need to engage in problem sexual behaviour. This is only addressed by:

  • having an understanding of area for intervention/goals common to all children with problem sexual behaviour;
  • providing within an assessment process a means to identify the most relevant areas for intervention with each child;
  • prioritising interventions which prioritise the child's psychological well-being;
  • promoting and describing interventions to facilitate the child's goal attainment; and
  • providing support to help the young person achieve these goals.

489. In taking forward risk management and risk reduction, the diversity of potential behaviour should be considered. There is a wide range of sexual behaviour that children and young people can display, relating to the nature of behaviour, degree of force, motivation, level of intent, level of sexual arousal, age and gender of victims, as well as broader developmental issues relating to the age of the young person, their family and background experiences, intellectual capacities and stage of development. Young people with learning difficulties are a particularly vulnerable and often neglected group who may need specific types of interventions.

490. Approaching problem sexual behaviour and their inherent risks can invoke a real anxiety in practitioners across disciplines. Having an agreed risk management framework based on research and best practice supported by training for key practitioners makes the risk more tangible and thus enables practitioners to employ strategies for effective risk management and risk reduction. This would include shared definitions and language, joint ownership of the management of risk and a collaborative approach.

Female Genital Mutilation

491. Female genital mutilation ( FGM) is a culture-specific practice in some communities that should trigger child protection concerns. The legal definition of FGM is "to excise infibulate or otherwise mutilate the whole or any part of the labia majora, labia minora, prepuce of the clitoris, clitoris or vagina". 16 It includes all procedures which involve the total or partial removal of the external female genital organs for non-medical reasons. There are four types of FGM ranging from a symbolic jab to the vagina to the partial or total removal of the external female genitalia. The Prohibition of Female Genital Mutilation (Scotland) Act 2005 makes it illegal to perform or arrange to have FGM carried out in Scotland or abroad and a sentence of 14 years imprisonment can be imposed.

492. This procedure usually takes place on children between four and ten years. It is a deeply rooted cultural practice in certain African, Asian and Middle Eastern communities. Justifications for FGM may include:

  • tradition;
  • family honour;
  • religion;
  • increased male sexual pleasure;
  • hygiene; and
  • fear of exclusion from communities.

493. There is a range of health problems associated with having this procedure performed, and can be immediate, long-term or both, depending on the type of procedure performed. The short-term effects can include haemorrhage and pain, shock and infection. Longer-term effects include difficulties associated with bladder, menstrual, child birth and sexual difficulties. The emotional effects of FGM may include flashbacks, sleep difficulties, emotional anger, difficulties in adolescence, panic attacks and anxiety. In Western cultures, the young person may also be disturbed by Western opinions of the practice which they perceive as part of being female.

494. FGM is usually done for strong cultural reasons and the significance of these needs reflection. Action should be taken in close collaboration with other agencies and should be proportionate and sensitive to the cultural norms and pressures on parents/carers and children. Where possible, workers with knowledge of the culture involved may be able to assist but the welfare of the child must always be paramount. Nevertheless, FGM should always be seen as a cause of significant harm and normal child protection procedures should be invoked. Some distinctive factors need consideration in this context, for example:

  • FGM is usually a single event of physical abuse (with very severe physical and mental consequences) and these need to be taken in to consideration within the risk assessment;
  • there is a risk that a child or young person is likely to be sent abroad to have the procedure performed;
  • where a child or young person within a family has already been subjected to FGM, consideration must be given to other female siblings or close relatives who may also be at risk;
  • an inter-agency practitioner meeting should be arranged if the above conditions are met, where appropriate specialist health expertise should be sought;
  • where other child protection concerns are present they should be part of the risk assessment process and may include factors such as trafficking or forced marriage (detailed elsewhere in this guidance);
  • legal advice should be obtained where appropriate; and
  • appropriate interpreters should be used with enough time allowed.

495. Local guidelines should be in place to ensure a co-ordinated response from all agencies and highlight the issue for all staff that may have contact with children who are at risk from FGM. As with other forms of child protection as far as possible work should be done in partnership with parents/carers, but this may not always be possible.

Further Information

496. The attached links provide further information on FGM:

Honour-based Violence and Forced Marriage

497. Honour-based violence ( HBV) is a crime or incident, which has been committed to protect or defend the perceived honour of the family and/or community. Such violence can occur when perpetrators perceive that a relative/community member, who may be a child, has shamed the family and/or the community by breaking their honour code. The punishment for transgressing the code of behaviour may include assault, abduction, confinement, threats and murder. 17 Incidents that may seem like a trivial transgression to others may be sufficient motivation for a child to be punished, including:

  • inappropriate make-up or dress;
  • the existence of a boyfriend/girlfriend;
  • inter-faith relationships;
  • kissing or intimacy in a public place;
  • pregnancy outside of marriage; and
  • rejecting a forced marriage.

498. HBV is a spectrum of violence with threats and abuse at one end and honour killing at the most extreme.

499. A forced marriage is defined as a marriage conducted without the full and free consent of both parties and where duress is a factor. Duress can include physical, psychological, financial, sexual and emotional pressure. 18A clear distinction must be made between a forced marriage and an arranged marriage. An arranged marriage is one in which the families of both spouses are primarily responsible for choosing a marriage partner for their child or relative, but the final decision as to whether or not to accept the arrangement lies with the potential spouses. Both spouses give their full and free consent. The tradition of arranged marriage has operated successfully within many communities for generations.

500. In Scotland, a couple cannot be legally married unless both parties are at least 16 on the day of the marriage, and both must be capable of understanding the nature of a marriage ceremony and of consenting to the marriage. Parental consent is not required.

501. The consequences of forced marriage can be devastating to the whole family, but especially to the young people affected, with them often becoming estranged from their families and wider communities; losing out on educational opportunities as they are taken prematurely from school; suffering domestic abuse; and/or having a high rate of self-harm and suicide rates. Potential indicators of HBV and forced marriage can include combinations of a number of signs and the list below is not exhaustive:

Education

  • Absence and persistent absence from education
  • Request for extended leave of absence and failure to return from visits to country of origin
  • Decline in behaviour, engagement, performance or punctuality
  • Being withdrawn from school by those with parental responsibility
  • Being prevented from attending extra-curricular activities
  • Prevented from going onto further/higher education

Health

  • Self-harm
  • Attempted suicide
  • Depression
  • Eating disorders
  • Accompanied to doctors or clinics and prevented from speaking to health practitioner in confidence
  • Female genital mutilation

Police

  • Reports of domestic abuse, harassment or breaches of the peace at the family home
  • Threats to kill and attempts to kill or harm
  • Truancy or persistent absence from school

502. It is important that assumptions and stereotyping are resisted and all efforts should be made to establish the full facts of cases at the earliest opportunity. Cases of HBV/forced marriage can involve complex and sensitive issues. For example, mediation and involving the family can place a child or young person in danger and should not be undertaken as a response to forced marriage or HBV. This includes visiting the family to ask them whether they are intending to force their child to marry or writing a letter to the family requesting a meeting about their child's allegation that they are being forced to marry or claims of HBV.

503. Concerns may be expressed by a child or young person themselves about going overseas. Often they have been told that the purpose is to visit relatives, attend a wedding or because of the illness of a grandparent or close relative. On arrival, their documents, passports, money and mobile phones are often taken away from them. These concerns should be taken seriously though it is important that practitioners should be careful of making assumptions. These cases may initially be reported to the joint Home Office/Foreign and Commonwealth Office Forced Marriage Unit.

504. As with all cases of forced marriage, confidentiality and discretion are vitally important. It is not advisable to immediately contact an overseas organisation to make enquiries. If, through this action, the family becomes aware that enquiries are being made, they may move the child or young person to another location or expedite the forced marriage.

505. Once a child or young person has left the country, the legal options open to social work services, other agencies or another person to recover the child or young person and bring them back to the UK are limited. Sometimes the Forced Marriage Unit may ask a social work services department for assistance when a child is being repatriated to the UK from overseas. In these cases, the child or young person may be extremely traumatised and frightened, sometimes because they have been held against their will for many months and suffered emotional and physical and sexual abuse. Victims are particularly vulnerable to further action from their families and/or communities when they return to the UK.

506. Returns to the UK can take place at short notice, as due to the urgency of the situation, the Foreign and Commonwealth Office may not be able to give social work services a great deal of notice of the child's or young person's repatriation. The Foreign and Commonwealth Office is obliged to explore all options for funding the cost of repatriation. For victims who are children or young people, this means asking the young person themselves, a trusted friend or children's social work service or a school or college if they are able to meet the costs of repatriation. However, this should never delay the process of getting the child or young person to safety. Local areas should consider what multi-agency arrangements can be put in place to ensure safe accommodation of a repatriated child or young person while legal remedies and action are considered.

507. When a child or young person has already been forced to marry, there may be occasions when a child or young person approaches children's social care or the police because they are concerned that they may need to act as a sponsor for their spouse's immigration to the UK. In these situations, the practitioner should reassure the child or young person that they will not be required to act as a sponsor until they are 21. Confronting the family may be extremely risky for the child or young person. They may not get the support they hope for and further pressure may be put on them to support the visa application. These risks must be discussed with the child or young person if only to exclude this option.

508. Cases of forced marriage may initially be reported to social work services as cases of domestic abuse. Spouses forced into marriage may suffer domestic abuse but feel unable to leave due to a lack of family support, economic pressures and other social circumstances - some may fear losing their own children. In all cases, the social worker needs to discuss the range of options available to the child or young person and the possible consequences of their chosen course of action. A spouse who is the victim of a forced marriage can initiate nullity or divorce proceedings to end the marriage. The child or young person should be informed that a religious divorce would not end the marriage under UK law.

Further Information

509. Further helpful information can be found in the following publications or on the links noted below:

Fabricated or Induced Illness

510. Fabricated or induced illness in children is not a common form of child abuse, but nonetheless it is important for practitioners to understand the indicator. The age range of children in whom illness is fabricated or induced extends throughout childhood, although it is most commonly identified in younger children. Where concerns do exist about the fabrication or induction of illness in a child, practitioners must work together, considering all the available evidence, in order to reach an understanding of the reasons for the child's signs and symptoms of illnesses. A careful medical evaluation is always required to consider a range of possible diagnoses and a range of practitioners and disciplines will be required to assess and evaluate the child's needs and family history.

511. There are three main ways of the carer fabricating or inducing illness in a child. These are not mutually exclusive and include:

  • fabrication of signs and symptoms - this may include fabrication of past medical history;
  • fabrication of signs and symptoms and falsification of hospital charts, records and specimens of bodily fluids - this may also include falsification of letters and documents; and
  • induction of illness by a variety of means.

512. For those children who are suffering, or at risk of suffering significant harm, joint working is essential, to protect the child and - where necessary - take action, within the criminal justice system, and within the child protection system regarding the perpetrators of crimes against children. All agencies and practitioners should:

  • be alert to potential indicators of illness being fabricated or induced in a child;
  • be alert to the risk of harm which individual abusers, or potential abusers, may pose to children in whom illness is being fabricated or induced;
  • share, and help to analyse information so that an informed assessment can be made of the child's needs and circumstances;
  • contribute to whatever actions (including the cessation of unnecessary medical tests and treatments) and services are required to safeguard and promote the child's welfare;
  • regularly review the outcomes for the child against specific planned outcomes;
  • work co-operatively with parents/carers unless to do so would place the child at increased risk of harm; and
  • assist in providing relevant evidence in any criminal or civil proceedings, should this course of action be deemed necessary.

513. The majority of cases of fabricated or induced illness in children are confirmed in a hospital setting because either medical findings or their absence provide evidence of this type of abuse though the GP may also be source for identifying concerns. The initial role for the paediatrician is to find out whether a child's illness and individual symptoms and signs have an unequivocal explanation as a natural illness. If this is not clear the possibility of fabrication or illness induction and the effect of this on the child has to be considered. Psychiatrists and psychologists may be needed to look at the effects on the child and establish whether there are underlying disorders in the carer. Police must investigate a possible crime. Social workers will co-ordinate the assessment of concerns about the child's welfare or the risk of harm and provide support to parents/carers during the assessment. Co-ordinated planning and assessment is essential in the investigation of fabricated or induced illness and some issues, such as the use of covert video surveillance, will require agreed consideration and implementation.

514. Fabrication of illness may not necessarily result in the child experiencing physical harm. Where children have not suffered physical harm, there may still be concern about them suffering emotional harm and a thorough assessment of the child's needs will be required to consider the needs of the child and family.

Further Information

515. Further helpful information on fabricated or induced illness and how agencies can contribute to the investigation and assessment of it, can be found in:

Both documents, while providing useful guidance on how agencies should respond when concerns are raised about fabricated or induced illness, are written for practitioners in England and Wales and would need to be considered within a context of Scottish legislation and processes.

Sudden Unexpected Death in Infancy and Children

516. Only a small number of children die during infancy in Scotland and while the majority of such deaths are as a result of natural causes, physical defects or accidents, a small proportion are avoidable, having been caused by the commission or omission of an act i.e. through neglect, violence, malicious administration of substances or by the careless use of drugs.

517. One of the implications of Section 2 of the Human Rights Act 1998 is that public authorities have a responsibility to investigate the cause of a suspicious or unlawful death. This will help to support the grieving parents and relatives of the child and it will also enable medical services to understand the cause of death and, if necessary, formulate interventions to prevent future deaths.

518. In Scotland, the Procurator Fiscal has a duty to investigate all sudden, suspicious, accidental, unexpected and unexplained deaths and any deaths occurring in circumstances causing serious public concern. As such, the police act as the agents of the Procurator Fiscal and have a duty to secure any information or evidence that establishes the true cause of death. The police, therefore, have a key role in the investigation of infant and child deaths, and their prime responsibility is to the child, as well as to siblings and any future children who may be born into the family concerned.

519. There are occasions where the cause of death cannot be established. In such cases pathologists may classify the death as Unascertained, pending investigations; Sudden Unexplained Death in Infancy ( SUDI) or may record the cause of death as Sudden Infant Death Syndrome (by definition a death due to natural causes which have not been determined).

520. The six guiding principles that underpin the work of practitioners dealing with any infant or child death investigations are:

  • sensitivity;
  • open mind/balanced approach;
  • appropriate response to the circumstances;
  • an inter-agency response;
  • sharing of information; and
  • preservation of evidence.

521. When a death of a child is reported to the police a Senior Investigating Officer ( SIO) should always be appointed to oversee the investigation, whether or not there are any obvious suspicious circumstances.

522. It is important that the police and hospital/medical staff establish a collaborative approach to any such investigation. While it is appreciated that police and health practitioners have specific duties to perform, they should be sensitive to the nature of the inquiry and respect each other's role. Information-sharing between police and health staff is expected to ensure that a comprehensive picture of what is jointly known is established in early course and updated throughout any investigation.

523. Police forces should consider using suitably trained officers from force Public Protection Units or equivalent for more specialist tasks during such an investigation, such as:

  • interviewing child witnesses;
  • obtaining other background information from specialist police databases and other agency records; and
  • liaison with the relevant local authority social work services to ensure their records are checked, including the Child Protection Register (and previous registrations if possible), and involve them in a strategy discussion, if appropriate.

524. On occasions when the infant/family was not resident in or had recently moved to the area in which the death occurred, the SIO will ensure that enquiry is made with other police forces and partner agencies in the area the child resided or is known to have recently resided.

525. It is recognised that the investigation into a death of an infant/child is particularly challenging. Notwithstanding, it is essential that a full and thorough investigation takes place and it is undertaken in a tactful, sensitive and sympathetic manner. The investigation requires a joint approach with collaboration between practitioners to ensure that the fullest information is gathered and considered.

Page updated: Thursday, May 27, 2010