In England and Wales, the rate of domestic abuse of women varies by age, being most common in the 16- to 19-year-old group where 10% of women will experience domestic abuse in a 3-year period. This rate drops to 6% by the time UK women fall in the 55- to 59-year-old group. This abuse includes any controlling, coercive, or threatening behaviour, or violence between family members or intimate partners aged 16 or over.1
As a result of domestic abuse, it is estimated that in 2017 there were 13 414 women supported by refuge services in England. They were accompanied by an estimated 14 353 children.2 The majority of refuge residents have been forced to move from a different local authority area in order to escape the abuse, with 10 161 such journeys across local authority boundaries being made in 2008–2009.3
The health needs of the children in refuges are a product of the domestic abuse that they have been exposed to, and of being forced into geographical displacement.
DOMESTIC ABUSE AND CHILD HEALTH
Children exposed to domestic abuse face a number of health challenges: their development is globally affected, their mental health is put at risk, they face an increased risk of vaccine-preventable infections, and there are barriers to secondary care access to overcome.
Exposure to domestic abuse in the first 6 years of life has been shown to double the risk of delayed language and social development. It also triples the risk of delayed gross-motor development.4 Children in refuges have been shown to have higher rates of mental illness compared with baseline; one study of children in a refuge in Cardiff put the rate of mental illness at 48% compared with a baseline rate of 10–28%.5
These children also have reduced rates of immunisation. The Cardiff study found that only 70% had a complete vaccination history, far below the 90–95% required to provide herd immunity against diseases such as measles.5,6 No research exists that examines the impact of geographical relocation on the health of these children, but parallels can be drawn between them and children with parents in the Armed Forces, who often move region at short notice. It has been shown that Armed Forces children are at risk of having their secondary care access interrupted, with GPs advised to ensure their care is transferred appropriately.7 The same inequality in secondary care access is likely to affect children in refuges, given that most have moved to a different local authority to enter the refuge.
The health inequalities faced by these children are stark, but GPs are ideally placed at the healthcare front line to tackle them, yet barriers exist to this happening.
BARRIERS TO AND SOLUTIONS FOR ACHIEVING HEALTH EQUALITY
Children in these situations can be difficult to identify, GPs have concerns around documentation of domestic abuse, and there is a lack of guidelines for their management.
By being aware of refuges in their area, practices can identify patients at registration, or by collaborating with refuge staff, and ensure that parents are encouraged to divulge the information and seek additional GP support for their children.
Once identified, the next challenge is in documenting this. UK GPs have expressed concerns that by documenting exposure to domestic abuse they may place a child at increased risk should their parent access their medical notes.8 However, they should remember that the GMC states that we must ‘record concerns, including minor ones, in the child’s or young person’s records’.9 If done using Read codes, such as ‘at risk of domestic abuse’, all clinicians become aware of a child’s vulnerable status and the coding should move with the patient if they change practice.
The RCGP has produced guidance for the management of a number of marginalised groups, including travellers, sex workers, and the homeless, but none exists for this group.10 This leaves it up to practices to implement their own auditable protocols for these children, which could include: ensuring they all have an appropriate Read code in their electronic medical record, an assessment of vaccination status with a catch-up service, GP assessment of the child’s development, and assessment and facilitation of ongoing secondary care needs.
CONCLUSION
If the barriers described here can be overcome and locally appropriate services to support them are implemented, GPs have the opportunity to make a significant difference to the health of these vulnerable and isolated children during the time they are registered with a practice.
- © British Journal of General Practice 2019