Recognition of Abuse and Neglect

The Concept of Significant Harm

The Children Act 1989 provides the legal framework for defining the situations in which a local authority has a duty to make enquiries about what, if any, action to take to safeguard or promote a child’s welfare.

Section 47 of the Act requires that if a local authority has ‘reasonable cause to suspect that a child who lives or is found in their area is suffering or is likely to suffer Significant Harm, the authority shall make, or cause to be made, such enquiries as they consider necessary…’

In Section 31 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’ includes physical and mental health;
‘Ill treatment’ includes Sexual Abuse and forms of ill treatment, which are not physical; and

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

There are no absolute criteria on which to rely to determine what constitutes Significant Harm. It is often a compilation of significant events, both acute and longstanding, which impact on the child’s physical and psychological development. Children’s Social Care must consider all the circumstances when determining whether a referral about abuse and / or neglect to a child satisfies the criteria for a section 47 Enquiry – for further details, please see Section 47 Enquiries Procedure.

Categories of Abuse and Neglect

Abuse and neglect are forms of maltreatment of a child. Somebody may cause or neglect a child by inflicting harm, or failing to act to prevent harm. Children may be abused in a family, or in an institutional or community setting; by those known to them or, more rarely by a stranger. They may be abused by an adult or adults or another child or children.

Working Together to Safeguard Children 2018 includes definitions of the four broad categories of abuse which are used for the purposes of recognition:

Physical Abuse;
Emotional Abuse;
Sexual Abuse; and
Neglect

These categories overlap and an abused child does frequently suffer more than one type of abuse. This chapter provides definitions of these categories and information to help identify potential abuse and neglect and the required response.

Physical Abuse

Physical abuse may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating, or otherwise causing physical harm to a child.

It may also be caused when a parent or carer fabricates the symptoms of, or deliberately induces illness in a child. This unusual and potentially dangerous form of abuse is described as fabricated or induced illness in a child (see Fabricated or Induced Illness Procedure).

Emotional Abuse

Emotional abuse involves 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 include not giving the child opportunities to express their views, deliberately silencing them or ‘making fun’ of what they say or how they communicate. 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.

Sexual Abuse

Sexual abuse involves forcing or enticing a child or young person to take part in sexual activities, not necessarily involving a high level of violence, whether or not the child is aware of what is happening. The activities may involve physical contact, including penetration (for example rape or oral sex) or non-penetrative acts such as masturbation, kissing, rubbing and touching outside of clothing. They may also include non-contact activities, such as involving children in looking at, or in the production of, sexual images, watching sexual activities, encouraging children to behave in sexually inappropriate ways, or grooming a child in preparation for abuse. Sexual abuse can take place online, and technology can be used to facilitate offline abuse. Sexual Abuse is not solely perpetrated by adult males. Women can also commit acts of Sexual Abuse, as can their children.

The Sexual Offences Act 2003 introduced a range of new sexual offences designed to address all inappropriate activity with children.

Child Sexual Abuse includes:

Rape, vaginal, anal or oral penetration committed by a male on a female or male without consent (this is the only sexual offence that can be committed exclusively by a man, as the penetration must be by a penis);
Sexual assault by penetration: penetration of the vagina or anus with a part of the body or anything else (this is a new offence that replaces indecent assault and recognises the seriousness of penetration);
Sexual assault: touching a person sexually without consent (this also replaces the offence of indecent assault and covers non-penetrative touching of a victim and would include fondling, masturbation, digital penetration and oral genital contact);
Sexual activity with a child: a person 18 or over intentionally sexually touching a child under 16 (this offence replaces the offences of indecent assault and unlawful sexual intercourse – a separate offence deals with the situation where both persons involved are under 18 and reduces the penalty); these offences include situations where there is consent between the parties; where this consent exists, and the parties are of a similar age, it is not anticipated that any criminal proceedings will take place;
Causing or inciting a child to engage in sexual activity: a person aged 18 or over making a child under 16 commit a sexual act on another person (including making a child touch the offender);
Other forms of sexual activity e.g. taking indecent photographs of children or exposing children to abusive images of children.

Child Sexual Exploitation is a form of Child Sexual Abuse. It occurs where an individual or group takes advantage of an imbalance of power to coerce, manipulate or deceive a child or young person under the age of 18 into sexual activity (a) in exchange for something the victim needs or wants, and/or (b) for the financial advantage or increased status of the perpetrator or facilitator. The victim may have been sexually exploited even if the sexual activity appears consensual. Child sexual exploitation does not always involve physical contact; it can also occur through the use of technology. See also Child Sexual Exploitation: Definition and Guide for Practitioners (DfE 2017).

In law children under 16 years of age cannot consent to any sexual activity occurring, although in practice young people may be involved in sexual contact to which, as individuals, they may have agreed. Children under 13 years cannot in law under any circumstances consent to sexual activity and specific offences, including rape, exist for child victims under this age (see Sexually Active Children Procedure).

Neglect

Neglect is 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 misuse. Once the child is born, neglect may involve a parent or carer failing to:

Provide adequate food and clothing, 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 appropriate medical care or treatment.

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

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

Domestic Violence and Abuse

These definitions are used when determining significant harm and children can be affected by combinations of maltreatment and abuse, which can be impacted on by for example domestic violence and abuse in the household or a cluster of problems faced by the adults.

In addition, research analysing Serious Case Reviews has demonstrated a significant prevalence of domestic abuse in the history of families with children who are subject of Child Protection Plans. Children can be affected by seeing, hearing and living with domestic violence and abuse as well as being caught up in any incidents directly, whether to protect someone or as a target. It should also be noted that the age group of 16 and 17 year olds have been found in recent studies to be increasingly affected by domestic violence in their peer relationships.

It should therefore be considered in responding to concerns that the Home Office definition of domestic violence and abuse (2013) is as follows:

“Any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence and abuse between those aged 16 or over, who are or have been intimate partners or family members regardless of gender and sexuality.

This can encompass, but is not limited to, the following types of abuse:

Psychological;
Physical;
Sexual;
Financial;
Emotional.

Controlling behaviour is: a range of acts designed to make a person subordinate and/or dependent by isolating them from sources of support, exploiting their resources and capacities for personal gain, depriving them of the means needed for independence, resistance and escape and regulating their everyday behaviour.

Coercive behaviour is: an act or a pattern of acts of assault, threats, humiliation and intimidation or other abuse that is used to harm, punish, or frighten their victim.”

Risk Indicators

The factors described in this section are frequently found in cases of child abuse. Their presence is not proof that abuse has occurred, but:

Must be regarded as indicators of possible Significant Harm;
Must prompt the professional to seek further information;
Justify the need for careful assessment and discussion with designated / named / lead person, manager, (or in the absence of all those individuals, an experienced colleague);
May require consultation with and/or referral to Children’s Social Care – see the Making a Referral Procedure.

In an abusive relationship the child may:

Appear frightened of the parent(s);
Act in a way that is inappropriate to her/his age and development (though full account needs to be taken of different patterns of development and different ethnic groups).

The parent or carer may:

Persistently avoid child health services and treatment of the child’s illnesses;
Have unrealistic expectations of the child;
Frequently complain about / to the child and fail to provide attention or praise (a high criticism / low warmth environment);
Be absent;
Be misusing substances;
Persistently refuse to allow access on home visits;
Be involved in domestic violence;
Be socially isolated.

Consideration must be given to the impact on the care of the child of any issues / problems affecting the parents e.g. substance misuse, mental health problems, learning disabilities, childhood experiences of severe neglect.

Staff should be aware of the potential risk to children when individuals, previously known or suspected to have abused children, move into or have substantial access in the household (see Managing Individuals Who Pose a Risk of Harm to Children).

It should be recognised that those who pose a risk to children often will not be honest with others. Staff should be mindful of this. Of particular note are carers who present a risk due to either fabricating or inducing illnesses within the children they are responsible for – see Fabricated or Induced Illness Procedure.

Practitioners should, in particular, be alert to the potential need for early help for a child who:

is disabled and has specific additional needs
has special educational needs (whether or not they have a statutory Education, Health and Care Plan)
is a young carer
is showing signs of being drawn into anti-social or criminal behaviour, including gang involvement and association with organised crime groups
is frequently missing/goes missing from care or from home
is at risk of modern slavery, trafficking or exploitation
is at risk of being radicalised or exploited
is in a family circumstance presenting challenges for the child, such as drug and alcohol misuse, adult mental health issues and domestic abuse
is misusing drugs or alcohol themselves
has returned home to their family from care
is a privately fostered child

Recognising Physical Abuse

This section provides information about the sites and characteristics of physical injuries that may be observed in abused children. It is intended primarily to assist staff in the recognition of bruises, burns and bites which should be referred to Children’s Social Care and / or require medical assessment.

Further useful information can be found on the Core Info website, about a series of systematic reviews defining the evidence base for the recognition and investigation of physical child abuse and neglect.

The following are often regarded as indicators of concern:

An explanation which is inconsistent with an injury;
Several different explanations provided for an injury;
Unexplained delay in seeking treatment;
Parents / carers who are uninterested or undisturbed by an accident or injury;
Parents who are absent without good reason when their child is presented for treatment;
Repeated presentation of minor injuries (which may represent a ‘cry for help’ and if ignored could lead to a more serious injury) or may represent fabricated or induced illness (see Fabricated or Induced Illness Procedure);
Family use of different doctors and A&E departments;
Reluctance to give information or mention previous injuries.

Acute Life Threatening Event

Most acute life threatening events have a medical or physiological basis, although a precise explanation is not always found. Some have unnatural causes and assessment should always include consideration of these through careful history taking, examination and investigation similar to the list for unexplained deaths.

Child protection checks must be initiated for the child and any siblings. Any suspicions must be reported immediately to the duty social worker.

Bruising

Children can have accidental bruising, but the following must be considered as highly suspicious of a non-accidental injury unless there is an adequate explanation provided and experienced medical opinion sought:

Any bruising or other soft tissue injury to a pre-crawling or pre-walking infant or non-mobile disabled child;
Bruising in or around the mouth, particularly in small babies which may indicate force feeding;
2 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;
The outline of an object used e.g. belt marks, hand prints or a hair brush (a pinch causes small double bruises, a punch or kick causes an irregular bruise with a paler centre, gripping causes ovals from fingertips or lines between fingers);
Linear pink marks, haemorrhages or pale scars may be caused by ligature, especially at wrists, ankles, neck, male genitalia;
Bruising or tears around, or behind, the earlobe(s) indicating injury by pulling or twisting;
Bruising around the face;
Broken teeth and mouth injuries (a torn frenulum – the flap of tissue in the midline under the upper lip – is highly suspicious);
Grasp marks on small children;
Bruising on the arms, buttocks and thighs may be an indicator of Sexual Abuse.

Bruises are difficult to age accurately because they change colour at differing rates.

Bite Marks

Bite marks can leave clear impressions of the teeth. Human bite marks are oval or crescent shaped. Those over 3cm in diameter are more likely to have been caused by an adult or older child.te treatment or adequate explanation.

A medical opinion from a forensic dentist / odontologist 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. Any burn with a clear outline may be suspicious e.g:

Circular burns from cigarettes are characteristically punched out lesions 0.6 – 0.7 cm in diameter, and healing, usually leaves a scar;
Friction burns resulting from being dragged;
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 her/his 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.

Fractures

Fractures may cause pain, swelling and discolouration over a bone or joint.

Non-mobile children rarely sustain fractures.

There are grounds for concern if:

The history provided is vague, non-existent or inconsistent with the fracture type;
There are multiple fractures or old fractures (in the absence of major trauma, birth injury or underlying bone disease);
Medical attention is sought after a period of delay when a fracture has caused symptoms e.g. swelling, pain or loss of movement;
There is an unexplained fracture in the first year of life.

Scars

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

Shaken Baby Syndrome

Shaking and/or inflicting an impact injury on a baby often results in no visible external injury. Nevertheless, significant internal injuries may be caused, e.g. intra-cranial bleeding, brain injury, small fractures to the ends of the long bones, other fractures (such as ribs and neck) and retinal haemorrhages. Signs and symptoms can be non-specific, which may result in a delay in seeking advice.

The infant can present with:

Lethargy;
Poor feeding;
Vomiting;
Stops in breathing (apnoea);
Pallor;
Variable consciousness;
Irritability;

In suspected cases it is essential that a full paediatric assessment is carried out including an ophthalmological examination, blood tests and CT/MRI scans/skeletal survey (according to the RCR/RCPCH guidance).

Self-Harming and Siblings

Caution must be used when interpreting an explanation by parents/carers that an injury or series of injuries was self-inflicted or caused by a sibling. This is especially important in young or disabled children not able to offer a reliable explanation themselves.

Due consideration must be given to the possibility that the injury may:

Be non-accidental, particularly if the explanation appears discrepant for the nature of the injury;
Possibly have occurred in circumstances where neglect is a consideration.

In these circumstances a referral to Children’s Social Care should be made in accordance with the Making a Referral Procedure

Recognising Emotional Abuse

Emotional Abuse may be difficult to recognise, as the signs are usually behavioural rather than physical.

Indicators of Emotional Abuse are also often associated with other forms of abuse.

Recognition of Emotional Abuse is usually based on observations over time and the following offer some associated indicators:

Parent / Carer and Child Relationship Factors

Abnormal attachment between a child and parent / carer e.g. anxious, indiscriminate or failure to attach;
Persistent negative comments about the child or ‘scape-goating’ within the family;
Inappropriate or inconsistent expectations of the child e.g. over-protection or limited exploration.

Child Presentation Concerns

Delay in achieving developmental, cognitive and / or other educational milestones;
Failure to thrive / faltering growth;
Behavioural problems e.g. aggression, attention seeking;
Frozen watchfulness, particularly in preschool children;
Low self-esteem, lack of confidence, fearful, distressed, anxious;
Poor relationships with peers, including withdrawn or isolated behaviour.

Parent / Carer Related Issues

Dysfunctional family relationships including domestic violence;
Parental problems that may lead to lack of awareness of child’s needs e.g. mental illness, substance misuse, learning difficulties;
Parent or carer emotionally or psychologically distant from the child;
Contextual factors may include:
Child left unsupervised / unattended;
Child left with multiple carers;
Child regularly late attending, or, not being collected from school;
Child repeatedly reported lost / missing;
Parent/carer regularly unaware of child’s whereabouts;
Child regularly not available for meetings with childcare workers.

Recognising Sexual Abuse

Please also see: Policy Document for the referral of Child and Young Persons to the Sexual Assault Referral Centre.

Children of all ages and gender may be sexually abused and are frequently scared to say anything due to guilt and/or fear. This is particularly difficult for a child to talk about and full account should be taken of the cultural sensitivities of any individual child / family.

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

Behavioural Indicators

Inappropriate sexualised conduct;
Sexually explicit behaviour, play or conversation, inappropriate to the child’s age;
Continual and inappropriate or excessive masturbation;
Self-harm (including eating disorder), self-mutilation and suicide attempts;
Involvement in prostitution 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);
Running away.

Physical Indicators

Pain or itching of genital area;
Vaginal discharge;
Sexually transmitted infections;
Blood on underclothes;
Pregnancy;
Physical symptoms e.g. injuries to genital or anal area, bruising to buttocks, abdomen and thighs, sexually transmitted infection, presence of semen on vagina, anus, external genitalia or clothing.

Recognising Neglect

Evidence of neglect is built up over a period of time and can cover different aspects of parenting.

Child Related Indicators

An unkempt, inadequately clothed, dirty or smelly child;
A child who is perceived to be frequently hungry;
A child who is observed to be listless, apathetic and unresponsive with no apparent medical cause; displaying anxious attachment; aggression or indiscriminate friendliness;
Failure of a child to grow or develop within normal expected patterns with an accompanying weight loss or speech / language delay;
Recurrent / untreated infections or skin conditions e.g. severe nappy rash, eczema or persistent head lice / scabies;
Unmanaged / untreated health / medical conditions including poor dental health;
Frequent accidents or injuries;
A child frequently absent from or late at school;
Poor self esteem;
A child who thrives away from the home environment.

Indicators in the Care Provided

Failure by parents or carers to meet basic essential needs e.g. adequate food, clothes, warmth, hygiene, sleep;
Failure by parents or carers to meet the child’s health and medical needs e.g. poor dental health, failure to attend or keep appointments with health visitor, GP or hospital, lack of GP registration, failure to seek or comply with appropriate medical treatment;
A dangerous or hazardous home environment including failure to use home safety equipment, risk from animals;
Poor state of home environment e.g. unhygienic facilities, lack of appropriate sleeping arrangements, inadequate ventilation (including passive smoking) and lack of adequate heating;
A lack of opportunities for child to play and learn;
Child left with adults who are intoxicated or violent;
Child abandoned or left alone for excessive periods;
Neglect of pets.

Where there are any concerns about the neglect of a child in a household, consideration must be given to the possibility that other children in the household may also be at risk of neglect or abuse.

Obesity

Obesity in children is an increasingly common problem in the general population and differentiating when there is a Safeguarding issue can be difficult and complex. Neglect can result in poor supervision of food intake, or an inappropriate diet being offered to the child with resultant excessive weight gain. A sedentary lifestyle with limited opportunity for physical activity, when combined with an inappropriate diet, can result in excessive weight gain.

It is important to take into account:

The impact of the obesity on the child, particularly evidence that the child is developing medical complications (e.g. undue breathlessness), restrictions in day to day activities or social/emotional difficulties as a result of their obesity;
The context / is there other evidence of emotional harm or neglect.

Excessive calorie intake is the cause of most childhood obesity. In a very small proportion of obese children there is an underlying medical cause. The parent/carer is responsible for monitoring their child’s diet and seeking appropriate advice/support if the child or adolescent is overweight or obese. The management of obesity in children therefore requires parental engagement to enable and support their child to adopt healthy eating patterns, participate in age appropriate levels of physical activity and attend medical and dietetic appointments as necessary. Parental failure to engage with an appropriate management plan in a child who is severely obese and/or is developing serious complications of obesity should be considered a safeguarding issue.

Impact of Abuse and Neglect

The sustained abuse or neglect of children physically, emotionally, or sexually can have long-term effects on the child’s health, development and well-being. It can impact significantly on a child’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, 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, emotional and behavioural problems and educational difficulties.

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

Sexual abuse can lead to disturbed behaviour including self-harm, inappropriate sexualised behaviour and adverse effects which may last into adulthood. 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’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, helps the child to understand the abuse and is able to offer help and protection.

There is increasing evidence of the adverse long-term consequences for children’s development where they have been subject to sustained emotional abuse. Emotional abuse has an important impact on a developing child’s mental health, behaviour and self-esteem. It can be especially damaging in infancy. Underlying emotional abuse may be as important, if not more so, than other more visible forms of abuse in terms of its impact on the child. Domestic abuse, adult mental health problems and parental substance misuse may be features in families where children are exposed to such abuse.

The context in which the abuse takes place may also be significant. The interaction between a number of different factors can serve to minimise or increase the likelihood or level of Significant Harm. Relevant factors will include the individual child’s coping and adapting strategies, support from family or social network, the impact and quality of professional interventions and subsequent life events.

Non-recent (Historical) Abuse

Non-recent abuse (also known as historical abuse) is an allegation of neglect, physical, sexual or emotional abuse made by or on behalf of someone who is now 18 years or over, relating to an incident which took place when the alleged victim was under 18 years old.

Allegations of child abuse are sometimes made by adults and children many years after the abuse has occurred. There are many reasons for an allegation not being made at the time including fear of reprisals, the degree of control exercised by the abuser, shame or fear that the allegation may not be believed. The person becoming aware that the abuser is being investigated for a similar matter or their suspicions that the abuse is continuing against other children may trigger the allegation.

Reports of historical allegations may be complex as the alleged victims may no longer be living in the situations where the incidents occurred or where the alleged perpetrators are also no longer linked to the setting or employment role. Such cases should be responded to in the same way as any other concerns and the Referrals Procedures should be followed. It is important to ascertain as a matter of urgency if the alleged perpetrator is still working with, or caring for, children.

N.B. Historical abuse is not just about professionals. Also refers to past familial (etc) abuse.

Organisational responses to allegations by an adult of abuse experienced as a child must be of as high a standard as a response to current abuse because:

There is a significant likelihood that a person who abused a child/ren in the past will have continued and may still be doing so;
Criminal prosecutions can still take place despite the fact that the allegations are historical in nature and may have taken place many years ago.

If it comes to light that the historical abuse is part of a wider setting of institutional or organised abuse, the case will be dealt with according to the Organised and Complex Abuse Procedure.

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