In recent years persistent child abuse in some children’s homes has come to light, with widespread publicity following o?enders’ appearances in court. Local communities have also protested about convicted paedophiles, released from prison, coming to live in their communities.
In England and Wales, local-government social-services departments are central in the prevention, investigation and management of cases of child abuse. They have four important protection duties laid down in the Children Act 1989. They are charged (1) to prevent children from suffering ill treatment and neglect; (2) to safeguard and promote the welfare of children in need; (3) when requested by a court, to investigate a child’s circumstances; (4) to investigate information – in concert with the NSPCC (National Society for the Prevention of Cruelty to Children) – that a child is suffering or is likely to suffer signi?cant harm, and to decide whether action is necessary to safeguard and promote the child’s welfare. Similar provisions exist in the other parts of the United Kingdom.
When anyone suspects that child abuse is occurring, contact should be made with the relevant social-services department or, in Scotland, with the children’s reporter. (See NONACCIDENTAL INJURY (NAI); PAEDOPHILIA.)... child abuse
Secondly – and more commonly termed the ‘At-risk register’ – this is a list held by social-service departments, and accessible to doctors in A&E departments, of children whom a local-authority social-services case conference has deemed to have been harmed or to be at risk of harm from mental, physical or sexual abuse (see also CHILD ABUSE).... risk register
Although there is wide variation in individual rates of progress, most children develop certain skills within predictable age ranges.
For example, most infants start to walk at 12–18 months.
Capability for new skills is linked to the maturity of the child’s nervous system.
Individual rates of maturity are determined genetically and modified by environmental factors in the uterus and after birth.
Development is assessed in early childhood by looking at abilities in 4 main areas: locomotion; hearing and speech; vision and fine movement; and social behaviour and play.
(See also developmental delay.)... child development
Child guidance professionals include psychiatrists, psychologists, and psychiatric social workers. For young children, play therapy may be used for diagnosis. Older children may be offered counselling, psychotherapy, or group therapy. Family therapy may be used in cases where there are difficulties between the child and 1 or both parents.... child guidance
Adoption declined as the availability of babies fell with the introduction of the Abortion Act 1968, improving contraceptive services and increasing acceptability of single parenthood.
However, with 10 per cent of couples suffering infertility, the demand continued, leading to the adoption of those previously perceived as di?cult to place – i.e. physically, intellectually and/or emotionally disabled children and adolescents, those with terminal illness, and children of ethnic-minority groups.
Recent controversies regarding homosexual couples as adoptive parents, adoption of children with or at high risk of HIV/AIDS, transcultural adoption, and the increasing use of intercountry adoption to ful?l the needs of childless couples have provoked urgent consideration of the ethical dilemmas of adoption and its consequences for the children, their adoptive and birth families and society generally.
Detailed statistics have been unavailable since 1984 but in general there has been a downward trend with relatively more older children being placed. Detailed reasons for adoption (i.e. interfamily, step-parent, intercountry, etc.) are not available but approximately one-third are adopted from local-authority care.
In the UK all adoptions (including interfamily and step-parent adoption) must take place through a registered adoption agency which may be local-authority-based or provided by a registered voluntary agency. All local authorities must act as agencies, the voluntary agencies often providing specialist services to promote and support the adoption of more di?cult-to-place children. Occasionally an adoption allowance will be awarded.
Adoption orders cannot be granted until a child has resided with its proposed adopters for 13 weeks. In the case of newborn infants the mother cannot give formal consent to placement until the baby is six weeks old, although informal arrangements can be made before this time.
In the UK the concept of responsibility of birth parents to their children and their rights to continued involvement after adoption are acknowledged by the Children Act 1989. However, in all discussions the child’s interests remain paramount. The Act also recognises adopted children’s need to have information regarding their origins.
BAAF – British Agencies for Adoption and Fostering – is the national organisation of adoptive agencies, both local authority and voluntary sector. The organisation promotes and provides training service, development and research; has several specialist professional subgroups (i.e. medical, legal, etc.); and produces a quarterly journal.
Adoption UK is an e?ective national support network of adoptive parents who o?er free information, a ‘listening ear’ and, to members, a quarterly newsletter.
National Organisation for Counselling Adoptees and their Parents (NORCAP) is concerned with adopted children and birth parents who wish to make contact.
The Registrar General operates an Adoption Contact Register for adopted persons and anyone related to that person by blood, half-blood or marriage. Information can be obtained from the O?ce of Population Censuses and Surveys. For the addresses of these organisations, see Appendix 2.... child adoption
Special needs The Children Act 1989, Education Acts 1981, 1986 and 1993, and the Chronically Sick and Disabled Persons Legislation 1979 impose various statutory duties to identify and provide assistance for children with special needs. They include the chronically ill as well as those with impaired development or disabilities such as CEREBRAL PALSY, or hearing, vision or intellectual impairment. Many CDTs keep a register of such children so that services can be e?ciently planned and evaluated. Parents of disabled children often feel isolated and neglected by society in general; they are frequently frustrated by the lack of resources available to help them cope with the sheer hard work involved. The CDT, through its key workers, does its best to absorb anger and divert frustration into constructive actions.
There are other groups of children who come to the attention of child health services. Community paediatricians act as advisers to adoption and fostering agencies, vital since many children needing alternative homes have special medical or educational needs or have behavioural or psychiatric problems. Many see a role in acting as advocates, not just for those with impairments but also for socially disadvantaged children, including those ‘looked after’ in children’s homes and those of travellers, asylum seekers, refugees and the homeless.
Child protection Regrettably, some children come to the attention of child health specialists because they have been beaten, neglected, emotionally or nutritionally starved or sexually assaulted by their parents or carers. Responsibility for the investigation of these children is that of local-authority social-services departments. However, child health professionals have a vital role in diagnosis, obtaining forensic evidence, advising courts, supervising the medical aspects of follow-up and teaching doctors, therapists and other professionals in training. (See CHILD ABUSE.)
School health services Once children have reached school age, the emphasis changes. The prime need becomes identifying those with problems that may interfere with learning – including those with special needs as de?ned above, but also those with behavioural problems. Teachers and parents are advised on how to manage these problems, while health promotion and health education are directed at children. Special problems, especially as children reach secondary school (aged 11–18) include accidents, substance abuse, psychosexual adjustment, antisocial behaviour, eating disorders and physical conditions which loom large in the minds of adolescents in particular, such as ACNE, short stature and delayed puberty.
There is no longer, in the UK, a universal school health service as many of its functions have been taken over by general practitioners and hospital and community paediatricians. However, most areas still have school nurses, some have school doctors, while others do not employ speci?c individuals for these tasks but share out aspects of the work between GPs, health visitors, community nurses and consultant paediatricians in child health.
Complementing their work is the community dental service whose role is to monitor the whole child population’s dental health, provide preventive programmes for all, and dental treatment for those who have di?culty using general dental services – for example, children with complex disability. All children in state-funded schools are dentally screened at ages ?ve and 15.
Successes and failures Since the inception of the NHS, hospital services for children have had enormous success: neonatal and infant mortality rates have fallen by two-thirds; deaths from PNEUMONIA have fallen from 600 per million children to a handful; and deaths from MENINGITIS have fallen to one-?fth of the previous level. Much of this has been due to the revolution in the management of pregnancy and labour, the invention of neonatal resuscitation and neonatal intensive care, and the provision of powerful antibiotics.
At the same time, some children acquire HIV infection and AIDS from their affected mothers (see AIDS/HIV); the prevalence of atopic (see ATOPY) diseases (ASTHMA, eczema – see DERMATITIS, HAY FEVER) is rising; more children attend hospital clinics with chronic CONSTIPATION; and little can be done for most viral diseases.
Community child health services can also boast of successes. The routine immunisation programme has wiped out SMALLPOX, DIPHTHERIA and POLIOMYELITIS and almost wiped out haemophilus and meningococcal C meningitis, measles and congenital RUBELLA syndrome. WHOOPING COUGH outbreaks continue but the death and chronic disability rates have been greatly reduced. Despite these huge health gains, continuing public scepticism about the safety of immunisation means that there can be no relaxation in the educational and health-promotion programme.
Services for severely and multiply disabled children have improved beyond all recognition with the closure of long-stay institutions, many of which were distinctly child-unfriendly. Nonetheless, scarce resources mean that families still carry heavy burdens. The incidence of SUDDEN INFANT DEATH SYNDROME (SIDS) has more than halved as a result of an educational programme based on ?rm scienti?c evidence that the risk can be reduced by putting babies to sleep on their backs, avoidance of parental smoking, not overheating, breast feeding and seeking medical attention early for illness.
Children have fewer accidents and better teeth but new problems have arisen: in the 1990s children throughout the developed world became fatter. A UK survey in 2004 found that one in ?ve children are overweight and one in 20 obese. Lack of exercise, the easy availability of food at all times and in all places, together with the rise of ‘snacking’, are likely to provoke signi?cant health problems as these children grow into adult life. Adolescents are at greater risk than ever of ill-health through substance abuse and unplanned pregnancy. Child health services are facing new challenges in the 21st century.... child development teams (cdts)
History Child health services were originally designed, before the NHS came into being, to ?nd or prevent physical illness by regular inspections. In the UK these were carried out by clinical medical o?cers (CMOs) working in infant welfare clinics (later, child health clinics) set up to ?ll the gap between general practice and hospital care. The services expanded greatly from the mid 1970s; ‘inspections’ have evolved into a regular screening and surveillance system by general practitioners and health visitors, while CMOs have mostly been replaced by consultant paediatricians in community child health (CPCCH).
Screening Screening begins at birth, when every baby is examined for congenital conditions such as dislocated hips, heart malformations, cataract and undescended testicles. Blood is taken to ?nd those babies with potentially brain-damaging conditions such as HYPOTHYROIDISM and PHENYLKETONURIA. Some NHS trusts screen for the life-threatening disease CYSTIC FIBROSIS, although in future it is more likely that ?nding this disease will be part of prenatal screening, along with DOWN’S (DOWN) SYNDROME and SPINA BIFIDA. A programme to detect hearing impairment in newborn babies has been piloted from 2001 in selected districts to ?nd out whether it would be a useful addition to the national screening programme. Children from ethnic groups at risk of inherited abnormalities of HAEMOGLOBIN (sickle cell disease; thalassaemia – see under ANAEMIA) have blood tested at some time between birth and six months of age.
Illness prevention At two months, GPs screen babies again for these abnormalities and start the process of primary IMMUNISATION. The routine immunisation programme has been dramatically successful in preventing illness, handicap and deaths: as such it is the cornerstone of the public health aspect of child health, with more potential vaccines being made available every year. Currently, infants are immunised against pertussis (see WHOOPING COUGH), DIPHTHERIA, TETANUS, POLIOMYELITIS, haemophilus (a cause of MENINGITIS, SEPTICAEMIA, ARTHRITIS and epiglottitis) and meningococcus C (SEPTICAEMIA and meningitis – see NEISSERIACEAE) at two, three and four months. Selected children from high-risk groups are o?ered BCG VACCINE against tuberculosis and hepatitis vaccine. At about 13 months all are o?ered MMR VACCINE (measles, mumps and rubella) and there are pre-school entry ‘boosters’ of diphtheria, tetanus, polio, meningococcus C and MMR. Pneumococcal vaccine is available for particular cases but is not yet part of the routine schedule.
Health promotion and education Throughout the UK, parents are given their child’s personal health record to keep with them. It contains advice on health promotion, including immunisation, developmental milestones (when did he or she ?rst smile, sit up, walk and so on), and graphs – called centile charts – on which to record height, weight and head circumference. There is space for midwives, doctors, practice nurses, health visitors and parents to make notes about the child.
Throughout at least the ?rst year of life, both parents and health-care providers set great store by regular weighing, designed to pick up children who are ‘failing to thrive’. Measuring length is not quite so easy, but height measurements are recommended from about two or three years of age in order to detect children with disorders such as growth-hormone de?ciency, malabsorption (e.g. COELIAC DISEASE) and psychosocial dwar?sm (see below).
All babies have their head circumference measured at birth, and again at the eight-week check. A too rapidly growing head implies that the infant might have HYDROCEPHALUS – excess ?uid in the hollow spaces within the brain. A too slowly growing head may mean failure of brain growth, which may go hand in hand with physically or intellectually delayed development.
At about eight months, babies receive a surveillance examination, usually by a health visitor. Parents are asked if they have any concerns about their child’s hearing, vision or physical ability. The examiner conducts a screening test for hearing impairment – the so-called distraction test; he or she stands behind the infant, who is on the mother’s lap, and activates a standardised sound at a set distance from each ear, noting whether or not the child turns his or her head or eyes towards the sound. If the child shows no reaction, the test is repeated a few weeks later; if still negative then referral is made to an audiologist for more formal testing.
The doctor or health visitor will also go through the child’s developmental progress (see above) noting any signi?cant deviation from normal which merits more detailed examination. Doctors are also recommended to examine infants developmentally at some time between 18 and 24 months. At this time they will be looking particularly for late walking or failure to develop appropriate language skills.... child health
Child abuse may take the form of physical injury, sexual abuse, emotional mistreatment, and/or neglect; it occurs at all levels of society.
Being deprived or ill-treated in childhood may predispose people to repeat the pattern of abuse with their own children.
Children who are abused or at risk of abuse may be placed in care while the health and social services decide on the best course of action.... they generally heal without treatment child abuse
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