Child abuse in children living with special guardians, a service evaluation of child protection medical examinations.

Objective: To determine difference in frequency of referral for child protection medical examination (CPME) in children subject to special guardianship order (SGO), subject to child protection plan (CPP) or neither. Design: Service evaluation analysing data from CPME reports. Setting: Acute and community healthcare providers in Birmingham UK, during 2018. Patients: All children aged 0-18 years requiring CPME. Main outcome measures: Details were obtained from CPME reports on: age, SGO status, CPP status, reason for CPME, injuries sustained, presence of non-accidental injury.Population data were obtained from the local children's safeguarding board and national statistics.
Results: Reports were available for 292/298 (98%) CPME, relating to 288 children. 5 children were subject to SGO, 39 were subject to CPP, none subject to both. Non-accidental injury was substantiated in 189/288 (66%). The child population was 288 000. 1665 children were subject to CPP and approximately 750 subject to SGO. The relative risk (RR) for children subject to SGO requiring a CPME compared with children not subject to SGO or CPP is 7.86, p<0.0001 with 95% CI (3.26 to 19.02). The RR for children subject to a CPP requiring CPME compared with children not subject to SGO or CPP is 27.65, p<0.0001 with 95% CI (19.78 to 38.63). Conclusions: This is a small study and findings need interpreting cautiously. Children subject to SGO may potentially be at higher risk of abuse than the general population despite living with carers who have passed social care parenting assessments. There is no register of children subject to SGO so professionals may be unable to offer families additional support. SGO families should be offered enhanced support and monitoring routinely. Children subject to CPP are not being adequately protected from further abuse. © Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

When children cannot live with birth families due to abuse or neglect, children are often placed with extended family members such as grandparents.

Special guardianship orders are an alternative to adoption aiming to give long-term stability to children and carers.

The assessment process for special guardians is shorter than for adoption raising concerns that these may not be thorough.

There may be an increased risk of physical abuse for children subject to special guardianship order (SGO) as they are over-represented among children attending for child protection medical examinations.

It is difficult identifying children subject to SGO, which may limit the support that professionals can provide to families.

Children on child protection plans remain at high risk of further non-accidental injury.

Introduction

When children have suffered or are at risk of significant harm in the care of their parents they are removed by local authorities (administrative body in local government) in Great Britain. Out of Home care options include placement with family members (kinship care). This is often desirable, as maintaining family ties is important for emotional and mental wellbeing and may help subsequent family reunification.1 Some children will require long-term placement in foster care, kinship care or by adoption. Special guardianship orders (SGOs) were introduced in 2002 as an alternative to adoption in England and Wales.2 Children subject to SGO are placed with legal guardians with whom there are existing relationships, such as a foster carers or relatives. Guardians gain parental responsibility and children are no longer the responsibility of local authorities. Birth parents cannot apply for removal of SGO without court permission. SGOs maintain the relationship between a child and their birth parents, although guardians can stop contact with birth parents if they feel it is in the child’s best interests. Special guardianship is available in both private and public law proceedings. In private law proceedings families initiate applications themselves, public law proceedings apply for children in the care of the local authority. In all cases local authorities must assess potential guardians’ suitability. In 2019, 3830 children in England became subject to SGO under public law, 54% were under the age of 5 years.3 There are no national statistics for private law SGO applications. Local authorities have registers of children subject to SGO if families apply for additional support.

A review of SGOs was commissioned following concerns that as the assessment process for potential guardians is quicker and less rigorous than adoption this might impact on the quality of assessments and placements.4 Although kinship care has been long-established many professionals worry that placing children with grandparents may be high risk: poor parenting by grandparents may have led to birth parents’ own parenting difficulties, however, the risks of intergenerational transmission may well have been over-estimated.5 Harwin et al4 reported that SGOs are very stable placements compared with long-term foster care. However, significant emotional and behavioural difficulties are associated with increased risk of SGO placement breakdown, with special guardians frequently struggling to access support services.4 Many children prior to SGO will have experienced challenging life situations, adversity, neglect and abuse, contributing to later emotional and behavioural difficulties so come to the attention of health and care professionals. Emotional and behavioural difficulties may increase the risk of carer stress and subsequent physical abuse, particularly if there is limited support for and assessment of guardians.

When any child presents with suspected maltreatment, a formal child protection medical examination (CPME) may be required; this provides a holistic assessment of the child’s health, documents injuries and determines possible causes including the reasonable likelihood of non-accidental injury (NAI). CPMEs are undertaken or supervised by an experienced consultant paediatrician,6 following rigorous standards for consent, conduct of the examination, documentation of history, findings and formulation, photo documentation and report writing,7 with reports subject to regular peer review.8 CPME reports are shared with police and social care, and stored within the child’s medical records.

Birmingham is the second largest city in the UK and the largest local authority in Europe with 23% of its population being children under 16 years old.9 The proportion of children subject to a child protection plan (CPP) is similar to other areas at 44.7 per 10 000 children.10 In Birmingham the majority of CPMEs are undertaken by paediatricians at the community healthcare trust setting during working hours, with three hospitals (one specialist children’s and two district) providing CPME out of hours or for children requiring admission and treatment of injuries. Children may present at any hospital regardless of their home address. Children with suspected sexual abuse are assessed at regional child sexual assault referral centres.

There have been few published studies of the risk of further abuse once a child is subject to SGO. However, there have been children seriously harmed or killed by special guardians, highlighting the lack of thorough assessment and follow-up.11–13 Given these concerns we decided within the CPME service, to evaluate the frequency of children subject to SGO requiring CPME compared with children subject to CPP and children not subject to any order during 2018. This was to inform local service provision and support for families by more accurately identifying needs. The question for this service evaluation was:

What is the difference in frequency of referrals for CPME in children subject to SGO, children subject to CPP and children not subject to any order?

Methods

Study design

Service evaluation of CPME reports.

Setting and sample

All children aged 0–18 requiring for CPME in Birmingham, total population 1.1 million of which 288 000 are children aged <18.9 Data were collected from all CPME reports during the period 01 January to 31 December 2018 from all four healthcare providers responsible for CPME for Birmingham resident children: the community healthcare trust, children’s hospital and two district hospitals.

Procedure

For the community healthcare trust we obtained a list of all children referred for CPME from the booking service, which is the single point of contact for all CPME referrals in the trust, and accessed the electronic patient records for these children, obtaining copies of reports from CPME. For the hospital trusts, we approached Safeguarding teams for details of children requiring CPME in emergency departments, outpatient or inpatient areas and obtained reports from electronic patient records. We carefully checked postcodes only including CPME reports for Birmingham resident children. We read the reports, and completed a pseudonymised data extraction form for each CPME, this is shown in table 1.

Table 1

Data extraction form

NHS no
Date of medical
Age of child in months
SGO	Yes/no
Residence order/adopted/ other order please detail
Usual place of residence	Birth parents/other relatives/adopted/foster care/residential home/other
Child protection plan	Yes/no/previously
Reason for child protection medical
Potential physical injury to child	Yes/no
Physical injury to sibling	Yes/no
Neglect	Yes/no
Other—please state
Outcome of medical
Detail physical injuries	Burn/fracture/head injury/bruise/other—please state
Brief description of injuries including whether NAI or not

CP, child protection; NAI, non-accidental injury; NHS, National Health Service; SGO, special guardianship order.

Outcomes were taken either directly from the conclusion of the CPME report, or if the conclusion was unclear, were determined based on the description of injuries and events within the report, including results from inpatient investigations such as skeletal survey. We excluded cases where we could not access the CPME report. The data extraction form was piloted by JG, GC and CM on the first 10 CPME reports and revised to eliminate ambiguities, prior to further use.

Data were extracted by doctors based in each healthcare team providing the CPME. The doctors were specialist trainees in paediatrics, all had a minimum of 4 years’ postgraduate paediatric training. In the event of uncertainty about the conclusion of any CPME report, the case was discussed with JG, a former designated doctor for safeguarding. We initially obtained data for the period January to June 2018, but after initial analysis we expanded the project to include the months July to December 2018. Due to changes in personnel we could not obtain data from the two district hospitals for the second 6-month period.

We obtained details of the number of children subject to SGO from Birmingham Children’s Trust (social care). Child population and numbers of children subject to CPP were obtained from National Statistics.

Statistical analysis

Anonymised data were entered into IBM SPSS V.26. Cases were analysed according to whether they were subject to SGO, CPP or neither. We calculated the relative risks (RR) and OR of children referred for CPME using Medcalc online statistical software14 based on first attendance for CPME only, discounting any subsequent attendance. Statistical significance was set at p≤0.05 and confidence at 95%.

Patient and public Involvement

As this was a service evaluation, there was no patient and public involvement.

Results

We obtained details of 298 CPME in Birmingham during 2018, relating to 288 children, of which we obtained reports for 292/298 (98%), reports were not available for six CPME at the community trust. We obtained data from all trusts for January to June 2018, but were unable to obtain any from the two district hospitals for July to December 2018, however, there were only 32 CPME at these two hospitals during January to June, accounting for 11% of CPME.

The numbers CPME reports from each hospital are shown in figure 1.

Figure 1

Numbers Child Protection Medical Examination reports from each Hospital. Note: There were only four cases at District Hospital 2 as this hospital mainly treats non-Birmingham residents.

At the first CPME there were five children subject to SGO and 39 subject to CPP. No children were subject to both SGO and CPP. One additional child was subject to a residence order and living with grandparents. One child subject to SGO had a second CPME 3 months’ later and one child was only subject to CPP at a second CPME but not at the first. We have only considered children’s first CPME in our analysis.

The median age of all children at the time of first CPME was 47 months (3 years 11 months, range 0 month to 17 years 7 months).

The referral reasons and outcomes for children subject to SGO, children subject to CPP or children subject to neither are shown in table 2. Due to the small numbers of children subject to SGO we have not attempted to determine whether there are significant differences between the groups. CPME reports concluded that there was evidence to substantiate NAI following 189/288 (66%) of CPME.

Table 2

Reasons for CPME referral and outcomes

	CPME in children subject to SGO (n=5)	CPME in children subject to CPP (n=39)	CPME in children not subject to SGO or CPP (n=244)
Referred for suspected physical abuse*	4	32	217
Referred for suspected neglect*	0	9	33
Referred due to non-accidental injury in sibling*	1	12	74
Non-accidental injury substantiated	4	24	161

*More than one reason for referral could be selected.

CPME, child protection medical examination; CPP, child protection plan; SGO, special guardianship order.

Bruises were the most common injury accounting for 118/189 (62%) of NAI. Burns were rare overall with eight cases in total, one child subject to SGO presented twice with burns.

Of 288 000 children in Birmingham, 1665 are subject to a CPP10 with approximately 750 children subject to SGO.15 Children subject to SGO accounted for 1.7% of first CPME but 0.26% of the child population.

The numbers of children, their outcomes (requiring CPME) and exposures (SGO/CPP status or neither) are shown in table 3.

Table 3

Exposures and outcomes of children requiring CPME

	Exposure
	SGO	CPP	Neither SGO/CPP
Outcomes
CPME	5	39	244
No CPME	745	1626	287 756
Total	750	1665	288 000

CPME, child protection medical examination; CPP, child protection plan; SGO, special guardianship order.

The RR for children in Birmingham subject to SGO and requiring a first CPME compared with children not subject to SGO or CPP is 7.86, p<0.0001 with 95% CI (3.26 to 19.02), the OR is 7.92, p<0.0001 with 95% CI (3.26 to 19.24). The RR for children subject to a CPP requiring CPME compared with children not subject to SGO or CPP is 27.65, p<0.0001 with 95% CI (19.78 to 38.63), the OR is 28.3, p<0.0001 with 95% CI (20.10 to 39.80). This is shown in figure 2.

Figure 2

Relative risks and OR for children requiring CPME. CPME, child protection medical examination; CPP, child protection plan; SGO, special guardianship order.

Discussion

Children subject to SGO appear over-represented in those requiring CPME, accounting for 1.7% of CPME but representing just 0.26% of the child population covered in this study. They could have eight times the risk of needing a CPME compared with other children. This is concerning given that potential guardians are assessed for their suitability as permanent carers prior to SGO being granted, so these children should have a similar or even lower risk of abuse than other children. Children subject to CPP are also significantly over-represented, with 28 times the risk. This suggests that CPP may, in some instances at least, be failing to protect very vulnerable children from further abuse. However, children subject to CPP are more closely monitored by professionals so may be referred more frequently than others for CPME, and subsequent referrals may be unrelated to the concerns originally leading to the CPP.

This is a unique population based study in which we managed to obtain reports for nearly all CPME for Birmingham resident children during 2018. Our findings are potentially applicable outside of Birmingham as this is the largest local authority in Europe with a diverse population. Our limitations include the very small numbers of children subject to SGO, despite collecting data for 12 months from a large child population. There is, however, no equivalent national data repository. As our data source was reports written at the time of CPME we were unable to include information from subsequent child protection investigations and strategy meetings so have no details of medium or longer term outcomes. Despite findings of NAI at CPME these may not be substantiated subsequently at child protection conferences or court hearings. We could only obtain an estimate for the number of children subject to SGO in Birmingham, as there is no requirement for local authorities to keep such records unless they are providing support to the families or there was a public law application for SGO. This means that the rRR and ORs presented should be treated with extreme caution as the number of children subject to SGO may be underestimated. However, any study using CPME as an outcome may represent ‘the tip of the iceberg’ of children with abuse and neglect as only a minority of children referred for these concerns have CPME. During 2018, there were 4902 children in Birmingham referred to social care and classified as ‘in need’ due to abuse or neglect10 but less than 10% of these children attended for CPME.

No other UK study has reported physical abuse in children subject to SGO despite concerns about limited assessments of potential guardians. A recent study found that 3 years after SGO placement 4% of children had been neglected with further care proceedings in 6%, although there were no reports of physical abuse.4 Two US studies have reported higher rates of neglect in kinship care than other out of home placement,16 although the highest levels were found in informal kinship care that was not subject to professional scrutiny prior to placement.17 Conversely another US study concluded that kinship care provided higher quality care than unrelated foster care.18 It is well recognised that child abuse may continue despite children being subject to CPP, 10%–17% of Serious Case Reviews between 2005 and 2017 were for children subject to CPP.19 20

Our findings suggest that children subject to SGO may be at higher risk of physical abuse, although less at risk than those subject to CPP. At present, children subject to SGO can be invisible to services, with local authorities not required to keep records of these families. Services can only offer enhanced support if they are aware of the need. Children subject to SGO should be considered as having additional need for support and be offered this routinely by health and social care services. At present, guardians are not entitled to the same level of assessment and support as adoptive parents, particularly if children were not previously in care. There could be many more children subject to SGO experiencing abuse and neglect who do not require CPME. Further research is needed, detailing the frequency of SGO children presenting to social care with abuse and neglect so that the scale and nature of this problem can be accurately determined. Only once we have a more nuanced understanding of the issues can we plan better assessments, support and monitoring for these vulnerable children.