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© Borgis - Postępy Nauk Medycznych 6/2016, s. 424-428
Piotr Hartmann1, 2, *Teresa Jackowska1, 2
The algorithm for dealing with suspected domestic violence against children – practical recommendations**
Algorytm postępowania w przypadku podejrzenia przemocy w rodzinie wobec dzieci – praktyczne wskazówki
1Department of Pediatrics, Centre of Postgraduate Medical Education, Warsaw
Head of Department: prof. Teresa Jackowska, MD, PhD
2Department of Pediatrics, Father Jerzy Popiełuszko “Bielański” Hospital, Independent Public Health Care Institution in Warsaw
Head of Department: prof. Teresa Jackowska, MD, PhD
Streszczenie
Problem krzywdzenia dzieci i zagrożenia z tego wynikające są często niedoceniane przez pracowników ochrony zdrowia, którzy w wielu przypadkach mogą być pierwszymi, a często również jedynymi osobami, które uzyskały informacje o przemocy w rodzinie. Od wybranej metody postępowania może zależeć dalsze zdrowie i życie dziecka doświadczającego przemocy. Eksperci z zakresu przeciwdziałania przemocy w rodzinie wspólnie ze stowarzyszeniem „Niebieska Linia” opracowali algorytmy postępowania dla pracowników ochrony zdrowia, które mogą być przydatne w pracy. Proponowane algorytmy mają służyć poprawie kompetencji i skuteczności podejmowanych działań.
W większości przypadków sygnały świadczące o krzywdzeniu dziecka są pośrednie i wymagają właściwego różnicowania. W ocenie możliwości zagrożenia dziecka przemocą w rodzinie można posłużyć się opracowanymi czynnikami ryzyka. Stwierdzenie ich występowania powinno spowodować uwzględnienie w diagnostyce różnicowej możliwości występowania przemocy w rodzinie.
Algorytm postępowania w przypadku podejrzenia przemocy w rodzinie ułatwia zastosowanie skutecznej interwencji poprzez określenie kolejnych etapów postępowania, w tym o konieczności podjęcia działań prawnych, takich jak zawiadomienie Sądu Rodzinnego, prokuratury i/lub policji oraz wszczęcia procedury Niebieskiej Karty.
W pracy przedstawiono przykłady praktycznego wykorzystania algorytmu postępowania na podstawie dwóch hipotetycznych sytuacji.
Summary
The problems of child abuse and threats arising from it are often underestimated by health care staff, who in many cases are the first and only persons informed about domestic violence. The chosen mode of proceeding may affect the health and further life of the abused child. Experts in the field of domestic violence prevention, alongside with the “Niebieska Linia” [The Blue Line] association, have developed algorithms for healthcare staff that may be useful at their work. The proposed algorithms are designed to improve the competences and effectiveness of the interventions.
In most cases the signs of child abuse are indirect and require proper differentiation. To assess the risk of violence against the child in the family, health care staff may consider the risk factors developed here. If the occurrence of these factors is confirmed, such information should be reflected in the differential diagnosis, and the diagnosis should include the possible occurrence of domestic violence. The algorithm for dealing with suspected domestic violence facilitates selecting the most effective intervention by defining the next steps of the proceedings, including the need to take legal action, such as notifying the Family Court, the prosecutor’s office and/or the police, and the initiation of the “Niebieska Karta” [Blue Card] procedure. The paper presents examples of using the algorithm of procedures in practice, based on two hypothetical cases of family violence.
Introduction
The role of the health care staff in diagnosing and preventing domestic violence is very important. After the Regulation of the Council of Ministers on the procedures of the “Niebieska Karta” [Blue Card] and the “Niebieska Karta” questionnaire forms came into force on 13 September 2011 (Journal of Laws No 209 pos. 1245), the health care staff became included in the proceedings of the “Niebieska Karta” procedures. However, data on the initiation of the procedure by the representatives of the institutions listed in the Regulation indicate that the participation of the health care staff in initiating the procedures is minor. In 2012, in Warsaw, out of the 1761 “Niebieska Karta” cards processed by the “Interdisciplinary Teams”, only 36 (2.0%) were filled in by a health care staff representative. In 2013 it was 43 out of 2393 cards (1.8%), and in 2014 it was 52 out of 2466 cards (2.1%) (own data based on the records of the Office of Social Assistance and Projects, City of Warsaw). Taking into account the whole country, in 2013 the Teams received 73 119 applications, out of which health care staff filled out 619 (0.85%) forms (1).
The doctor may be the first, and often also the only person who finds out about the possible occurrence of family violence. Regardless of the circumstances, it must always be assumed that child abuse has not been revealed before.
The lack of interventions in the cases of suspected domestic violence against the child may be caused by two major reasons:
– not taking into account a potential case of child abuse in the differential diagnosis,
– the lack of knowledge on the possibilities of providing assistance and further proceedings.
To meet the need of developing the competences of health care staff regarding the identification and prevention of family violence, the Ogólnopolskie Pogotowie dla Ofiar Przemocy w Rodzinie “Niebieska Linia” [Polish Emergency Center for Victims of Family Violence “Blue Line”] launched a project “Algorithms of dealing with cases of family violence” in May 2014, aimed to develop an algorithm of actions in the cases of a suspected family violence and carry out a pilot study among health care staff and education specialists on the usefulness of this tool. On 27 May 2015 the final version of the proposed algorithms was presented.
The paper discusses the possibilities of using the “Proposed algorithm of dealing with cases of suspected domestic violence against the child” in practice.
Assessing the risk of a potential occurrence of domestic violence
The form includes risk factors of the occurrence of domestic violence against the child. They are divided into: data from the medical history, observation of the child and the physical examination. The occurrence of risk factors should signal a potential occurrence of family violence in the differential diagnosis. Observing the occurrence of risk factors does not explicitly confirm the occurrence of domestic violence, but it calls for considering such diagnosis. Moreover, persons who take care of the child, within their own competences, may suggest suspected domestic violence even without the occurrence of risk factors. The last part of the form contains symptoms that indicate an alarming state and serves to assess the direct risk concerning the occurrence of domestic violence. It may also be used to assess the necessity to provide the child safety by taking immediate action, such as notifying the police or Prosecutor’s Office, taking the child away from the family or hospitalization.
Algorithm of actions
The proposal presented here allows selecting the procedure of actions in the case of suspected family violence. The suspicion may be based on the results of the questionnaire, but it may also be a result of one’s own observations or information from the child or another person. The algorithm facilitates a successful intervention, by defining the subsequent steps to take. However, the patients’ well-being and providing them proper medical assistance should always be a priority.
The recommended procedures of actions assume that the medical staff member possesses basic knowledge on the diagnosis and procedures in the case of child abuse. However, due to the doubts reported by the users of the preliminary versions of the algorithms, an additional leaflet was created that presents the phenomenon of violence and the possibilities of providing effective assistance (2).
Information in the above materials is consistent with other publications concerning this issue that have appeared to date (3).
Examples using the algorithm of proceedings in practice, as exemplified by two hypothetical cases
Case 1
A 14-year old girl was brought to hospital by ambulance. She was found in the park nearby and had impaired consciousness. The emergency service was called by a passer-by. It was not clear if the girl had been accompanied by other persons, because she was alone when the ambulance arrived.
At the admittance to hospital she was in the state of mental confusion, had a balance disorder, and her speech was unclear. It was possible to smell alcohol from her. In the physical examination several linear scars and fresh cuts on the thighs were found, otherwise no additional dysfunctions. Laboratory tests confirmed the presence of ethanol in the blood. Urine tests for drugs were performed, with a negative result. The parents, notified by the police, arrived immediately at the hospital, were very nervous and anxious about the state of the child. The girl, however, refused to talk to them and was insulting them. They left the patients’ room, but the mother stayed for the night at the hospital, anxious about the child.
In a conversation with the doctor on duty the patient said she was afraid of her parents’ reaction and mentioned a “spanking” she was sure to get at home. She had older siblings (sister, 23, and brother, 25) who did not live at home anymore, but received financial support from the parents. The patient was a good student, not causing any problems at school so far. The parents, when asked about her hobbies, were not consistent, and also not certain as to what extracurricular activities their daughter attended.
In a conversation with the girl it turned out that she did not attend any extracurricular activities at that moment, rather spending her free time playing computer games. She did not have many friends, as she did not fit into any peer group and felt disliked in the class. The psychological consultation revealed that she had been cutting her thighs for about 2 years, and that pain provided her ease in difficult situations. She did not want to answer questions on physical violence at home. The girl’s depressive mood was evident. Her parents did not notice any self-harming or changes in their daughter’s behaviour. The psychological consultation confirmed distorted family relations and a lack of communication between the parents and the child. The parents asked for advice how to behave in the future, expressing a concern that similar incidents may repeat. After 4 days of hospitalization, the girl was discharged from hospital.
Case 2
A 4-year old boy was admitted to hospital due to shortness of breath in a respiratory tract infection. After the administration of inhaled drug therapy the symptoms gradually started disappearing, but on the 3rd day a fever appeared and a chest x-ray was performed. Apart from small peribronchial thickening, the results included periosteal apposition in the area of the 7th, 5th and 6th rib in both lungs and in the area of the 7th rib on the left side. The mother denied any injuries in the child. The father informed that a year before, during a fast bike ride, the child hit a wall with great force, and that they had a surgical consultation at a hospital, where they did not receive any recommendations. When asked to bring the hospital information card, the parents “remembered” that the child was only consulted by an outpatient clinic physician and they do not have any documentation of that fact.
Due to the subsequent questions on the post-traumatic changes observed, on the 7th day of hospitalisation the parents made a complaint at the head of the ward, claiming that “the doctor deals with old injuries instead of treating the present disease”. On the following day they demanded a discharge from hospital and they did not consent to further treatment. They also did not agree to consult a psychologist. The doctor responsible for the treatment refused to discharge the child due to the persistent shortness of breath in the child and the need to apply medicines and oxygen therapy. The child’s father started behaving aggressively towards the staff, removed the child’s cannula himself, and started packing its things with the intention of leaving the ward...
Specific aspects of working with a child who experienced domestic violence
Children are especially prone to be victims of domestic violence. Their position of dependence on the perpetrator(s), alongside with strong emotional bonds, cause that in many cases the statement of child abuse by its parents is very difficult.
A disclosure or suspicion of family violence usually occurs when the child has contact with a health care staff member due to a sudden disease or the necessity to perform prophylactic examinations. In a conversation with the child, one has to take into consideration its age, level of development and emotional sensitivity. Such conversation must be carried out in a safe place that allows freedom of movement. It is necessary to create an atmosphere of trust, assure about the possibility of actual help and express an understanding for the child’s lack of knowledge. During the conversation it is recommended to use examples and ensure the child that the situation will change for the better. One should avoid giving empty promises, asking closed questions and questions that suggest a specific answer. The conversation should be carried out only until necessary information is collected, but it should not be interrupted if the child wishes to continue speaking.
It is also important to have a conversation with the parents. Considering the fact that in most cased child abuse results from the lack of parenting skills or following unfavorable patterns, the aim of our activity should be improving the functioning of the family and discontinuation of using violence. Contrary to what might be expected, in most cases parents cooperate willingly, if only they are not “attacked” by accusations or a clearly negative judgment of them as persons.
In a conversation with the parents, one should indicate the unfavorable behaviors, simultaneously pointing to the possibilities of changing them. It is also important to explain the procedure of the “Niebieska Karta” (if we decide to apply it) and not to provoke conflict situations, and thus not to terminate the possibility of cooperating with the parents already at the initial stage of the procedure.
It is not always required to take legal action against the parents if a suspicion of family violence occurs, however, in the situation when they definitely lack any will to cooperate, especially when they start harming the child, it is necessary to act with determination in order to provide safety for the patient.
Discussion of the described cases
Case 1
Analysing the data from the medical history and the physical examination it was possible to observe such risk factors as:
– inconsistencies in the history of the parents and the child, due to the lack of interest,
– signs of self-mutilation (self-harm, autodestructive behaviours),
– the child’s fear of going back home,
– low self-esteem.
Another alarming symptom that was observed concerned the child’s fear of physical punishment after returning home. The parents were willing to accept the advice and recommendations concerning further actions and contacted the school psychologist already during the hospitalisation, which is a positive sign. In this case, there was no reason to state a direct threat of the child. However, the need of further contact and monitoring of the family was pointed to, and thus the procedure of the “Niebieska Karta” [Blue Card] was initiated. The girl’s parents were informed about this fact.
As an effect of the initiated procedure, a work group was called that included employees of the Social Assistance Office, the local police officer, the doctor responsible for the treatment, the psychologist from the hospital ward, and also the class teacher from the present school (“gimnazjum” – junior high school), as well as the class teacher from the girl’s previous school were invited to the team. A few conversations with the parents were carried out, motivating them to participate in family therapy. The girl received psychological assistance at the school and at the psychological centre.
Case 2
In the case of this patient it was necessary to take immediate action. Because the father’s behaviour caused a threat to the child’s health and life, the police was notified. Simultaneously, attempts were made to speak to the parents. The child’s mother did not answer any questions; she was only sitting in the hall and observing her husband. The police arrived when the child was being carried out of the hospital room by the father. Seeing the police officers, the father’s aggression escalated, which caused that he was detained and taken out of the hospital. The child’s mother gave consent to the child’s further hospitalisation. A psychological consultation revealed domestic violence that had been taking place for a few years and was experienced by both the mother as well as the child. Within the previous year, violence against the child had taken place several times.
The doctor responsible for the treatment initiated the procedure of the “Niebieska Karta” [Blue Card]. At the same time, he filed a report of an offence to the Prosecutor’s Office. He also submitted a request to the Family Court to examine the child’s situation.
The work group was called already while the child was being hospitalised. The group included employees of the Social Assistance Office, the local police officer, the doctor responsible for the treatment, a probation officer and a psychologist from the family counselling centre. Based on the data collected, the Interdisciplinary Team also filed a report of an offence, alongside with a request to take preventive measures.
Due to the father’s lack of previous criminal record, the prosecutor did not order a detention, but to leave the house (flat) and prohibited approaching the mother and the child. The supervision on the compliance with the decisions of the court was to be carried out by a probation officer. After the hospital stay, the boy was discharged, under the care of his mother.
“Niebieska Karta” [Blue Card] Procedure
Initiating the procedure of the “Niebieska Karta” may only take place in the case when health care staff members suspect family violence while performing their professional duties. In the case of children, initiating the procedure may take place in the presence of the parent who does not harm the child or in the presence of another person who is close to the child, including the actual guardian. The lack of possibility to establish contact with the person suspected of being a victim of family violence or with his or her guardian does not prevent the initiation of the procedure.
The form is completed according to the instructions it contains, providing comprehensive information and answers to the questions. Due to the way the form is structured, certain spaces may remain empty, and at the end of the form there is space for adding information that is important, but was not included in the form. It is recommended to complete the patient’s data (date of birth, age) and provide contact to the person completing the form (telephone number, email – at the end of the form).
The form, once it is signed, is then sent, while a copy remains with the files of the person initiating the procedure. The “Niebieska Karta” [Blue Card] Form is not a medical document and its copy should be stored according to the procedures established for the given health institution. This is extremely important, because this way we avoid access to the files by the abuser, who otherwise is entitled to have access to the medical documentation.
The original form should be sent to the head of the proper Interdisciplinary Team in the area where the victim lives, within 7 days of completing it. The address of the Interdisciplinary Team is the address of the appropriate Social Assistance Office, according to victim’s the place of residence. The form is sent in a sealed envelope, addressed “to the Head of The Interdisciplinary Team”. Also, a clear sign “Niebieska Karta” should be placed on the envelope in order to avoid access of unauthorized persons. The form called “Niebieska Karta B” [Blue Card B] is given to the parent, legal guardian or actual guardian who is not suspected of family violence (provided such person exists).
After initiating the procedure, it is necessary to provide security for the child who experienced violence by safeguarding the evidence (especially any medical records), informing the child (taking into account its age) on the possible forms of assistance, providing safety and intimacy (especially when collecting the history and other evidence on family violence), notifying the law enforcement institutions, and psychological help. Initiating the procedure does not mean excluding other activities, such as notifying the Family Court, the police and the Prosecutor’s Office. An ongoing criminal investigation does not cease any activities related to the “Niebieska Karta” procedure, also after the investigation finishes, and regardless of its result.
Conclusions
The basic and ultimate goal of the procedure described here is to stop violence, achieved through improving the functioning of the family, by affecting its individual members. Thanks to the option of interdisciplinary cooperation it is possible to analyse the given situation precisely and to provide complex assistance activities. Penal measures may (but need not be) a tool serving to carry out the aim of the procedure.
It must be remembered that the proposed questionnaire form and the algorithm of activities do not cover all the possibilities for the activity of a representative of health care staff in the case of suspected family violence. Nevertheless, the most important task always remains to rescue the life and health of the child. Taking legal action may in this case be postponed until the patient’s state is stable.
In order to develop the competences of health care staff regarding the prevention of family violence, it is necessary to carry out regular educational activities.

**Supported by the Centre of Postgraduate Medical Education in Warsaw grant number 501-1-20-19-16. Grant Foundation for the Development of Pediatrics
Piśmiennictwo
1. Ministerstwo Pracy i Polityki Społecznej „Sprawozdanie z realizacji krajowego programu przeciwdziałania przemocy w rodzinie” od 1 stycznia do 31 grudnia 2013 r.
2. Materiały Ogólnopolskiego Pogotowia dla Ofiar Przemocy w Rodzinie „Niebieska Linia” IPSPTP opracowane w ramach projektu „Algorytmy działania w przypadkach przemocy w rodzinie”; https://www.niebieskalinia.pl/algorytmy/.
3. Hartmann P, Jackowska T: Postępowanie medyczno-prawne w przypadku podejrzenia występowania przemocy w rodzinie. Postępy Nauk Medycznych 2014; 27(10B): 28-32.
otrzymano: 2016-05-04
zaakceptowano do druku: 2016-05-25

Adres do korespondencji:
*Teresa Jackowska
Department of Pediatrics Centre of Postgraduate Medical Education
ul. Marymoncka 99/103, 01-813 Warszawa
tel. +48 (22) 864-11-67
tjackowska@cmkp.edu.pl

Postępy Nauk Medycznych 6/2016
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