Definitions and Recognition of Abuse and Neglect

The Children Act 1989 introduced the concept of Significant Harm as the threshold which justifies compulsory intervention in family life in the best interests of children.

Under Section 31(9) of the Children Act 1989, as amended by the Adoption and Children Act 2002:

'Harm' means ill-treatment or the impairment of health or development, including for example impairment suffered from seeing or hearing the ill-treatment of another;

'Development' means physical, intellectual, emotional, social or behavioural development;

'Health' means physical or mental health; and

'Ill-treatment' includes Sexual Abuse and forms of ill-treatment that are not physical.

Under Section 31(10) of the Act:

Where the question of whether harm suffered by a child is significant turns on the child's health and development, his or her health and development shall be compared with that which could reasonably be expected of a similar child.

There are no absolute criteria on which to rely when judging what constitutes Significant Harm. Consideration of the severity of ill-treatment may include the degree and the extent of physical harm, the duration and frequency of abuse and neglect, the extent of premeditation, the degree of threat, coercion, sadism, and bizarre or unusual elements in child sexual abuse. Each of these elements has been associated with more severe effects on the child or young person and/or relatively greater difficulty in helping the child or young person overcome the adverse impact of the maltreatment.

Sometimes a single traumatic event may constitute Significant Harm, e.g. a violent assault, suffocation or poisoning. More often, Significant Harm is a compilation of significant events, both acute and long-standing, which interrupt, change or damage the child/young person's physical and psychological development. Some children/young people live in family and social circumstances where their health and development are neglected. For them, it is the corrosiveness of long term emotional, physical or sexual abuse that causes impairment to the extent of constituting Significant Harm. In each case, it is necessary to consider any ill-treatment alongside the family's strengths and supports.

Section 47 of the Children Act 1989 places a duty on local authorities to make enquiries, or cause enquiries to be made, where it has reasonable cause to suspect that a child is suffering, or is likely to suffer Significant Harm.

See Procedures:

• Contacts and Referrals Procedure;
• Single Assessment Procedure;
• Strategy Discussion and Meetings Procedure.

To understand and establish Significant Harm, it is necessary to consider:

• The nature of the harm, in terms of maltreatment or failure to provide adequate care;
• The impact on the child/young person's health and development;
• The child/young person's development within the context of the family and wider environment;
• Any special needs, such as a medical condition, communication difficulty or disability that may affect the child/young person's development and care within the family;
• The capacity of parents/carers to meet adequately the child/young person's needs;
• The wider and environmental family context.

A court may only make a Care Order or Supervision Order in respect of a child/young person if it is satisfied:

• That the child/young person is suffering, or is likely to suffer Significant Harm; and
• That the harm or likelihood of harm is attributable to a lack of adequate parental care or control (section 31).

Some children/young people have pre-existing vulnerabilities which may make them more susceptible to further and ongoing abuse. Children/young people with learning difficulties, mental health challenges and who are socially isolated are more likely to be victims of online abuse and may find it difficult to disclose what is happening to them.

Abuse and neglect are forms of maltreatment of a child/young people. They can be caused by inflicting harm or by failing to act to prevent harm. Harm can include ill treatment that is not physical as well as the impact of witnessing ill treatment of others. This can be particularly relevant, for example, in relation to the impact on children/young people of all forms of domestic abuse. Children/young people may also be abused in a family or in an institutional or community setting, by those known to them or, much more rarely, by a stranger. They may be abused by an adult or adults, or another child or children.

The following definitions are taken from Working Together to Safeguard Children.

They have been included to assist those providing services to children/young people in assessing whether the child/young person may be suffering actual or potential harm.

The following guidance is intended to help all professionals who come into contact with children/young people. It should not be used as a comprehensive guide, nor does the presence of one or more factors prove that a child/young person has been abused, but it may however indicate that further enquiries should be made.

The following factors should be taken into account when assessing significant harm to a child/young person. This is not an exhaustive list.

• An unexplained delay in seeking treatment that is obviously needed and the impact of that delay;
• An unawareness or denial of any injury, pain or loss of function;
• Incompatible explanations offered or several different explanations given for a child/young person's illness or injury;
• A child/young person reacting in a way that is inappropriate to his/her age or development;
• Reluctance to give information or failure to mention previous known injuries;
• Frequent attendances at Accident and Emergency Departments or use of different doctors and Accident and Emergency Departments;
• Frequent presentation of minor injuries (which if ignored could lead to a more serious injury);
• Unrealistic expectations/constant complaints about the child/young person;
• Alcohol misuse or other substance misuse;
• A parent's request to remove a child/young person from home or indication of difficulties in coping with the child/young person;
• Domestic abuse;
• Parental mental ill health;
• The age of the child/young person and the pressures of caring for a number of children in one household.

This section provides a guide to professionals of some common injuries found in child abuse. Whilst some injuries may appear insignificant in themselves, repeated minor injuries, especially in very young children, may be symptomatic of physical abuse.

It can sometimes be difficult to recognise whether an injury has been caused accidentally or non-accidentally, but it is vital that all concerned with children/young person are alert to the possibility that an injury may not be accidental, and seek appropriate expert advice. Medical opinion will be required to determine whether an injury has been caused accidentally or not. See: Child Injury Information Sharing Pathway.

Bruising

See Management of Suspicious Bruises / Marks in Infants Under 6 Months Old.

Children/young people can have accidental bruising, but it is often possible to differentiate between accidental and inflicted bruises. It may be necessary to do blood tests to see if the child/young person bruises easily.

The following must be considered as non accidental unless there is evidence or an adequate explanation provided:

• Any bruising to a pre-crawling or pre-walking baby;
• Bruising in or around the mouth, particularly in small babies, for example 3 to 4 small round or oval bruises on one side of the face and one on the other, which may indicate force feeding;
• Two simultaneous bruised eyes, without bruising to the forehead, (rarely accidental, though a single bruised eye can be accidental or abusive);
• Repeated or multiple bruising on the head or on sites unlikely to be injured accidentally, for example the back, mouth, cheek, ear, stomach, chest, under the arm, neck, genital and rectal areas;
• Variation in colour possibly indicating injuries caused at different times - it is now recognised in research that it is difficult to age bruises apart from the fact that they may start to go yellow at the edges after 48 hours;
• The outline of an object used e.g. belt marks, hand prints or a hair brush;
• Linear bruising at any site, particularly on the buttocks, back or face;
• Bruising or tears around, or behind, the earlobe(s) indicating injury by pulling or twisting;
• Bruising around the face;
• Grasp marks to the upper arms, forearms or leg or chest of small children;
• Petechae haemorrhages (pinpoint blood spots under the skin). These are commonly associated with slapping, smothering/suffocation, strangling and squeezing.

Fractures

Fractures may cause pain, swelling and discolouration over a bone or joint. It is unlikely that a child will have had a fracture without the carers being aware of the child's distress.

If the child is not using a limb, has pain on movement and/or swelling of the limb, there may be a fracture.

There are grounds for concern if:

• The history provided is vague, non-existent or inconsistent with the fracture type;
• There are associated old fractures;
• Medical attention is sought after a period of delay when the fracture has caused symptoms such as swelling, pain or loss of movement;
• There is an unexplained fracture in the first year of life;
• The child is non mobile.

Rib fractures are commonly caused in major trauma such as in a road traffic accident, a severe shaking injury or a direct injury such as a kick.

Skull fractures are uncommon in ordinary falls, i.e. from three feet or less. The injury is usually witnessed, the child/young people will cry and if there is a fracture, there is likely to be swelling on the skull developing over 2 to 3 hours. All fractures of the skull should be taken seriously.

Subdural haematoma is a very worrying injury, seen usually in young children; it may be associated with retinal haemorrhages and fractures, particularly skull and rib fractures. The cause is usually a severe shaking injury in association with an impact blow. There may or may not be a fractured skull. The baby may present in the Accident and Emergency Department with sudden difficulty in breathing, sudden collapse, fits or as an unwell baby - drowsy, vomiting and later an enlarging head.

Joints

A tender, swollen "hot" joint with normal X ray appearance may be due to infection in the bone or trauma. There may be both. A further X ray will usually be required in 10 to 14 days. Where there is infection, this of course will require treatment.

Mouth Injuries

Tears to the fraenulum (tissue attaching upper lip to gum) often indicates force feeding of a baby. There is often finger bruising to the cheeks and around the mouth. Rarely, there may also be grazing on the palate. Blunt trauma to the mouth causes swelling and damage to the inner aspect of the lips.

Internal Injuries

There may be internal injury e.g. perforation or a viscous with no apparent external signs of bruising to the abdomen wall.

Poisoning

Ingestion of tablets or domestic poisoning in children under 5 is usually due to the carelessness of a parent or carer, but it may be self harm even in young children.

See also Fabricated or Induced Illness and Perplexing Presentation Procedure.

Bite Marks

Bite marks can leave clear impressions of the teeth when seen shortly after the injury has been inflicted. The shape then becomes a more defused ring bruise or oval or crescent shaped. Those over 3cm in diameter are more likely to have been caused by an adult or older child.

A medical/dental opinion, preferably within the first 24 hours, should be sought where there is any doubt over the origin of the bite.

Burns and Scalds

It can be difficult to distinguish between accidental and non-accidental burns and scalds, and will always require experienced medical opinion.

Scalds are the commonest intentional burn injury recorded (source: the Welsh Child Protection Systematic Review Group). Apart from head injury, intentional burns are also the most likely injury to cause death or long term morbidity

Any burn with a clear outline may be suspicious e.g.:

• Circular burns from cigarettes (but may be friction burns if along the bony protuberance of the spine or impetigo in which case they will quickly heal with treatment);
• Linear burns from hot metal rods or electrical fire elements;
• Burns of uniform depth over a large area;
• Scalds that have a line indicating immersion or poured liquid (a child getting into hot water of its own accord will struggle to get out and cause splash marks);
• Old scars indicating previous burns/scalds which did not have appropriate treatment or adequate explanation.

Scalds to the buttocks of a small child, particularly in the absence of burns to the feet, are indicative of dipping into a hot liquid or bath.

The following points are also worth remembering:

A responsible adult checks the temperature of the bath before the child gets in

A child is unlikely to sit down voluntarily in a hot bath and cannot accidentally scald its bottom without also scalding his or her feet

A child getting into too hot water of his or her own accord will struggle to get out and there will be splash marks.

Scars

A large number of scars or scars of different sizes or ages, or on different parts of the body, or unusually shaped, may suggest abuse.

Emotional abuse may be difficult to recognise, as the signs are usually behavioural rather than physical. The indicators of emotional abuse are often also associated with other forms of abuse

The following may be indicators of emotional abuse:

• Developmental delay;
• Abnormal attachment between a child/young person and parent/carer e.g. anxious, indiscriminate or no attachment;
• Indiscriminate attachment or failure to attach;
• Aggressive behaviour towards others;
• A child/young person scapegoated within the family;
• Frozen watchfulness, particularly in pre-school children;
• Low self esteem and lack of confidence;
• Withdrawn or seen as a 'loner' - difficulty relating to others.

The most common presentation of Child Sexual Abuse is with a statement by the child/young person that (s)he has been abused. Such a statement is usually made to a friend or an adult in the first instance before any professional involvement occurs. The child/young person's statement may be supported by the occurrence of certain behavioural symptoms and / or medical findings. Only very rarely is the abuse witnessed by a third party.

In a sizeable minority of sexually abused children/young people there are no overt behavioural changes. Furthermore, most sexually abused children/young people show no physical evidence of their abuse. Hence, for the majority of sexually abused children/young people, recognition is dependent upon the child/young person's account alone.

Children/young people of both genders and of all ages may be sexually abused and are frequently scared to say anything due to guilt and/or fear. This is particularly difficult for a child/young person to talk about and whilst full account should be taken of any cultural sensitivities of any individual child / family, cultural beliefs should are not a means to justify, condone or accept any abuse.

Recognition can be difficult, unless the child/young person discloses and is believed. There may be no physical signs and indications are likely to be emotional / behavioural.

Possible causes of concern are:

• Something the child/young person says;
• Something that the adults say about the child/young person;
• The child/young person's behaviour - which may cause suspicion either because of its sudden change or because of its type, e.g. sexualised behaviour;
• The child/young person's physical condition may create suspicion e.g. genital warts, scratches or other injuries, sexually transmitted infections or pregnancy.

Some behavioural indicators associated with this form of abuse are:

• Inappropriate sexualised conduct;
• Sexual knowledge inappropriate for the child/young person's age;
• Sexually explicit behaviour, play or conversation, inappropriate to the child/young person's age;
• Continual and inappropriate or excessive masturbation;
• Self-harm (including eating disorder), self mutilation and suicide attempts;
• Running away from home;
• Poor concentration and learning problems;
• Loss of self-esteem;
• Involvement in selling sex or indiscriminate choice of sexual partners;
• An anxious unwillingness to remove clothes for - e.g. sports events (but this may be related to cultural norms or physical difficulties).

Some physical indicators associated with this form of abuse are:

• Pain or itching of genital area;
• Recurrent pain on passing urine or faeces;
• Blood on underclothes;
• Pregnancy in a younger girl where the identity of the father is not disclosed and/or there is secrecy or vagueness about the identity of the father;
• Physical symptoms such as injuries to the genital or anal area, bruising to buttocks, abdomen and thighs, sexually transmitted infections, presence of semen on vagina, anus, external genitalia or clothing.

See also Children who Abuse Others Procedure for further guidance of what constitutes Sexual Abuse.

The growth and development of a child/young person may suffer impairment when the child/young person receives insufficient food, love, warmth, care and concern, praise, encouragement and stimulation.

Child Neglect is recognised through:

• History - preferably from more than one source;
• Direct observations of the Neglect of the child/young person;
• Observations of the effects of neglect on the child/young person's health and development.

Where appropriate, confirmation is obtained through the demonstration of improvements in the child/young person's condition on removal to an appropriately caring environment.

The following are examples of how child Neglect might be evidenced, though each of these may have other causes besides neglect:

The sustained abuse or neglect of children physically, emotionally, or sexually can have long-term effects on the child/young person's health, development and well-being. It can impact significantly on a child/young person's self esteem, self image and on their perception of self and of others. The effects can also extend into adult life and lead to difficulties in forming and sustaining positive and close relationships. In some situations it can affect parenting ability and lead to the perpetration of abuse on others.

In particular, physical abuse can lead directly to neurological damage, as well as physical injuries, disability or at the extreme, death. Harm may be caused to children/young people, both by the abuse itself, and by the abuse taking place in a wider family or institutional context of conflict and aggression. Physical abuse has been linked to aggressive behaviour in children/young people, emotional and behavioural problems and educational difficulties.

Severe neglect of young children is associated with significant impairment of growth and intellectual development. Persistent neglect can lead to a serious impairment of health and development, and cause long term difficulties with social functioning, relationships and educational progress. Neglect can also result in extreme cases in premature death.

Sexual abuse can lead to disturbed behaviour including self-harming, inappropriate sexualised behaviour and adverse effects which may last into adulthood, including mental health problems. The severity of impact is believed to increase the longer the abuse continues, the more extensive the abuse and the older the child. A number of features of sexual abuse have also been linked with the severity of impact, including the extent of premeditation, the degree of threat and coercion, sadism and bizarre or unusual elements. A child/young person's ability to cope with the experience of sexual abuse, once recognised or disclosed, is strengthened by the support of a non-abusive adult or carer who believes the child/young person, helps the child/young person to understand the abuse and is able to offer help and protection.

There is increasing evidence of the adverse long-term consequences for children/young people's development where they have been subject to sustained emotional abuse. Emotional abuse can understandably have a negative and challenging impact on a developing child/young person's mental health, behaviour and self-esteem. It can be especially damaging in infancy. Underlying trauma of emotional abuse may be as concerning, if not more so, than other more visible forms of abuse in terms of its impact on the child/young person.

Domestic abuse, adult mental health problems and parental substance misuse may be intersecting features in families where children are subjected to abuse. The context in which the abuse takes place may also be significant. The interaction between a number of different factors can serve to reduce or increase the likelihood or level of significant harm. Relevant factors will include the individual child/young person's coping and adapting strategies, support from family or social network, the impact and quality of professional interventions and subsequent life events.