Safeguarding Children and Young People-Everyone`s Responsibility

Mansoor T1, Mansoor N2 and Ahmed M2

1. School of Medicine, University of Leeds and

2. Queen`s Hospital, Burton upon Trent, United Kingdom

Corresponding to: Dr Mansoor Ahmed

Email: mansoor.ahmed2@nhs.net,

https://doi.org/10.36570/jduhs.2019.3.703

ABSTRACT

Safeguarding children is a pathway of protecting susceptible children and young people from abuse and neglect. Child Protection is part of safeguarding process which protects children suffering from or likely to suffer significant harm. True incidence of child abuse is higher than reported in the literature. Adverse family dynamics and humanitarian disasters increase the risk of harm. Professionals dealing with children, especially paediatricians, have an imperative responsibility in recognising and reporting child abuse. There is an urgent need to roll out mandatory child protection training program nationally. This training is likely to improve the knowledgebase and train the paediatricians and other professionals with the recent evidence to empower them to recognise various forms child abuse. It will also sign post them to the available local services for onward referral and support. Appropriate infrastructure and legislative support is of paramount importance to protect children reported to the statutory authorities.

Keywords:

Abuse, child protection, neglect, safeguarding

 

BACKGROUND

Abuse has no boundaries and is prevalent across all ethnicities, race, religions, gender and social classes. Child abuse is any type of harm that is perpetrated on children, leading to substantial detrimental effects. Not only inflicting harm by the perpetrators can lead to child abuse but ignorant behaviour or deliberate inability to prevent ill treatment may equally put children at risk of long-lasting harmful effects. Children may be abused within or outside their home by known individuals such as their own family members, relatives, neighbours or a family friend. It may also take place in an institution such as a residential accommodation/hostel, school or madrasa. Comparatively, abuse by a stranger is less common. A child may be abused by an adult, gang of adults, another child or a group of children. This may take the form of physical abuse, sexual abuse, emotional abuse, neglect, fabricated/induced illness, child sexual exploitation, child prostitution, child trafficking, child labour, child slavery and online abuse/harm. It is not uncommon for such children to experience more than one type of aforementioned abuse. Abuse may take the form of an isolated event or it may happen repeatedly over a period of time.

The United Nations Convention on the Rights of the Child has been signed and adopted by more than 190 countries around the world. It outlines children`s rights and Article 19 lays responsibility on governmental administrative, legislative, social, and educational institutions to work together and protect children from all types of abuse while they are in the care of their parents or carers.1

 

INCIDENCE

It is impossible to predict the exact incidence of child abuse and neglect as majority of cases are either not recognised or not reported. Hence, it is perceived that the reported cases of child abuse are merely the tip of the ice burg. It is estimated that approximately 700,000 children are identified as sufferers of abuse or neglect in the United States each year. On the other hand, the figures in the United Kingdom (UK) are close to 58,000 children. The National Society for the Prevention of Cruelty to Children (NSPCC) in the UK estimates that for every single case identified and reported, there are another eight unreported children who are suffering abuse.2 It is impossible to predict the incidence of child abuse in Pakistan. There is an urgent need to roll out, legally formalise and empower Child Protection and Welfare Bureau, Child Protection Units (CPU), Hospital Child Protection Committees and Social Care institutions across the country with responsibility to collate all the data related to child abuse in Pakistan as well as lead the safeguarding process in conjunction with other statutory agencies such as police and legal services.

 

HUMANITARIAN CATASTROPHES

In times of crisis and emergencies, whether instigated by armed conflict (between groups or nations), a sudden-onset natural disaster (earthquake or large-scale flooding) or a disease epidemic, children are exposed to significant vulnerability and safeguarding issues. Not infrequently, due to mass immigration of vulnerable population in such situations, local capacity to deal with such humanitarian disasters is exceeded or inadequate. Collapse of governmental control and break down of legislative power further aggravates the situation. These children are exposed to poor physical/mental wellbeing, risk of physical injury, disability, neglect, exploitation, physical/sexual violence, psychosocial distress, mental disorders, nutritional deprivation, dearth of schooling/education facilities and lack of availability of clean drinking water/sanitation facilities. As a result of separation from their families and forced recruitment into armed groups, their lives are at risk. They are at risk of sexual exploitation, being trafficked/sold to another group or forced into modern slavery and child labour.

Unfortunately, the number of individuals affected by humanitarian crises has mounted over the recent decades, perpetuated and compounded by armed conflict and natural disasters.3 According to the United Nations refugee agency, 70.8 million individuals were forced to emigrate out of their homes. Among them, there were nearly 25.9 million refugees and more than 50% of these were children and young people.4

 

CYBER BULLYING AND INTERNET ABUSE

Internet has become a cheap and major information source for all of its users. Easy access to cell phone and internet over the recent times has exposed young generation to the threat of cyberbullying and internet abuse. Apart from huge advantages at the click of a button at any time, these gadgets which include computers, tablets and mobiles also enable easy and unrestricted access to inappropriate and indecent material which is freely available on the internet.5 Moreover, it also provides a platform for social interaction and interpersonal communication via a number of social media applications. Young people are the highest users of these social interaction platforms.6,7 Some of these applications enable a young person to authorise access of his/her personal information/uploads to unlimited number of followers (known and unknown). Thus they are at risk of falling prey of potential abusers. Child`s attachment to their parents can have a significant impact on internet use. Parents` warmth and affection towards their children and collaborative strategies can contribute to decreased risk of cyberbullying.8

 

ROLES AND RESPONSIBILITIES

Safeguarding children, a process of providing safe and effective care for children and young persons who are exposed to or are at danger of significant harm, is everyone`s responsibility. This is best achieved when professionals are trained in its recognition and are clear about their roles and responsibilities. Those involved in child protection work may range from teachers, medical/nursing professionals, police and social service (child protection agency) workers. These professionals must acquire basic competencies which encompass not only a variety of diagnostic/clinical capabilities but also self-assurance, empowerment, appropriate attitudes/feelings and ability to overcome the obstacles to effective safeguarding. It is of paramount importance that those professionals who are exposed to children and involved in looking after children in the health sector have an understanding of the referral process when child abuse is suspected. Paediatricians have a key role in this process and have a responsibility to safeguard children if/when they suspect child abuse. Appropriately trained professionals should be in a position to recognise child abuse when children are brought by their carers for various ailments. They should also be aware of key National legislations pertaining to child protection. At the same time, it is important to acknowledge the limit of one`s competence and be prepared to seek advice from more experienced colleagues.

In the UK, the Children Act 1989 necessitates all professionals to consider the child`s welfare as of paramount importance. They are expected to always act in the best interests of children.9 Health professionals have a vital role in assessing children when child abuse is suspected. They contribute to formal child protection medical examination, arranging appropriate medical investigations (such as blood tests, neuroimaging, ophthalmology assessment and skeletal survey) and/or direct/indirect professional observations to determine how the child`s developmental progress, physical well-being and mental health may have been impaired as a result of abuse or neglect. They are also required to produce a formal child protection medical report which encompasses all the findings and summary/conclusion. In order to achieve the above mentioned required standards, appropriate training, supervision and support for staff is of utmost significance.

The first step in the whole process is to undertake an appropriate level of safeguarding training. This is followed by maintaining their skills by regular refresher sessions. It is not just the hospitals and health authorities but other organisations (such as nurseries/schools, madrasas, residential hostels and leisure/sports clubs) should also have an accountability to guarantee that their staff has all the necessary training and competencies in fulfilling their obligation to protect, safeguard and promote the well-being of children. All of these organisations should ensure that they create a supportive atmosphere where staff is empowered to raise concerns when fulfilling their safeguarding role. Hence, all such staff must attend a compulsory induction at the start of their employment, which should include recognition as well as understanding the child protection policies and processes locally and nationally. All staff involved with children should have regular meetings with their safeguarding supervisors on a regular basis. During these meetings, an open discussion and review of their safeguarding practices should be undertaken. If needed, appropriate support and further training should be arranged to enhance their competencies and to overcome any barriers to safeguarding children. The importance of professional collaboration and appropriate information sharing should be advocated and implemented via child safeguarding legislation in the Country.

 

DETECTING CHILD ABUSE IN EMERGENCY DEPARTMENTS

Infants and children who are being abused are brought in to the emergency department (ED) more frequently than their peers.10 Unfortunately, unless the systems are in place, these frequent attenders are often unrecognised and remain under the detection radar.11-14 Up to 1% of all injury related visits to the ED are secondary to physical abuse. Sub-optimal detection of child abuse in the hospital setting is even in existence in the developed world.15 Hence, implementation of a screening protocol or a check list of red flags in the ED can be a stepping stone towards identification of high risk group of infants and children.16 Unfortunately, there is no universally validated check list available for use even in the western countries. Once a case is suspected, it is of paramount importance that the clinician informs parents or legal guardian about his/her concerns. At the same time, it is equally vital to immediately follow the referral process without accusing anyone. Identification and bringing the perpetrator to justice should be the responsibility of the statutory agencies (e.g. social services) and legislative organisations (such as police).

 

CURRENT SITUATION IN PAKISTAN

There is no formal referral and reporting system in existence for child abuse and neglect in Pakistan. As a result, it is not possible to predict the true incidence or prevalence of this delicate and extremely stigmatised subject matter. There are a number of Non-Governmental Organisations (NGO) currently working to protect children from abuse and harm in Pakistan. Sahil is one of NGO that has been working since 1996. It mainly focusses on child sexual abuse in Pakistan in addition to providing free legal aid.17 It has produced Cruel Number reports for the last two decades. According to Cruel Numbers 2018, during the year 2018 in Pakistan, 3832 cases were reported in 85 newspapers in Pakistan (a rise of more than 11% compared to 2017 data).17 Protection and Help of Children Against Abuse and Neglect (PAHCHAAN) is another NGO which is actively working in Pakistan. It focusses on a number of projects such as children in emergencies, empowering street children, managing abused children in hospitals and raising awareness against abuse and neglect.18 Some of the other NGOs include Society for the Protection of the Rights of the Child (SPARC), Voice of Children (VOC), Children First, Save the Children, Child Care Foundation of Pakistan (CCF), AGHS Legal Aid-Child Rights Unit, KONPAL Child Abuse Prevention Society, Idara Aaghosh, Azad Foundation, Initiator Human Development Foundation (IHDF) and Alliance for the Rights of the Child (ARC).

In a study of 800 children (11-17 years) residing in peri-urban and urban communities in Karachi, Lakhdir MPA et al identified significantly higher incidence of child emotional maltreatment if their parents also had a history of childhood victimisation (intergenerational transmission of maltreatment and abuse).19

There are various legislations in the federal and as well as provincial law in Pakistan which encompass child labour under the age of 14 years, free and compulsory education under the age of 16 years, protecting the rights of women and children, minimum age of criminal responsibility, protection of children from cruelty and from exposure to obscene and sexually explicit material, criminalization of child pornography, internal trafficking, child sexual abuse and protection to children from exposure to obscenity, exposure to seduction, child prostitution and sexually explicit material. In reality, the situation is far from being perfect. Multiple provincial and federal legislations provide a variety of definitions and interpretations thus creating a huge amount of confusion leading to disparity during the implication of justice. There is an urgent need to develop and implement a Childrens Act in order to encompass all the legislations relating to welfare and protection of children from all forms of abuse and neglect.

In some of the tertiary hospitals in larger cities in Pakistan, CPU have already been set up. Any child with reasonable suspicion of abuse is reported to the CPU co-ordinator who arranges immediate consultation with the designated medical officer and/or Consultant ED. Child is then admitted to the hospital for further investigation and care. There is a drive to formulate hospital child protection committees (HCPC) in general hospitals in big cities as well as in the district/peripheral hospitals. HCPC liaise with and feed into CPU. Government based `Child Protection and Welfare Bureau` has been established in various cities of Punjab since 2004. Its role is to protect children from criminals. It provides food, shelter, education, rehabilitation and skills to the vulnerable children. Neglected and deprived street children are rescued and placed in secured units. Their legal section provides legal support and legal custody is obtained if it is in child`s best interest. One of the objectives of Child Protection and Welfare Bureau is to reunite kidnapped, run away, missing or trafficked children with their parents via family tracing.

 

CHILD PROTECTION TRAINING PROGRAMME

In a qualitative study involving healthcare staff (including doctors and nurses), Maul KM and colleagues identified multiple challenges including poor understanding of referral process to legal services, lack of empowerment as well as concerns about the safety of the abused child and healthcare staff themselves. Interview participants also suggested the need for further training and guidance.20 This has also been emphasized by Raman S and colleagues as they recommend adopting a public health model in order to improve monitoring and surveillance of violence against children and women. The authors also stress on the importance of training all professionals working in the field of child protection alongside interagency collaboration and interdisciplinary partnership.21

In the UK, independent serious case reviews are undertaken for every case following the death of a child due to abuse or neglect. Moreover, these reviews are also carried out if a child suffers a serious harm following an abuse/neglect and when there are concerns about the way organisations and professionals dealt with that particular case. The whole purpose of this exercise is to identify any deficiencies and omissions as well as share the outcome/summary and recommendations of the findings in order to prevent such incidents from happening in future. Over the last 30 years, these reviews have repeatedly highlighted the subject matter of not taking appropriate action when child abuse is suspected, taking decisions in isolation, lack of communication between professionals and agencies alongside lack of appropriate Child Protection training as key factors leading to failure in protecting these children.

In the UK, all healthcare staff dealing with children are required to attend training in safeguarding and promoting the well-being of children at an appropriate level. They are also required to attend refresher sessions as part of their continuing professional development.22 Different levels of child protection training courses are required depending upon staff roles and responsibilities at work environment. Level 1 core safeguarding training is compulsory for all organisational staff that work with children regardless of their nature of duties. This includes receptionists, porters, administrative staff, caterers, maintenance staff and other non-clinical staff workers. This short duration training is either made available online or face to face as part of induction process along with an accompanying leaflet covering various potential indicators of child maltreatment and signposting to actions if there are safeguarding concerns. Level 2 training is a prerequisite for all staff (clinical or non-clinical) that come in direct contact with children and/or their parents/carers. This includes managerial staff, dentists, medical and nursing students, ambulance staff as well as adult surgeons, radiology and anaesthetic staff treating children. In addition to Level 1 core training, they are required to have additional online or face to face training which covers identification of various forms of child abuse and neglect. Multidisciplinary and scenario-based discussion is incorporated around real case studies. They are also taught about female genital mutilation, child trafficking and child sexual exploitation and are empowered to refer the child to statutory agencies such as social care. Level 3 training is mandatory for clinical staff (e.g. paediatric consultants, paediatric trainees, paediatric nurses, paediatric sub-specialty clinical staff, paediatric mental health workers, paediatric psychologists, midwives and obstetricians) who may contribute to child protection medical examination thus assessing and evaluating the needs of susceptible children. In addition to level 1 and level 2 skills, they are also given training about recording child protection concerns and compiling child protection medical reports. They are expected to contribute to inter-agency assessments and are expected to attend serious case reviews, case management reviews and child death review processes. They are expected to be aware of child`s rights, legislations pertaining to safeguarding children, court/criminal justice system and their role as professional witness. Level 4 and level 5 training is reserved for named and designated professionals in the field of child protection. They are expected to contribute to the development of safeguarding policies, protocols, guidelines and care pathways. They are part of the local safeguarding team and are available for advice and expert opinion. They are also required to oversee/deliver Level I, II and III training and lead on child protection peer review process.

It`s about time to establish and roll out a nationally recognised child protection course in Pakistan immediately. Undergoing an established training programme must be compulsory for any individual who may potentially encounter children at work. It would be equally important to run updates/refresher training courses at regular intervals. The overall aim of a child protection course should be to promote awareness and empower paediatricians and other professionals with the recent evidence and skills. The depth of these courses should be varied based on delegates` stage of training and responsibility in their clinical practice. Similar to paediatric and neonatal life support courses, all paediatric trainees and paediatricians should undergo compulsory level III child protection training. There should be regular peer review of their work and safeguarding supervision in order to promote and sustain their competence and confidence in this stressful and demanding area of work.

 

SUMMARY

Child protection is the responsibility of each and every individual. Incidence of child abuse is much higher than reported in the literature. Identification and reporting all child abuse cases to a single National designated statutory authority should be made compulsory in Pakistan. This agency should have offices in each district of the country and should be responsible to develop a robust reporting and data collecting system. It should be provided trained staff with legislative powers to work with health professionals, police and judicial system to safeguard vulnerable children. All staff dealing with children and young persons have an obligation to protect and promote their well-being. It is imperative that they acquire appropriate knowledge/skills and they should be able to follow the appropriate referral processes if they have any safeguarding/child protection concerns. In order to implement this goal, nationally agreed and standardised compulsory child protection courses (various levels) should be rolled out at the earliest possible opportunity. These courses will ensure uniform staff training and will develop necessary competencies/skills required by them to safeguard and protect our future generation.

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