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Safeguarding children in osteopathic practice part 2: Managing concerns about children
International Journal of Osteopathic Medicine (2015) 18, 297e304
www.elsevier.com/ijos
CLINICAL PRACTICE
Safeguarding children in osteopathic practice part 2: Managing concerns about children A. Feld a, A.F. Maddick b,*, S. Laurent c a
The Children’s Hospital at Westmead, Hawkesbury Road and Hainsworth Street, Westmead, Sydney, New South Wales, 2145, Australia b British College of Osteopathic Medicine, Lief House, 120-122 Finchley Rd, London, NW3 5HR, UK c Barnet & Chase Farm Hospitals NHS Trust, Wellhouse Lane, Barnet, Hertfordshire, EN5 3DJ, UK Received 26 October 2012; revised 7 May 2015; accepted 1 July 2015
KEYWORDS Safeguarding; Children; Paediatric; Child protection; Child abuse: neglect; Children at risk; Children in need; Social worker; Sharing information
Osteopaths working with children are likely to encounter child abuse and neglect. In this second of two parts we discuss how to manage safeguarding concerns that may arise in osteopathic practice. We review whether to involve GPs and social services to make informal enquiries and the use of anonymised “what if” conversations. We encourage osteopaths to check family backgrounds and be active in excluding risk. We also discuss practical ethical and legal aspects of consent and confidentiality that can often arise in safeguarding cases. Osteopaths with concerns should feel confident in contacting social workers for a second opinion and for many cases it is not necessary to identify the patient. When details of the patient are communicated, ideally this should be done with the parent’s permission to help families in need. In cases where a child may be at risk it may be more appropriate to discuss with a social worker without a parent’s or patient’s consent. It is the best interests of the child that should guide the osteopath in his management of suspicions of abuse or neglect. ª 2015 Elsevier Ltd. All rights reserved.
Abstract
* Corresponding author. E-mail address: [email protected] (A.F. Maddick). http://dx.doi.org/10.1016/j.ijosm.2015.07.001 1746-0689/ª 2015 Elsevier Ltd. All rights reserved.
298 Implications for practice Osteopaths will encounter children who they suspect may be abused or neglected. Osteopaths should be aware of their responsibilities to families and children and understand when and how to seek advice on safeguarding.
Abuse and neglect Abuse can be defined as the “maltreatment of a child. either directly by inflicting harm, or indirectly, by failing to act to prevent harm.”1 Child abuse and neglect are common, with a recent survey showing that around a quarter of young adults were abused at some point during their childhood.2 Almost a third of all children are bullied and 16% of children experience serious maltreatment by parents.2 Statistically almost every osteopath will have encountered children and families with safeguarding issues, whether they realise it or not. Abuse occurs in all types of families, in all classes and levels of education.1,3,4 Rates of child abuse are similar across developed countries and estimates of incidence of abuse worldwide range as high as 17e31%.5,6 This prevalence is comparable with paediatric back pain, childhood migraine and OsgoodeSchlatters disease.7e9 There is little reason to believe that patients who consult osteopaths are less likely to be at risk of abuse than the general population. With such a high prevalence of abuse it is likely that any osteopath treating children on a regular basis will encounter children who are being abused or neglected. The osteopath therefore has a responsibility to identify these patients and communicate concerns. Osteopaths have a professional, ethical and moral duty to protect their patients from abuse.10e12 Whilst it could be suggested that an osteopath is less likely to see a neglected child (certainly if the child’s healthcare is neglected), there are a number of reasons why osteopathic patients may be at greater risk than the general paediatric population. Children with chronic conditions, younger children, crying babies, children requiring additional care, children of parents with psychiatric illnesses and those with learning difficulties are at increased risk of abuse and neglect.13,14 These children (or their parents) commonly seek osteopathic care.15,16 Many parents seek osteopathic treatment for their children because of a musculoskeletal problem, injury or pain.17 These
A. Feld et al. problems may have resulted from abuse. Some families may use osteopaths as a way to avoid detection, appear concerned or be seen to take action. “Disguised compliance” describes these instances where superficial co-operation can be used to conceal abuse.18 It is possible that the osteopath who treats a “clumsy child” is unwittingly enabling a parent to avoid a GP or accident and emergency visit and avoid the possible reporting of an injury. Identifying children at risk is not simple but all osteopaths should be able to identify children with suspicious signs or symptoms and patients who may be at risk of abuse or neglect. However, it is important to note that osteopaths are not responsible for confirming abuse or physically protecting the child, this requires investigation by a team of social workers and specialist paediatricians.19 The role of the osteopath in child protection is to identify children who may be at risk and to pass on any concerns. Osteopaths should be aware of the natural tendency of clinicians to downplay suspicions and over-identify with parents.20 In the case of Victoria Climbie ´, the school, GP, hospital and social workers all had their own concerns about the child but did not adequately share this information with each other.21,22 The consequent Laming Inquiry placed emphasis on the importance of sharing information. Communicating concerns is probably the most valuable role of the osteopath in safeguarding children.
Sharing information It is essential that osteopaths are able to seek advice and discuss children who may be at risk of abuse. The level of suspicion needed to justify action presents problems for all healthcare professionals, but there is no defined level of injury or behaviour, and any objective “threshold” is likely to be inappropriate.23,24 This is a particularly difficult decision for primary care professionals especially those in private practice like osteopaths, chiropractors, and dentists who lack the networks and management of the National Health Service.25 A recent study of dentists found that even with safeguarding training few dental professionals had experience of making referrals and worryingly there was a wide gap in practice between recognising safeguarding issues and responding effectively.26 The study concluded that dentists had missed a number of opportunities to save children from continuing abuse. The National Institute for Health and Care Excellence (NICE) Guidelines on safeguarding
Managing concerns about children children “When to suspect child maltreatment” outlines a number of obstacles for clinicians identifying abuse or taking action.27 These obstacles include: the fear of losing a positive relationship with the family; discomfort of disbelieving, thinking ill of, or wrongly blaming a parent or carer; concerns about breaching confidentiality, fear of complaints and possibly doubts about the benefits of the child protection process. These are often valid apprehensions but they should not deter osteopaths from seeking advice and sharing information in cases where there are safeguarding concerns. One of the barriers to identifying children at risk is the lack of context. For an osteopath to interpret injuries or behaviour it is often necessary to understand the context and the family background. There are fine lines between poor parenting skills and neglect, smacking and assault, cultural traditions and inappropriate behaviour. Decisions about normal or abnormal behaviour and unusual or suspicious injuries are not simple and osteopaths are not always in a position to judge the relevance of particular findings without a wider context of the family circumstances or history. In some instances, like the Baby P case, just one smack can be an indication of more significant abuse.28 The death of Daniel Pelka might have been avoided had his school contacted his GP and realised that his signs of abuse were not the result of a medical diagnosis as his mother claimed.29 Osteopaths should communicate concerns of suspected abuse, unusual behaviour, and suspicious injuries and enquire about family backgrounds for children at risk. As the General Medical Council (GMC) states “decisions about child protection are best made with others”.30 This includes not just osteopaths who treat children but also those who have adult patients with children.31 As suggested in Part 1, it may be useful for osteopaths to manage suspicions of abuse as they would manage suspicions of pathology.32 Just as an osteopath considering multiple sclerosis or cancer would communicate concerns to or seek advice from a GP and refer a patient, the osteopath should seek the guidance of a social worker when he has concerns about a child’s wellbeing and the possibility of abuse. In exactly the same way that an osteopath with suspicions of neoplasm should not wait for severe pain to become night sweats or weight loss before referring, osteopaths should not wait until suspicions of abuse are overwhelming to take action and seek advice. Like suspicions of serious pathology, abuse is not a diagnosis that an osteopath can make alone.
299
Guidance for osteopaths Osteopaths have little formal guidance on handling suspicions, making enquiries or reporting abuse. Statutory and professional bodies provide guidelines or standards of practice but these tend to be too broad to provide any clear practical guidance. In the General Osteopathic Council’s Standards of Practice section C9 outlines an osteopath’s responsibility to “act quickly to help patients and keep them from harm.” and “comply with the law to protect children and vulnerable adults”.10 However, the law provides limited guidance. The legal aspects of reporting are really only relevant when cases of abuse or neglect are clear and an osteopath has taken no action.33 Some osteopaths may be concerned about legal action against them by parents of children whom the osteopath has referred or enquired about. This is an extremely unlikely contingency and we have never encountered this in practice. In many jurisdictions where reporting of suspicions of abuse is mandatory, clinicians are automatically protected from legal action. Even where there is no protection for clinicians, disciplinary action by regulating bodies or legal action would not be mandated unless referral was clearly erroneous and malicious. Despite the legal and bureaucratic differences between and within different countries, all developed countries have based their laws on the “best interests principle” outlined in the 1989 Convention on the Rights of the Child.34e36 And it is the best interests of the child that should guide the osteopath in his management of suspicions of abuse or neglect. The safety of the child is paramount and the child’s safety overrides issues of patient confidentiality or data protection when information is shared with other clinicians or child protection agencies.37e40 For most osteopaths any suspicion of abuse will be far from clear and most contact with social workers will be seeking advice and context, rather than making official referrals or reports. Child protection and safeguarding largely involves dealing with children who are being cared for insufficiently or inappropriately, rather than children who are the victims of criminal behaviour. Often abuse is not malicious or intentional but the result of poor parenting, alcoholism or drug addiction, parental learning difficulties or a result of ignorance.41,42 In these cases intervention is largely supportive, with the family receiving advice and support from social workers and other agencies. In some cases legal involvement requires family courts to determine a plan based on the
300 best interests of the child. Criminal law is used with caution and police will only prosecute in particular circumstances taking into account the child’s welfare, the “moral culpability” of the parents and the likelihood of a repeat offence.43,44 Osteopaths should not contact the police for routine advice about a child.
Contacting a social worker The first contact for advice should be a social worker. Social workers are experts on abuse, welfare and management of children and families. In the United Kingdom the local councils coordinate Child and Family Health Services and the osteopath can contact a duty social worker for the area where the clinic is located or where the child lives. Social workers can give advice and guidance and accept formal referrals. They can provide vital support and access to additional resources. Many osteopaths’ experiences of social services are influenced by media reporting of safeguarding cases. The Cleveland scandal in 1988 involved amplified accusations by social workers and exaggerated responses with a vast number of children placed into foster care with very little evidence of harm. This was a disaster for the families involved and destroyed the public’s perception of social workers’ approach to safeguarding. This was a one-off case and it should not deter osteopaths from involving social services. Taking a child into care is usually a last resort. In every case the welfare of the child is paramount and in line with The Children Act, social workers do their best to keep a child within the family and to educate and work with the family to get the best possible outcome for the child.17 One osteopath making an enquiry about a child will not precipitate immediate action unless the suspicions are serious or there is significant history of previous abuse. The social worker receives information from schools, GPs, dentists, sports clubs, youth clubs and other health professionals, but can only analyse information about a child if it is passed on. Minor concerns from the osteopath may be dismissed if the social worker has no other suspicion, but may take on greater significance if other professionals in contact with the child make similar enquiries.21,45 Equally social workers will have access to information about children at risk or those with a history of abuse. Specific concerns and relevant background information can then be shared between appropriate parties. This information can
A. Feld et al. be vital to an osteopath in their assessment of the child. For osteopaths in private practice the practicalities of sharing information perhaps applies more to seeking information rather than simply disclosing it. Often distinction can made between a child “at risk” and a child “in need”. Children “in need” are commonly identified as requiring more help and support; this may be help with care, help with educational needs, assistance with behavioural problems, or support for something else. In cases of children in need, social services work to support a family and many families welcome the assistance of a social worker and access to additional help.11,46 There can be a fine line between a child “at risk” and a child “in need”, but an early referral of a child in need may allow the family to access help early and reduce the possibility of later abuse.
“What if” conversations Most contact with social services will be informal advice and guidance. This can be done anonymously and many cases can be discussed without needing to name the child or family. This is commonly referred to as a “what if” conversation with the social worker giving guidance based on a hypothetical and anonymous case. This type of guidance may be the most useful for osteopaths. It allows the osteopath to ask specific questions or seek advice without the fear of getting a family in trouble or breaching confidentiality. Osteopaths should be encouraged to make use of what if conversations. However, social workers have access to information on a family’s background which may not be known to the osteopath and this information can only be accessed by providing patient details. Discovering that a child already has a child protection plan in place may change the context of minor injuries or unusual behaviour.
Reporting and referring children The UK, Canada, Australia and the USA all have similar systems of child protection with some practical differences.47,48 The UK and New Zealand have no mandatory reporting laws for child abuse and no-one is legally obliged to refer suspicions of abuse. In most provinces of Canada, territories of Australia and certain American States, reporting is mandatory for all citizens.49,50 In other countries reporting is mandatory for various health professionals.13 However, for each jurisdiction there
Managing concerns about children are differences in the detail of what should be reported, the type of abuse, the threshold for reporting, the person suspected of carrying out the abuse and the individual or professional who is obliged to report.49,51e53 In jurisdictions where reporting is mandatory there is usually protection for the reporter through confidentiality and subsequent immunity from legal action, but even in places where reporting is voluntary, health professionals should be protected.51 In most developed countries legislation and procedure is aimed at encouraging reporting, and authorities avoid penalising anyone reporting abuse, even for dubious or incorrect reports.33,54,55 We recommend that osteopaths review the laws governing their own country for the legal frameworks relating to child abuse.
Other sources of advice Instead of social services, the family doctor can be contacted. The families of abused and neglected children may avoid their doctor or may not be registered and most doctors are not experts in safeguarding.21 However, all family doctors are trained in dealing with concerns, they should be aware of their child patients who are at risk and will be able to involve social services if necessary. A GP referral may be a useful mechanism for referring suspected abuse without offending the parents. The osteopath can ask the patient for consent to refer for a “second opinion on clinical findings” accompanied by an informal telephone conversation or email to the GP about suspicions of abuse. This is similar to the approach taken if osteopaths suspect serious pathology in a patient: osteopaths make it clear that a referral is necessary even if they are not explicit about the precise reason for the referral. The GP’s opinion will be invaluable and his management (either a referral to social services or to a paediatrician for another opinion) provides the osteopath with an alternative to the social worker. NGOs, charities and governmental agencies provide other options for voicing concerns. Although they do not collect information as local social services will, they have a role in gathering details about children which they can then pass on. They also encourage people to call them with concerns, including non-professionals like friends or neighbours. The British National Society for the Prevention of Cruelty to Children (NSPCC) has web pages specifically for health professionals and they provide safeguarding advice and training for professionals.56 Most countries have similar charities
301 which can provide advice and guidance, including the National Association for Prevention of Child Abuse and Neglect (NAPCAN) in Australia and “Jigsaw” or the Children’s Action Plan in New Zealand.57e60
Consent For many initial discussions the identity of the child or family does not need to be disclosed. “What if” conversations are often sufficient to get the advice of a social worker and they can then give further advice about whether disclosing or exchanging patient information is necessary. In most countries the “best interests principle” and the welfare of the child overrides the child’s or parents’ right to confidentiality and consent.33,34,38 In “Information sharing: Practitioners’ guide” this is included as “when not to seek consent”.45 This enables the osteopath to discuss any child or family with the GP or social services when there is suspicion of abuse or neglect, without informing the family and without consent. For an osteopath with suspicions or concerns, asking for consent to involve social services could risk offending and alienating a family.45,61 In these cases raising suspicions with the parent or asking for consent to contact social services may harm the welfare of the child. Expected social services involvement may cause the family to avoid future consultation thereby endangering the child further. For a child who may be at risk of abuse, ongoing care and monitoring is essential and contact with the osteopath may even deter abuse. However, in all cases important to consider asking for parental consent when making a formal social services referral, but remembering that the safety of the child is paramount.
Conclusion Osteopaths working with children are likely to encounter abuse. All osteopaths should be able to identify children at risk of abuse and signs and symptoms suggestive of this, and should not wait until abuse is obvious before taking action. All osteopaths should understand how to report concerns and how to seek advice and guidance about children with safeguarding issues. In most cases “what if” conversations will enable an osteopath to ask questions and seek advice from a social worker without revealing the identity of a patient. Most osteopaths will feel comfortable maintaining patient confidentiality at
302 an early stage of enquiry. Often the social worker can provide advice and guidance for queries or suspicions without knowing the identity of the patient. Social workers often have different sources of information which may be necessary for understanding the background and history of a family. This information can provide a better context on which to base decisions about minor injuries, unusual behaviour or children with certain risk factors. In cases where the social worker feels that it would be appropriate to check a specific child or family, the osteopath can be guided by the social worker to reveal the patient’s identity, either to check the child’s background, to help lead the osteopath through a process of formal referral, to take over the case or to suggest another course of action. In many cases the parent’s or patient’s consent to discuss the case, or to make a formal referral is unnecessary and may be harmful by preventing ongoing care or undermining the trust of the patient. As a result in most cases where abuse is suspected consent should not be asked.45 In cases where both osteopath and parent are concerned about the needs of the child, or potential abuse, the parent’s consent to discuss the case should be sought and is likely to be given. Osteopaths should be prepared to consider abuse as a possible factor in all consultations and should consider the “red-flag” signs of possible abuse that we reviewed in Part 1 as they would signs for suspected serious pathology and manage them in a similar way.
Author contribution statement AM conceived the idea and AM and SL wrote the initial draft in a case series format. AF restructured and rewrote, and AF and AM provided further drafts. AM, SL, and AF all contributed to the final draft.
Conflicts of interest None declared.
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CLINICAL PRACTICE
Safeguarding children in osteopathic practice part 2: Managing concerns about children A. Feld a, A.F. Maddick b,*, S. Laurent c a
The Children’s Hospital at Westmead, Hawkesbury Road and Hainsworth Street, Westmead, Sydney, New South Wales, 2145, Australia b British College of Osteopathic Medicine, Lief House, 120-122 Finchley Rd, London, NW3 5HR, UK c Barnet & Chase Farm Hospitals NHS Trust, Wellhouse Lane, Barnet, Hertfordshire, EN5 3DJ, UK Received 26 October 2012; revised 7 May 2015; accepted 1 July 2015
KEYWORDS Safeguarding; Children; Paediatric; Child protection; Child abuse: neglect; Children at risk; Children in need; Social worker; Sharing information
Osteopaths working with children are likely to encounter child abuse and neglect. In this second of two parts we discuss how to manage safeguarding concerns that may arise in osteopathic practice. We review whether to involve GPs and social services to make informal enquiries and the use of anonymised “what if” conversations. We encourage osteopaths to check family backgrounds and be active in excluding risk. We also discuss practical ethical and legal aspects of consent and confidentiality that can often arise in safeguarding cases. Osteopaths with concerns should feel confident in contacting social workers for a second opinion and for many cases it is not necessary to identify the patient. When details of the patient are communicated, ideally this should be done with the parent’s permission to help families in need. In cases where a child may be at risk it may be more appropriate to discuss with a social worker without a parent’s or patient’s consent. It is the best interests of the child that should guide the osteopath in his management of suspicions of abuse or neglect. ª 2015 Elsevier Ltd. All rights reserved.
Abstract
* Corresponding author. E-mail address: [email protected] (A.F. Maddick). http://dx.doi.org/10.1016/j.ijosm.2015.07.001 1746-0689/ª 2015 Elsevier Ltd. All rights reserved.
298 Implications for practice Osteopaths will encounter children who they suspect may be abused or neglected. Osteopaths should be aware of their responsibilities to families and children and understand when and how to seek advice on safeguarding.
Abuse and neglect Abuse can be defined as the “maltreatment of a child. either directly by inflicting harm, or indirectly, by failing to act to prevent harm.”1 Child abuse and neglect are common, with a recent survey showing that around a quarter of young adults were abused at some point during their childhood.2 Almost a third of all children are bullied and 16% of children experience serious maltreatment by parents.2 Statistically almost every osteopath will have encountered children and families with safeguarding issues, whether they realise it or not. Abuse occurs in all types of families, in all classes and levels of education.1,3,4 Rates of child abuse are similar across developed countries and estimates of incidence of abuse worldwide range as high as 17e31%.5,6 This prevalence is comparable with paediatric back pain, childhood migraine and OsgoodeSchlatters disease.7e9 There is little reason to believe that patients who consult osteopaths are less likely to be at risk of abuse than the general population. With such a high prevalence of abuse it is likely that any osteopath treating children on a regular basis will encounter children who are being abused or neglected. The osteopath therefore has a responsibility to identify these patients and communicate concerns. Osteopaths have a professional, ethical and moral duty to protect their patients from abuse.10e12 Whilst it could be suggested that an osteopath is less likely to see a neglected child (certainly if the child’s healthcare is neglected), there are a number of reasons why osteopathic patients may be at greater risk than the general paediatric population. Children with chronic conditions, younger children, crying babies, children requiring additional care, children of parents with psychiatric illnesses and those with learning difficulties are at increased risk of abuse and neglect.13,14 These children (or their parents) commonly seek osteopathic care.15,16 Many parents seek osteopathic treatment for their children because of a musculoskeletal problem, injury or pain.17 These
A. Feld et al. problems may have resulted from abuse. Some families may use osteopaths as a way to avoid detection, appear concerned or be seen to take action. “Disguised compliance” describes these instances where superficial co-operation can be used to conceal abuse.18 It is possible that the osteopath who treats a “clumsy child” is unwittingly enabling a parent to avoid a GP or accident and emergency visit and avoid the possible reporting of an injury. Identifying children at risk is not simple but all osteopaths should be able to identify children with suspicious signs or symptoms and patients who may be at risk of abuse or neglect. However, it is important to note that osteopaths are not responsible for confirming abuse or physically protecting the child, this requires investigation by a team of social workers and specialist paediatricians.19 The role of the osteopath in child protection is to identify children who may be at risk and to pass on any concerns. Osteopaths should be aware of the natural tendency of clinicians to downplay suspicions and over-identify with parents.20 In the case of Victoria Climbie ´, the school, GP, hospital and social workers all had their own concerns about the child but did not adequately share this information with each other.21,22 The consequent Laming Inquiry placed emphasis on the importance of sharing information. Communicating concerns is probably the most valuable role of the osteopath in safeguarding children.
Sharing information It is essential that osteopaths are able to seek advice and discuss children who may be at risk of abuse. The level of suspicion needed to justify action presents problems for all healthcare professionals, but there is no defined level of injury or behaviour, and any objective “threshold” is likely to be inappropriate.23,24 This is a particularly difficult decision for primary care professionals especially those in private practice like osteopaths, chiropractors, and dentists who lack the networks and management of the National Health Service.25 A recent study of dentists found that even with safeguarding training few dental professionals had experience of making referrals and worryingly there was a wide gap in practice between recognising safeguarding issues and responding effectively.26 The study concluded that dentists had missed a number of opportunities to save children from continuing abuse. The National Institute for Health and Care Excellence (NICE) Guidelines on safeguarding
Managing concerns about children children “When to suspect child maltreatment” outlines a number of obstacles for clinicians identifying abuse or taking action.27 These obstacles include: the fear of losing a positive relationship with the family; discomfort of disbelieving, thinking ill of, or wrongly blaming a parent or carer; concerns about breaching confidentiality, fear of complaints and possibly doubts about the benefits of the child protection process. These are often valid apprehensions but they should not deter osteopaths from seeking advice and sharing information in cases where there are safeguarding concerns. One of the barriers to identifying children at risk is the lack of context. For an osteopath to interpret injuries or behaviour it is often necessary to understand the context and the family background. There are fine lines between poor parenting skills and neglect, smacking and assault, cultural traditions and inappropriate behaviour. Decisions about normal or abnormal behaviour and unusual or suspicious injuries are not simple and osteopaths are not always in a position to judge the relevance of particular findings without a wider context of the family circumstances or history. In some instances, like the Baby P case, just one smack can be an indication of more significant abuse.28 The death of Daniel Pelka might have been avoided had his school contacted his GP and realised that his signs of abuse were not the result of a medical diagnosis as his mother claimed.29 Osteopaths should communicate concerns of suspected abuse, unusual behaviour, and suspicious injuries and enquire about family backgrounds for children at risk. As the General Medical Council (GMC) states “decisions about child protection are best made with others”.30 This includes not just osteopaths who treat children but also those who have adult patients with children.31 As suggested in Part 1, it may be useful for osteopaths to manage suspicions of abuse as they would manage suspicions of pathology.32 Just as an osteopath considering multiple sclerosis or cancer would communicate concerns to or seek advice from a GP and refer a patient, the osteopath should seek the guidance of a social worker when he has concerns about a child’s wellbeing and the possibility of abuse. In exactly the same way that an osteopath with suspicions of neoplasm should not wait for severe pain to become night sweats or weight loss before referring, osteopaths should not wait until suspicions of abuse are overwhelming to take action and seek advice. Like suspicions of serious pathology, abuse is not a diagnosis that an osteopath can make alone.
299
Guidance for osteopaths Osteopaths have little formal guidance on handling suspicions, making enquiries or reporting abuse. Statutory and professional bodies provide guidelines or standards of practice but these tend to be too broad to provide any clear practical guidance. In the General Osteopathic Council’s Standards of Practice section C9 outlines an osteopath’s responsibility to “act quickly to help patients and keep them from harm.” and “comply with the law to protect children and vulnerable adults”.10 However, the law provides limited guidance. The legal aspects of reporting are really only relevant when cases of abuse or neglect are clear and an osteopath has taken no action.33 Some osteopaths may be concerned about legal action against them by parents of children whom the osteopath has referred or enquired about. This is an extremely unlikely contingency and we have never encountered this in practice. In many jurisdictions where reporting of suspicions of abuse is mandatory, clinicians are automatically protected from legal action. Even where there is no protection for clinicians, disciplinary action by regulating bodies or legal action would not be mandated unless referral was clearly erroneous and malicious. Despite the legal and bureaucratic differences between and within different countries, all developed countries have based their laws on the “best interests principle” outlined in the 1989 Convention on the Rights of the Child.34e36 And it is the best interests of the child that should guide the osteopath in his management of suspicions of abuse or neglect. The safety of the child is paramount and the child’s safety overrides issues of patient confidentiality or data protection when information is shared with other clinicians or child protection agencies.37e40 For most osteopaths any suspicion of abuse will be far from clear and most contact with social workers will be seeking advice and context, rather than making official referrals or reports. Child protection and safeguarding largely involves dealing with children who are being cared for insufficiently or inappropriately, rather than children who are the victims of criminal behaviour. Often abuse is not malicious or intentional but the result of poor parenting, alcoholism or drug addiction, parental learning difficulties or a result of ignorance.41,42 In these cases intervention is largely supportive, with the family receiving advice and support from social workers and other agencies. In some cases legal involvement requires family courts to determine a plan based on the
300 best interests of the child. Criminal law is used with caution and police will only prosecute in particular circumstances taking into account the child’s welfare, the “moral culpability” of the parents and the likelihood of a repeat offence.43,44 Osteopaths should not contact the police for routine advice about a child.
Contacting a social worker The first contact for advice should be a social worker. Social workers are experts on abuse, welfare and management of children and families. In the United Kingdom the local councils coordinate Child and Family Health Services and the osteopath can contact a duty social worker for the area where the clinic is located or where the child lives. Social workers can give advice and guidance and accept formal referrals. They can provide vital support and access to additional resources. Many osteopaths’ experiences of social services are influenced by media reporting of safeguarding cases. The Cleveland scandal in 1988 involved amplified accusations by social workers and exaggerated responses with a vast number of children placed into foster care with very little evidence of harm. This was a disaster for the families involved and destroyed the public’s perception of social workers’ approach to safeguarding. This was a one-off case and it should not deter osteopaths from involving social services. Taking a child into care is usually a last resort. In every case the welfare of the child is paramount and in line with The Children Act, social workers do their best to keep a child within the family and to educate and work with the family to get the best possible outcome for the child.17 One osteopath making an enquiry about a child will not precipitate immediate action unless the suspicions are serious or there is significant history of previous abuse. The social worker receives information from schools, GPs, dentists, sports clubs, youth clubs and other health professionals, but can only analyse information about a child if it is passed on. Minor concerns from the osteopath may be dismissed if the social worker has no other suspicion, but may take on greater significance if other professionals in contact with the child make similar enquiries.21,45 Equally social workers will have access to information about children at risk or those with a history of abuse. Specific concerns and relevant background information can then be shared between appropriate parties. This information can
A. Feld et al. be vital to an osteopath in their assessment of the child. For osteopaths in private practice the practicalities of sharing information perhaps applies more to seeking information rather than simply disclosing it. Often distinction can made between a child “at risk” and a child “in need”. Children “in need” are commonly identified as requiring more help and support; this may be help with care, help with educational needs, assistance with behavioural problems, or support for something else. In cases of children in need, social services work to support a family and many families welcome the assistance of a social worker and access to additional help.11,46 There can be a fine line between a child “at risk” and a child “in need”, but an early referral of a child in need may allow the family to access help early and reduce the possibility of later abuse.
“What if” conversations Most contact with social services will be informal advice and guidance. This can be done anonymously and many cases can be discussed without needing to name the child or family. This is commonly referred to as a “what if” conversation with the social worker giving guidance based on a hypothetical and anonymous case. This type of guidance may be the most useful for osteopaths. It allows the osteopath to ask specific questions or seek advice without the fear of getting a family in trouble or breaching confidentiality. Osteopaths should be encouraged to make use of what if conversations. However, social workers have access to information on a family’s background which may not be known to the osteopath and this information can only be accessed by providing patient details. Discovering that a child already has a child protection plan in place may change the context of minor injuries or unusual behaviour.
Reporting and referring children The UK, Canada, Australia and the USA all have similar systems of child protection with some practical differences.47,48 The UK and New Zealand have no mandatory reporting laws for child abuse and no-one is legally obliged to refer suspicions of abuse. In most provinces of Canada, territories of Australia and certain American States, reporting is mandatory for all citizens.49,50 In other countries reporting is mandatory for various health professionals.13 However, for each jurisdiction there
Managing concerns about children are differences in the detail of what should be reported, the type of abuse, the threshold for reporting, the person suspected of carrying out the abuse and the individual or professional who is obliged to report.49,51e53 In jurisdictions where reporting is mandatory there is usually protection for the reporter through confidentiality and subsequent immunity from legal action, but even in places where reporting is voluntary, health professionals should be protected.51 In most developed countries legislation and procedure is aimed at encouraging reporting, and authorities avoid penalising anyone reporting abuse, even for dubious or incorrect reports.33,54,55 We recommend that osteopaths review the laws governing their own country for the legal frameworks relating to child abuse.
Other sources of advice Instead of social services, the family doctor can be contacted. The families of abused and neglected children may avoid their doctor or may not be registered and most doctors are not experts in safeguarding.21 However, all family doctors are trained in dealing with concerns, they should be aware of their child patients who are at risk and will be able to involve social services if necessary. A GP referral may be a useful mechanism for referring suspected abuse without offending the parents. The osteopath can ask the patient for consent to refer for a “second opinion on clinical findings” accompanied by an informal telephone conversation or email to the GP about suspicions of abuse. This is similar to the approach taken if osteopaths suspect serious pathology in a patient: osteopaths make it clear that a referral is necessary even if they are not explicit about the precise reason for the referral. The GP’s opinion will be invaluable and his management (either a referral to social services or to a paediatrician for another opinion) provides the osteopath with an alternative to the social worker. NGOs, charities and governmental agencies provide other options for voicing concerns. Although they do not collect information as local social services will, they have a role in gathering details about children which they can then pass on. They also encourage people to call them with concerns, including non-professionals like friends or neighbours. The British National Society for the Prevention of Cruelty to Children (NSPCC) has web pages specifically for health professionals and they provide safeguarding advice and training for professionals.56 Most countries have similar charities
301 which can provide advice and guidance, including the National Association for Prevention of Child Abuse and Neglect (NAPCAN) in Australia and “Jigsaw” or the Children’s Action Plan in New Zealand.57e60
Consent For many initial discussions the identity of the child or family does not need to be disclosed. “What if” conversations are often sufficient to get the advice of a social worker and they can then give further advice about whether disclosing or exchanging patient information is necessary. In most countries the “best interests principle” and the welfare of the child overrides the child’s or parents’ right to confidentiality and consent.33,34,38 In “Information sharing: Practitioners’ guide” this is included as “when not to seek consent”.45 This enables the osteopath to discuss any child or family with the GP or social services when there is suspicion of abuse or neglect, without informing the family and without consent. For an osteopath with suspicions or concerns, asking for consent to involve social services could risk offending and alienating a family.45,61 In these cases raising suspicions with the parent or asking for consent to contact social services may harm the welfare of the child. Expected social services involvement may cause the family to avoid future consultation thereby endangering the child further. For a child who may be at risk of abuse, ongoing care and monitoring is essential and contact with the osteopath may even deter abuse. However, in all cases important to consider asking for parental consent when making a formal social services referral, but remembering that the safety of the child is paramount.
Conclusion Osteopaths working with children are likely to encounter abuse. All osteopaths should be able to identify children at risk of abuse and signs and symptoms suggestive of this, and should not wait until abuse is obvious before taking action. All osteopaths should understand how to report concerns and how to seek advice and guidance about children with safeguarding issues. In most cases “what if” conversations will enable an osteopath to ask questions and seek advice from a social worker without revealing the identity of a patient. Most osteopaths will feel comfortable maintaining patient confidentiality at
302 an early stage of enquiry. Often the social worker can provide advice and guidance for queries or suspicions without knowing the identity of the patient. Social workers often have different sources of information which may be necessary for understanding the background and history of a family. This information can provide a better context on which to base decisions about minor injuries, unusual behaviour or children with certain risk factors. In cases where the social worker feels that it would be appropriate to check a specific child or family, the osteopath can be guided by the social worker to reveal the patient’s identity, either to check the child’s background, to help lead the osteopath through a process of formal referral, to take over the case or to suggest another course of action. In many cases the parent’s or patient’s consent to discuss the case, or to make a formal referral is unnecessary and may be harmful by preventing ongoing care or undermining the trust of the patient. As a result in most cases where abuse is suspected consent should not be asked.45 In cases where both osteopath and parent are concerned about the needs of the child, or potential abuse, the parent’s consent to discuss the case should be sought and is likely to be given. Osteopaths should be prepared to consider abuse as a possible factor in all consultations and should consider the “red-flag” signs of possible abuse that we reviewed in Part 1 as they would signs for suspected serious pathology and manage them in a similar way.
Author contribution statement AM conceived the idea and AM and SL wrote the initial draft in a case series format. AF restructured and rewrote, and AF and AM provided further drafts. AM, SL, and AF all contributed to the final draft.
Conflicts of interest None declared.
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