Child Protection Policy

INTRODUCTION

Maltreatment of children (abuse and neglect) occurs in all socioeconomic levels, across all ethnic and cultural lines, within all religions and at all educational levels in New Zealand society. The maltreatment of a child can have long term adverse physical, psychological and behavioral consequences for that child. Child maltreatment is a cyclic problem with abused children often becoming abusive parents. Children and young people have the right to be protected from all forms of abuse and neglect.
Child protection means protecting a child from maltreatment. Child protection requires the interaction of services including dental practitioners, children and families. For child protection to work effectively it is essential that everyone understands and fulfils their ethical, legal and social responsibilities. Dental practitioners and the dental team have a duty of care to consider the wellbeing of their patients, and as part of this, a responsibility in identifying and reporting concerns regarding the wellbeing of children and young people.
Dental practitioners should have the knowledge and skills to identify signs and symptoms that may indicate maltreatment and must know how, and to whom, to share this information. Where a practitioner has reasonable cause to suspect or believe that a child is at risk of significant harm the practitioner has a responsibility to share these concerns with the appropriate authority. The overriding principle is that the child’s welfare is paramount.
This Policy outlines the responsibilities of dental practitioners with regard to child protection and provides guidance on how these responsibilities can be met. This Policy does not constitute legal advice.

DEFINITIONS

CHILD AND YOUNG PERSON
A child is a boy or a girl under the age of 14 years. A young person is a person under the age of 18 years who is not married or in a civil union.

CHILD ABUSE
Child abuse is a deliberate act of harming (whether physically, sexually or emotionally), ill-treatment, neglect or deprivation of any child or young person. Child abuse can be categorised as: physical abuse, emotional abuse, sexual abuse, and neglect.

CHILD NEGLECT
Any serious act or emission that, within the bounds of cultural tradition, constitutes a (persistent) failure to provide conditions that are essential for the physical health and emotional development of a child. A failure to act.

DENTAL NEGLECT
Dental neglect is the persistent failure to meet a child’s basic oral health needs which is likely to result in the serious impairment of a child’s oral or general health or development.

CHILD MALTREATMENT

Child abuse and neglect are forms of maltreatment of a child. Child maltreatment can take many forms and can harm a child suddenly or over a period of time. Abusers can be members of the family (parents, siblings), people known to the child (including other children) or more rarely strangers. In New Zealand most perpetrators are parents. The overriding characteristics of abusers is their apparent normality. Risk factors for child maltreatment include domestic violence, unstable parent relationships, parental misuse of drugs or alcohol or mental illness. The vulnerability of children to maltreatment is amplified when a child has an increased dependence on a parent/guardian/caregiver and when that child lacks the ability to communicate a need for help (eg preschool and disabled children).

RESPONSIBILITIES

Dental practitioners and their staff have a responsibility to be mindful of, and vigilant for, signs that a child may be being maltreated. They must be familiar with the perioral signs of child abuse and neglect. If a practitioner has concerns about the welfare of a child they must act (see Responding to Concerns)
Dental practitioners have an obligation to ensure that children and young people are not at risk from practice staff members. Safety checking of staff working with children is an important element of this. Concerns and/or allegations about staff members employed in the practice are to be taken seriously. The decision to follow up an allegation of child maltreatment by a staff member should be made in consultation with Child Youth and Family (CYF) and/or the Police.
Practitioners should note that the statutory responsibility for investigation of allegations of child abuse lies with CYF and the Police and not with them. Practitioner responsibilities are principally recognition and responding appropriately to concerns they may have.
Dental practitioners and their staff are encouraged to seek educational opportunities to improve their knowledge in issues of child protection.

CHILD PROTECTION – ASSESSMENT

Concerns about a child or young person may arise over a period of time or in response to a particular incident. Concerns may arise from observations made by dental staff, reports from child/young person or from a third party. Practitioners should listen, observe and must exercise sound professional judgement in identifying concerns that require child protection actions. The signs of maltreatment can be physical and/or behavioural and are wide and varied in presentation.

INDICATORS OF CHILD ABUSE
DISCLOSURE.
If a child discloses an incident or incidents which may constitute abuse the practitioner’s role is not to conduct an investigation to confirm whether or not abuse has occurred, but to observe, document and as necessary refer. The practitioner should take the claim seriously, listen carefully and sympathetically avoiding expressing a ‘view’ on the matter. Questions should be limited to only those that are needed to clarify the information being provided, and care must be taken to ensure questions are open ended. No in-depth interview of the child should be attempted which is more properly the domain of CYF or the Police. Any disclosure should be carefully recorded at the time.
If a practitioner has concerns about the welfare of a child, based on information given by that child, the practitioner should explain to the child, assuming the child is able to understand, (IE is ‘competent’) that the practitioner may need to share that information. If this is the case the child should be told to whom and when the information will be shared.

OROFACIAL INJURIES.
Children commonly suffer injuries to the mouth and face and these injuries need to be distinguished from those potentially arising from abuse. Suspicious injuries to the head, face, mouth or neck of a child mat include; contusions, ecchymosis and bruising, laceration, fractures, burns, bites and dental trauma. When attempting to distinguish accidental injuries from injuries arising from abuse the following may assist:
Implausible, inadequate or inconsistent explanation as to the cause of the injury
Discrepancies between the characteristics of the injury and the purported mechanism and timing of the injury for a child of that age. Is the injury consistent with the history given and/or is it unusual for that specific age group?
Discrepancies between the history provided by the child and that of the parent/guardian
A history (or signs) of repeated or previous trauma including injuries at different stages of healing
Significant delays in a parent/guardian seeking treatment for a child’s injuries

BEHAVIORAL OBSERVATIONS.
Observations of child behaviour and parent-child interaction may assist in the assessment process.
Unusual behaviour exhibited by the child (Eg an exaggerated or detached response to questioning, overly anxious, watchful)
Parent/guardian who appears withdrawn or unconcerned
Evidence of neglect or poor supervision of the child
Further detail regarding warning signs of child abuse is contained in Appendix A

CHILD NEGLECT.
A neglected child may be constantly hungry, listless and fatigued, have poor personal hygiene, inappropriate or inadequate clothing, have unmet medical needs and lack supervision. Neglect is usually appended to abuse.

DENTAL NEGLECT.
Untreated oral disease and a neglected dentition are suggestive of dental neglect especially when a child shows signs of general neglect. Whilst research has demonstrated that children confirmed as having suffered abuse or neglect have a higher incidence of untreated dental caries and other oral problems, it is unwise to make an automatic assumption regarding general neglect based on the presence of a neglected dentition or suspected dental neglect.
Practitioners should note the distinction between a ‘neglected dentition’ and dental neglect. A key element in determining this is the child’s presenting dental situation is a result of a parent/guardian’s lack of knowledge and awareness or a result of a wilful failure to address the child’s needs. The child’s health and welfare must always be the overriding consideration irrespective of the wilfulness (or otherwise) of the suspected dental neglect.
Signs and symptoms of dental neglect present a long a spectrum of severity and may include:
Rampant untreated dental caries easily detected by a lay person
Untreated orofacial pain, infection, bleeding or trauma. Parent/guardian ignores the child’s symptoms.
Failure of parents/guardians to respond to offers of acceptable and appropriate treatment
History of lack of appropriate dental care over time (continuity of care) in the presence of identified dental pathology. Failure to obtain planned treatment when access is available (Eg repeated failure to attend appointments)

CHILD PROTECTION – RESPONDING TO CONCERNS

Abuse and neglect

If a practitioner has concerns that a child is being maltreated they may act on this concern or may first choose to seek advice and council from an appropriate colleague or other professionals first. If, having discussed the matter, the concerns remain a key first point of contact is CYF which provide a contact service 24 hours a day, 365 days a year. CYF will be able to help determine the urgency of the concern, whether CYF need to do anything further, or if the child or young person’s needs could be better met by another agency.
If at any point there is concern that the child is suffering significant harm from maltreatment, a referral should be made to CYF or the Police. Timelines of action is central to effective support of children who may be being maltreated.
If there are immediate concerns for the physical safety of a child, contact the Police by calling 111 and ask for the ‘Police’.
Less immediate referrals of suspected child maltreatment should be made in the first instance to CYF.
CYF contact details:
Phone 0508 326 459
Fax 09914 3820
Email cyfcallcentre@cyf.govt.nz
See http://www.cyf.govt.nz/about-us/contact-us/
CYF intake social workers deal with contacts concerning child maltreatment and are likely to require the following information:
Practitioner details, the details of the child and their family/whanau
The specific concerns and full details of any previous concern
Opinion regarding the urgency of the matter
The current location of the child or young person
Any alleged abuser (if known/suspected) and that person’s access to the child
History of any known violence, stress, substance abuse, mental illness or incapacity, social isolation to which the child may be exposed
Any physical hazards at the child’s home; eg weapons, threats of violence, dogs
Any additional information which may assist in determining the appropriate response
This information should be carefully documented in the child’s record. If the information was provided to CYF or the Police verbally it should, as soon as practicable, be followed-up in writing.
Practitioners working for a District Health Board (DHB) should follow the respective DHB child abuse referral protocols, but generally, the first step is to consult with the on-duty paediatrician.

CYF Response

In situations where CYF believe further action is required a case/key social worker will contact the referring practitioner about the case. The contact with the practitioner is to ensure the social worker has full and correct information, to receive any update on further developments and to give the practitioner information on action being taken. The timing of this contact will vary depending on the assessed urgency of the case.
At the end of the investigation (which can take 6 to 16 weeks from referral) the case/key social worker has a legal obligation to inform the practitioner that the referral has been investigated and whether any further action has been taken.

Allegation of child maltreatment by a staff member

If concerns and/or allegations of child maltreatment by a staff member are raised, these are to be taken seriously. Interim action may include ensuring that the person concerned does not have unsupervised contact with children until the employer believes on reasonable grounds there is no risk to children. The decision to follow-up an allegation of abuse by an employee should be made in conjunction with CYF and the Police.
If, after discussion with CYF and/or the Police, there is a need to pursue an allegation as an employment matter the person concerned should be advised as such. Further management of the matter should be taken in the context of the worker’s employment contract and legal advice.

Disclosure of information

There are no legal barriers to disclosure of patient information relating to suspected or actual child maltreatment when that information is given in good faith to an appropriate authority (eg Police, social worker or a Care and Protection Coordinator)
In most situations a practitioner should explain any concerns about the child to both the parents and to the child. As part of this process the practitioner should inform the parents if there is an intention to refer the child to other agencies (family support, CYF etc) and the parent’s consent for this should be requested. Such conversations can be difficult however open discussion is important.
A decision not to discuss concerns with parents is a judgement call. Circumstances where a practitioner may elect not to disclose to the parents include:
Situations where discussions might put the child at increased risk
Where sexual abuse by a family member, or organised or multiple abuse is suspected
Where parents are being violent or abusive and discussion would place the practitioner or others at risk
Where it is not possible to contact parents without undue delay and so would potentially slow down the referral.

Dental neglect

Dental neglect should be considered if, following the identification of dental pathology, the careful explanation of treatment and homecare requirements, and the removal of significant barriers to care the parent or guardian continues to fail to follow through with a prescribed treatment.
If dental neglect is suspected practitioners should take a systematic ‘stepwise’ approach to intervention noting that most neglect is caused or exacerbated by poverty, ignorance and isolation.
Dental neglect – Step 1 Dental Management
Practitioners should work with the child and their family to re-establish good oral health for the child. The primary aim of the intervention is to ensure the child receives the necessary care and not to blame the parent/guardian. A preventive approach is essential if long-term dental health is to be maintained, however, it is recognised that the initial focus needs to be on the management of pain and infection and subsequently restoration of function and appearance. Dental treatment plans must be reasonable and achievable without placing unrealistic demands on the child and their family. A thoughtful follow-up plan is required.
Effective dental management requires the cooperation and participation of the child’s parent/guardian. Implicit in this is that the parent/guardian has the knowledge and wherewithal to assist with this management. Individual families may face significant challenges in accessing care and in improving a child’s oral health so the practitioner should make efforts to understand these and find strategies to mitigate such challenges.

Dental neglect – Step 2 Seek Assistance

If the interventions undertaken in Step 1 – Dental Management, fail to address the underlying issues or if there is a deterioration in the situation the practitioner should consider involving other professionals to help. Consideration should be given to involving agencies to support the child and their parent/guardian for example – the child’s doctor, public health nurse, social worker etc.
The consent of the child and their parent/guardian should be obtained before such contacts are made although there may be times when it is not possible (eg following repeated missed appointments) or when there is an urgent risk to a child’s wellbeing. The overriding principle is that the child’s welfare is paramount.

Dental neglect – Step 3 Referral

If at any point there is concern that the child is suffering significant harm from dental neglect or showing other signs of neglect or abuse, a referral to CYF or the Police should be made noting that timeliness of action is central to effective support of children.

DOCUMENTATION


If child maltreatment is suspected it is important that a detailed record of the observations are made in the child’s records. Details should be specific, objective and include the date and who was present. Accounts of the incident should be recorded verbatim. Injuries should be carefully described and/or photographed. Behavioural observations should be recorded. Documents all actions taken, eg if advice on the case was sought, record from whom and the content of the discussions or if referral to CYF or the Police was made.

INFORMATION SHARING

Other agencies and practitioners may from time to time require information about a patient. Under the Health information Privacy Code a practitioner normally must not disclose health information other than to the individual concerned (or the individual’s representative). There are exceptions to this, eg if the disclosure is authorised by the individual concerned (or the individual’s representative.
There may be circumstances where requests for health information are made by other practitioners. The most common situation is where another health care provider makes a request in order to provide health or disability services to an individual. Such disclosure is permitted by the Health Act 1956 and there are only limited circumstances where such a request can be refused. The health care professional making the request does not usually need the patient’s consent to request the disclosure but one important ground on which the request may be refused is if the practitioner believes that the individual concerned would not want the information disclosed to the requester.
Under other legislation information can be requested from a practitioner by authorities or other statutory regulatory bodies. If the law authorises or requires information to be made available (using words like shall or must) the information MUST be made available. Prior to disclosure of such information the practitioner should request in writing exactly what information is required and the statutory provision which requires the practitioner to provide the information.
Other legislation may permit but not ‘mandate’ the disclosure of information. The Children Young Persons and Their Families Act 1989 has provisions which allows (rather than requires) disclosure of information to a relevant authority or person in cases of suspected neglect or abuse of a child or young person.
Under the Health Act 1956 practitioners are allowed to disclose health information to various agencies (eg Police) if that information is required for those people to carry out their functions. The disclosure is always discretionary.
Practitioners should ensure their staff are familiar with the rules around disclosure of health information.

VULNERABLE CHILDREN ACT 2014

The Vulnerable Children Act 2014 (VCA) has as its purpose promoting the best interests of vulnerable children. This Act applies in the dental practice context and includes taking measures aimed at protecting vulnerable children from abuse and neglect, improving their physical and mental health and their cultural and emotional well-being and increasing their participation in decision making about them. The VCA specifically applies to dental practices which provide services as part of State funded schemes such as ACC and the Dental Benefits Scheme.
The VCA requires practices funded by State Services that employ or contract people to work with children to have child protection policies and to ‘safety check’ staff. These requirements are part of practice culture of child protection which is open and accountable, understands the needs of children and makes their safety and security a priority.