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At-risk child: a nurse's dilemma

Janet Webb
BSc(Hons) RGN DipN(Lond)
Practice Nurse
Lindum Medical Practice

One morning in telephone triage I spoke to an angry man - the divorced single parent of 10-year-old Sally-Jo. He was angry because of her bedwetting, which he said made their flat smell, caused his recent relationship to end and his partner to move out. He felt nobody cared about his plight and swore loudly and aggressively.
According to Sally-Jo's notes, the doctor had seen her for her enuresis. Urinalysis had been normal and she had been referred to the paediatrician, who had diagnosed constipation, prescribed an aperient, discussed bladder training and intended to arrange for a bedwetting alarm. The alarm had never arrived; her father denied having been advised and repeated that nobody was interested in the stress it was causing, going on to say the only way he could manage it was to hold Sally-Jo up against a wall and threaten to spank her.
I wondered whether this was factual or a figure of speech, so repeated his words back to him for clarification. He confirmed he had meant it, adding that he could chastise his child as he saw fit, and I had no right to interfere. Threats, criticism, negative attitudes and harsh discipline, however, could constitute emotional abuse under the Children Act (1989).(1)
I wondered about the onset of enuresis; the fact that it was blamed for the relationship breakdown and the aggression in her father's description were concerning. His cry for help could signify warning of a crisis - what Reder and Duncan term "a covert admission that abuse was critically escalating".(2) They continue: "... five out of 10 physically abusing parents had seen a doctor immediately preceding the assault, including to complain about the child's behaviour and to seek help in management." They described crisis developing from stress such as a relationship breakup, intensified by behaviour - for example, enuresis - in the child, which demanded the parents' attention while being beyond their control, as a "conflict of control". Abusing parents tend to be lonely, unhappy, angry and stressed, provoked by "offensive behaviour" such as wetting, and intensified by physical exhaustion and family crisis, such as marital strife.(3)
I told Sally-Jo's father that I was concerned about what he had told me and intended not only to help but to record and act upon my concern to prevent harm. He became angrier, and as I did not want to alienate him and deter further contact, I quickly added that he had been right to request help, he clearly needed help and I would do my best to facilitate it. I gave him a doctor's appointment and promised to chase up the bedwetting alarm and refer Sally-Jo to a local nurse-run enuresis clinic. I rang him back to confirm a delivery date for the alarm and inform him that I had made the referral.
Following the local Child Protection policy, I then notified Social Services of my concerns and completed the necessary form. This involved examining the Child Protection Register - a record of unresolved child protection issues - which informed me that the police had been called to an incident of domestic violence the week before at Sally-Jo's address. Any concerns relating to child protection should involve contact with this register; three separate contacts (ie, concerns) automatically generate follow-up from social services.
They attended the doctor's appointment; no abnormality was found with Sally-Jo, but her father was considered to be very stressed. Social Services contacted me later that week to report on their visit generated by my formal notification of a child in need of care. They found no cause for concern, but relayed the father's message that I would be hearing from his solicitor.
They did not attend the enuresis clinic. I telephoned to ask how things were; the appointment had not been convenient but the alarm had arrived and seemed to be helping. I told him I would arrange another appointment. I did, but again they did not attend. I did not hear from the solicitor.
Local guidelines state that concern, suspicion or knowledge of abuse should always lead to action; the Working Together document stresses the importance of sharing concerns among professionals.(4) I telephoned the school nurse and Sally-Jo's headmaster, who shared some of my concerns. We all agreed to remain vigilant.
It can be difficult to report concerns while keeping channels of communication and service provision open, as well as avoiding harassment from a stressed parent struggling to cope. Maintaining a child-centred focus is key in detecting cases of abuse, and even the smallest doubts are worth reporting and following up on. Sometimes it's better to be wrong.


  1. The Children Act 1989. Available from:
  2. Reder P. Lost innocents. London: Routledge; 1999:130.
  3. Schmitt BD. Abuse and neglect of children. In: Behrman RE, editor. Nelson textbook of paediatrics. 14th ed. Philadelphia: Saunders; 1992.
  4. DH. Working together under the Children Act 1989. London: HMSO; 1991.

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