A key theme throughout this child public health series is the opportune and unique position paramedics have within the community to encounter children in their natural environments. Not only does this facilitate screening and opportunities to promote healthy behaviour, but also the identification of those children who are vulnerable to risk of abuse and neglect. As clinicians, paramedics are well versed in advocating and protecting the rights of children. Recently, the competency of paramedics has been raised to a safeguarding of level 3, as established in an interdisciplinary document produced by the Royal College of Nursing (RCN) (2019):
‘Clinical staff working with children, young people and/or their parents/carers and/or any adult who could pose a risk to children and who could potentially contribute to assessing, planning, intervening and/or evaluating the needs of a child or young person and/or parenting capacity (regardless of whether there have been previously identified child protection/safeguarding concerns or not’
Certainly, the last decade has seen the government prioritise child protection, enforcing agencies including ambulance and primary care services to provide requisite training to anyone who encounters children (HM Government, 2018), where health professionals are expected to adhere to National Institute for Health and Care Excellence (NICE) (2017) and professional guidelines (Brown et al, 2019) in recognising and interpreting the signs of abuse and neglect. Yet, despite the government's efforts to increase awareness to safeguard children, it may come as a surprise that abuse and neglect continue to rise in the UK (Raff and Brown, 2017). This begs the question: why? Is the UK failing in protecting vulnerable children? Or paradoxically, is the UK improving recognition of a child's vulnerability, and therefore increasingly reporting protection concerns?
Unfortunately, the answers to these questions are beyond the scope of this article. Nevertheless, the focus of the final part of this series on child public health explores where paramedics reside within the bigger picture of child protection.
Revisiting child rights
In the UK, the Children Act 1989 and 2004 and the Children and Social Work Act 2017 make up the primary legislation that guides parents and local authorities in child welfare. Largely derived from the United Nations Convention on the Rights of Children (UNICEF, 1989), the key principles to uphold are:
In a perfect society, no child would be excluded from these principles and, certainly in the UK, families have the liberty to raise their child as they wish so long as the principles are upheld. Sadly though, some children remain vulnerable or invisible to social workers and health professionals until it is too late. The tragedies of Victoria Climbie (which spurred the Laming Report, 2003 and subsequent Children Act 2004), Peter Connelley (Baby P), and Daniel Pelka are landmark examples which gained public attention, though many further cases continue to be reviewed annually, which perhaps ought to be of public concern, are omitted from view (see https://learning.nspcc.org.uk/case-reviews for further examples). The hindsight nature of these cases often makes it easy to identify specific root causes. However, prospectively recognising children at risk is difficult, often requiring a multidisciplinary approach.
Families are becoming increasingly complex and diverse. Examples include separated parents, the father as primary caregiver, same-sex couples, and variations in cultural beliefs (Walsh and Mason, 2018). Certainly from a paramedic perspective, the child may be encountered in a non-familial setting such as at school, in the consultation room, or with non-nuclear family members. This illustrates some of the potential difficulties in identifying family and environmental factors, and the level of parental capacity that influences a child's wellbeing (Blair et al, 2010).
Further, the ability of paramedics in the UK to recognise a child in need is poorly understood. Of the limited evidence, Brady (2018) noted that UK paramedics were not confident in identifying sexual abuse, attributed to a lack of knowledge and concern that the hidden nature of sexual abuse would make it difficult to identify.
Moreover, there is an argument that when a paramedic (on an ambulance) enters an incident with a child, there has been a systemic failure to protect the child's health status. Examples include:
The difficulty is weighing up when further support or investigation is required, or whether educational advice would be sufficient.
The continuum of need
A useful tool being adopted by local authorities is the continuum of need assessment (see Figure 1). The tool provides a brief outline enabling individuals to identify where children are positioned within their stage of development, environment and family, and adopt a stepwise approach to address level of needs to ensure a child is protected and supported throughout their formative years. A particularly useful aspect of the tool is that it enables the individual to review whether the child and family's needs are met, increasing in demand, and what further steps may need to be taken.
At the far left are the universal services such as the provision of education and healthcare. Children with additional needs may require additional services, and from an acute perspective, the day-to-day of ambulance and primary care paramedic work largely sits within this stage, predominantly providing health advice, reviewing any development concerns such as diet, height and weight (primary care), and initiating care plans in order to avoid adverse consequences. Children with multiple needs will be complex, requiring a multidisciplinary approach. The final stage is for the vulnerable children, requiring immediate specialist support such as those affected by abuse and neglect—something which paramedics also encounter.
Although the tool is not currently adopted within ambulance services, it could be a useful framework to incorporate into child assessments, particularly where multiple callouts occur for one child indicating that there may be an unmet need. In contrast, there is also little evidence to indicate whether the tool improves recognition of children's needs, or whether clinician judgement alone is sufficient. Research, therefore, ought to explore whether the use of a tool in conjunction with paramedic judgement may improve the identification of vulnerable children.
Conclusion
Paramedics are highly trained in identifying vulnerable children and play a vital part in encountering and referring those that are hard to reach or who may be encountering public services for the first time. However, little is known regarding whether paramedics are effective at identifying children in need and, at the public health level, more is required to ensure that every child is afforded a safe and thriving childhood. Despite brief encounters, using tools such as the continuum of need, may help paramedics to visualise the level of need of a child and family, and whether this is increasing or decreasing in degree of concern. Indeed, this latter element is something that ambulance services should closely monitor.
Series conclusion
This series has introduced some core concepts in child public health and applied them to paramedic practice. Ideally, all three components of prevention, promotion and protection should be combined into a holistic assessment of the child's health status at the point of contact. Of course, in the critically unwell child, this may not be feasible; yet, it would be worth noting what circumstances led up to the child becoming unwell, and engaging in discussions with other health professionals and local authorities about whether there is a means to apply child public health frameworks that moves a step closer to developing a community where all children thrive.