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Child protection guidance needs to address parent behaviour.

Dear editor, NICE guidance, ‘When to suspect child maltreatment’, highlighted how child maltreatment, particularly the chronic forms of neglect and emotional abuse, can be recognized through parenting styles or potentially harmful parent–child interactions (National Collaborating Centre for Women’s and Children’s Health 2009). We determined how often parent behaviour (e.g. disregard of a child’s needs, aggression towards family members, parental mental health affecting child’s care), or need for parent support (emotional support or welfare – such as housing or immigration status), was the main reason for discussing a child at our weekly multidisciplinary psychosocial meeting. The meeting helps to co-ordinate sharing of information and decision making between paediatric, mental health and social care services for children admitted to the paediatric ward. Any child in whom maltreatment is considered is discussed, as are children with mental health and social welfare problems, children who have recently died, and children whose parents need additional psychosocial or welfare support. Most cases are on a spectrum of safeguarding concerns (at risk of harm or impairment) (Department for Education 2010). We prospectively audited all children discussed over 3 months (12 meetings).Paediatric trainees prospectively recorded reasons for discussion and main presentation on proformas (available from authors) for all children discussed and two of us (BK, RG) used these data to independently classify the main reason for discussion (Table 1) and the main reason for admission to hospital (injury or other). The audit, based on anonymized records, was designed to inform delivery of care. No consent was sought from patients or parents. To avoid disclosure, we do not report cell sizes less than five. Sixty-four children were discussed 94 times, of whom five had died (an estimated 14.3% of all 1900 admissions each year). Nearly one-third (31%) of children were discussed because of concerns about maltreatment or assault by a peer (one case; Table 1). Three quarters of the possible maltreatment cases presented with medical problems (15/20): non-accidental injury was uncommon. A large proportion of cases were discussed because of concerns about potentially harmful parental behaviour (17%) or the need for parental support (22%): in total, 39% of cases were discussed because of concerns about the parents. One-fifth of cases were discussed primarily because of the child’s mental health problems, although many also raised safeguarding concerns. Half of the children with mental health problems had been admitted for injury, mostly self-harm. However, contrary to much guidance on recognizing child maltreatment, only a minority of concerns were prompted by children with injuries. This audit highlights the importance of child health professionals observing and assessing parental behaviour and parent–child interaction for early indicators of safeguarding concerns. As the government acknowledged in their response to the Munro Review (Department for Education 2011), guidance is needed on how health services for adults and children could intervene early on to support families where parental behaviour, particularly poor mental health, domestic violence and substance misuse, places the child at risk of potential harm.