The Child in Mind: A Child Protection Handbook 3rd Edition

THE CHILD IN MIND

All public sector workers in contact with children and families, both in health care and allied services, need access to clearly written information about what to do if they are concerned about the safety and welfare of a child. Ensuring the safety of children who are at risk of harm is not an easy undertaking. It is sometimes difficult to assess the significance of information about a child, to gauge its seriousness or decide what to do next. This handbook will help health service workers negotiate the complexities of child protection practice, with the aim of preventing abuse and neglect and protecting children from further harm once it has occurred. The text explains how the child protection process works. It covers all the key areas of child protection practice, including: risk assessment physical, sexual and emotional abuse neglect the child protection conference key changes in the legal framework and their application in practice. Clarifying a complex area of work, The Child in Mind provides sound advice aimed at improving individual practice. It is unique in that although it is directed to all health care workers, it can be used as part of in-service training, as a handy reference for students and indeed by anyone who works with children. Judy Barker has extensive experience working with child abuse and neglect. Her clinical expertise is drawn from many years in practice as a health visitor, child protection consultant and Designated Nurse for Child Protection in Inner London. Deborah Hodes is a consultant community paediatrician and Designated Doctor for Child Protection in Camden and University College London Hospital. She has a wide range of clinical, teaching and research experience in community and child health.

THE CHILD IN MIND A CHILD PROTECTION HANDBOOK Third edition

Judy Barker and Deborah Hodes

First published 2002 by City and Hackney Primary Care Trust Revised edition published 2004 by Routledge, reprinted 2005 and 2006 This edition published 2007 by Routledge 2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN Simultaneously published in the USA and Canada by Routledge 270 Madison Ave, New York, NY 10016, USA This edition published in the Taylor & Francis e-Library, 2007. “To purchase your own copy of this or any of Taylor & Francis or Routledge’s collection of thousands of eBooks please go to www.eBookstore.tandf.co.uk.” Routledge is an imprint of the Taylor & Francis Group, an informa business © 2007 Judy Barker and Deborah Hodes The right of Judy Barker and Deborah T. Hodes to be identified as the Authors of this work has been asserted by them in accordance with the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data Barker, Judy, 1949 June 14– The child in mind : a child protection handbook / Judy Barker and Deborah Hodes. – 3rd ed. p. cm. Includes bibliographical references and index. ISBN 978–0–415–42601–5 (hardback) – ISBN 978–0–415–42602–2 (pbk.) 1. Child welfare– Great Britain. 2. Abused children – Services for – Great Britain. 3. Abused children – Health risk assessment – Great Britain. 4. Child abuse – Great Britain – Prevention. I. Hodes, Deborah T. (Deborah Tamara), 1953– . II. Title. HV751.A6B35 2007 362.760941 – dc22 2007015928 ISBN 0-203-93387-7 Master e-book ISBN ISBN10: 0–415–42601–4 (hbk) ISBN10: 0–415–42602–2 (pbk) ISBN13: 978–0–415–42601–5 (hbk) ISBN13: 978–0–415–42602–2 (pbk)

To our children Daniel and Matthew Lydia, Emilio and Clara

Contents Foreword viii Acknowledgements ix Introduction 1 1

Safeguarding children 3

2

Partnership, collaboration and co-operation 9

3

Assessment of risk 14

4

Physical abuse 23

5

Sexual abuse 35

6

Neglect 44

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Emotional abuse 50

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Failure to thrive 56

9

Abuse of children with disabilities 61

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Parental non-engagement 67

11

The child protection conference 69

12

Records 78

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The legal framework 81 Appendix 1: The Common Assessment Framework 90 Appendix 2: The paediatric assessment 100 Suggested reading 108 Index 111

Foreword I am delighted, but not surprised, that the authors of this very practical book have been invited to take it into a third edition. It was important to bring up to date this most useful of handbooks as there have been so many changes in the legal framework governing child protection practice since the publication of the Victoria Climbié report. In addition to describing the changes introduced in a number of policy documents, notably Every Child Matters and Working Together to Safeguard Children, the authors have given advice on the use of the Common Assessment Framework and shown how the new legislation and government guidance can be applied in practice to support front line staff in responding to children at risk. Moreover, they have expanded on the different forms of abuse and deliberate harm. They have included new subjects such as the effects of domestic violence, parental mental illness and substance misuse as well as new material on how difficulties in the parent/child relationship can develop and lead to abuse and neglect. From the outset the authors have succeeded in presenting guidance on working with children and families in straightforward language. It is a great credit to them that their sole motivation is converting a wide range of specialist information about child abuse and neglect into everyday practical use. Their wish is to secure improvements in day-by-day practice and that shines through in this volume. Because of that it gives me great pleasure to commend it in the hope it will be widely read and used. The Lord Laming March 2007

Acknowledgements We thank Sue Dutch and Laura Sharpe for supporting the initial publication. We thank Elaine Merrin for her continuing support and many helpful suggestions. In particular, we acknowledge the work and contribution to our understanding of abuse and neglect of Danya Glaser, Chris Hobbs and David Howe. The acknowledged inspiration for the title of this handbook is A Child in Mind: Protection of Children in a Responsible Society, the report of the Commission of Inquiry into the circumstances surrounding the death of Kimberley Carlisle, first published by the London Borough of Greenwich in 1987.

Introduction

W

hether a nurse, doctor or allied health professional, manager or clerical worker, the contribution of health service workers to the protection of children is crucial. The well-being of children and in some cases a child’s life depends not only on professional vigilance and a willingness to consider the possibility of abuse but also on action taken in response to it. It depends on talking to the child, listening to what they say; sometimes believing things people think do not, could not or should not happen to children. The inquiry into the death of Victoria Climbié from abuse and neglect found the professional network failed to act on concerns about her safety and welfare. It said that there were many occasions when intervention could have saved her life. All these opportunities were lost, not because nobody suspected she was being abused but because nobody followed the most straightforward procedures in response to suspicions that she was being deliberately harmed. Ensuring the safety and promoting the welfare of children who are at risk of harm is not an easy undertaking. It is sometimes difficult to assess the significance of the information about a child, to gauge its seriousness and decide what to do next. It is easy to lose a sense of perspective and the focus on the child in an attempt to also take into account the needs of the parent/carer, family and professional network. In acknowledging this The Child in Mind is a guide on how to keep the focus on the child: how to keep the child in mind. Its practical approach aims to inform professional judgements about how best to safeguard the child within the context of their family and wider environment. It is not necessary to be an expert in paediatrics or child abuse to have concerns about a child but following child protection guidance once abuse is suspected is a requirement for everyone, managers and clinicians alike. The Child in Mind recognises that the protection of children is a responsibility that crosses all services and all hierarchies. It places equal value on each person’s contribution to the process of protecting children, and its guidance is designed to inform everyone working in the health

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service as well as workers in other agencies. None of the material is exclusive to any one agency or individual worker; for example, the reader may choose the degree of detail they feel they require in order to best understand physical or sexual abuse of children. Those working alongside doctors and who refer children to them may find information about the paediatric assessment helpful to an understanding of what doctors do and how they contribute to the child protection process. The Child in Mind provides a context for the Local Safeguarding Children Board (LSCB) procedures and the national framework for child protection practice, Working Together to Safeguard Children, and is designed to be used in conjunction with them and, indeed, other more detailed textbooks, reports and journals. Furthermore, it is intended to complement the arrangements for consultation, supervision and training that already exist in every health service trust.

1 Safeguarding children I

that between two and four children die every week as a consequence of abuse and/or neglect and many more suffer irreversible long-term effects. All these children will come into contact with health services at some point in their lives. A large proportion of child protection referrals are made by health service staff, and many of the services that make a difference to the quality of life for vulnerable children are provided by people working in a variety of services within the health service. Many of these workers will have information that may prove significant for children at risk. Health care workers have a distinct contribution to make to the protection of children – from the prevention of abuse to its identification, through monitoring the health and development of children who have been abused, to therapeutic intervention and the prevention of further abuse. Their role in the care of children and families is vital not only in preventing abuse but also to safeguarding vulnerable children once abuse has been identified. Health service staff working in all fields may at some time come into contact with children who are at risk of abuse and/or neglect; for example those involved in adult-focused services, such as mental health or drug and alcohol services, will be in contact with adults whose problems may adversely affect children in their care. The safeguarding of children is therefore integral to the provision of any health service. While some practitioners offer advice to families on how to promote health and prevent illness and disability, others deal with acutely ill children and families in crisis. Wherever they are working, health care workers are key to the prevention of child maltreatment and the early identification of abuse and neglect. T IS ESTIMATED

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WORKING TOGETHER TO SAFEGUARD CHILDREN The duty to safeguard and promote the safety and welfare of children and young people has been part of the legal framework governing child protection practice since the Children Act 1989. Following the inquiry into the death of Victoria Climbié which criticised the lack of attention given by public services to safeguarding children it became part of Every Child Matters, the government’s comprehensive programme of change for all children. The Children Act 2004 provides the legal underpinning for the Every Child Matters programme. It has added to the provisions of the 1989 act, placing a legal duty on all organisations that provide services for children and families, and this includes all health organisations, to work together to ensure that they: Protect children from maltreatment Prevent the impairment of children’s health and development Ensure that children grow up in circumstances consistent with the provision of safe and effective care Working Together to Safeguard Children (DfES, 2006) is the national guidance for safeguarding children and it applies to everyone working with children and families in England. It describes how organisations and individuals should work together to meet the statutory requirements of the Children Acts 1989 and 2004. It explains how the child protection process works, the responsibilities of professionals and the procedures to follow when there are concerns about a child. One of the principles of Working Together is that child protection practice should operate within a broader framework of safeguarding and promoting the welfare of children in general. This includes the welfare of children who are, for example, looked-after, disabled or suffer social exclusion. The guidance in Working Together sets out the national strategy for safeguarding children based on five outcomes that are considered to be essential to children’s well-being. These are: Staying safe Being healthy Enjoying and achieving Making a positive contribution Economic well-being

SAFEGUARDING

CHILDREN

In achieving these outcomes Working Together stresses the importance of an integrated multi-professional approach by all organisations and agencies to the assessment, planning, intervention and review processes for all vulnerable children. What To Do If You’re Worried a Child Is Being Abused (DfES, 2007) is a short guide initially written in response to the issues raised in the Victoria Climbié inquiry. It provides a condensed version of Working Together in the form of step-by-step action points and flow charts designed to help front line workers respond appropriately when they suspect abuse and neglect. DESIGNATED AND NAMED PROFESSIONALS The responsibility for child protection services in the health service lies with the Primary Care Trusts. They appoint a designated nurse and doctor (usually a senior nurse and a consultant paediatrician) to take the professional lead in all aspects of the health service contribution to safeguarding children. Designated professionals are responsible for ensuring that policies and procedures are in place and that there are adequate arrangements for consultation, supervision and training. They represent the health service on the Local Safeguarding Children Boards (LSCBs). In addition, all National Health Service (NHS) trusts must appoint a named doctor and a named nurse/midwife to take the professional lead on child protection matters within their respective trusts and service areas. They are the principal points of contact within health for child protection advice and paediatric opinion and can be consulted about the management of individual cases. In some areas one person will take on the responsibilities of both named and designated professionals in child protection. WHAT HEALTH SERVICE WORKERS CAN DO Anyone may come into contact with or hear about a child who is being harmed and/or an adult who is harming a child. This can happen anywhere and at any time. Whatever the circumstances, remember that safeguarding children is everyone’s responsibility. Inquiries into fatal child abuse show that the warning signs are frequently there and known to

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people both in the wider community as well as the professional network. These reports demonstrate time and time again how important it is that people know what to do if they are concerned about the safety and welfare of a child and how disastrous the outcome can be if they do not. Working Together to Safeguard Children sets out the parameters of good practice: Be alert to potential indicators of abuse or neglect Be alert to the risks that individual abusers, or potential abusers, may pose to children Share and help analyse information so that an assessment can be made of the child’s needs and circumstances Contribute to whatever actions are needed to safeguard and promote the child’s welfare Take part in regularly reviewing the outcomes for the child against specific plans Work co-operatively with parents unless this is inconsistent with ensuring the child’s safety Where abuse and neglect are suspected, assess the child’s current situation and needs. In the unlikely event that the child needs immediate protection or urgent medical attention, contact the local authority children’s social care (social services) and/or the police and emergency services. In all other cases: Discuss any concerns with the parent/carer unless it is inappropriate or unsafe to do so – in some circumstances it may place the child at greater risk Listen to the child and document their views and feelings Check the child/family record for any earlier or ongoing concerns Share information and consult other professionals who may know the child/family such as the social worker, general practitioner (GP), health visitor or teacher Seek advice if necessary from one of the named or designated professionals or other experienced colleague Document full details of the incident/circumstances and all action taken Decide whether or not to refer the child to children’s social care

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CHILDREN

If a decision is made to refer the child or family to children’s social care, do this in accordance with the LSCB procedures. Discuss concerns with the duty social worker and confirm the referral in writing. Record whether the referral has been discussed with the parent and, if not, why. Always follow up the outcome of any referral to establish that the concern has been understood and is being responded to appropriately. If there is a problem with the response of either children’s social care, the police or the National Society for the Prevention of Cruelty to Children (NSPCC), talk this over with one of the named or designated professionals. The local authority children’s social care service has the statutory responsibility for making enquiries into all child protection referrals and for co-ordinating the inter-agency response. All public sector workers have a duty to co-operate with any such enquiry and to provide any information relevant to it. As child protection enquiries often reveal other unmet needs, consider any measures taken to safeguard children as part of a wider-ranging assessment of their needs and family circumstances. This is the way to secure the best possible outcome for the child. Work with children and families cuts across the range of services and disciplines within the health service, in both hospital and community settings. Consider everyone therefore as part of a multi-disciplinary as well as a multi-agency team. Effective information sharing helps to ensure that all work with vulnerable children is properly co-ordinated. Remember, the more vulnerable the child the greater the number of services likely to be involved and the greater the importance of an integrated multiprofessional approach. Research and experience have shown repeatedly that it is only when information from a number of sources has been shared that it becomes clear that a child is at risk of harm or is being harmed. THE PAEDIATRIC ASSESSMENT A child may be referred for a paediatric assessment by a member of the primary health care team, another health professional and/or a professional from another agency, for example children’s social care or education. Knowing what a paediatrician does will help prepare the child and family for the assessment and what they can expect. Paediatricians can offer an opinion on the medical aspects of abuse and/ or neglect. Their expertise enables them to identify the signs of

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maltreatment in a child. The paediatric assessment is part of the jigsaw that makes up the whole picture; it adds to the information that is being accumulated from the child, family and professional network. Always ensure that the child is referred to a suitably qualified and experienced doctor in order to secure the best assessment available. The function of the paediatric assessment is to: Confirm the suspicion of non-accidental injury, neglect or sexual abuse and assist in protecting the child by contributing to child protection enquiries, and if necessary providing evidence for care or criminal proceedings Verify a diagnosis of accidental injury Identify any medical problem that may cause the symptoms or signs or co-exist with abuse and neglect Provide the child with an opportunity to be seen in their own right and, if they are old enough, to ask questions Inform and reassure the child and family about the long-term consequences of any injury – particularly in cases of child sexual abuse Provide follow-up medical support to deal with new signs and symptoms that may have arisen out of continued abuse, symptoms related to any previous injury or in the case of sexual abuse, infections Monitor any improvement or deterioration in the child’s health Ensure the child has access to health care that is not necessarily abuse related, e.g. child and family consultation service Consider the safety and welfare of siblings and their need for assessment

2 Partnership, collaboration and co-operation PARTNERSHIP WITH PARENTS AND CHILDREN HE CHILDREN ACT 1989 places great emphasis on the value of working openly and collaboratively with families. Indeed, the participation and involvement of parents and children is one of the underlying principles of the act. The protection of children and the prevention of abuse can only be achieved by helping parents to provide good enough care of their children. They have a central role in their children’s protection and welfare and should therefore be party, wherever possible, to all decisions and actions relating to them. The outcome for the child is usually better if the parent is involved in all stages of the child protection process. Ensure that the wishes and feelings of the child, as far as age and understanding permit, are heard and accounted for in plans for their future care. Children have a right to know and a need to understand the process through which concerns are raised about their safety and welfare. They should be informed and consulted about those actions and decisions that affect them; their views and feelings acknowledged and taken into account. Be sensitive to and considerate of the impact of the family background, culture, religion, ethnicity and class when reviewing a child’s physical, emotional and educational needs. Always talk about problems in an open and honest way and give

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parents the opportunity to discuss what concerns them. It creates a better understanding of the difficulties, strengths and needs that the child and family have, and helps clarify what can be done to help. Parents also need to understand what concerns professionals have so that they can begin to address the difficulties and use the support provided more appropriately. This may feel uncomfortable in the first instance; to raise concerns with a parent about their care of a child is never easy and may be difficult for the parent to hear. Making concerns known may also introduce a fear of damaging the relationship with the parent/carer, especially if, initially at least, they do not agree. Nonetheless, never collude with parents over aspects of care that might threaten the child’s safety and welfare; ensure the working partnership always operates to secure the best outcome for the child. There will be instances in which it is not possible to share professional concerns for a child with the parent/carer. This may be either because the parent is not available or because there is a feeling that the child’s safety or even that of the health professional might be further compromised by doing so. Whatever the reason, respond promptly to the child’s need for protection, even if a referral has to be made without the knowledge or consent of the parent/carer. Any delay may jeopardise the child’s safety and put them at greater risk. Remember, the aim of partnership is to work together to safeguard and promote the welfare of the child. Where this is not possible, or at times when such attempts have failed, children’s social care and/or the police can use their statutory powers to safeguard the child. This may be necessary where it is apparent that the child needs immediate protection, or a more secure framework for their long-term safety and well-being is required. INTER-AGENCY COLLABORATION AND CO-OPERATION It is vital that public sector workers in all services and within all agencies work together to ensure that the child is safeguarded, and that services for children and their families are properly co-ordinated. It is only possible to safeguard children effectively if all health service workers are committed to working collaboratively with others as part of a multi-agency as well as a multi-disciplinary team.

PA R T N E R S H I P,

COLLABORATION

AND

CO-OPERATION

Everyone must be clear about their own role and understand the part played by colleagues in other disciplines and agencies. Appreciate how information sharing on a ‘needs to know’ basis is essential for successful inter-agency work. Many communication problems between individuals and agencies arise from a lack of understanding and clarity about roles and responsibilities. In order to secure the best possible outcome for the child, not only must everyone’s role be respected and understood but also there should be a willingness to work collaboratively, sharing relevant information to a joint end: the provision of a comprehensive and co-ordinated service for vulnerable children. ETHNICITY, CULTURE AND RACISM Child-rearing practices are highly diverse, influenced as they are by differences in culture, religion, class, ideology and sexuality. In assessing the needs of children and families, try to understand the influence that different cultures and religions have on parental beliefs, values and behaviour. Judge the care given to a child on an assessment of the individual child’s needs and the ability and willingness of the parent to meet them, not on assumptions or stereotyped views, either positive or negative, of divergent cultural values and styles of parenting. Remember, child abuse and neglect exists within all communities and all cultures; if cultural and religious factors are accepted as an explanation for abuse it could put some children at greater risk. Never condone or collude with abuse in order to avoid being labelled racist; if parental behaviour is perceived as harmful, challenge it, but do so sensitively and not in a way that compounds disadvantage. Be aware in particular of the effects of racial harassment and institutional racism and how this can influence the perceptions of both professionals and families. Many families have experienced discriminatory and/or insensitive services at one time or another and the apparent non-engagement of a parent with a professional may be related to misinterpretation and misunderstanding of cultural differences. Ensure that help is provided in a manner that does not discriminate further but positively promotes the safety and well-being of all children.

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LOCAL SAFEGUARDING CHILDREN BOARDS (LSCBs) LSCBs were established in 2006 following the Children Act 2004. The purpose of LSCBs is to ensure that services for vulnerable children are properly co-ordinated and that the inter-agency arrangements for safeguarding and promoting their welfare work effectively and secure the best outcomes for them. Every local authority is required to have an LSCB made up of all agencies with responsibility for services to children and/or vulnerable adults who may be carers of children. Local authority children’s social care (the lead agency), health, education, police, probation and the voluntary sector are all represented on the LSCB. Within each main agency a number of different services may be represented; everyone involved has joint responsibility for contributing to the work of the LSCB. LSCBs are expected to promote safeguarding children as a shared responsibility across all organisations and partner agencies as well as the wider community. They work within the framework established by the local Children and Young People’s Plan, which includes all local services for children with a cross-agency agreement on targets and priorities and the actions required to achieve them. The LSCB delegates much of its work to a series of sub-committees, whose membership reflects the diversity of services and agencies involved in safeguarding children. The number and format of the sub-committees may vary among local authorities. However, they will always include a sub-committee responsible for the development and review of policies and procedures and a training sub-committee responsible for the provision of multi-agency training. The LSCB is also responsible for reviewing all unexpected child deaths including cases of abuse in which a child has died (fatal child abuse) or suffered serious injury. The LSCB ensures that lessons are learnt from such tragedies, with changes incorporated into the practice of agencies in the future. LSCBs are also responsible for raising awareness of the need to safeguard children in the wider community and this includes minority ethnic groups and communities as well as different faith groups. As part of promoting the involvement of the wider community they have a responsibility to listen to and consult children, ensuring their views and opinions are taken into account in the planning and delivery of services. Each LSCB has an up-to-date procedure manual that details the local

PA R T N E R S H I P,

COLLABORATION

AND

CO-OPERATION

procedures that individuals and agencies must follow when abuse is identified. It describes not only how referral works locally but also how each stage of the child protection process is managed. The local procedures should reflect and be consistent with the guidance in Working Together to Safeguard Children. They should include inter-agency protocols to deal with specific issues, for example children abused through prostitution and other forms of commercial sexual exploitation. To ensure the smooth running of inter-agency work, access the LSCB procedure manual and become familiar with its content. Everyone is expected to follow the local procedures and work within the framework established by Working Together to Safeguard Children. This way, child protection practice works to secure the best outcomes for the child.

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3 Assessment of risk A

occurs whenever there is a substantial failure of one person to act towards another with the care appropriate to their relationship. Adults have a duty of care in many aspects of life, both at work and at home, and society expects them to exercise that obligation responsibly and safely. The closer and more dependent the relationship, however, the greater the responsibility to provide care and the greater the risk to the child if care is not provided. BUSE OR NEGLECT

PARENTAL CARE Judgements about what does and does not constitute reasonable care are crucial; decisions about the actual or likely risk to a child depend on them. While the Children Act 1989 does not define what it means by reasonable parental care, there is broad agreement that it should include: Physical care – food, warmth, shelter Maintenance of physical health Protection from violence and abuse Emotional responsiveness, affection and approval Access to education and opportunities for socialisation While some forms of abuse are clearly damaging, for example withholding food from a child, other forms of abuse may be less obvious and more difficult to define. Judgements about whether a child is at risk depend on views of what does and does not constitute acceptable care, and opinions about this vary over time and across cultures. While it is important to be sensitive to the wide diversity of parenting styles that exist, remember to keep the focus on the child when deciding whether parental behaviour is harmful. Parental care can be placed on a continuum

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from optimal at one end to unacceptable at the other. Thinking about it in this way may help in assessing the risk to a child and deciding if, when and how to intervene. A parent may demonstrate: Consistent love, warmth and attention. There is appropriate concern, a desire to protect the child from harm, an understanding of the child’s needs and feelings and pride in their achievements Responsiveness to the child’s needs with intermittent difficulties in relationships and expectations. This may lead to some problems in the child’s health, development and/or behaviour Critical or neglectful behaviour showing a poor understanding of and response to the child. This may lead to withdrawn, attention seeking or aggressive behaviour in the child Hostility, cruelty and rejection. Failure to meet the child’s basic needs, including the need for emotional responsiveness, leading to significant harm in many aspects of their physical and mental health PREDISPOSING FACTORS Parents often carry into their adult lives unresolved losses and trauma from their own childhood experiences, and these can have an adverse impact on their capacity to form loving and sensitive relationships with their own children. A secure attachment to a primary caregiver is central to a child’s growth and development, and early attachment in particular lays the foundation for future development. Parents who have been abused or neglected often have unmet needs themselves, and some will find it difficult to respond appropriately to the physical and emotional needs of a dependent child. In order to help the parent develop a ‘good enough’ relationship with their child, attempt to identify the influences and complex processes that can lead to parenting difficulties and abuse. Consider why some parents and some children are more vulnerable than others, in the sense that they are more likely to abuse or become victims. None of the predisposing factors that follows has a clear causal link with child abuse. However, there are characteristics common to abusing families, abusing parents and abused children. For any preventive strategy to work give special attention to those parents in the greatest need of help and support. The following pointers will help.

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FAMILIES may be vulnerable if there is: Drug and alcohol misuse Domestic abuse/domestic violence Previous history of abuse Frequent moves, homelessness Social isolation, weak supportive networks of family and friends Socio-economic problems, such as poverty and unemployment Diffuse social problems Poor engagement with professionals PARENTS/CARERS may be vulnerable if they have: Mental health problems, personality disorders Unrealistic expectations of child, intolerant and/or indifferent Negative perceptions e.g. child miserable, difficult to control, wilful Little or no antenatal and post-natal care A learning disability Poor physical health or disability A history of abuse and neglect No support, e.g. lone parent A teenage pregnancy Consider the impact of a combination of different risk factors. If domestic violence co-exists with drug use and/or poor parental mental health, for example, the risk to the child may increase considerably. This risk is also compounded if a family refuses to respond to agency intervention. Those who deny the problem, reject help and avoid the involvement of professionals are the most difficult to assist and the most resistant to change. Whatever the source or form of the original abuse, the poor outcomes for many children are often the result of continued inadequate parenting. CHILDREN may be vulnerable if they are: Premature and low birth weight Separated from mother/primary caregiver

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Disabled and/or have chronic ill health Difficult temperament/difficult to care for Multiple birth (e.g. twins) and/or less than 18 months between siblings Different to expectations, for example the ‘wrong’ sex Unwanted and/or unplanned Looked-after, e.g. foster care, residential care Not attending school The exception can disprove the rule. There are always families where risk factors are present, but no abuse. Many families under great stress succeed in bringing up their children in warm, loving and supportive environments in which each child’s needs are met. The opposite is also true: serious abuse sometimes occurs in the absence of any of the established predictive factors. A full understanding of why abuse happens in some vulnerable families but not in others can best be gained by looking at its context. Consider abuse in the light of family history, individual characteristics of parents and children, social and environmental circumstances, health problems, life events and chance crises. Understanding the factors that create stress within families helps plan prevention, so that help and support can be given before it occurs. Equally, not all children are damaged by abuse and neglect in the same way; its impact will depend on the resilience of the child, that is, their ability to cope with stress. The child who does well may have an easy temperament, good social skills or above average intelligence, characteristics that evoke a more positive response from a caregiver. They may have the ability to foster relationships that offer safety at times of danger, for example, an aunt, a neighbour, a teacher who helps them overcome the consequences of adversity. Remember, the availability of a significant person in the child’s life who consistently gives them a sense of their own self-worth together with the opportunity to excel in their own right at school or elsewhere; this is what will help promote resilience in the child.

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DOMESTIC VIOLENCE, MENTAL ILLNESS AND SUBSTANCE MISUSE Parents who suffer from mental illness, misuse alcohol or drugs and/or are involved in domestic abuse can generate stressful and damaging environments for their children. While not all parents with these problems are a danger to their children, their capacity to provide good enough care can be disrupted and impaired, putting the child at risk of both abuse and neglect; this risk can increase substantially if mental health problems and substance misuse co-exist and overlap with domestic violence. Domestic violence is a common pattern of abusive and controlling behaviour through which the perpetrator (usually a male) seeks to exert power over the victim (usually a female). It can pose a serious risk to children’s safety as they often become victims themselves. Unborn children are particularly at risk; violence often begins or increases in severity during pregnancy and women are frequently battered in the abdomen. Domestic abuse can also have a damaging effect on the child’s psychosocial development and emotional well-being. Witnessing physical and psychological abuse and being exposed to prolonged parental conflict, even where physical violence is not present, can cause anxiety and distress in the child. Mental illness can impair a parents’ capacity to care for their children. It can range from the unavailability of a depressed parent at one end of the spectrum to the murderous violence of a parent with psychotic symptoms at the other. The episodic nature of some mental health problems means that parenting can be inconsistent and unpredictable and children may take on a caring role themselves, either for a parent or more dependent sibling. Remember, the risks are greater if the parent’s behaviour conveys irritability towards the child or if the child becomes the target for parental aggression and/or features in the delusional thinking of a parent. Adult mental health workers have a particular responsibility to keep the dependent children of their adult clients in mind and to collaborate closely with children’s services to minimise the risk of harm to the child. Drug and alcohol misuse can also diminish a parent’s ability to attend to the basic tasks of parenting, especially if dependency on the substance becomes the main priority within the family. Chaotic family lifestyles characterised by a lack of consistency in parenting can result in the chronic neglect of children. It features in many families whose children become

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the subject of child protection enquiries, often becoming apparent during pregnancy and likely to continue to compromise health and development throughout early childhood. Although certain factors seem to highlight a predisposition to abuse, reality is never so clear. While abuse may be triggered by a single event or isolated crisis, it is more likely to be associated with other long-term difficulties such as those described above. Every incidence of child maltreatment is part of a complex history along a road that leads to the current problem – something that may have begun years before the child was first harmed. Consider, therefore, not only the immediately obvious but also the less evident and see it in a wider context, as part of the bigger picture. ASSESSING HARM All forms of abuse and neglect are harmful and have adverse physical and psychological consequences for the child. Although there is no one sign or symptom that can be categorically linked to one form of abuse rather than another, children commonly suffer attachment disorders, post-traumatic stress disorder, psychosomatic symptoms and mental health problems. While the degree of harm will depend on the severity and duration of abuse, the loss of trust and distortion of the parent/child relationship is likely to have irreversible long-term effects for all its victims. The Children Act 1989 introduced the notion of harm to describe the various forms and consequences of child maltreatment. Harm covers impaired health and development and is defined as ‘the state of a child which is attributable to ill-treatment or failure to provide adequate care’. It includes forms of ill treatment, classified, according to the guidance of Working Together to Safeguard Children, as: Physical abuse Emotional abuse Sexual abuse Neglect Whatever the source or nature of harm, professional judgements have to be made about whether the harm to a child is significant enough to

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reach the threshold to justify a formal child protection enquiry. Significant harm describes the degree of harm caused by ill treatment or the absence of a reasonable standard of parental care. A single traumatic event may constitute significant harm, for example a violent assault. However, its impact and extent can perhaps be best understood as an accumulation of events, occurring over time, which interrupt, change or damage the child’s physical and psychological development. Being the victim of persistent ill treatment is therefore likely to have a considerable effect both on the child’s view of themselves and on their future lives. As well as bringing together a wide range of possible acts of commission and omission, types of abuse overlap so the source of significant harm for the child is likely to be from more than one form of abuse. A child who is physically harmed, for example, will suffer emotionally; sexual abuse sometimes involves physical coercion as well as emotional damage; children physically abused may also suffer sexual abuse. For this reason the term ‘child maltreatment’ is used more frequently now to describe all forms of child abuse and neglect. This is in line with the growing recognition that there are more similarities than differences in its various characteristics and manifestations. When making an assessment, remember that harm is not simply a product of poor parental care. Children exposed to extreme poverty and inadequate living conditions often have poorer health and lower educational achievement than their better off peers. Those who suffer from chronic illness and/or disability are less likely to achieve or maintain a reasonable standard of health and development without the provision of a wide range of services. They may not be in need of protection but their circumstances are harmful and they are ‘children in need’ as described in the Children Act 1989. Equally, be aware that there is a disproportionate presence of minority ethnic communities in areas of high social need. Some of these families will have suffered racial harassment and some parents, for example asylum seekers, will further suffer the stigma associated with this. Accessing services and being honest about problems can be difficult in a place where you do not necessarily feel at home. Always consider the wider needs of children and families whether or not concerns about maltreatment have been substantiated. Child protection is an integral part of a wider responsibility to safeguard and

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promote the welfare of children. Consider too any special needs, such as a medical condition, communication difficulty or other disability that may affect the child’s development and care within the family. Use the Common Assessment Framework (CAF) to consider the child’s safety and welfare within the context of their family and wider community. The Framework provides all professionals with a standardised way of conducting an assessment of the needs of a child and deciding how those needs should be met. It is particularly suitable for use in universal services such as those provided by primary health care, schools and children’s centres to identify and tackle problems before they become serious. Use it to gain an understanding of: A child’s developmental needs Is the child safe and if not what needs to happen to protect them? Is their health and development being impaired? If so, in what respects? What are the possible consequences if the child’s needs are not met? The capacity of parents and carers to respond appropriately to those needs What is the reason for the concern? What are the difficulties and what needs to change? What other specialist assessments might be needed and what services need to be provided for the child and family? The impact of wider family and environmental factors on both the child and parent What are the strengths of the family? What other sources of knowledge are there that might inform the assessment? Who else in the family as well as the professional network could contribute to the assessment? In assessing the degree of risk to a child from abuse or neglect, consider its severity and duration and any consequences (both actual and likely) for the child’s health and development. Consider too the parents’/carers’ response to professional concerns. Do they understand and accept them or are their concerns completely different? Use professional judgement to decide whether or not the situation has reached the threshold for a referral to children’s social care and a formal child protection enquiry.

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With the impact or consequences of abuse not always immediately obvious, this can be a complicated process. Some effects are immediate and evident; others more hidden and enduring. Share concerns with other experienced colleagues to make these difficult judgements and decisions easier.

4 Physical abuse P

serious. It starts at one end of the continuum with minor injuries or bruising, and ends at the other with injuries that can prove fatal. Physical abuse is thought to be responsible for the death of approximately 200 children a year in the UK. It can be the product of a single violent act or an accumulation of regular assaults and beatings. Its dangers relate closely to age: the younger the child, the more at risk they are from physical harm. A baby who has been shaken, for example, can suffer severe and irreversible damage; even a small bruise in an infant may be a predictor of more severe or possibly fatal abuse. Most societies condone the use of physical chastisement to discipline children and it remains widespread across all social classes and cultures, involving children of all ages. While there is a difference between physical chastisement and physical abuse, it is clear that the two are closely linked. Punishment can be abusive. Many parents who abuse their children believe that strict, harsh punishment is the only way to control and discipline them. Injury results when they lose control and what they perceive as ‘normal’ parenting gets out of hand. While some parents at one end of the spectrum will need help to develop more appropriate strategies for dealing with normal childhood misbehaviour, others will be parents whose violent behaviour is brutal, sadistic and premeditated and who present a very serious risk to their children. Always remember the link between child abuse and domestic violence. The physical abuse of women and children frequently co-exist and can begin in pregnancy; if one is present, the other should always be suspected. An injury that results from failure to protect or provide proper adult supervision can be physically just as damaging as a deliberately inflicted assault. Placing a child in danger can reflect ambivalent feelings, or an HYSICAL ABUSE IS

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unconscious urge to hurt: leaving an unsupervised toddler in a bath full of water is but one example of how parental neglect can put the child at risk of physical injury. DEFINITION Physical abuse here is violence directed towards children. It involves a wide range of harsh, punitive, controlling and aggressive styles of parenting. Working Together to Safeguard Children describes it as including: Hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating, or otherwise causing physical harm to a child. Physical harm may also be caused when a parent or carer fabricates the symptoms of, or deliberately induces illness in a child. Physical abuse does not occur in the absence of other forms of abuse and, apart from those children who suffer serious injury, it will be the psychological and emotional consequences that are the most damaging for the child. When normal expressions of dependency (i.e. crying) in early infancy are responded to sensitively, the child has the opportunity to develop a secure attachment and to begin the process of learning to regulate their own feelings and behaviour. Physical abuse disrupts this process. It causes fear and agitation in the infant, which can lead to the impairment of brain growth and development; the younger the child, the more traumatic the effects, especially if the perpetrator is the primary caregiver. The physically abused child quickly learns that displays of need and dependence cannot be tolerated and they may become increasingly careful and compliant in their responses in order to avoid abuse. Frozen watchfulness has been a term used to describe the wariness of young children whose survival depends on being constantly alert and hypervigilant in the face of unpredictable and violent caretaking. The child learns over time that close relationships cannot be trusted and that emotional independence and self-reliance is the safest option. Older children may develop a stoical and even tough persona but maintaining it takes up most of their psychological energy and their self-esteem is likely to be low. Some physically abused children develop behaviour disorders and coping strategies in which violence and aggression are a feature.

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These children often become bullies and may be involved in violent crimes and other forms of anti-social behaviour. Children subjected to harsh and violent parenting are more likely to develop depression and are among those most likely to think about suicide. SIGNS Most serious physical abuse occurs in early childhood because of the inability of the dependent and non-ambulant child to protect themselves. However trivial the injury, remain alert to any signs of physical violence to children: the severity of an injury is only a partial guide to any danger to the child’s life and health; even apparently minor problems sometimes signal something more acute. The following pointers may help: IN THE CHILD Injuries of different ages at different stages of healing Certain types of injury, such as bruising to a young baby, cigarette burns and fractures in infants and toddlers Frequent minor injuries, scratches and abrasions for which there is no adequate explanation Presence of other signs of abuse, such as neglect, failure to thrive and sexual abuse Sites of bruising not likely to be accidental, e.g. ears, face, trunk, inner thigh Child alleges abuse Injuries not consistent with the explanation given by the child Child not accompanied by parent/carer Child appears fearful/wary of adults IN THE PARENT/CARER Injuries that are inconsistent with the explanation given by the parent, that is, too many, too severe, the wrong kind, wrong distribution or wrong developmental age Unusual behaviour in the parent/carer, such as delay in seeking medical advice, unusual lack of concern, refusal/reluctance to allow treatment, hostile or other inappropriate response towards professionals

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Parent/carer who attributes the cause of the injury to a third party Unexplained injury noticed by others, such as at day nursery or school History of abuse, neglect and/or domestic violence CHARACTERISTIC INJURIES Bruises occur in many physically abused children and can arise from: Slapping, pinching or poking Use of straps, sticks, buckles or other implements Throwing, swinging or pushing on to a hard object Gripping with or without violent shaking Adult human bites The site of the bruising can be meaningful: injuries to the face, eyes, ears, mouth and hands in particular should be viewed with suspicion. Bruising around the neck can suggest suffocation. Bruises below the elbow and knee generally carry less significance and may be caused by play activities and accidents. Those to the trunk (chest, back and abdomen) tend to indicate abuse, with any to the breasts, lower abdomen suggestive of sexual abuse. Bruises on the buttocks, lower back and outer thighs are often punishment related. Injuries to the inner thigh and genital area may suggest either sexual abuse or punishment for perceived toileting misdemeanours, such as bed wetting or lapses in toilet training. Fractures represent serious injury. They can result from falls and/or extreme violence and may be seen with other injuries, particularly soft tissue damage. The fracture that follows abuse may be single or multiple, recent or old, or a combination of any of these, and found in one or more sites on the body. When an injury is the consequence of abuse, the history given by the parent/carer may be vague, inconsistent or non-existent. Medical attention is very often sought after a period of delay when the fracture has caused symptoms such as swelling or loss of function. Burns and scalds to children are common. While some result from accidents caused by varying degrees of parental neglect, some involve deliberate abuse and are the most likely to cause death or long-term health problems. Presentation can be as an acute injury, a healed burn or

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scar or a neglected injury. A delay in presentation or avoidance of treatment may occur and effective first aid may mask the severity of a scald making it harder to identify. Some parents may not accept responsibility, feeling the child deserved what happened and even blame them for it. Always view parental hostility towards the child as suspicious. While self-inflicted burns or scalds are rare, when they do occur, they are likely to be a sign of extreme disturbance in an abused child. FABRICATED OR INDUCED ILLNESS BY CARERS (FII) FII is a form of abuse in which a parent/caregiver exaggerates or makes up (fabricates) symptoms and/or causes (induces) illness in a child. They may actively intervene in their child’s medical treatment, secretly administer drugs or other poisonous substances or smother the child, which can cause apnoea, fits and even death from poisoning or suffocation. The perpetrator, commonly the mother, has a need for recognition of ill health in her child. She repeatedly brings the child for medical assessments and treatment, often resulting in multiple medical and surgical procedures and opinions but no diagnosis. FII can co-exist with disability, medical conditions and other types of abuse and neglect. Emotional abuse is also a feature and any distress due to the fabrication or induction of an illness will be further compounded for the child by the invasive medical investigations and associated hospital admissions. POISONING Accidental poisoning of children is a major child health issue in the UK, especially in toddlers aged between two and four years old, although repeated ingestion of medicine, tablets or liquids may indicate neglect or deliberate poisoning (FII). Whether due to accident, neglect or wilful intent on the part of the parent/carer there is a considerable overlap in the clinical presentation. SUFFOCATION In an infant, suffocation is difficult to detect as a form of abuse because in spite of the violence of the act there is often no sign of injury, even at autopsy. Unexpected and unexplained deaths in infancy may be sudden

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infant death syndrome (SIDS), or abuse, especially if a child in the family has died before in unusual or suspicious circumstances.

Medical guidance The following guidance elaborates on the previous section and should be read with the paediatric assessment (Appendix 2). It is aimed at doctors involved specifically in the diagnosis and management of physical abuse. However, it may be informative to any professional. ABDOMINAL INJURY Abdominal injury is rare. Be suspicious if there is abdominal bruising, although this does not always need to be present to make a diagnosis. Severe injury may lead to the child presenting with unexplained collapse due to perforation of the gut or haemorrhage from rupture of the liver, spleen, bowel and pancreas. Denial of trauma and delay in presentation adds to the diagnostic difficulty. BRAIN – NON-ACCIDENTAL HEAD INJURY (NAHI) Injury to the head and brain is the most common cause of death in childhood. Violently shaking a small child can cause all types of intracranial bleeding, encephalopathy as well as retinal haemorrhages. Signs include poor feeding, irritability, vomiting, drowsiness, fits and, in extreme cases, sudden collapse and death. Throwing can cause an impact injury; signs may include fractures of the skull and other bones, and sometimes bruising. Other internal injuries can be present without visible external signs. Any combination of these signs can be indicative of non-accidental head injury (NAHI). BRUISING Bruises may be variable in size and colour, unexplained, and found anywhere on the body. They cannot be aged accurately.

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If there are bruises on the face, mouth, ear or side of the head in a baby or young child, check for accompanying internal head injury, which could be life threatening. Remember that bruising at a site not usually or easily injured, such as the head and neck, is always suspicious; the latter may be caused by strangulation. Suspect sexual abuse when bruising is seen on the trunk, thighs or abdomen. Injury to the genital area may be due to sexual abuse or perceived toilet misdemeanours. Any bruising on the buttocks and/or lower back may be punishment associated. SUSPICIOUS SIGNS Any bruising on a non-ambulant infant Bruising on a child, especially on non-bony prominences, on the trunk, abdomen, cheek, head or to the ears. Purple ear or petechial bruising usually occurs on the upper half of the ear, from blows or pinching Any lacerations or bruising in and around the mouth, especially if the frenum is torn (the frenum is the bridge of tissue that joins the middle of the inside top lip to the gum) Fingertip bruising (small, round or oval marks indicating gripping), slap or punch marks (note imprint of hand, ring, knuckle, etc.) Bruising from adult human bite marks (in the shape of two opposing concave arcs with a central bruise). If between 3 and 5cm across, this may have been caused by an adult or older child with permanent teeth Linear bruises or outlines of weapons such as sticks, belts or other instruments (the weapon’s shape may be clearly etched on the skin) Evidence of multiple bruising in clusters Do not confuse Mongolian blue spots with bruising. These are birthmarks common to children of African, Caribbean,

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Asian or Chinese ethnicity, and can occur in ‘white’ children. They are dark blue and often look similar to a fading bruise; they last for about two years. They feature mainly on the lower back but may be seen anywhere on the body. BURNS AND SCALDS Burns maybe associated with all other forms of abuse including sexual abuse. Skin allergies, infection (e.g. impetigo), birthmarks and old scars (e.g. chickenpox) can resemble burns, but the deliberate burn is more likely to be regular in shape with a clear outline. No site is exempt but they commonly include the backs of hands, buttocks, genitalia and feet. Decide whether a burn is accidental or deliberately inflicted in the light of a child’s age and development and in the context of the explanation given by the child and/or the carer. SUSPICIOUS SIGNS Burns to the lips and surrounding skin, sometimes including the inside of mouth Cigarette burns seen as small circular areas of skin loss that vary in size from 6mm to 2cm depending on pressure and duration. Accidental brushing against a cigarette end rarely makes such marks and usually results in a ‘tail’ Contact burns are caused by holding a hot object such as electric fire, poker or iron against a child’s skin. The margins are delineated, reflecting the pattern of the object, and the depth is usually uniform Radiant burns are usually extensive in a limited area and can be caused by standing too close to a fire Friction burns can be caused by dragging a child across a carpet or from restraining them with a tie, e.g. a rope Immersion burns from dipping a child into hot water tend to be uniform over all exposed areas with clear demarcation lines

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Splash burns from hot water thrown at or poured over a child will leave an irregular margin and depth; more difficult to distinguish from an accidental burn FABRICATED OR INDUCED ILLNESS BY CARERS (FII) This condition includes a wide spectrum of behaviours that can range from the over-anxious parent at one end of the spectrum to the parent who deliberately fabricates and/or induces illness in their child at the other. Although the perpetrator (usually the mother) will deny any knowledge of the cause of the child’s condition, the signs and symptoms usually cease when the child is separated from them. Be suspicious if a child who repeatedly presents for medical assessments and treatment, often resulting in multiple medical procedures and opinions, continues to have no diagnosis. SUSPICIOUS SIGNS Unexplained signs and symptoms, despite extensive medical investigation Treatment does not produce the expected effect Presence of unexplained illnesses or multiple surgery in other family members Withdrawal of special treatment (e.g. naso-gastric feeds, intravenous lines) and ‘getting better’ not viewed with enthusiasm by the parents/carers Repeat presentations to a variety of doctors with a variety of problems Child’s daily activities curtailed more than expected The following situations are harmful and can be life threatening: Parent/carer causes illness in the child by administration of noxious substances, for example salt and drugs (poisoning) High level of demand for multiple and unnecessary investigations

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Active withholding of food or restricted diets so that the child fails to thrive Suffocation causing fits and Apparent Life Threatening Events (ALTE) Be aware how this can impair the child’s psychosocial development through: Exposure to unnecessary, harmful and painful investigations or treatment Confusion and anxiety about their own health and illness Social isolation/over-protection Missing school FRACTURES Any fracture in the first year of life, with no clear accidental history, is of immediate concern; non-ambulant infants rarely break their bones accidentally. Such fractures may present with pain, swelling and/or unwillingness to use the affected part, though confirmation by X-ray is essential. Exclude intracranial injury in a child under one year and also consider it in an older child. Twisting and pulling, a direct blow, shaking or squeezing a limb resulting in a fracture may or may not be associated with bruising and other external signs. Fractures can be a presenting feature in genetic, metabolic and other bone disease, such as osteogenesis imperfecta and osteomyelitis. Rib fractures after cardiopulmonary resuscitation are rare, but when they do occur are usually anterior. SUSPICIOUS SIGNS Rib fractures – single or multiple are common in abused infants, and strongly suggest squeezing, shaking, kicking or blows Skull fracture with intracranial injury e.g. subdural haemorrhage

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Multiple fractures at different stages of healing in the presence of normal bones Evidence of old fractures Unusual fractures e.g. scapula, spine TYPES Greenstick fractures, in which the bone cracks halfway across and splits some way up its length resulting in an incomplete break; they are often accidental Long bone fractures may result from violent pulling, gripping or twisting injuries and do not always have external signs. Shaft fractures may result from direct blows, bending and violent pulling to long bones Spiral fractures are due to a twisting force, such as being swung by the arms or legs; highly suggestive of abuse in non-ambulant children. An accidental fall with a twisting action may sometimes cause a spiral fracture, especially of the tibia Metaphyseal fractures, in which fragments of the bone become separated from the distal ends of long bones, either as a chip or a whole plate, and show up on X-ray in the shape of a ‘bucket-handle’. The force disrupts the fine layer of new bone close to its junction with the cartilage. Such injuries are usually from gripping and twisting movements and shaking. Usual sites affected are elbows, knees, wrists and ankles. There may be soft tissue swelling initially and little pain, tenderness or swelling after the injury Periosteal new bone formation. The periosteum is a thin layer of bone that protects the long bones in the arms and legs. Damage caused by gripping or twisting injuries raises it from the shaft of the bone and new bone appears seven to ten days later

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ORAL INJURIES Always look for injuries to the mouth, especially if there are facial or any other non-accidental injuries and seek a dental opinion when necessary. Types of injury may include: Torn labial frenum: this can be caused by a direct blow or by force feeding an infant or small child. Often found in association with other signs of physical abuse Lacerations and bruises to lips and tongue Injury to palate and pharynx Consider neglect if there are signs of poor dental hygiene, discoloured, unfilled, decayed or missing teeth.

Always investigate any presenting symptoms or signs that appear to be suspicious and may result from non-accidental injury. Discuss individual cases with a senior doctor/consultant and decide the type and extent of the investigations required. Use local guidance along with the Royal College of Paediatrics and Child Health Child Protection Companion (2006) and the Welsh Child Protection Systematic Review, www.core-info.cf.ac.uk to help inform further management.

5 Sexual abuse C

is devastating for children, for boys as much as for girls. It happens to children of all ages, including the very young, and in all cultures and all communities. It is a form of abuse that many people find difficult to think about as it confronts the most deeply held beliefs and taboos about what is and what isn’t acceptable behaviour towards children. Recognition of child sexual abuse and the protection of its victims will however depend on the willingness of adults to acknowledge that sexual abuse might be happening, to listen to and believe the child and take appropriate action in response to what they are being told. HILD SEXUAL ABUSE

DEFINITION Child sexual abuse is the sexual molestation of children by adults or older children (sexual, here meaning any activity that leads to sexual arousal in the perpetrator). The abuse may range from voyeurism and exhibitionism to oral, vaginal or anal penetration. It may be perpetrated by single or multiple perpetrators, on one or more occasions, and associated with other types of abuse. Working Together to Safeguard Children describes it as: Forcing or enticing a child or young person to take part in sexual activities, including prostitution, whether or not the child is aware of what is happening. The activities may involve physical contact, including penetrative (e.g. rape, buggery or oral sex) or non-penetrative acts. They may include non-contact activities, such as involving children in looking at, or in the production of, sexual online images, watching sexual activities, or encouraging children to behave in sexually inappropriate ways.

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CHARACTERISTICS OF SEXUAL ABUSE These can be summarised as follows: Responsibility rests entirely with the perpetrator Sexual gratification of the perpetrator is the usual aim of the abuse Power/age gap means the child cannot refuse It is usually secretive and collusive The element of force or coercion is an important one. While some abuse is clearly the result of violent acts resulting in physical injury, the majority of sexually abused children are victims of a more cautious if equally determined approach that involves the use of threats, bribes and emotional manipulation. In determining whether the activity is abusive, remember that the issue of coercion relates closely to age difference. Distinguish between normal sexual development in children, for example the mutually exploratory sexual play of pre-school children, and sexual activity that involves coercion. Sexual abuse is an abuse of power and as such can be perpetrated by adults, children and young people, of both genders. Be aware that a child under 13 is not legally capable of consenting to sexual activity and it is classified as statutory rape. Sexual activity with a young person over 13 but under 16 is also an offence but where it is consensual there may be less risk to the young person. In assessing the risk, consider the following pointers: Age of the child and their ability to understand what is involved Age and/or power inbalance Use of coercion or bribery Attempts to secure secrecy Whether grooming is suspected Misuse of substances as a disinhibitor Behaviour of the child e.g. withdrawn, anxious, over-confident for age Child denies or minimises concerns Sexual partner is known to one of the agencies If there is any doubt about whether to refer to children’s social care and, in

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particular if the child is under 13 years old, discuss with one of the designated or named professionals or other experienced colleague. PATTERNS OF ABUSE In the majority of cases the perpetrator is known to the child and is probably a family member. He is more likely to be male than female, although sexual abuse by women is now increasingly recognised. Child sexual abuse occurs in all social classes and across all cultures, affecting children of all ages, including babies. Sexual abuse occurs when a perpetrator has access to an available and vulnerable child. As it is a secretive activity the family can offer a safe outlet. Within it, the child can be controlled and manipulated into silence and any risk of discovery minimised. Intra-familial abuse may involve a pattern of relationships in which there is collusion with other members of the family and where clear boundaries within and between generations do not exist. Sexual abuse may also involve other adults known to the child from a variety of sources, for example extended family members, babysitters, youth workers. Perpetrators will also deliberately target families where they think the abuse is likely to remain undetected. They will form relationships with lone, vulnerable mothers in order to gain access to children who may have already been victims of sexual and/or other forms of abuse and neglect. Children and young people are also abused through prostitution and other forms of commercial sexual exploitation; this group may include children who have become victims of paedophile rings, human trafficking or abuse through the internet. Whatever the circumstances, refer any child or young person considered to be at risk of significant harm to children’s social care to secure their safety and to enable the police to gather evidence about the perpetrators. Action can then be taken by the police and children’s social care to prosecute known offenders and/or control their access to children. PHYSICAL INDICATORS Physical indicators of child sexual abuse are uncommon but are important as they may be the only signs of abuse in infants and young children or in older children not able to communicate. For the child

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who discloses abuse such signs can help corroborate their story. Nonetheless, an examination by a paediatrician that does not find physical evidence to support a diagnosis should not be used to exclude the possibility of child sexual abuse. Healing takes place rapidly, and scarring is uncommon so be aware that many children who have been sexually abused show no physical signs. With the exception of pregnancy, or the presence of semen in the vagina or rectum, there are rarely diagnostic signs of sexual abuse. Injury and/or infection can be a consequence of physical interference with the child’s genitalia, anus or mouth. Principal symptoms of injury are pain, soreness, swelling and bleeding. Symptoms of infection can include vaginal discharge and soreness. Irritation of the urethra may cause frequency and sometimes pain when passing urine. The child may appear uncomfortable; anxious or unhappy, for example, during toileting or nappy changes or even walk with an awkward gait. Be aware, sexual and physical abuse are closely linked; some sexually abused children are also abused physically; bruising to the breast, inner thigh and genital area in particular is indicative of sexual abuse. BEHAVIOURAL INDICATORS Children who are abused sexually are often groomed and trained by perpetrators to respond in certain ways and this process can continue over several months or years. Although children do not like it and want it to stop, their need for physical affection and attention can sometimes lead to their apparent complicity or willingness to initiate the abuse. They can behave in a way that seems to encourage or provoke a sexual response in the perpetrator. This does not however make the child responsible for the abuse; what they need is a relationship that provides them with comfort and protection. Always view these behavioural signs as the consequence of the abuse rather than its cause. Over time children can develop a pattern of adjustment to the abuse, displaying characteristics such as: Secrecy. Children are told not to tell. Threats of withdrawal of love and affection, fear of punishment and/or fear of not being believed are often all that is needed to secure a child’s silence Helplessness. Children in most cases are not able to stop the

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abuse. They give up resisting and accommodate the abuse as a way of protecting themselves and trying to keep the family together Self-blame. Children sometimes hold themselves responsible for the abuse. Self-blame and guilt are almost universal feelings in sexually abused children Delayed disclosure/allegation. Many children never tell; for those who do it is often delayed and understated; it may take place when the abuse has stopped Retraction. This is a frequent response by the child to the disruption of the family and the involvement of professionals once abuse has been disclosed Be aware that because children develop complex coping mechanisms to accommodate the abuse they may not appear to be suffering. Some sexually abused children show no signs or symptoms at all. Others, however, may show signs of: Anxiety, depression, withdrawal Aggression, attention seeking and/or poor concentration Inappropriate sexualised behaviour Stomach aches, headaches Enuresis (wetting), encopresis (soiling) Sleep disturbance, nightmares and other signs of post-traumatic stress disorder Low self-esteem Social isolation, poor peer relationships Self-harm, running away Many children who suffer sexual abuse experience feelings of shame and confusion, particularly if the perpetrator has not needed to use physical force. Although threats and coercion are frequently used to secure a vulnerable child’s compliance, there are perpetrators who can do it solely by manipulating the child into believing the abuse is an expression of love. The child may learn that to like and value someone requires the relationship to be sexual even though the experience is mixed with feelings of uncertainty, anxiety and fear. This confuses the child and leaves

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them with a very distorted understanding of what it means to be in a loving relationship. Children who have a secure attachment to a non-abusing caregiver who believes them and tries to protect them are more likely to disclose and less likely to suffer from emotional and/or behaviour problems. Those who suffer more extreme and prolonged abuse, whether or not they are believed, are the most likely to develop long-term mental health problems and difficulties in developing and sustaining intimate relationships in adulthood. PERPETRATORS Remember that perpetrators: Are often related or known to the child May commit a large number of offences involving a lot of children Include both men and women Often begin their offending behaviour as adolescents Are likely to have been abused as children Will nearly all re-offend Often deny the abuse and refuse to participate in treatment programmes While the police take action to secure the safety of individual victims of abuse and to prosecute known offenders, limiting the access that offenders have to any vulnerable child is a major public safety issue. Safeguarding the community from the dangers of serious and violent offenders is now the responsibility of the Multi Agency Public Protection Arrangements (MAPPA). It is led by the police, probation and prison services and supported by agencies that provide services to offenders such as health, housing, adult social care services and Youth Offending Teams. The MAPPA has a statutory responsibility, in each borough, for the assessment and management of risks posed by offenders. It monitors and reviews the cases of individuals on the Sex Offenders Register (a register of those convicted or cautioned for certain sexual offences) as well as others who are considered to represent a continuing risk to children. This includes individuals who abuse children through prostitution and other

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forms of commercial sexual exploitation as well as those who abuse and exploit children through trafficking or the internet.

Medical guidance The following short guide elaborates on the previous section. It is aimed at doctors involved specifically in the diagnosis and management of child sexual abuse and should be read with the paediatric assessment (Appendix 2) and Clinical Handbook for Physical Signs of Child Sexual Abuse (RCPCH, 2007). SUSPICIOUS SIGNS AND SYMPTOMS Child sexual abuse may present in a variety of ways; some of which clearly indicate the probability of abuse, for example allegation, others only its suspicion. As in any other form of child maltreatment, always consider the differential diagnosis as the following signs and symptoms may signify conditions other than sexual abuse. Be aware that sexual abuse and some medical conditions may co-exist, for example, lichen sclerosus et atrophicus. When taking a history, remember that many children are confused about the exact nature of the abuse, particularly if they have been groomed over a long period of time, and it may be difficult to obtain a clear history. The child may not have a clear concept of penetration; they may, for example, describe rubbing or pushing against the labia, thighs or buttocks. A child’s anus and hymen stretch quite easily and partial penetration, especially after grooming and/or the misuse of drugs, may not cause injury. An allegation/disclosure of sexual abuse is an important pointer to a diagnosis whether or not it is corroborated by physical signs. The absence of physical signs does not imply absence of abuse; false allegation is rare and there may be other findings that support an allegation e.g. dysuria and soreness following contact with a suspected perpetrator. In

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some cases the child may not disclose at all and suspicions may be raised by a child or young person who presents, for example, with recurrent vulvovaginitis. Always consider the following signs in the context of all the other information known about the child and family: Pregnancy, where the identity of the father is unknown or concealed Bruises, scratches or other acute injuries to the genital or anal areas, or to other ‘sexual’ areas, such as breasts and lips: these injuries may be minor but are inconsistent with accidental injury Some acute genital and/or anal trauma and no history of accidental injury Some sexually transmitted infections (STIs) outside the relevant incubation period for vertical transmission e.g. warts Transection to the base of the posterior hymen Vaginal discharge also may indicate an STI or a foreign body Vaginal bleeding Vulvovaginitis (common but consider child sexual abuse in differential diagnosis) Psychosomatic illness e.g. stomach ache, headache Recurrent urinary tract infections, dysuria, enuresis Rectal bleeding Encopresis (soiling), constipation DIAGNOSTIC SIGNS There are very few diagnostic physical signs in child sexual abuse apart from the following: Semen in vagina, anus or on external genitalia Pregnancy

SEXUAL

ABUSE

MANAGEMENT OF SUSPECTED OR ACTUAL CHILD SEXUAL ABUSE Where there are suspicions of sexual abuse always discuss with a senior experienced paediatrician. The urgency of the response will depend on the time of the last episode. The definition of an acute assault is: In a female 13 years or older within the last seven days In a female of 12 years or younger within the last three days In all males within the last three days The ideal facility for an examination following an acute assault is the Sexual Assault Referral Centre (SARC) where there should be paediatric facilities and professionals trained to collect forensic specimens. Children should not bathe prior to a paediatric forensic medical examination. Where the suspicion or allegation of abuse does not relate to one of the recent episodes described above, refer the child or young person for a further opinion. These children may not need to be seen urgently, but if possible within a week in a special clinic with an experienced paediatrician.

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6 Neglect N

breakdown or absence of parental care. It is the most prevalent form of child maltreatment in the UK, and now represents more than one half of children and young people who become the subject of formal child protection processes. It is an insidious form of abuse affecting children in a variety of ways, including impaired growth and development and poor health. Its consequences can be irreparable, severe and long term, depriving children of the opportunity to realise their potential in all areas of social functioning, relationships and educational achievement. Neglect encompasses emotional deprivation and can coexist with physical and sexual abuse. It is a contributory factor in many child deaths and in extreme cases it may be the direct cause. Working Together to Safeguard Children describes neglect as: The persistent failure to meet a child’s basic physical and/or psychological needs, likely to result in the serious impairment of the child’s health and development. Neglect may occur during pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer failing to: Provide adequate food, clothing and shelter (including exclusion from home or abandonment) Protect a child from physical and emotional harm or danger Ensure adequate supervision (including the use of inadequate care-takers) Ensure access to appropriate medical care or treatment EGLECT DESCRIBES THE

It may also include neglect of, or unresponsiveness to a child’s basic emotional needs.

NEGLECT

NEGLECTFUL PARENTING Unlike physical abuse, where the parent behaves in a way that is hostile and interfering, neglect is often defined through acts of parental omission. Sometimes known as ‘passive abuse’, the neglectful parent is more likely to avoid, cut off and disengage from the child. Neglectful parenting can range from the inadequate but well-intentioned efforts of a parent with a mild learning disability to the detached disinterest and indifference of a clinically depressed parent. It also includes the disorganised neglect of the substance misusing parent whose erratic caregiving is dominated by chaos and continual crises. Neglect frequently involves lack of physical care, limited or non-existent emotional responsiveness and the absence of supervision and control. It can also be expressed in the deliberate deprivation of basic requirements such as food, warmth, protection and affection. Rarely expressed through a single incident, neglect is usually chronic and the result of a culmination of factors operating over many years. Mental health problems, learning disabilities, substance misuse and domestic violence feature regularly in the histories of the parents. In addition, poverty and chaotic lifestyles all too often testify to grim home environments and bleak lives. The problems of neglectful parents are often multiple: further adversity compounds disadvantage, and patterns of disadvantage prevail from generation to generation. Many parents who neglect their children lack the skills, resources and motivation to be ‘good enough’ parents. Neglected children are subsequently at risk of growing up into adults with limited skills and competence, becoming themselves, in turn, inadequate and neglectful parents. The signs of parental neglect are familiar to most health care practitioners; the majority of chaotically neglectful families are well known to them. Typically, mothers do not take up antenatal care when pregnant, children do not attend child health clinics for routine child health promotion (immunisations and developmental checks), parents do not seek medical care appropriately, or if they do, they present late with an untreated condition. When the child is seen in hospital or other primary health care settings, parents often ignore advice and fail to return for follow up assessments and reviews. The neglected child often does not attend nursery or school regularly and when they do, they arrive late. It is a

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sad irony that the very children who have the greatest need for health care and the stimulating environment provided by nursery or school are the ones least likely to get it. Dealing with the consequences of the neglect of the child’s health and educational needs tends to take up a disproportionate amount of professional resources and can produce very little change in the outcome for the child. Engagement with professionals, when it occurs, is often short lived; it may involve, for example, a single visit to the child health clinic for an immunisation, reflecting a strategy to avoid more unwelcome home visits rather than any real commitment to change parenting behaviour. Neglectful parents have volatile and unstable relationships, they are generally preoccupied with their own unmet needs and anxieties and this can propel them to make large demands on the professional network for practical and emotional support. Many have suffered neglectful childhoods themselves and are therefore the least well equipped to deal with continuing hardship and the relentless demands of small children. A sense of hopelessness and despair often prevails in such families and this can also overwhelm professionals who may feel a similar sense of helplessness in the face of problems that appear insurmountable. Consider how a preoccupation with the problems of the parent can divert the focus away from the child and obscure their needs. This can be exacerbated by the parent who constantly defers responsibility for their parenting difficulties onto the professional network: ‘If only social services sorted out my housing problems everything would be okay’, is one example of a ploy that often succeeds in deflecting concerns being raised by professionals. However, while the resolution of an acute housing problem or other pressing need may help in the short term, it will neither compensate for a severely depriving environment nor in itself change the behaviour of a parent who is chronically neglecting a child. IMPAIRMENT OF HEALTH AND DEVELOPMENT The impact of neglect varies according to the temperament, characteristics and coping mechanisms (resilience) of the child as well as the severity of the neglect. Take this into account when making a connection between neglectful parenting and the child’s health and

NEGLECT

development. Consider the signs below as potential indicators of neglect to be assessed and understood in the context of any other relevant information about the child and family’s circumstances. INFANTS: 0–2 YEARS PHYSICAL Poor growth Recurrent and persistent minor infections, neglected nappy rash Frequent accidents/injuries DEVELOPMENT Late attainment of milestones, e.g. pre-linguistic and social skills BEHAVIOUR Insecure attachments: anxious, avoidant Fractious, irritable, difficult to console Listless, lack of social responsiveness Self-soothing behaviours – rhythmical rocking and head banging The primary health care team sees infants more regularly than older children, with a greater opportunity therefore to recognise the neglect of their physical and emotional needs. Neglected infants and toddlers can be difficult to care for; they cry, cling, fret and fuss longer than other children and their behaviour can exacerbate the neglect of their needs by a parent who is already under stress. Neglected infants may have poor weight gain if they are not fed sufficiently or appropriately for their age. PRE-SCHOOL CHILDREN: 2–5 YEARS PHYSICAL Continuing sub-optimal growth, pale or anaemic Poor hygiene, dirty clothes and body Dental caries Untreated conditions e.g. squint Frequent accidents DEVELOPMENT Delayed speech and language development Poor relationships, peers and others BEHAVIOUR Hyperactivity, restlessness and attention difficulties Attention seeking

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Emotionally withdrawn or inappropriate friendliness towards unfamiliar adults Physical consequences of neglect persist through the pre-school period and often include poor growth. Speech and language development is especially vulnerable to the effects of a severely depriving environment, frequently compounded by recurrent and inadequately treated middle ear infections that cause mild to moderate hearing loss. Some children continue to develop one minor illness after another. Those who are persistently ignored will have difficulty in developing practical skills such as toileting and dressing. They will suffer more accidents and injuries through lack of supervision. Peer relations for neglected and under-stimulated children are likely to be difficult as they lack the opportunity to develop the social skills necessary for co-operative play. Behaviour in the clinic can also be revealing. Some children will seek attention and have frequent temper tantrums whereas others may be quiet and withdrawn; some may elicit intimate contact from complete strangers, even in the presence of their primary caregiver. SCHOOL-AGE CHILDREN: 5–16 YEARS Fails to reach potential height Undernourished, underweight or obese Poor hygiene, poor general health Chronic infestations (head lice) Tiredness, lethargy DEVELOPMENT Poor self care and social skills Poor concentration, low academic achievement Low self-esteem BEHAVIOUR Poor self regulatory skills, impulsive, immature Poor relationships, including peer rejection Deliberate self-harm Disruptive, destructive and/or withdrawn behaviour Aggressive, coercive and bullying behaviour Poor attendance at school, truanting, school exclusion Running away, antisocial behaviour PHYSICAL

NEGLECT

In the school-age child the effects and main indicators of long-term abuse and neglect are usually found in poor social and emotional adjustment, behavioural problems and low educational attainment. Neglected school children are often tired and lethargic. Schools may not be able to compensate for the long-term lack of cognitive stimulation at home because neglected children have great trouble attending to learning tasks, often exacerbated by poor attendance. Children who are poorly dressed and/or smell (poor hygiene) are also an easy target for peer taunts and bullying at school. Remember too, many of these behavioural difficulties will be part of the coping strategies the child develops to live with and accommodate the abuse. Never rule out neglect as a possible cause in children who are disruptive and difficult to manage at school. SAFEGUARDING THE NEGLECTED CHILD As with other forms of abuse, recognition and a prompt response to signs of neglect are crucial as the longer it continues the more difficult it becomes to influence the long-term outcome for the child. Children who do well are often those whose resilience is promoted and helped by other people. The neglected child has a need for an attachment figure that takes notice of them so the opportunity to develop a nurturing relationship with an adult who gives them a sense of their own self-worth will help. Equally, it has been shown that the opportunity to achieve and excel in their own right either at school or elsewhere can also help compensate for the effects of neglectful parenting. Remember this when the neglected child becomes the subject of a protection plan or any other ‘child in need’ plan, and help ensure that those supportive relationships are sustained and that children are taken to nursery and school regularly and on time.

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7 Emotional abuse E

probably the most complex form of abuse to define, identify and respond to. Although it is the most obvious and visible form of abuse, expressed as it is through the everyday interactions of parents and children, it continues to be under-recognised, frequently viewed as an accompanying or subordinate feature of other forms of abuse. Few children who are the subject of child protection plans are listed under the category of emotional abuse, even though the emotional consequences of all forms of abuse are likely to be the most damaging. The impact of continual emotional maltreatment is cumulative, serious and long term. Emotional abuse impairs the child’s psychological and emotional development with a potentially lifelong influence on any capacity to develop close relationships. MOTIONAL ABUSE IS

DEFINITION Emotional development in infancy and later childhood largely depends on ‘good enough parenting’, and this determines the quality of the attachment between parent and child. Emotional abuse describes a relationship that is characterised by harmful interactions, which impair a child’s psychological and emotional health and development: no physical contact is required. The abusing adult is nearly always the primary carer and attachment figure for the child. Different forms of emotional abuse affect children differently according to age and shape the development of psychological function at the time of their occurrence. Often children who are maltreated experience emotional abuse from an early age, frequently as a precursor to other abuse. Working Together to Safeguard Children describes emotional abuse as:

EMOTIONAL

ABUSE

the persistent emotional maltreatment of a child such as to cause severe and persistent adverse effects on the child’s emotional development. It may involve conveying to children that they are worthless or unloved, inadequate, or valued only insofar as they meet the needs of another person. It may feature age or developmentally inappropriate expectations being imposed on children. These may include interactions that are beyond the child’s developmental capability, as well as overprotection and limitation of exploration and learning, or preventing the child participating in normal social interaction. It may involve seeing or hearing the ill-treatment of another. It may involve serious bullying causing children frequently to feel frightened or in danger, or the exploitation or corruption of children. Some level of emotional abuse is involved in all types of maltreatment of a child, though it may occur alone. FEATURES OF EMOTIONAL ABUSE These are not easy to define precisely. How can the quality of the relationship between a child and parent be measured and judged? How often and to what degree does a child have to be shouted at before it becomes damaging? When does the behaviour of a frustrated parent berating a child for a misdemeanour become something that signals a more serious problem? All parents behave in ways that are hurtful to their children from time to time; these are usually temporary upsets in what is otherwise a securely attached parent/child relationship. Emotional abuse, on the other hand, is a pattern of behaviour where persistent and repetitive responses of negative emotion such as criticism, threats or ridicule, convey to children that they are worthless, unloved and unwanted. It may include some or all of the following: Rejecting. Refusing to acknowledge the child’s worth, their dependency and vulnerability Isolating. Cutting off the child from normal social experiences and contact with peers or adults Terrorising. Threatening to abandon, hurt or even kill the child, creating a climate of fear and bullying

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Ignoring. Depriving the child of essential stimulation and emotional responsiveness Corrupting. ‘Mis-socialising’ the child, encouraging destructive and anti-social behaviour Some parents and caregivers knowingly and deliberately harm their children through emotional abuse in the ways outlined above, for example, some violent men may terrorise a child in order to maintain control and dominance in the family. The majority, however, have no conscious wish to do so and may appear in many respects to be quite ordinary parents. It is often the accumulation of seemingly minor observations that provoke a feeling of unease and provide the first clue. There may be little the child does that pleases the parent, few expressions of warmth, little spontaneous touching and/or a sense of carefulness and wariness in the child’s interactions with their parent. The child may be viewed as constantly at fault, treated harshly and/or seen as the source of all of the parent’s difficulties. Parents with mental health problems, those whose problems are expressed through violent relationships or substance misuse and those with learning difficulties may all behave in ways that are emotionally abusive. Witnessing violence between parents, for example, or living with the emotional disengagement of a depressed parent are harmful experiences for a child, even though this may not be something deliberate on the part of the parent. They may not even be aware of the impact of their behaviour on the child, a state of affairs that can sometimes contribute to professional reluctance to acknowledge the abuse. Remember, it is the sustained, repetitive and inappropriate parental response that is key to determining the degree of harm/damage to the child. It can be illustrated by the following: Emotional unavailability, unresponsiveness and neglect Conditional parenting, inconsistency and unpredictability Persistent negative attributions – denigration, belittling, hostility or blaming, child seen as deserving discipline, rejection and punishment Developmentally inappropriate or inconsistent interactions, unrealistic expectations of a child, failure to protect or over-protection

EMOTIONAL

ABUSE

Failure to recognise and acknowledge child’s individuality and psychological boundary, an inability to distinguish between child’s reality and parents’ beliefs and wishes. Using the child to meet parents’ own needs Failure to promote child’s social adaptation or actively mis-socialising Parents who abuse their children emotionally and psychologically are very likely to have unresolved traumas from their own childhood experiences. These can be reactivated by the unregulated and constant demands of dependent children causing feelings of anxiety and agitation. Parents sometimes deal with the anxiety by withdrawing care; the greater the child’s need, the greater the need to avoid dealing with it. They may respond by becoming unavailable, unresponsive and cold; they may shut the child away, treat their need as contemptible and unworthy of attention or, in some more extreme cases, terrorise the child by threatening to harm them or something of crucial importance to them, such as a pet. Whatever form it takes the emotionally abusive parent usually fails to provide comfort and care at the very moment the child needs it most. IMPAIRMENT OF HEALTH AND DEVELOPMENT Infants and very young children are particularly at risk from emotional abuse as they often communicate needs and distress by crying and tantrums, the very responses that are most likely to provoke a hostile response in a parent under stress. The impact can be devastating for the child. The more traumatic, hostile and rejecting the caregiving, the more healthy brain development may be compromised, especially in the first year of life. Severe emotional unresponsiveness and rejection can impair the developing brain, in particular disrupting the child’s ability to process and regulate emotional arousal. It is a sad irony that children who experience the highest levels of emotional stress feel the least safe in expressing their fears and are denied the opportunity to explore, understand and regulate their emotions within a containing and supportive relationship. For the emotionally abused child there is nowhere to go with their distress; many develop coping mechanisms that put their

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physical health at risk as well as their emotional and psychological development. Children who have been emotionally abused often exhibit high levels of anxiety and have an insecure attachment to their parent. They do not seek comfort or safety when they are distressed or frightened; nor do they access their primary caregiver even if they are present. The child’s inability to control events and manage their own feelings can result in provocative, aggressive and anti-social behaviour, on the one hand, and despair, depression and withdrawal on the other. Some children are compliant and watchful, eager to please adults in order to avoid further abuse. Others direct their anger and aggression towards themselves. Emotionally maltreated children generally have very low self-esteem; those who have been constantly belittled, disparaged, mocked and humiliated, had their every effort criticised, can feel defective, ashamed and without worth, unlovable. They experience difficulty in giving and receiving affection and form poor relationships both within their family and at school. They can be punitive to others and lack empathy. Some or all of the following indicators may be expressions of a child’s distress at emotional abuse. CHILD’S AGE 0–1 Sleep/feeding problems, irritability, apathetic, anxious or avoidant attachments to primary caregivers, poor growth. 1–3 As above plus indiscriminate affection, fearful and anxious, withdrawn, aggressive, inability to play, anxious and ambivalent attachments, speech and language delay. 3–6 As above plus peer-relationship difficulties, attention seeking, clingy, poor performance in school, poor social skills. 6–12 As above, although sleep and feeding problems may resolve, inability to form close relationships, rejection by peers, poor school attendance, poor educational attainment, developing anti-social behaviours, running away, truancy, wetting, soiling, stealing, victims of as well as perpetrators of bullying. 12+ As above plus depression, escalated aggression, anxiety, self-harm, psychosomatic illness, substance misuse, criminal activities, promiscuity and abuse through sexual exploitation.

EMOTIONAL

ABUSE

When emotional abuse becomes integral to the relationship between the child and primary caregiver, the child may respond by attempting to minimise the risk of further abuse. An infant’s response to an anxious mother, for example, may be to resist eating in order to avoid a traumatic feed, which, in turn, creates greater tension and anxiety in the mother. If this pattern continues the infant may lose weight and become harder to handle, the situation potentially spiralling down into physical abuse, rejection and failure to thrive. A tragic consequence of this downward curve of attachment behaviour is that the very attempts of the child to avoid harm may increase the likelihood of further abuse. SAFEGUARDING THE EMOTIONALLY ABUSED CHILD Although there is no single event, sign or symptom that characterises emotional abuse, always consider it if the harmful interactions between parent and child are constant and there is serious concern about the child’s functioning and emotional state. Unlike sexual abuse, which is a secret activity, the quality of the relationship between parent and child is easily observable. Emotional abuse may be hard to identify and manage, but being able to articulate concerns about negative parent/child interactions, and show that they are causing significant harm, will be crucial in improving the outcome for emotionally abused children.

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8 Failure to thrive F

describes children who do not adequately gain weight or achieve the expected rate of growth for their age. Although mostly used with reference to infants and young children, failure to thrive can persist throughout childhood and into adolescence. If it passes unrecognised and untreated it may have adverse consequences for the child’s health and development. Failure to thrive can be organic (a feature of some medical conditions) or non-organic (no underlying physical cause), or a mixture of both. It may be associated with all types of child maltreatment, including emotional abuse and neglect. What causes failure to thrive is complex and varied, and there are both genetic and environmental influences. Organic failure to thrive is rare; it usually has a physiological basis and is associated with inadequate nutrition secondary to gastrointestinal disorders, chronic infection, major structural congenital abnormalities, and metabolic and endocrine defects. Non-organic failure to thrive is also linked to inadequate nutrition, but refers to children whose failure to grow has no underlying medical condition. In some cases it may be accompanied by other concerns about the child’s well-being and safety. Whatever causal factors are involved, all children who fail to thrive have a less than adequate intake of calories and are therefore not able to grow well. Organic and non-organic factors commonly co-exist, and the presence of one often leads to the rise of the other. Feeding or eating problems are common in children whether they have been maltreated or not. However, mothers of infants who fail to put on weight often experience an acute sense of failure themselves, which may lead to harmful interactions. These may be expressed in behaviour that ranges from indifference and withdrawal (that is, failure to provide adequate/appropriate food, ignoring AILURE TO THRIVE

FAILURE

TO

THRIVE

signals of hunger) to active hostility (such as force-feeding, screaming or smacking) and rejection of the child. The temperament and response of the child can add to the downward spiral of attachment. Children who are often unwell, for example, or difficult to feed, or who cry persistently can provoke a negative response from their parents/carers that makes matters worse. A negative pattern of interaction then develops that, if not interrupted at an early stage, can lead to a further distortion of the parent/ child relationship, attachment disorders, developmental impairment and poor growth. Some infants and children fail to thrive because they are generally under-stimulated and neglected as well as underfed. Parents who lack the capacity or are unwilling to provide adequate physical and emotional care are often unresponsive to their children’s needs and show limited concern for their welfare. PATTERNS OF GROWTH: CRITERIA FOR CONCERN The distribution of growth parameters – that is weight, height and head circumference – is shown on a growth chart. Up to six months, weight may continue to be influenced by maternal health in pregnancy and crossing centiles up or down is common. Thereafter, with the influence of the child’s genetic growth potential, growth is usually a smooth, continuous process with small variations around the child’s own centile. In general terms the nearer the child is to their own centile and the more closely they follow it, the more likely they are to be in good health. Healthy children approximately match height and weight centiles so consider any deviation in the expected growth trajectory in the light of other information about the child’s circumstances. As a guideline, the criteria for poor growth should be applied to all children whose weight deviates downwards across two or more centiles. Abnormal patterns of growth exist where the: Growth trajectory falls or crosses the centile Height and weight centiles are markedly discrepant GROWTH TRAJECTORY FALLS OR CROSSES THE CENTILES The child continues to put on weight although the gain is insufficient for their age and height, as demonstrated by the fall in centile position. If the

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child loses weight the decline in centile position will be faster. The latter may be due to an acute illness that is followed by recovery and rapid weight gain. Many children who fail to thrive cross several centiles over the first few years and then continue to grow along the low height and weight centile that they have reached. In addition some children start life on a low centile, and their poor rate of growth only becomes apparent when their circumstances change and their rate of growth accelerates. It is now thought that some children are able to adapt to a state of poor nutrition that often involves loss of appetite. Once there is a change in the child’s circumstances and their level of food intake increases there can be significant change in growth velocity and an improvement in the centile position – ‘catch-up growth’. This can be seen in children taken into hospital or foster care where changed circumstances prompt them to eat voraciously, leading to a rapid acceleration of growth. HEIGHT AND WEIGHT CENTILES ARE MARKEDLY DISCREPANT There is a marked or increasing discrepancy in the centile ranking between height and weight. Initially children may continue to grow in height and lose weight; it is only much later that height is affected. This discrepancy may also operate in reverse where there is increasing weight gain, leading to obesity and serious impairment of the child’s health. ASSESSMENT AND MANAGEMENT The process of assessing growth and managing failure to thrive has four interrelated stages: Measuring Recording and monitoring Consultation and referral Management MEASURING Assessment of a child’s growth is integral to any programme of child health promotion. Weight is usually checked at birth, at the six-week developmental check and at times of immunisation, that is, at two, three

FAILURE

TO

THRIVE

and four months old. The monitoring of weight at these times facilitates the early detection of poor growth. Continue to make regular measurements if an abnormality in growth is suspected and plot them on the growth chart. Measure length and head circumference (in children less than two years old) if there is any doubt about the adequacy of the weight gain. Carefully follow the detailed instructions given on the charts on how to plot these measurements. RECORDING AND MONITORING Growth charts are essential in helping to identify normal and abnormal growth patterns. Routinely plot all measurements on the A5 growth charts within the Personal Child Health Record (PCHR). Babies are weighed naked; toddlers wear only pants. If abnormal weight and/or height loss or gain is found, ensure there are no calculation errors. Continue to correct for prematurity (born before 37 weeks) up to one year of age. If there are concerns about a child’s growth, maintain parallel A4 charts in addition to the A5 chart in the PCHR. Keep these to facilitate monitoring and referral. CONSULTATION AND REFERRAL Discuss any perceived abnormal growth pattern with a more experienced colleague. Weight velocity changes significantly during the first two years of life, and many infants may cross up or down one or two centiles, particularly in the first year. A diagnosis of normal and adequate growth is very supportive for most parents; repeated weighing sometimes creates unnecessary anxiety, which itself can be damaging. Recognise and act on failure to thrive as early as possible, before patterns of poor nutrition and growth become entrenched. The condition can be difficult to acknowledge, lying as it does at the heart of what is considered to be ‘good enough’ parenting. There can be denial about it by both parents and professionals, and professional reluctance to discuss these issues with parents and respond promptly is potentially damaging for the child. Without active intervention children with poor growth or excessive weight gain may never reach their full potential.

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MANAGEMENT Once failure to thrive is identified, effective management includes addressing the underlying cause as well as taking steps to improve nutrition. In many cases, where poor growth (underweight or obese) is the outcome of the wrong food or poor feeding techniques for example, it can be managed by the advice, support and monitoring from members of the primary health care team. However, if failure to thrive does not respond to this intervention then consider referral to the consultant paediatrician. When a diagnosis of non-organic failure to thrive is made, children’s social care may need to become involved. View the management of non-organic failure to thrive as a multi-disciplinary and multi-agency responsibility. This will secure the best outcome for the child.

9 Abuse of children with disabilities C

can be and are abused. They represent a significant number of the total child population and are at a higher risk of abuse and neglect. Disabled children tend to be treated differently from other children, often isolated physically, geographically and socially. They are more dependent on others for their care and more likely to spend time in residential care. Children with disabilities can suffer abuse in all areas of life, whether in the home or at school, in foster or respite care, in a hospital or hostel. Wherever it occurs abuse has the same damaging and long-term consequences for the disabled child as it does for everyone else. HILDREN WITH DISABILITIES

RELATIONSHIP BETWEEN DISABILITY AND ABUSE Children with disabilities are children with difficulties that range from the mild to the severe and the simple to the complex. These include physical, sensory (that is, hearing and vision) and/or learning disabilities. They may include chronic illness or significant mental health problems. Children with learning disabilities and autistic spectrum disorders comprise the largest single group of disabled children. Many disabled children have multiple disabilities. In order to safeguard the disabled child it is important to appreciate both the nature and impact of a child’s disability as well as the type of abuse and its effect on the child. Children with disabilities are particularly vulnerable to abuse and neglect. Research suggests that they are many more times as likely to suffer abuse than other children and the presence of multiple disability compounds the risk. Abuse may also be implicated in the cause of

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disability. A child who has been physically abused (for example, nonaccidental head injury) may suffer permanent physical damage. Some children with a history of abuse and/or chronic neglect develop learning disabilities. The trauma of abuse can also compound a pre-existing disability and thereby increase a child’s vulnerability. The interrelationship between disability and abuse is complex. The maltreatment of children at home and in residential care covers a range of actions and behaviour. Some methods used to treat children may be abusive in themselves. The lack of privacy of children with high dependency needs can be compounded by actions that may be perceived as abusive, such as opening letters, listening to telephone calls or public toileting. WHAT MAKES A CHILD WITH A DISABILITY MORE VULNERABLE? STEREOTYPES AND PREJUDICE The prejudices and stereotypes that exist about disability tend to make children with disabilities more vulnerable to abuse and neglect. They can be perceived negatively, as different and therefore inferior, which can mean they are not responded to in the same way as other children. The child may be seen as having intrinsically less value within the family and as not having the same rights as the child without a disability. Some families do not believe that a child with a disability is capable of learning, which can lead to poor parenting, ineffective boundary setting and a failure to help the child to reach their full potential. There is also a belief among some people that children with disabilities do not have the same feelings or needs as other children. This can lead people to deny the importance of bereavement, loss, missing a parent, or the impact of other changes for children with disabilities. These assumptions can be exacerbated if the child has difficult or limited verbal communication. Negative perceptions of children with disabilities occur across a wide variety of cultures. This means disabled children from different ethnic and cultural backgrounds may be doubly disadvantaged, experiencing discrimination in relation to their ethnicity and culture as well as their disability. Discrimination may be further compounded by assumptions held about disability in the professional network. Parental abuse or neglect may be

ABUSE

OF

CHILDREN

WITH

DISABILITIES

tolerated by professionals particularly if the child is difficult to care for. The demands in caring for a child who requires constant monitoring, has challenging behaviour and/or is unable to respond to the parent, require understanding and support on the part of the professional network. However this should not lead to collusion with parental behaviour that would be considered unacceptable if it occurred in relation to a child without a disability. LACK OF PHYSICAL BOUNDARIES Age-appropriate physical boundaries do not exist for some disabled children, and it is often difficult for them to distinguish between touching that feels comfortable and appropriate, and touching that does not. The concept of ‘private parts’ has limited meaning for children, particularly if most or all of their physical care is attended to by other people. Their isolation and inexperience may mean they have a limited understanding of the boundaries of acceptable behaviour; some may not realise they are being abused, especially if they trust the perpetrator and there is no pain. Physical dependency also leaves disabled children less able to resist abuse; they cannot get away. COMPLIANCE AND PASSIVITY Attitudes to disability within the wider community foster compliance and passivity in the disabled child. Encouraged to do what they are told, they may have learned not to ‘complain’. Many disabled children have a desire to please and may appear to respond positively to the affection and closeness that can accompany sexual abuse. Children living in residential care may also find it difficult to complain about their care or incidents of abuse in case they are not believed or are punished in some way. Many disabled children have poor self-esteem; they may internalise a negative view of themselves and their disability and believe, as a consequence, that they deserve the abuse. COMMUNICATION DIFFICULTIES Disabled children are more dependent on others for their care and may be socially as well as physically isolated. They are likely to have fewer social opportunities so may not have the opportunity to disclose abuse or

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know who to tell. Children with limited communication skills and/or learning disabilities may find it difficult to express what is happening to them and to make themselves understood. A disabled child’s dependency on an abusing caregiver can also create difficulties in disclosing abuse, especially if they are a key person through whom the child communicates. All the difficulties outlined above are compounded by the fact that the testimony of disabled children is less likely to be believed. Distressed by the abuse and their desire for it to stop, their attempts to communicate may be misinterpreted as fantasy or challenging behaviour. Many child safety programmes do not include the disabled child and their particular needs; consequently disabled children receive less information about abuse and how to protect themselves. Safety strategies usually rely on a child’s cognitive skills, for example their ability to understand the difference between appropriate and inappropriate touch, something difficult for the disabled child. A disabled child may be more immature, dependent, inexperienced, inarticulate and needy than a child without a disability. The increasing integration of children with disabilities in mainstream schools can make them a target for bullying by peers as well as carers and teachers. Remember, perpetrators recognise their vulnerability; they are aware of the difficulties that such children have not only in reporting abuse but also in being believed. RECOGNISING ABUSE IN THE DISABLED CHILD FORMS OF MALTREATMENT OF CHILDREN WITH DISABILITIES Children with disabilities may be abused at home or in residential care. Wherever it occurs, the signs of abuse in the disabled child can be confusing, and changes in behaviour may be wrongly attributed to the disability itself. In addition to the universal indicators of maltreatment, the abuse and neglect of disabled children can cover a range of actions and behaviours that include the following: Force-feeding Segregation Unjustified or excessive physical restraint

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Rough handling Confinement to a room or cot Misuse of medication and over-sedation Ill-fitting equipment, e.g. poorly fitting splints Some methods used to treat children may be abusive in themselves, such as: Over-zealous behaviour modification including the deprivation of liquid, food, clothing or medication Misapplication of programmes or regimes Treatment without proper analgesia Invasive procedures without the child’s consent SIGNS OF ABUSE IN DISABLED CHILDREN If a disabled child is being abused they may show some of the following signs: Changes in behaviour e.g. aggressive, sexualised or unusually withdrawn behaviour Unexpected fear of a particular adult or reluctance to interact with them Sleep problems Unexplained injuries or bruising Repeated injuries or illnesses that do not receive the necessary medical attention Changes in eating patterns or fluctuations in weight Self-harming behaviour Remember these signs are not necessarily indicative of abuse. Disabled children will develop common childhood illnesses and normal developmental changes that may affect their behaviour. Complications arising from the disability may also prompt a change in behaviour. An understanding of the nature of the child’s disability as well as the abuse will help distinguish between behaviour that relates to the disability and behaviour that does not. In this way the impact of both can be properly assessed and acted on.

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THE IMPACT ON FAMILIES Be aware that when a child is diagnosed with a disability or chronic condition it is a major crisis for the whole family. Coming to terms with the child’s disability has been described as similar to a bereavement process particularly in relation to the shock, denial, anger, feelings of sadness and finally acceptance of the disability. Some families never come to terms with the situation. However if they are offered support and counselling at key stages, there is a greater likelihood that they will ‘let go’ of the perfect child they wanted and learn to love the child for who they are. As the child gets older, the demands on the parent’s time can become greater. This may be because the child is physically more difficult to care for or because they are more mobile but have no sense of danger, no concentration span and/or very challenging behaviour. If the child has limited or no verbal communication this can lead to frustration and temper tantrums when they are not able to make themselves understood. Parents may get very little sleep if the child has a poor sleeping pattern. The family will also have to engage with a range of different professionals and may have numerous appointments, which are time-consuming and stressful. The demands on the parents may also mean that the siblings get less attention and find themselves expected to play a large role in the child’s care. SAFEGUARDING THE DISABLED CHILD Working to safeguard children who have been abused or are at risk of abuse is a complex, stressful and demanding process, made harder when the child involved has a disability. Children with disabilities are often perceived and treated differently from other children by both parents/ carers and professionals. There is a common belief that disabled children are less likely to be abused, which can lead to a denial that abuse is taking place and failure to respond to it. In order to secure the best possible outcome for the child with a disability always act upon concerns about their welfare in the very same way as for any other child.

10 Parental non-engagement T

HERE WILL ALWAYS be parents/carers who do not wish to be helped by the

professional network for a variety of reasons, and they have the right to exercise that choice. However, the refusal or reluctance of parents or carers to engage with professionals where there are concerns about a child’s safety or welfare is often referred to as non-engagement or noncompliance and should trigger further enquiries. Always consider whether the non-engagement of a parent or carer is concealing child abuse or neglect. The checklist below helps pinpoint those occasions when parental non-engagement could indicate that a child is at risk: Outright refusal of a service, such as child health promotion, with little explanation and/or refusal to allow the child to be seen Child has not been seen for long periods Covert refusal of service, for example arrangements are made but not kept, leading to repeated failed appointments at home and/or in clinic Failure to comply with appointments (such as dentist, orthoptist, therapist, dietician, paediatric outpatients and so on) in circumstances that might jeopardise the child’s health and development

Consider too the following: Hostile behaviour towards health care workers and/or other individuals Prior history of abuse and/or neglect of the child or sibling

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Current concerns about the child and capacity of parent to meet child’s needs Families who have had a series of changes of address and children who change schools, nursery or GP frequently Children who access accident and emergency departments rather than primary care Parents sometimes withdraw from contact with the professional network when abuse is escalating. They may become difficult to contact. A professional may be regularly denied access to the home, the family may repeatedly fail to keep scheduled appointments and the child may stop attending nursery or school. In some circumstances a family may disappear altogether. If there is also a history of abuse the child may be at increased risk, and vigilance is vital until there is evidence that the child is safe. Equally, parents may appear to comply and co-operate with professionals because they recognise that permitting limited access is a more effective way of keeping figures of authority at bay than outright refusal. Some parents can be devious, manipulative and/or threatening. Some lie in order to conceal abuse. Others evoke sympathy and demand the attention and support of the professional network in meeting their own needs. Whatever the circumstances, be suspicious if the apparent willingness of a parent to co-operate does not produce any change in the outcome for the child. Judge each situation on its individual merits and in the context of all the available information about child and family. Inform other agencies and professionals who know the family. Refer to children’s social care if there is any possibility that a parent’s non-engagement is concealing abuse or neglect. When the parents/carers of a child who is the subject of a child protection plan do not comply with it, inform the key worker immediately with a view to reconvening a child protection conference.

11 The child protection conference A

is a formal meeting convened by the local authority children’s social care. It is the principal forum for professionals and families to share information and concerns about a child considered to be at risk of continuing significant harm. CHILD PROTECTION CONFERENCE

INITIAL ASSESSMENT AND CHILD PROTECTION ENQUIRY The initial assessment is the first part of the process of analysing information gathered following a referral to children’s social care. The aim of the initial assessment is to assess the child’s needs and the capacity of the parents and wider family to ensure their safety and respond appropriately to their health and developmental needs. All agencies involved with the child and family have a responsibility to share information at this stage so that a decision can be made about whether a child protection enquiry is needed. If the child is considered to be suffering significant harm, a child protection conference will be convened by the local authority children’s social care. It will involve the family, children’s social care, police, health, education and sometimes other individuals and agencies. THE CONFERENCE The purpose of the child protection conference is to share information collected during the enquiry process, and to analyse and assess the degree of risk to the individual child or children within a family. If the conference decides that the child is at continuing risk of significant harm it makes

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recommendations for action in the form of a protection plan to safeguard the child and promote their welfare. The conference includes parents and/or other carers and their representatives. Parents are encouraged to attend because in most cases they are key to the care and protection of their children. The Children Act 1989 places a duty of care on parents and a duty on the professional network to assist them in fulfilling their responsibilities. Parents are rarely excluded from conferences. This only happens if it is considered their involvement could compromise the safety or well-being of the child or otherwise interfere with the task of the conference to ensure the child’s safety. The safety and welfare of the child is always the central and primary focus. Conferences sometimes include children and their presence will depend on their age and level of understanding. In assessing the child’s capacity to benefit from participating in the conference, a balance needs to be struck between their need to be involved and their need to be protected from the stresses and conflicts of the process. Always look at ways in which the child’s views and feelings can be communicated to the conference irrespective of whether or not they are present; they are a crucial source of information about what has happened to them. The conference symbolises the inter-agency nature of the assessment and planning process. It draws together professionals from all agencies with specific responsibilities for the child and family (children’s social care, health, police, education, probation and the voluntary sector) as well as others able to offer specialist advice (such as solicitors or housing officers). It provides a joint forum for conducting and agreeing a combined approach to work with the child and family to secure the best possible outcome for the child. As part of this process health representation at conferences is vital; it ensures that relevant details of the child’s health, growth and development are communicated to involved professionals from other agencies. Health professionals will also be able to give an opinion about the capacity of the parent/carer to promote the child’s health and development and protect them from further harm. The conference will not be able to fully assess the risk to the child, or make informed decisions and recommendations about their welfare, without a health professional present and/or their report.

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THE CHILD PROTECTION CONFERENCE PROCESS In fulfilling its statutory role the child protection conference will: Share relevant information about the child and family Assess the risk to the child Decide whether the child is at continuing risk of significant harm Decide whether the actions required to safeguard and promote the welfare of the child need to be formulated within the framework of a child protection plan Appoint a key worker who must be a social worker or a nominee from the NSPCC Identify membership of the core group who will develop and implement the plan Ensure a contingency plan is in place if agreed actions are not completed and/or circumstances change Agree about if and when to reconvene and review There are two types of child protection conference: initial and review. The initial child protection conference is convened following a child protection enquiry. The subsequent use of the word ‘review’ describes all the ensuing conferences. A child protection review conference is held within three months of the initial conference and further reviews should be held at intervals of not more than six months while the child remains the subject of a protection plan. When there are concerns about the safety of an unborn child, a pre-birth child protection conference is held. Such conferences have the same status and are conducted in the same manner as initial child protection conferences. The conference needs to establish, as far as possible, the cause of harm or the likelihood of harm. This is something that might apply to siblings or other children in the same household and might justify their assessment and subsequent inclusion in a protection plan. Children are categorised according to the area of concern; the chair of the conference will decide under which category or categories of abuse or neglect the child has suffered or is likely to suffer. This will indicate to those consulting the child’s social care record the primary presenting concerns at the time the child became the subject of a child protection plan. A child will not continue to be the subject of a child protection plan if

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they are no longer considered to be at risk of significant harm. However, unless the child has reached the age of 18 or permanently left the UK, only a child protection review conference can decide that a protection plan is no longer necessary CONFIDENTIALITY Participants at child protection conferences are bound by the rules of confidentiality. They are expected to share information that is relevant to the protection of the child. Anything discussed at a conference is confidential to those participating and shared only on a strictly ‘needs to know’ basis, that is, with other professionals who hold responsibility for the protection of the child. Discuss any decision to withhold information that might adversely affect a child’s safety and well-being with either one of the designated or named professionals or another experienced colleague. DISSENT Be aware that conference attendees may not always reach agreement about the degree of risk to a child. Judgements about significant harm and the actions that need to follow them can be difficult to make, especially where the issues are complex. There may sometimes appear to be no obvious right or wrong answer and in some cases no options that do not appear to entail some risk of harm for the child. Where differences of opinion are significant, ensure any dissent and the reason for it is recorded in the minutes. Issues arising from a lack of consensus at a conference may require further discussion if the dissenter wishes to challenge the decision reached by the conference; this is especially important if the dissenter feels a conference decision has put a child at further risk of harm. Discuss this with one of the named or designated professionals or another experienced colleague. THE CHILD PROTECTION PLAN The child protection conference is responsible for deciding if the child needs to be the subject of a child protection plan or, in the case of the review conference, if the child needs to continue to be the subject of a protection plan. In making this decision it should consider the following question:

THE

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Is the child at continuing risk of significant harm? The test should be that either: The child can be shown to have suffered ill treatment or impairment of health or development as a result of physical, emotional or sexual abuse, or neglect, and professional judgement is that further ill treatment or impairment is likely; or Professional judgement, substantiated by the findings of enquiries in this individual case or by research evidence, is that the child is likely to suffer ill treatment or the impairment of health or development as a result of physical, emotional, or sexual abuse or neglect If the child is considered to be at continuing risk of harm, professional support and intervention will be co-ordinated and managed within the formal framework of a child protection plan. An outline plan will specify what needs to change and how that is expected to reduce the risk of harm to the child within a certain time scale. It will detail each agency’s contribution to the future protection of the child and will clarify what is expected of the parents and what in turn the parents can expect of each agency. It will also identify any further core and specialist assessments required. THE CORE GROUP The core group is responsible for the development and implementation of the outline child protection plan. Core group meetings take place between conferences; membership will include the parent/carer, wider family if appropriate, key worker and any professional within the multi-agency network directly involved in the implementation of the plan. In some cases the child is also involved. The core group undertakes the core assessment, co-ordinates and develops the work agreed upon in the child protection plan and monitors its progress in the light of the objectives set at the conference.

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CORE ASSESSMENT All children who are the subject of a protection plan will have a core assessment; this builds on the knowledge obtained through the initial assessment, enquiry process and conference. Health professionals are expected to contribute to the core assessment and provide or arrange specialist assessments where appropriate. PREPARATION OF CONFERENCE REPORTS Working Together to Safeguard Children states that all professionals attending a child protection conference should prepare a written report. The report should include an assessment of the child’s health and development (including growth charts where appropriate) and detail any professional involvement relevant to the child’s welfare. It should provide information, where known, about significant relationships within the family and any information that may highlight issues around the capacity of the parent/carer to meet the child’s needs and promote their health and development. All reports should distinguish between fact and observation, allegation and opinion, and support professional opinion with relevant evidence and/or research. Factual information should be clear, concise and relevant to the well-being of the child. Make every effort not only to ensure that the parent is aware of the report’s content but also to consider what the child needs to know in the context of their age and understanding. Remember to include the perceptions, views and feelings of both parent and child. The following checklist offers guidance to what might be included in the report. It does not provide an exhaustive list of risk factors. Nor can it indicate the nature, degree or severity of risk; that is a matter for individual professional judgement. Look at the relationship between a number of different factors. The fact that a child is not seen, for example, carries no risk in most cases. However, if this were to be combined with, say, a history of previous abuse, it might indicate a more serious concern. PARENTING CAPACITY PHYSICAL CARE Assess the parents’ capacity to meet a child’s physical needs and protect them from harm. Examples of less than ‘good enough’

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parenting might include: lack of supervision, poor nutrition, poor hygiene, inadequate clothing, not meeting identified health needs, failed appointments, unsafe/chaotic home conditions with little or no evidence of provision of basic needs (food, warmth, adequate shelter, basic hygiene and toys). Assess the quality of the parent/child relationship and the impact of any known difficulties. Examples of these might include: unrealistic or developmentally inappropriate expectations, over critical, little or no warmth, lack of understanding and responsiveness to a child’s needs, parental scapegoating or rejection of the child. EMOTIONAL/PSYCHOLOGICAL CARE

Consider the two elements of parenting capacity, ability and motivation; if either is missing, the parent will be unable to respond appropriately to the child’s needs. CHILD’S DEVELOPMENTAL NEEDS Assess the child’s appearance, growth and development. Make reference to growth charts, developmental checks, immunisation status, contacts with primary care team and other clinic/hospital attendance and their outcomes. Remember to include information on the child’s past history.

PHYSICAL HEALTH AND DEVELOPMENT

EMOTIONAL AND PSYCHOLOGICAL HEALTH Assess the child’s mood, non-verbal cues, behaviour, play, response to parent/siblings. Listen to what the child says and report any relevant allegation or disclosure. Identify and comment on behaviour that could indicate that the parent/ carer’s capacity to meet the child’s needs is less than adequate. Examples might include: aggressive, attention seeking behaviour, a withdrawn, wary, anxious or otherwise unhappy child, an over-dependent child or inappropriate friendliness.

Comment too on the protective factors for the child. Factors that may influence the outcome for the child include a secure attachment to the primary caregiver, other non-abusive, secure and enduring relationships, and the opportunity to excel in their own right, e.g. achievement at school.

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FAMILY AND ENVIRONMENTAL FACTORS This includes factors that may influence a parent/carer’s capacity to respond appropriately to their child’s needs and the impact of the wider family and social network. Examples might be: history of domestic violence, substance misuse, mental health problems, social isolation, diffuse social problems, homelessness, unemployment. A family genogram may be helpful in clarifying the relationships within the wider family network. FAMILY STRENGTHS/PROTECTIVE FACTORS Include strengths within the family with the potential to minimise risk to the child, the strong and positive aspects of the parent/child relationship as well as its weak and negative side. This creates a balanced view of the parent/carer’s capacity to provide ‘good enough’ care and their potential to make whatever changes necessary to meet this need in the future. Examples of protective factors in families might include a parent with insight into the problem, one prepared to take appropriate responsibility and accept the need to work with the professionals to achieve change. It might include the existence of an involved extended family network willing to assume some responsibility for the child’s welfare and support the parents in providing good enough care, or family difficulties where the child is not blamed and the parent can see the world from their point of view. ASSESSMENT OF RISK Look at the relationship between the evidence of maltreatment or lack of care and its impact on the child in order to reach a view about the risk of continuing significant harm to the child. Focus perhaps on one particular issue seen to have overriding significance, or summarise the principal issues identified in some or all of the previous four sections. FUTURE PLAN OF WORK Clarify the role and contribution of each service in meeting the needs of the child and family. Revise this perhaps after the conference when the multi-agency assessment, decision-making and planning process is complete.

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THE INTEGRATED CHILDREN’S SYSTEM The Integrated Children’s System (ICS) is a conceptual framework designed to facilitate the four key processes that underpin work with children and families: assessment, planning, intervention and review. It will be implemented electronically and enable information gathered during assessments to be used more effectively in making plans and deciding on the best interventions. Each local authority children’s social care service will record in the child’s electronic social care record (ESCR) when the child is the subject of a child protection plan. The ICS will be able to provide information about all children who are the subject of protection plans to concerned agencies and professionals. Children will be recorded as having been abused or neglected under one or more of the categories of physical, emotional or sexual abuse or neglect, according to a decision made by the chair of the child protection conference. The purpose of the ICS, which is managed by the local authority, is to: Enable agencies and professionals to obtain information about children who are the subject of a protection plan Provide 24-hour access to information for agencies such as the police and health professionals who have a legitimate right to access it Indicate to those consulting the local authority ICS the primary concern at the time the child became the subject of a child protection plan Provide a source of data for looking at trends in child abuse and neglect It is designed to replace the child protection register, a mechanism used to alert professionals to the need for continued surveillance. It is likely that child protection registers will continue to operate in some local authorities while they continue to develop their capacity to provide a fully operational ICS. Be aware that the ICS, like the child protection register that preceded it, is not a record of all children who have been abused. It contains the names of children about whom there are unresolved child protection issues and for whom there is an inter-agency protection plan.

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12 Records P

made formal and explicit through the accurate recording of information. This is an essential prerequisite for effective communication and as such plays a crucial part in safeguarding children. ROFESSIONAL ACCOUNTABILITY IS

BASIC PRINCIPLES Written communication in the form of good record keeping and effective verbal communication go hand in hand. Good documentation can shape the view of a case, clarify objectives, stimulate further action and in this way form the basis for sound professional decision-making. Where there is concern about the safety and welfare of a child, ensure that this is accurately documented in the child’s records. Include a precise and detailed account of the event/contact, the decision reached and any action plan and/or referral. Include discussions with other professionals. Distinguish between what is observation, suspicion and opinion. The record should be contemporaneous with the contact or otherwise written within 24 hours of it. In all cases, note the date and place of contact and remember to sign it. Check that the current and previous names of the child, the address, date of birth, GP and current day care/ nursery/school are recorded. Include the names of all adults who have parental responsibility and/or who live with the child; concerns about any of this information should trigger further enquiries. The record should be legible, continuous and clear; the information systematically stored and easy to access. It is for other professionals to read as well; they should be able to find historical information easily and use what is already known about the child and family to inform the current assessment and planning process for the child. Ensure there is a

RECORDS

mechanism to highlight those children about whom there are unresolved child protection concerns, for both written and electronic records. Once a child is known to have moved, discuss concerns, if possible, with the receiving professional and ensure that primary care records follow them as speedily as possible. Send letters and discharge summaries promptly with copies to professionals and parents as appropriate. This will enable historical information from a number of sources to be integrated into current assessments. Tell parents/carers and children about their health records. One of the principles of ‘working in partnership’ is that parents and children (depending on their age and understanding) are kept informed of what is recorded about them and why. Explain too why information needs to be shared with others. Involve them by completing the record with them and give them copies where appropriate. Remember all records are legal documents and can be used as evidence in legal proceedings as well as being read by the parent and sometimes the child. In addition parents may also have access to copies of correspondence that are held by a third party, for example children’s social care. CONFIDENTIALITY AND INFORMATION SHARING The sharing of information should operate in accordance with the Data Protection Act 1998, and all health service trusts have a responsibility for improving the way that the NHS handles and protects patient information. The general principles of the act are that: There is a general common law duty to safeguard the confidentiality of personal information; and Decisions to disclose information or to refuse a request for disclosure from another agency or individual should always be clearly recorded However, the degree of confidentiality should always be governed by the need to protect the child. Under certain circumstances the act does allow for the disclosure of information without the consent of the individual concerned. Discuss disclosure of all or part of any record with the parent and/or child (depending on their age and understanding), and seek and obtain their consent where possible. If agreement is withheld, and there is

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professional concern about the risk of harm to a child, disclose any relevant information. Make any disclosure on a strictly ‘needs to know’ basis, that is to other professionals who share responsibility for safeguarding the child. Ensure that maintaining the confidentiality of the record does not become a barrier to communication that places a child at further risk. If in doubt and concerned that withholding information may adversely affect a child’s safety and well-being, discuss with one of the named or designated professionals or another experienced colleague. CALDICOTT STANDARDS The Caldicott standards are based on the principles of the Data Protection Act 1998; they provide a framework for the management of confidential information and access to personal information for the NHS and social care services. This includes standards for the secure storage and transfer of confidential information/records. Local arrangements for information sharing within health and children’s social care have to comply with these standards; however, they do not prevent the sharing of information where there are concerns about the safety and welfare of a child.

13 The legal framework T

1989 and the Children Act 2004 set out the legal requirements for safeguarding children in England and Wales. The 1989 Act balances the duty to protect children with the need to promote their welfare in a series of principles governing practice and procedure, both in and out of court. It is based upon the belief that the welfare of the child is paramount and that children are generally best looked after within the family, with both parents playing a full part and without resort to legal proceedings. The 2004 Act sets the framework for partnership working and information sharing within the professional network. It requires all organisations to ensure that arrangements to safeguard and promote the well-being of children and young people are an integral part of every service provided for children and their families. HE CHILDREN ACT

MAIN PRINCIPLES OF THE CHILDREN ACT 1989 Welfare of the child is paramount Children should be brought up and cared for within their own families, wherever possible Children in danger should be kept safe and protected by effective intervention Agencies should work in partnership with parents in so far as this does not prejudice the welfare of the child Delays in decisions affecting children are likely to prejudice their welfare. Courts should ensure that delay is avoided and make an order only if to do so is better than not Children should be informed about what is happening to them, and their wishes and feelings taken into account (considered in the light of their age and understanding). They should have the

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opportunity to participate in decisions being made about their future Parents continue to have parental responsibility in relation to their children, even if their children are no longer living with them. They should be kept informed about their children and participate in decisions made about their future Parents with children in need should be helped to bring them up themselves Help should be provided as a service to the child and their family and be provided in partnership with the parents meet each child’s identified needs be appropriate to the child’s race, culture, religion and language be open to effective, independent representations and complaints procedures draw upon effective partnership between the local authority and other agencies, including voluntary agencies PARENTAL RESPONSIBILITY Responsibility is the key word here. Although defined as all the rights, duties, powers, responsibilities and authority that by law the parent of a child has in relation to that child, the legal emphasis is on responsibility. The Act expects parents to exercise responsibility for looking after their children, and local authorities have a duty to support them in so doing as the need arises. Parental responsibility may be shared by a number of people. The birth mother always has parental responsibility (unless it has been lost through the child being adopted). The birth father has parental responsibility jointly with the mother if they marry at any time before or after the child’s conception or, since 2003, if both parents register the birth together. Adults, such as the unmarried father, grandparents or step-parents can acquire parental responsibility through a Parental Responsibility Order, as can the local authority through the making of a Care Order. If parental responsibility is acquired through a court order, such as a Residence Order, it is lost when the order ends.

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Establish who has parental responsibility when seeking consent for treatment, for example immunisation. SIGNIFICANT HARM AND COURT PROCEDURES The Children Act 1989 introduced the concept of significant harm as the threshold that justifies compulsory intervention in family life in the best interests of children. The sole ground for initiating proceedings under the Children Act 1989 is that the child is suffering or is likely to suffer significant harm, and that the harm, or likelihood of harm, is attributable to: Care given to the child, or likely to be given to them, if the order were not made, not being what it would be reasonable to expect a parent to give to them, or The child being beyond parental control In reaching a decision about a child the court considers: The comparison of the child’s health and development with a similar child Whether the care given by the parents should be what might reasonably be expected Whether minor shortcomings in care or deficits in development may have a cumulative effect and result in significant harm The court’s Welfare Checklist therefore includes the following: Wishes of the child Child’s physical, emotional and educational needs Likely effect of any change in their circumstances Age, sex, cultural background and any other characteristic the court considers relevant Any harm the child has suffered or is at risk of suffering Capability of the child’s parents or any other potential carer to provide reasonable parental care If the local authority believes the threshold criteria are satisfied it will either apply for a court order or, if possible, seek other ways of addressing the shortfalls in parenting capacity, for example through a child protection

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plan. In some applications for court orders, primarily care applications, the court appoints a children’s guardian (formerly guardian ad litem), someone who reports on and makes recommendations about the child to the court. Guardians are independent practitioners, usually social workers, with responsiblity for helping the court reach a decision about a child. The guardian can inspect children’s social care files and request information or copies of documents relating to the child from any other agency involved. The children’s guardian does not have right of access to the child’s medical notes. Authority to see these records must be sought from whomever has parental responsibility. Be aware that in all care proceedings the local authority has to make a good enough case to convince the judge that on the balance of probabilities it is in the child’s interests to grant a Care Order committing the child to the care of the local authority. This is a lower standard of proof than that required for criminal proceedings where guilt must be proved beyond all reasonable doubt. Remember, while some cases of child abuse and neglect do result in criminal proceedings, the conviction of a parent is not a requirement for care proceedings. ENQUIRIES ABOUT CHILD SAFETY AND WELFARE Under the Children Act 1989 local authorities are required to provide services for children in need (Section 17) and to make enquiries about any child in their area whom they have reason to believe may be at risk of significant harm (Section 47). These enquiries usually follow a referral made by someone in the professional network (e.g. health or education) or a member of the family and/or community who is worried about a child’s safety and welfare. In the course of these enquiries children’s social care may request help from professionals in other agencies. Always cooperate with any such enquiry and provide information relevant to it. Children’s social care may request: Information about a child, young person or family in relation to an assessment of need or a child protection enquiry A specialist assessment as part of a core assessment or the provision of a service for a child in need Attendance and the provision of a report for a child protection conference

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In cases where there is a risk to life or very serious harm, emergency action may be required to secure the immediate safety of the child. In the great majority of cases, however, children will remain with their families following Section 47 enquiries even where concerns about abuse or neglect are substantiated. INFORMATION SHARING, CONSENT AND CONFIDENTIALITY All health service workers should maintain the confidentiality of patient/ client information and all professional regulatory bodies have their own code of conduct in relation to this. However, the willingness of professionals to share information is crucial where there are concerns about the safety or well-being of a child. In child protection practice there are three ways in which the disclosure of confidential information can be justified: With the consent of the parent/carer and/or child Without consent when the disclosure is required by law or by order of the court Without consent when disclosure is considered necessary in the public interest. This includes child abuse The issue of consent is one that presents most difficulty for health care workers. There will be occasions where abuse or neglect is suspected and it is either not possible to gain consent for information to be disclosed or consent is actively withheld. It may be the victim, the perpetrator of the abuse or another person who is withholding consent. Whatever the circumstances, the primary duty and responsibility of the professional is to act in the child’s best interests. Although disclosure without consent should be the exception rather than the rule, it is lawful to disclose confidential information if it appears necessary to do so to safeguard a child in the ‘public interest’. In practice this means that the public interest in protecting children may override the public interest in maintaining confidentiality. Remember to disclose information relevant to the concern about the child and share information on a ‘needs to know’ basis with those who have a duty of care towards the child.

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THE FRASER RULING The Fraser ruling refers to the Gillick case, which concerned the right of a young person under 16 years of age to give consent for medical treatment without the parents’ knowledge. The subsequent ruling said that a young person can be considered competent to consent to treatment if their age and understanding are sufficient to enable them to understand what is involved. The concept of competence is central to the law’s approach to consent, hence the commonly used term Gillick Competence. The Fraser ruling defines competence as an ability to understand information about a proposed treatment. However, in practice it may be difficult to define the level of understanding required for a particular treatment or procedure. There is no easy test of competence for young people and the ability to understand may not necessarily be the same as actual understanding. If in doubt, consult one of the named or designated professionals or another experienced colleague. THE CHILDREN ACT 2004 The Children Act 2004 provides the legal framework for the revised duties and responsibilties initially outlined in Every Child Matters, which was the government’s response to the findings of the Victoria Climbié inquiry in 2003. It forms part of a wider strategy for improving children’s lives that encompasses the universal services every child accesses as well as more targeted and specialist services for those with additional needs. The purpose of the act is to encourage an integrated approach to the planning, commissioning and delivery of childrens’ services as well as to improve inter-disciplinary and inter-agency working. It will have a major impact on the delivery of children’s services, both in relation to the development of children’s trusts and children’s centres and in providing a statutory framework for information sharing and partnership working. The Children Act 2004 places a statutory duty on all agencies and organisations to safeguard and promote the welfare of children and young people. It states that all organisations providing services to children, young people and/or parents or carers should: Have senior managers who are committed to children and young people’s safety and well-being

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Have a clear line of accountability within the organisation for work on safeguarding Be clear about people’s responsibilities to safeguard and promote children and young people’s welfare Have effective recruitment and human resources procedures including checking all new staff and volunteers to make sure they are safe to work with children and young people Have procedures in place for dealing with allegations of abuse against members of staff and volunteers Make sure staff get training that helps them do their job well Have procedures about how to safeguard and promote the welfare of young people Have agreements about working with other organisations The way in which agencies fulfil these requirements depends on their respective functions. In the health service it means compliance with the government’s Standards for Better Health and the National Service Framework for Children, Young People and Maternity Services standard that deals with safeguarding. The Healthcare Commission use these standards to assess and review the performance of all health organisations. Guidance on the duty to co-operate provides the underpinning framework for the development of children’s trusts and children’s centres that will form the basis for the development of inter-disciplinary and interagency teams integrating education, health and social care around the needs of the child. Within this framework children’s well-being has acquired a legal definition and safeguarding is viewed as an essential component of the universal support for all children and young people. ‘Well-being’ is the term used to define the five outcomes for children and young people: Staying safe (refers to protection from harm, including abuse and neglect) Being healthy (refers to physical, mental health and emotional wellbeing) Enjoying and achieving (refers to education, training and recreation) Making a positive contribution to society Economic well-being

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The Children Act 2004 also requires local authorities to produce in collaboration with other agencies, an inter-agency Children and Young People’s Plan that sets out how these five outcomes will be achieved. This strategic plan encompasses all local services for children with cross-agency agreement on targets, priorities and the actions required to achieve them. It is significant that the guidance for the implementation of the Act is issued in two parts, one supporting the strategic imperatives, policy, planning and children’s trust governance and the second focused on operational priorities, integrated front line delivery and the processes that support it. In separating the guidance in this way the message is clear; complying with the legislation is not just a matter of setting up the appropriate structures and processes, it is also about providing practitioners with the requisite tools to do the job well. To facilitate this, the second part is concerned with providing guidance on areas of practice such as information sharing, the Common Assessment Framework and the role of the lead professional. THE LOCAL SAFEGUARDING CHILDREN BOARD (LSCB) There are LSCBs in each local authority area. They have replaced area child protection committees (ACPCs) and have a statutory duty to agree how relevant organisations will co-operate to safeguard children in each locality. The Children Act 2004 sets out their core objectives and core membership, which includes local authorities, health, the police and voluntary agencies. Guidance on LSCBs can be found in Working Together to Safeguard Children. It covers their role, function and operation, including their relationship to the rest of local children’s services. The terms of reference of the LSCBs are much broader than the ACPCs that preceded them; they are expected to focus on co-ordinating local inter-agency work to ensure the effectiveness of the local area’s contribution to the ‘staying safe’ outcome, which includes keeping children safe from all dangers, for example road traffic accidents, as well as abuse and neglect. The work of LSCBs to ensure the effectiveness of inter-agency practice and the consistency of the contribution of individual agencies will be measured through a peer review process based on self-evaluation, performance indicators and joint audit. The local inspection framework

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will feed into this process, for example, in relation to the contribution from health services, the LSCB will draw on information provided by the Healthcare Commission, which measures and reports on the effectiveness of local health services. The LSCBs will have a duty to challenge individuals and agencies that are not performing effectively and for referring, if necessary, to the relevant inspectorate or government department if there is no improvement. The effectiveness of the LSCB itself will form part of the remit of local inspections through the joint area review (JAR) process that covers all aspects of children’s services.

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APPENDIX 1

The Common Assessment Framework

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THE COMMON ASSESSMENT FRAMEWORK (CAF) THE ASSESSMENT FRAMEWORK is an assessment tool, providing practitioners in all children’s services in England with a standardised way of assessing a child’s needs and deciding how those needs should be met. It is designed to facilitate earlier identification of additional needs, particularly in universal services, such as health and education. Its use will promote an integrated, inter-agency approach to both the assessment process and the provision of services. The Framework is represented in the form of a triangle with the child’s welfare at the centre. It consists of three domains: Child’s developmental needs Parenting capacity Family and environmental factors An assessment will depend on an analysis of the relationship between the three domains and the way they influence each other, positively and negatively. This will include an analysis of information about the child’s developmental needs, the capacity of parents and carers to respond appropriately to those needs and the impact of the wider family and environmental factors. It will also include an analysis of the parent’s ability and willingness to take responsibility for their parenting and work with the professional network to achieve change. An assessment can be completed at any time it is considered that a child will not be able to progress towards the five outcomes (see p. 4) without additional services. Use an assessment when: There is concern about how well a child is progressing. There may be concerns about health, behaviour, progress in learning or any other aspects of child well-being, or they or their parent may have raised a concern The needs are unclear, or broader than the primary care service can address There are concerns that a child may be suffering significant harm Remember, an assessment is a continuous process not a single or fixed event. Make sure that any new information about the child and family is

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integrated into the assessment; its impact on the safety and welfare of the child thought about and responded to. The Common Assessment Framework includes a pre-assessment checklist to help practitioners identify children who would benefit from an assessment. Assessments are intended to be completed with the family and to be used to: Promote early intervention once needs have been identified Determine what, if any, additional support may be required Share information with other practitioners Reduce the number of assessments a child may need to undergo THE LEAD PROFESSIONAL Where more than two agencies are involved in providing a service, a lead professional will be identified to: Act as a point of contact with the child and family Co-ordinate all inter-agency intervention to ensure that it works effectively The lead professional can be a practitioner from any agency and will vary according to the specific needs of the child. CONTACT POINT (THE INFORMATION SHARING INDEX) The information sharing index, known as Contact Point, is a national database that has information on every child and young person in England. Contact Point is a tool enabling practitioners to find out easily and quickly who else is working with the same child or young person so they can share relevant information and co-ordinate service provision. Access will be controlled and limited to authorised practitioners in children’s services. The index will contain the following information: Name, date of birth, address A unique identifying number Contact details for parent/carer School GP Contact details for practitioners and services involved with the child

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The named lead professional (if appointed) It will not hold any assessment or case information.

Dimensions of child’s developmental needs HEALTH Includes optimum growth and development as well as physical and mental well-being. It involves: A healthy lifestyle An adequate and nutritious diet Exercise Immunisations where appropriate and developmental checks Regular dental and optical care Receiving appropriate health care when ill It also involves, for older children, appropriate advice and information on issues that have an impact on health, including sex education and substance misuse. EDUCATION Covers all areas of a child’s cognitive (level of reasoning and understanding) development, which begins from birth. It includes opportunities: For play and interaction with other children For access to books, toys and play space To acquire a range of skills and interests To experience success and achievement It involves an adult interested in educational activities, progress and achievements, who takes account of the child’s individual needs including any special educational needs.

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EMOTIONAL AND BEHAVIOURAL DEVELOPMENT Concerns the appropriateness of the child’s behaviour and response to parents and caregivers and, as the child grows older, to others beyond the family. It includes the: Nature and quality of early attachments Development of emotional and social competence Capacity to regulate emotions and degree of appropriate self control Capacity to adapt to change IDENTITY Concerns the child’s growing sense of self as a separate and valued person. It includes: A positive sense of self and abilities Self-image and self-esteem, having a positive sense of individuality (ethnicity, religion, age, gender, sexuality and disability may all contribute to this) Feelings of belonging and acceptance by family, peer group and wider society FAMILY AND SOCIAL RELATIONSHIPS Concerns the development of empathy and the capacity to place self in someone else’s shoes. It includes: A stable and affectionate relationship with parents or caregivers Good relationships with siblings Age-appropriate friendships with peers and other significant persons in the child’s life Ability to socialise appropriately SOCIAL PRESENTATION Concerns the child’s growing understanding of the way in which appearance, behaviour and any impairment are perceived by the outside world and the impression being created. It includes:

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Appropriateness of dress for age, gender, culture and religion Cleanliness and personal hygiene Confidence about presentation in social situations SELF-CARE SKILLS Concerns the growing level of age-appropriate competence in practical and psychosocial skills. It includes: Early practical skills of dressing and feeding Opportunities to gain confidence to undertake activities away from the family and develop independent living skills as older children Consider how disability and/or social circumstances might affect the development of self-care skills.

Dimensions of parenting capacity BASIC CARE Providing for the child’s physical needs, and appropriate medical and dental care. It includes: Provision of food and drink Provision of warmth and shelter Provision of clean and appropriate clothing Adequate personal hygiene ENSURING SAFETY Ensuring the child is adequately protected from harm or danger. It includes: Protection from significant harm or danger, including self-harm Protection from contact with unsafe adults/children Recognition of the need to protect the child from hazards and danger both in the home and elsewhere

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Appropriate supervision and care arrangements EMOTIONAL WARMTH Ensuring the child’s emotional needs are met, giving the child a sense of being specially valued and a positive sense of their own identity. It includes: Responding to the child’s need for secure, stable and affectionate relationships Appropriate sensitivity and responsiveness to the child’s needs Appropriate physical contact and comfort sufficient to demonstrate warm regard, praise and encouragement STIMULATION Promoting the child’s learning and intellectual development through encouragement and cognitive stimulation. It includes: Facilitating the child’s cognitive development and potential through interaction and play Promoting social opportunities Enabling the child to experience success Ensuring school attendance and/or equivalent educational opportunities Helping the child to meet the challenges of life GUIDANCE AND BOUNDARIES Demonstrating and modelling appropriate behaviour and control of emotions in interactions with others. It includes: Setting boundaries to enable the child to develop appropriate values and social behaviour Enabling the child to regulate their own emotions and behaviour Providing opportunities for appropriate exploratory and learning experiences

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STABILITY Providing a sufficiently stable family environment to enable a child to develop and maintain a secure attachment to the primary caregiver(s) in order to ensure optimal development. It includes: Ensuring secure attachments are not frequently disrupted Providing consistency of emotional warmth over time Ensuring children keep in contact with important family members and significant others

Family and environmental factors FAMILY HISTORY AND FUNCTIONING Family history includes both genetic and psychosocial factors. Family functioning is influenced by: Who is living in the household and how they are related to the child Significant changes in family/household composition History of childhood experiences of parents Chronology of significant life events and their meaning to family members Nature of family functioning, including sibling relationships and their impact on the child Parental strengths and difficulties, including those of an absent parent The relationship between separated parents WIDER FAMILY Includes related and non-related persons and absent wider family. It also includes individuals who are considered to be members of the wider family. Consider their role and importance, positive and negative, to the child and parents.

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HOUSING Concerns the state of repair of the accommodation and its immediate surroundings. It includes: Basic amenities such as water, heating, sanitation, cooking facilities and sleeping arrangements Homelessness and/or over-crowding Hygiene and safety Consider whether housing is accessible and suitable for the needs of all family members, including those with a disability. EMPLOYMENT Concerns who is working in the household, their pattern of employment and the impact of any changes, e.g. new job, unemployment. It also concerns how paid employment or its absence is viewed and experienced by family members. Consider its impact on the child and other relationships within the family. INCOME Concerns whether: Income is sufficient to meet the family’s needs Money is available over a sustained period of time Resources available to the family are used appropriately The family is in receipt of all its benefit entitlements There are financial difficulties that affect the child FAMILY’S SOCIAL INTEGRATION Refers to the wider context of the local neighbourhood and community and its impact on the child and parents. Includes the degree of the family’s integration or isolation, their peer groups, friendship and social networks and the importance attached to them.

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COMMUNITY RESOURCES Describes all facilities and services in a neighbourhood, including universal services of primary health care, day care and schools, places of worship, transport, shops and leisure activities. Includes availability, accessibility and standard of resources and their impact on family members, including those with a disability.

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APPENDIX 2

The paediatric assessment W

actual or suspected child abuse and/or neglect, a paediatric assessment may be essential as it can provide an independent opinion that is helpful for professionals, parents and the child. Approach the assessment of the child in a rigorous and systematic way irrespective of whether there is an allegation of abuse, unexplained injury or the incidental discovery of abuse and/or neglect. Assess the child before any signs, such as bruises, have disappeared. Remember, the process for diagnosing abuse and neglect does not differ from the diagnostic process in any other disorder although it will occur within a multi-agency context of assessment and planning for the child. Document findings fully; make clear, precise and contemporaneous notes and sign them. Use body maps wherever possible or draw diagrams, label and sign. Distinguish between the history, observations, suspicions and interpretations. Always take the age and development of the child into account. List the necessary investigations and document any referral and the immediate and long-term management. HERE THERE IS

HISTORY Take a full paediatric history that includes: Views and feelings of the child Name of the person giving the history and relationship to child Duration and frequency of the alleged abuse Time and date of first episode Time and date of last episode

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Other injuries, including old injuries Past history, including any abuse Developmental history and immunisation status Behavioural and emotional problems, including symptoms of post-traumatic stress Social history, including family networks, current members of household and child care arrangements Siblings, safety and well-being Family history, genogram Remember, if the child is bought without the parent, obtain consent from someone with parental responsibility. EXAMINATION In relation to the examination, do the following: Ask the child for permission Try and allow the child some control of the situation and respect their wishes. If the child withholds consent and/or refuses to co-operate, invite them back Explain the process: respect privacy and build up the child’s confidence Allow the child to choose who they want to be with during the examination. Never use physical restraint (pre-verbal infants need to be held by their parent/carer) Evaluate demeanour, response to carer, play, attention, behaviour during the examination Record whether or not the child was able to co-operate. If the examination is incomplete, explain how and why Measure height, weight and head circumference. Record and plot the centiles Conduct a thorough general physical examination to include hair, nails, mouth, teeth, ears, nose, head, fundi skin and hidden areas – behind ears and neck Examine the cardiovascular, respiratory, abdominal and central nervous systems

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Examine buttocks, inner thighs, external genitalia and anus as part of the abdominal system, having asked the child or young person first. Comment on developmental milestones and cognitive ability Note the pubertal stage Take photographs if appropriate Remember to separate old injuries from new and document the following: Site Size: measure and draw on body charts Colour Stage of healing Cause of each lesion/injury as given by child and/or parent EXAMINATION OF GENITALIA AND ANUS As part of the general examination, it is important to examine the buttocks and genitalia of all children whether or nor there is a suspicion of sexual abuse. Examine the child in the left lateral position and with the child’s permission, view the buttocks, anus and in girls the external genitalia, including the labia majora. In boys, examine the genitalia as part of the examination of the abdomen. Genitalia In boys: Look for injury to the urethra, penis and scrotum, such as bruises, tears, lacerations and burns. Always comment on the position of the testes and whether or not the child is circumcised In girls: Note any injuries to the external genitalia. Remember to include the lower abdomen and upper thighs. Examine the vulval area for abrasions, lacerations or discharge Anus Note the extent of any injury, e.g. bruising, reddening or swelling of the skin and perineum Look at the anus and look for fissures/scars and describe their position, length and stage of healing

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If during the course of taking the history and doing the examination sexual abuse is suspected, consider a more detailed examination of the genitalia and anus which includes labial and buttock traction and photo documentation using the colposcope. In these cases follow the RCPCH guidelines: Clinical Handbook for Physical Signs of Child Sexual Abuse (2007). DIAGNOSIS/OPINION Give an opinion on whether the findings are consistent with the history given Decide whether the findings indicate accidental or nonaccidental injury If there is uncertainty and/or no diagnosis, say so and outline next steps i.e. investigations, further referrals, etc. Comment on other findings from history and examination, such as growth or language development MANAGEMENT Arrange investigations to exclude a medical cause Consider the immediate support available to the family and child Consider whether siblings are at risk Inform the primary care team and the referrer of the outcome of the assessment Consider referrals to other professionals, e.g. child and family consultation service, adult mental health services Obtain past records and complete a medical chronology reassessing current findings in the light of the past history Participate in strategy meetings and child protection conferences Paediatric follow up may be necessary in certain cases in order to: Assess and review symptoms and signs Find evidence of healing and/or of further abuse Diagnose underlying medical disorders or other co-existing conditions e.g. screening for STIs Provide a further detailed developmental assessment if appropriate

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The paediatric review in cases of abuse and neglect is just as important as any other medical follow up and perhaps even more so in cases of sexual abuse where it may help reassure the child who is not able to see the traumatised area and assess healing for themselves. Always remember: Paediatric assessment is only part of the jigsaw that makes up the whole picture Discuss findings with the child, parents, social worker and police as appropriate; raising concerns about abuse with a parent may be difficult, discuss with a senior doctor/consultant Parents, police and social services often want an instant opinion in a situation where there may be uncertainty and/or no diagnosis; in such cases always explain the differential diagnosis In cases involving an ABE (Achieving Best Evidence) interview work closely with the police to avoid unnecessary history taking and leading questions that may contaminate the evidence. Submit statements for the police for criminal proceedings and medical reports for care proceedings. Before going to court seek preparatory advice from a senior colleague. Be aware that in court, even strongly suggestive signs may not secure a conviction of a suspected perpetrator in criminal proceedings. While decisions about the safety of children in care proceedings are made on the balance of probabilities, in criminal proceedings guilt has to be established beyond reasonable doubt. INFORMATION SHARING, CONFIDENTIALITY AND CONSENT The principles and values on which good medical practice is founded are set out in the General Medical Council (GMC) guidelines. They outline the importance of obtaining a patient’s consent for the disclosure of information and make it clear that personal information may be released without consent to third parties in certain circumstances, e.g. agencies such as children’s social care or the police (GMC, 2004): If you believe a patient to be a victim of neglect or physical, sexual or emotional abuse and that the patient cannot give or withhold consent to disclosure, you must give information

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promptly to an appropriate responsible person or statutory agency, where you believe that the disclosure is in the patient’s best interests. If, for any reason, you believe that disclosure of information is not in the best interests of an abused or neglected patient, you should discuss the issues with an experienced colleague. If you decide not to disclose information, you must be prepared to justify your decision. The GMC in Good Medical Practice (2006) again makes it clear that all doctors are expected to safeguard and promote the health and well-being of children and young people. Further guidance in 2007 stipulates that the primary concern is the safety of children and young people and that where there are concerns about risk of abuse and neglect, these should be responded to promptly by informing an appropriate person. A decision not to share information that could put the child at further risk needs to be justified. If in doubt, seek advice from an experienced colleague (this could be the named or designated doctor and/or nurse) and record reasons for not sharing the information. The GMC also confirms that its guidance refers to information about adults who may pose a risk to children as well as children who may be victims of abuse. CONSENT The child’s consent is necessary for a medical or psychiatric examination and/or treatment if they have sufficient understanding to make an informed decision. Examination without consent may be held in law to be an assault. When assessing a child’s capacity to decide whether to give or refuse consent, consider the following laws or legal precedents: From age 16, with some exceptions such as learning disability, a young person can be treated as an adult and can be presumed to have capacity to decide about their care Under age 16, children may have capacity to decide (Fraser ruling) depending on their ability to understand what is involved However, when a competent child or young person under 18 refuses treatment, a person with parental responsibility or the court may authorise

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medical or psychiatric examinations or treatment if this is considered to be in the child’s best interests. When thinking about a child’s capacity to consent, consider their: Ability to understand that there is a choice and that choices have consequences Willingness and ability to make a choice, including the option of choosing that someone else makes it Understanding of the nature and purpose of the proposed procedure, including the risks and benefits SUDDEN UNEXPECTED DEATH OF AN INFANT (SUDI) AND THE CHILD DEATH REVIEW PROCESS An unexpected death is defined as the death of a child that was not anticipated as a significant possibility 24 hours before the death. All LSCBs are now responsible for developing procedures to ensure there is a rapid and co-ordinated inter-agency response to each unexpected child death. A consultant paediatrician (the SUDI paediatrician) in each local area has the designated responsibility to advise the LSCB on the management of any unexpected child death. In all cases local protocols should be followed; these should include: Guidelines for the management of the response in the accident and emergency department Notifying the coroner, police, hospital social worker, GP, named professionals and designated doctor for SUDI Ensuring a joint police/paediatric home visit within 24 hours Convening a multi-agency strategy meeting Meeting with the parents/carers and providing support As every unexpected death of a child is a tragedy for the family, be sensitive to the need to keep an appropriate balance between the forensic and medical requirements of an investigation and the family’s need for support. Some unexpected child deaths are the consequence of abuse or neglect, or have abuse or neglect as an associated factor, but these will be the minority of such deaths. In addition to the rapid response required in cases of unexpected deaths, child death review panels will be established in each LSCB area by

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2008. They have a statutory responsibility for reviewing all deaths in children and young people under 18; these include deaths from abuse and neglect, accidents and suicides as well as deaths from natural causes. This will facilitate a public health approach to potentially avoidable deaths in childhood. The child death review panels will collect and analyse information about each child death, including those that are unexpected and/or suspicious, with a view to identifying: Any case giving rise to the need for a serious case review Any matters of concern affecting the safety and welfare of children in the area of the authority Any wider public health or safety concerns arising from a particular death or from a pattern of deaths in that area This will provide useful information about patterns of childhood deaths as well as improved recognition of deaths where abuse and neglect have been a contributory factor. It will also inform local strategic planning about how best to safeguard children in the local area.

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Suggested reading Browne, K., Davies, C. and Stratton, P. M. (eds) (2002) Early Prediction and Prevention of Child Abuse, Wiley. DfES (Department for Education and Skills) (2000) Framework for the Assessment of Children in Need and their Families, The Stationery Office. DfES (Department for Education and Skills) (2000) Safeguarding Children Involved in Prostitution: Supplementary Guidance to Working Together to Safeguard Children, The Stationery Office. DfES (Department for Education and Skills) (2002) Learning from Past Experience – A Review of Serious Case Reviews, The Stationery Office. DfES (Department for Education and Skills) (2002) Safeguarding Children in Whom Illness is Induced or Fabricated by Carers with Parenting Responsibilities, The Stationery Office. DfES (Department for Education and Skills) (2002) Safeguarding Children – A Joint Chief Inspectors’ Report on Arrangements to Safeguard Children, The Stationery Office. DfES (Department for Education and Skills) (2006) Working Together to Safeguard Children, The Stationery Office. DfES (Department for Education and Skills) (2007) What To Do If You’re Worried a Child Is Being Abused: Children’s Services Guidance, The Stationery Office. GMC (General Medical Council) (2004) Confidentiality: Protecting and Providing Information, GMC. GMC (General Medical Council) (2006) Good Medical Practice, GMC.

SUGGESTED

READING

Hobbs, C. J., Hanks, H. and Wynne, J. M. (1999) Child Abuse and Neglect: A Clinician’s Handbook, Churchill Livingstone. Howarth, J. (2001) The Child’s World, Jessica Kingsley. Howe, D. (2005) Child Abuse and Neglect: Attachment, Development and Intervention, Palgrave Macmillan. Jones, D. P. H. and Ramchandan, I. P. (1999) Child Sexual Abuse: Informing Practice from Research, Radcliffe Medical Press. Laming, Lord (2003) The Victoria Climbié Inquiry, The Stationery Office. RCPCH (Royal College of Paediatrics and Child Health) (2002) Fabricated or Induced Illness by Carers, RCPCH. RCPCH (Royal College of Paediatrics and Child Health) (2006) Child Protection Companion, RCPCH. RCPCH (Royal College of Paediatrics and Child Health) (2007) Clinical Handbook for Physical Signs of Child Sexual Abuse, RCPCH. Reder, P. and Duncan, S. (1999) Lost Innocents: A Follow-up Study of Fatal Child Abuse, Routledge. Reder, P. and Lucey, C. (1995) Assessment of Parenting: Psychiatric and Psychological Perspectives, Routledge. Reder, P., Duncan, S. and Gray, M. (1993) Beyond Blame: Child Abuse Tragedies Revisited, Routledge.

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Index Abdominal injury physical abuse and 28 Agencies collaboration and co-operation among 10–11 Area Child Protection Committee (ACPC) see Local Safeguarding Children Board (LSCB) Assessment children in need and 20–1 child protection conference reports 74–6 Common Assessment Framework 21, 90–9 core assessment 74 harm and 19–20 initial assessment 69 paediatric assessment 7–8, 100–7 preparation of conference reports, and 74–6 risk assessment 14–22 Assessment framework see Common Assessment Framework (CAF) Attachment disorders of 24, 54, 57 importance of 15, 75 Bruises physical abuse and 26, 28–30 Burns and scalds physical abuse and 26–7, 30–1 Caldicott standards 80 Case conference see child protection conference Case review LSCB procedures and 12, 106 unexpected death and 106

Child developmental needs of 21, 93–5 resilience, and 17, 49 vulnerability, and 16–17 wishes and feelings, taking account of 9, 12, 70 Child abuse assessment of 19–22 disability and 61–6 domestic violence and 18, 23, 52 emotional 50–5 failure to thrive and 56–60 health workers role in 5–7 mental illness and 18 neglect 44–9 parental care and 14 physical 23–34 predisposing factors 15–17 sexual 35–43 significant harm and 19–20 substance misuse and 18–19 Children Act 1989 assessing harm and 19 child safety and welfare, enquiries about 84 children in need and 20 culture and 82 duty of care and 70 main principles 81 parental responsibility and 82 partnership and 9 significant harm and court procedures 83–4 Working Together and 4 Children Act 2004 Every Child Matters and 4, 86 five outcomes and 4, 87–8 legal duty and 4, 86–7

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LSCBs and 88–9 partnership working and 81 Working Together and 4 Children and Young People’s Plan five outcomes and 88 LSCBs and 12 Children’s centres 87 Children’s social care (formerly social services) child protection enquiries and 84–5 parental non engagement and 68 referral and 6–7, 10, 21, 84 statutory responsibilities of 7, 84–5 Child death review LSCB procedures and 12, 106 unexpected death and 106 Child death review panel 106–7 Child protection conference 69–77 attendance at 70 child protection plan and 68, 72–3 confidentiality and 72 core assessment and 74 core groups and 73 dissent and 72 enquiry and initial assessment 69 function of 71 Integrated Children’s System (ICS) and 77 reports, preparation of 74–6 role of health professionals at 70 types of 71 Child protection enquiry 7, 21, 69, 84 Child protection plan child protection conference, role in 72–3 parental non compliance and 68 Child protection referral see referral Child protection register see Integrated Children’s System Climbie, Victoria Every Child Matters and 4 inquiry into the death of 4 Common Assessment Framework (CAF) 90–9 use of 21

children in need and 20 core assessment and 74 dimensions of child’s developmental needs 93–5 dimensions of parenting capacity 95–7 family and environmental factors 97–9 preparation of conference reports and 74–6 Confidentiality Caldicott Standards and 80 child protection conference and 72 confidential information, disclosure of 85 Data Protection Act and 80 General Medical Council and 104 information sharing and 79 records and 79–80 Conference see child protection conference Consent disclosure of information and 85, 104–5 General Medical Council and 105–6 Fraser ruling and 86 medical examination and 105 Contact Point information sharing index and 92 Core group 73 Culture child abuse and 11 Children Act 1989 and 82 disability, impact on 62 Data Protection Act 1998 80 Designated professionals role of 5 Disability abuse of children with 61–6 families, impact on 66 recognition of abuse and 64–5 vulnerability and 62–4 Domestic abuse see domestic violence Domestic violence child abuse and 18 emotional abuse and 52

INDEX

physical abuse and 23 Drugs and alcohol see substance misuse

recording and monitoring of 59 Guardian in court orders, role of 84

Electronic social care record 77 Emotional abuse definition 50–1 domestic violence and 52 failure to thrive and 55, 57 health and development, impairment of 53–5 Ethnicity child abuse and 11 children in need, impact on 20 disability, impact on 62 Every Child Matters 4, 86

Harm assessment of 19–22 definition of 19 significant, concept of 19–20 Health service workers confidentiality, duty of 72, 79–80, 85, 104–5 parameters of good practice 6 safeguarding children, contribution to 3, 5–7 sharing information, duty of 7, 10–11, 72, 85, 79–80, 104–5

Fabricated or Induced Illness (FII) 27, 31–2 Failure to thrive assessment and management of 58–60 definition 56 emotional abuse and 56–7 neglect and 57 patterns of growth in 57–8 Five outcomes child well-being and 4–5, 87–8 Children and Young People’s Plan and 88 Families environmental factors and 21, 97–9 vulnerability and 16 Fractures physical abuse and 26, 32–3 Fraser ruling and competence 86 consent and 86

Information confidential, disclosure of 72, 79–80, 85, 104–5 sharing of 7, 10–11, 72, 79–80, 85, 104–5 Integrated Children’s System (ICS) child protection plan and 77 child protection register, replacement of 77 purpose of 77 Inter-agency collaboration and cooperation 10–11 duty to co-operate and 87

General Medical Council (GMC) confidentiality and consent, guidance on 104–6 Gillick Competence (see Fraser ruling) Growth centiles and 57–8 failure to thrive and 56–60 measurement of 58–9, 75, 101

Learning disability neglect and 45 abuse as cause of 62 Lead professional 92 Legal framework child safety and welfare, enquiries about 84–5 Children Act 1989 81–5 Children Act 2004 86–9 confidentiality and 82 Fraser ruling 86 LSCB and 88–9 parental responsibility 82–3 requirements of 81–9

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THE CHILD IN MIND

significant harm and court procedures 83–4 Local Safeguarding Children Board (LSCB) child death review and 12, 106 Children and Young People’s Plan and 12 designated professionals and 5 local procedures and 12–13 representation on 12 responsibilities of 12–13 referral and 6–7 statutory duties of 88–9 Maltreatment assessment of 19–22 Medical Guidance paediatric assessment 100–7 physical abuse 28–34 sexual abuse 41–3 Medical examination see paediatric assessment Multi Agency Public Protection Arrangements (MAPPA) responsibility of 40 Named professionals role of 5 Neglect definition of 44 failure to thrive and 57 impairment of health and development and 46–9 neglectful parenting and 45–6 Non-accidental head injury (NAHI) 28, 62 Non-compliance see non-engagement Non-engagement parents with professionals 16, 67–8 NHS trusts child protection responsibilities of 4 NSPCC 7, 71 Oral injuries 34

Paediatric assessment 7–8, 100–7 child protection enquiries and 7–8 forensic medical evidence and 43 function of 7–8 guidance on 100–4 Parental mental illness child abuse and 18 emotional abuse and 52 neglect and 45 Parental responsibility Children Act 1989 and 82 Parental substance misuse child abuse and 18–19 emotional abuse and 52 neglect and 45 Parenting capacity dimensions of 14–15, 21, 95–7 Parents care, provision by 14–15 domestic violence and 18, 23, 52 raising concerns with 10 child protection conference, attending 70 mental illness and 18, 45, 52 non-engagement of 16, 67–8 parenting difficulties of 14–16 partnership with 9–10 substance misuse and 18–19, 45, 52 vulnerability and 16 Partnership aim of 10 parents and children and 9–10 records and 79 Perpetrators sexual abuse and 37, 40–1, 64 Sex Offenders Register 40 Physical abuse abdominal injury 28 bruises in 26, 28–30 burns and scalds in 26–7, 30–1 chastisement and 23 definition of 24 domestic violence and 23 fabricated or induced illness and 27, 31–2

INDEX

fatal child abuse and 23 fractures in 26, 32–3 medical guidance 28–34 non-accidental head injury 28, 62 oral injuries 34 poisoning and 27 punishment and 23 sign of 25–6 suffocation and 27 sudden infant death syndrome (SIDS) 27–8 Poisoning physical abuse and 27 Punishment physical abuse and 23 Primary Care Trusts child protection responsibilities of 5 Primary health care team role of 47, 60 Racism child abuse and 11 disability, impact on 62 Records 78–80 basic principles 78 Caldicott standards and 80 confidentiality and 79–80 Data Protection Act and 80 documenting concerns and 6 paediatric assessment and 100 partnership and 79 Referral children’s social care and 6–7, 10, 21, 84 Children Act 1989, guidance on 84 responsibility of health service workers and 6–7, 10, 21 Resilience children and 17, 49 Risk assessment of 14–22 non-compliance and 67–8 Safeguarding children guidance on 3–8

Serious case review see case review Sexual abuse behavioural indicators 38 characteristics of 36 definition of 35 disability and 64 medical guidance 41–3 patterns of 37 perpetrators and 37, 40–41, 64 physical indicators 37–8 Sexual Assault Referral Centre 43 Significant harm child protection plan and 72–3 concept of 19–20 court procedures and 83–4 Sex Offenders Register 40 Social services see children’s social care Sudden infant death syndrome (SIDS) 27–8 Sudden unexpected death of an Infant (SUDI) 106 Suffocation physical abuse and 27 Vulnerability predisposing factors and 16–17 Working Together to Safeguard Children five outcomes and 4 forms of ill-treatment 19 definitions of abuse 24, 35, 44, 50–1 guidance of 4–5 LSCBs, guidance on 88 LSCB procedures and 12–13 parameters of good practice 6 partnership and 9 significant harm and 20 What To Do If You’re Worried A Child Is Being Abused guidance of 5

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