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THE LOUDOUN TRUST

RESPONSE TO THE DRAFT NICE GUIDELINES

WHAT TO NOTICE, HOW TO RESPOND:

SIGNS AND INDICATORS IN A CHILD THAT

MIGHT POINT TO PHYSICAL AND/OR SEXUAL ABUSE

SYMPTOMATOLOGY

DAVID MILLAR March 2017

Medical diagnoses of illnesses can be made with a high degree of accuracy whether they range from the common (the cold vs the ‘flu) to the complex (bronchitis vs asthma). Such diagnoses can still be problematic but physiological symptoms create an evidential trail that usually leads to a differential diagnosis.  The exigencies of finding the evidential trail in psychological symptoms, on the other hand, are more complicated and may lead to conflicting or even misleading diagnoses.

With this is mind let us look at the most recent consultation document produced by NICE offering certain specific guidelines on how to look for ‘soft’ signs of child (physical, emotional and sexual) abuse. It is obvious that no such document could be exhaustive but the NICE Guidelines do suggest quite a comprehensive list which appears below:

* Excessive clinginess

* Low self-esteem

* Recurrent nightmares

* Over-friendliness towards strangers/indiscriminate contact or affection-seeking

* Wetting and soiling

* Aggressive behaviour

* Withdrawing communication

* Habitual body-rocking

* Persistently seeking attention

* A child regularly attending school unkempt or with apparent injuries

* Overtly sexualised behaviour in children below the age of puberty

* Parents using excessive punishment

Any single or combination of presenting symptoms on this list could be an effective forewarning that a child is being abused.  However, at the same time, any single or combination of symptoms of this list could ALSO indicate:

* A child who has suffered trauma other than (physical or sexual) abuse

* A child going through an acrimonious divorce/separation by parents

* A child being bullied at school or on the internet

* A severely disabled child with, say, an emotionally-laden co-morbidity

* A child going through major medical treatment or surgery, perhaps, for cancer or a chronic illness

* A child experiencing emotional neglect, conflict or confusion other than physical or sexual abuse

I am sure other ‘exceptions’ occur but the point to be made here is that although such symptoms should never be over-looked (as the guidelines suggest) there is still the risk that an accurate diagnosis can remain problematic.

Dr Danya Glaser, Consultant Child and Adolescent Psychiatrist, and a member of the NICE guideline development committee, rightly exhorts professionals (teachers, police, social workers, clinicians) to use ‘a mixture of instinct and experience’ to make a judgement.  

This is sound advice but I’m sure Dr Glaser is also aware that child protection case conferences often display a range of ‘instincts’ and ‘experiences’ amongst committee members as they don’t always agree.   Importantly though, she does go on to point out that there is far more ‘under-recognition of child abuse than over-reporting that turned out to be untrue’.  She adds that these guidelines ‘may not always be proof of abuse … but they underline when to check on a child’s wellbeing’. This realistic note of caution – or reminding us of the need to make an accurate differential diagnosis – is what the Loudoun Trust is also drawing attention to.

So, do we leave it there? Does Loudoun have anything further to add? I suppose what comes next is: Who are the professionals/clinicians who make the final diagnosis.  Often the scenario is that teachers, residential workers, health visitors, child clinicians report the type of symptoms indicated above to the police and/or social care.

The question then needs to be asked: What are the guidelines to be followed by these two agencies? Further, if abuse is then proven or openly acknowledged then what agency (agencies) are these post-conviction cases passed on to and what are their guidelines?

Of course anyone, professional or lay, could accurately assess certain children who have been the victims of abuse if the symptoms and circumstances and evidence are clear and non-contentious and what are the guidelines for the general public to follow in such cases?  Perhaps there is a need for a series of inter-connected guidelines to make sure that each and every child is dealt with as comprehensively as possible.  

In my experience many child protection referrals from my (NHS ) agency to social care/the police are met with the response: ‘This referral does not meet our threshold criteria to launch an investigation’.  This is sometimes code for ‘We don’t have enough staff/resources to investigate all referrals’.

We are all aware of recent publicity by at least one national police force who commented on the number of referrals of adults (almost exclusively men) who were reported for viewing images of child pornography.  They said they were overwhelmed by such referrals and believed certain ‘low-level’ examples of these referrals should not face a criminal investigation but be passed on instead to a therapeutic agency. 

This might make sense to some but it begs the question(s): who are these agencies and are they sufficiently staffed to meet the demand?  Is there an argument here for another set of guidelines in ‘low-level’ cases?

I think we all understand that working in this particular area is fraught with complications and competing demands but, nonetheless, I feel we should be reminded of them.

Finally, this brings us to another ‘category’ that does not appear anywhere in the NICE Guidelines: disclosures.

DISCLOSURES

It might seem obvious that a child making a ‘direct disclosure’ does not appear in the list of NICE guidelines, above.  A disclosure, after all is not merely an indicator but a clear admission by the child that they have been abused.  So, do we need to consider disclosures any further let alone put them in the nebulous category of ‘symptoms’? 

There are, it seems to me, certain factors that need to be drawn to all of our attention that cover disclosures.  Firstly, there can be false disclosures even if the likelihood is quite small. Some reasons that ought to be borne in mind why a false declaration might be made are:

* A deliberate or malicious attempt to get someone into trouble (e.g. a  parent or teacher)

* A persistent delusion or even a psychotic phantasy of being abused

* A proxy admission i.e. on someone else’s behalf

* Envy, which might seem unlikely but sometimes one sibling might be envious or jealous, say, of a sibling who is getting more attention – even inappropriate sexualised attention – than they are.

I am sure this list could be added to but it will probably always remain a small list.  At the same time, such phenomena do exist and deserve our attention.

Secondly, let us turn to actual or real disclosures.  It is an obvious assumption to make that children disclose in order to be heard and protected and for the child’s wish for the offender to be dealt with.  This is a reasonable and logical assumption.  I suspect that the majority of disclosures probably fall into this category but in my thirty-five year clinical experience as a Child and Adolescent Psychotherapist in the NHS this has not been my personal clinical experience. 

My first-hand experience of my own cases and my second-hand experience of colleagues’ cases is that when a child, often tentatively, broaches the subject they say that they first want to talk about it. This usually means: “Can we talk about it before we do anything else?” 

The child may or may not have an idea as to where it might lead or what consequences might follow – but they first just want to talk.  Even for those who know the likely outcome they may still want to talk about their abuse, often at length,  before  any information is passed on to ‘the authorities’.  In such cases, it is virtually impossible as professional standards now stand (irrespective of statutory reporting) for a clinician to allow any extended period of discussion to take place.  An immediate (i.e. within 48 hours) referral to police/social care is the usual professional injunction for all public sector workers to follow. 

This existing professional mandatory reporting (as opposed to legal statutory reporting) does not allow time for the child or adolescent to talk through or even express their confusion, doubt, anxiety, fear of consequences, bewilderment, anger, rage  whatever it is they might be going through. 

SUMMARY/RECOMMENDATIONS

Returning to the NICE Guidelines, they express quite well the need to use ‘experience and instinct’ in assessing ‘soft’ symptoms that might be (hidden) indicators of child abuse.  

What I have tried to illustrate is how we need to use our experience and instincts both before as well as after such referrals are made to the police or social care.

Equally, we need to use our experience and instincts – and training - to govern the long-term therapy of such youngsters – crucial stages that the NICE Guidelines have not yet addressed.  

David Millar

Consultant (NHS) Child and Adolescent Psychotherapist (Retired) 

 

 


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