Safeguarding History – The Basics

Children are vulnerable. Unfortunately, child abuse does happen, and it has a significant and lifelong impact. You may be one of the only professionals to have sufficient access to the child to identify concerns. As such you have the responsibility to be knowledgeable of safeguarding issues and best practices for keeping children safe. This article gives you a basic introduction to considering safeguarding issues when taking histories from children and young people.

Risk Factors

There are many risk factors for abuse. However, it is important to bear in mind that many of these risk factors may be present in children who live happy healthy lives.

Family Factors
  • Substance abuse
  • Domestic Abuse
  • Mental health issues
  • Poor parental engagement with services
  • Previous abuse by or against parent
  • Low socioeconomic status
Child Factors
  • Age
  • Sex
  • Previous abuse or trauma
  • Learning disability or other disability
  • Looked after children

What you should ask about:

Every consultation that you conduct with children and young people should screen for safeguarding concerns. The first six topics below are good questions to ask in every encounter. It is important to become comfortable asking about these things and documenting whether (or not) you have any concerns. If you are unsure, always ask for help from someone more experienced.

Social Services input – Identifies at-risk families and is helpful for completing referrals. If a child has previous social services input, knowing the history can give you crucial context to the current presentation and may lower your threshold for suspicion of safeguarding issues.

Who is at home – Asking this allows you to assess the child’s support system and identifies exposure to risk factors.

Timing of presentation – Delayed presentation without sufficient explanation can indicate an attempt to cover up abuse or be a sign of neglectful care.

Who is with them – This is important for assessing the appropriateness of interactions. Children will be different with a parent, an older sibling, or their class teaching assistant.

How’s school/home – This is an open and casual way of exploring potential bullying, domestic violence or abuse, there’s a difference between “school’s boring” and “I dread going to school and cry every Sunday night”. School may report changes in behaviour to the parents for example being withdrawn, unfocussed, aggressive or overt sexualised behaviours.

Previous attendance – This helps identify issues such as poor medication compliance, lack of appropriate supervision or patterns of abuse.

Other important areas to consider include:

Mechanism of injury – You should enquire in detail about the mechanism of any physical injury. You need to assess whether the story matches the injury and is plausible. You need to record this history in a way that another healthcare professional can read your notes and watch a mental replay of the event so that they can assess if there are any further concerns.

Domestic violence – Any history of domestic violence in the home puts children at risk, witnessing domestic violence has a harmful lasting effect on children.

Relationships – Romantic in teenagers or friendships in younger children. Are the relationships age-appropriate? Does the relationship expose the child to additional risks?

Drugs/alcohol – You may want to ask teenagers if they are using drugs/alcohol when their parent/carer are not present. Consider if younger children are being exposed to adults abusing substances as this increases their risk of abuse and neglect.

Suicidal ideation – Relevant in psychiatric histories, injuries that you suspect may be self-inflicted and young people with a known history of self-harm.

Friendships – This can be a major source of stress for children and young people. Friendships can expose children to new risk factors such as abusive adults in other households.

Supervision – Is the child being suitably supervised? Different levels of supervision are appropriate for different age groups.

How should we approach assessing safeguarding concerns with children?

Child-led – When possible, it’s great to make all paediatric histories child-led. A child-led history allows us to get accurate information from the affected person and other sources of information, such as parents and carers, may have biases or blind spots. It is particularly important in safeguarding to give the child control of the interaction so that they can go at their own pace when discussing difficult topics. The experience of trauma or abuse takes away control from children and it is important to give them control here in order to form a trusting relationship.

Open questions – You want to avoid asking leading questions and let children express themselves in their own words. Children do not tend to lie about abuse or neglect but can easily be led to agree with inaccurate statements particularly when they are scared or overwhelmed.

Non-judgemental – Children who have been abused need to know that what has happened to them does not change how you see them, or they may not want to open up to you or anyone else further. Parents and carers need to see you as understanding so that they feel comfortable seeking and accepting your help.

Casual/routine – You do not want your questions to come across as accusatory or alarming. You can make children and their parents/carers defensive, overwhelmed, and damage your therapeutic relationship if you approach history taking in the wrong way. If you can put the child and their parent/carer at ease then you will likely get better quality information and be better positioned to offer help and advice.

Every encounter – Screening for safeguarding concerns should be performed every time you assess a child or young person. This ensures issues are not missed and that we do not fail to intervene and get children help as early as possible.

Your Responsibilities

  1. Document fully and accurately. Explicitly state if you have concerns or not.
  2. Escalate to a senior and don’t be afraid to get a second opinion from a more experienced colleague.
  3. Fill out the forms for information sharing / MASH (multi-agency safeguarding hub) referral / MARF (multi-agency referral form) etc straight away.

Resources

Written by Dr James Mackintosh (FY1)
Reviewed by Vicky Patterson (Safeguarding Paediatric Liaison Nurse)

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