Chapter Three

Recognising Abuse and Neglect

In this section:

Introduction
Children at increased risk of abuse
Physical abuse
Clinical presentations in life threatening situations
Emotional abuse
Sexual abuse
Neglect

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Introduction

3.1 This chapter provides guidance to assist in the recognition of abuse and neglect, and outlines potential indicators and common presentations. It is based on research and practice, which contributes to our understanding of parenting styles and behaviours, which are harmful to children, and interventions, which achieve the best outcomes for children.

3.2 The guidance supports professional judgment and assessment of the individual situation.  

3.3 Abuse and neglect are forms of maltreatment of a child.  Somebody may abuse or neglect a child by inflicting harm, or by 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.  An adult or another child or children may abuse them.

3.4 Sustained abuse or neglect of a child physically, emotionally or sexually, can have major long-term effects on all aspects of a child’s development and is likely to have a deep impact on their self-image and esteem.

3.5 It is not only the stress caused by individual incidents of abuse, but also the context in which abuse takes place that need to be considered when assessing the harm caused to the child. The impact of an abusive event in a household that is high in criticism and low on warmth and affection is likely to be far greater than for a child whose parent(s) are able to meet those essential needs.

3.6 Abusive incidents do not occur in isolation and it is often the combination of aggravating factors that increase the likelihood or level of severity of significant harm. Single incidents of maltreatment while being undesirable may not be significantly harmful.  Nevertheless, an injury must never be interpreted in isolation.  It must always be considered in the context of medical and social history, developmental stage, explanation given, full clinical examination and relevant investigations. Any unexplained injury that causes concern in a child should be investigated as appropriate.

3.7 All concerns about safety and welfare are important, as they may provide a greater understanding of what is happening in the child’s life, through the piecing together of sometimes apparently unrelated pieces of information.

3.8 It is essential that all staff are able to recognise potential abuse or neglect and:

• be aware of the behaviour of parents, which raise the level of concern for the child’s safety and welfare, and/or other adults who may pose a risk to children
• understand the ways in which abused or neglected children may present and the impact of the different forms of abuse on their behaviour
• understand the context in which abuse and neglect occurs, and recognise the common presentations
• be aware of those within their organisation who are able to advise and support them but understand that unnecessary delay may prejudice the child’s safety
• make clear and systematic records of concerns, and details of the child and parent(s), and any intended actions
• be aware of their own and their organisation’s duties and responsibilities to safeguard children
• understand the process of making a referral to the relevant social services department

3.9 When there are concerns about a child his /her safety and welfare are the  paramount consideration. Some situations divert attention from the child and these should be guarded against. These include:

• complex family situations with a lot happening in the family’s lives
• when a child is disabled, such that the disability masks other issues
• high levels of conflict between the parents or other adults in the household
• the parents' or carers' physical or mental health or learning difficulties
• the parents’ aggressive and threatening behaviour
• when there is a ‘duty of care’ to both child and parent(s), which may result in a conflict of interest

3.10 Other factors may impact on the process of recognition. These include:

• failing to listen to children
• myths around who abuses children, and which children are abused
• stereotypical views about child rearing patterns particularly across cultures
• beliefs that abuse only occurs in deprived and poor families
• views that children are the property of their parent(s)
• assumptions that safeguarding children is the responsibility of others
• viewing children in a family context rather than as individuals

Sources of stress for children and families

3.11 Many families living under stress manage to bring up their children in a warm, loving and safe environment. However, multiple disadvantage and associated stress affect parents’ capacity to respond to their child’s needs. This can have a negative impact on the child’s health and development.

3.12 Some parents' experiences may make them vulnerable, such that they are unable to cope with stresses that accompany parenthood. Young, immature or socially isolated parents may be overwhelmed by such stresses, resulting in incidents of maltreatment.

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Children at Increased Risk of Abuse

Disabled Children

3.13 Children in general are a vulnerable group within society. Evidence suggests that disabled children are at increased risk of abuse and that poorer standards of care are tolerated. Multiple disabilities appear to increase the risk.

3.14 Disabled children are children first and have the same right to be protected as others. Those working with disabled children should be vigilant in identifying when the threshold of intervention has been crossed, and the child is suffering or at risk of suffering significant harm.

3.15 Many of the problems that disabled children face, are not caused by their disability or condition but by social values, service structure and adult behaviour. There is an increased risk that behavioural changes and physical injuries are attributed to disability, so that abuse may be sustained for long periods of time.

3.16 There are factors that contribute to increased vulnerability. These include:

• perceptions that disabled children are of less value than others
• views that they are unable to make their own decisions, or understand what is happening
• limited verbal/communication skills, which may make disclosure less likely or poorly, understood
• denial of their sexual identity and neglect of sex education, which exposes them to sexual abuse and exploitation
• provision of intimate care by others which may make it more difficult to set boundaries of contact
• the nature of the disability may impact on their capacity to resist or avoid abuse
• family concerns about making allegations for fear that services may be withdrawn
• disabled children maybe especially vulnerable to bullying and intimidation; and/or
• be more vulnerable than other children to abuse by peers

Cultural Issues

3.17 Evidence suggests that black children may not receive the same level of protection from those organisations responsible for their welfare as white children.  

3.18 Inquiry reports into the deaths of black children through abuse and neglect identify:

• lack of intervention when there are obvious risks of significant harm from parents
• stereotyping and a reluctance to intervene for fear of being accused of racism

3.19 To make informed and sensitive judgements that respect diversity, workers need to recognise

• differing family patterns and lifestyles across racial, ethnic and cultural groups
• that stereotypical views about parenting can place a child at risk, and deny access to services
• the effects that racial harassment and discrimination can have on families

Please refer to: Culturally Appropriate Practice Guidance

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Physical abuse

Definition

(refer to page 37 and 38 of DfES Working Together 2006)

3.20 Within these procedures physical abuse is defined as:

Physical abuse may involve 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.

3.21 Physical injury to a child may occur as a result of:

• injury inflicted on the child by a carer or other family member, including a sibling
• injury sustained accidentally but as a result of neglect

3.22 As with all forms of abuse, physical abuse - the inflicting of injury to a child - often occurs against a background of other family problems. It is linked, in particular, with neglect and often injuries may be a mixture of direct abuse and accidents due to lack of safe parenting. It occurs across the social spectrum.

3.23 Most physical abuse occurs in families under stress, including the stresses of child rearing, and results from a loss of control. It may be a "one-off" incident or become a habitual response. It can involve scapegoating of one child or a way of responding to all the children in the family. The misuse of alcohol and certain substances are a recognised contributory factor to physical abuse.

3.24 Repeated incidents of physical abuse are likely to be emotionally damaging even where there is no serious physical harm. Emotionally abusive patterns of relationships, as outlined in the section on emotional abuse, make physical abuse more likely to occur.

3.25 Physical abuse of the child should always be considered as a possibility where there is known to be domestic violence against a parent. The child may be inadvertently caught up in violence between adults. Physical abuse of children is also more likely in families in which there is a pattern of domestic violence. Similarly, where there is known mistreatment of animals, the risk of child abuse increases.

3.26 Physical abuse can involve deliberate and pre-meditated harm of the child, and have sadistic and brutal elements. This is likely to present both physical danger and also serious emotional harm to the child.

3.27 Seemingly trivial injuries should not be ignored because abuse can and does escalate against a child if it goes unchecked. In terms of physical danger, babies and young children are at greatest risk. Further incidents may result in serious physical harm or be fatal

3.28 Suspicion that an injury may be non-accidental usually comes from a combination of medical and social factors, which, taken together, arouse concern. Commonly these are:

• inconsistency between the explanation and the injury observed (for example, multiple bruising from a simple fall)
• accounts which differ between parent and child, or which change over time
• explanations which do not fit the age and developmental level of the child, particularly when the child is said to have caused the injury himself
• any apparently unreasonable delay in seeking help, especially for a more serious injury
• incidental discovery of an unreported serious injury
• evidence that an implement has been used
• where the pattern of injuries itself raises concern
• injuries of different ages

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Common presentations in children

3.29 Behavioural signs:

• fearfulness
• flinching or backing away
• withdrawal from physical contact
• fear of parent being contacted
• frozen watchfulness in babies and young children
• persistently aggressive behaviour
• violent or aggressive play in young children
• reluctance to explain injuries
• changing explanations for injuries
• allegations of abuse

Bruises

3.30 Generally, bruising to the soft sites, which are normally protected in falls or accidents, is cause for concern. Those suggestive of abuse include:

• Bruising to cheeks, ears (particularly behind the ear), thighs and buttocks
• Bruises involving both eyes, unless the child has a primary injury to forehead or nose
• Linear bruises on face and ears (may extend into the scalp), buttocks, thighs or back, usually hand marks
• Patterns of small bruises, usually to the cheeks or jaw, shoulders and arms, upper arms or chest: may be gripping of the child
• Any "doughnut" bruise (pair of crescent shaped bruises, facing each other with a non bruised centre), often resulting from pinching
• Marks round the neck; may be a choke injury
• Bruises to inner thighs and genitals; may indicate sexual abuse
• Injury in and around the mouth, and in particular any tearing of the frenulum (tag of skin attaching lip and tongue inside the mouth), often by thrusting and twisting a bottle in a baby’s mouth
• Bruising to the lower abdomen; may indicate sexual abuse
• Bruising to abdomen; may indicate a kick/punch/being swung against a solid object, and delay in diagnosis can be life threatening
• Petechial bruising (i.e. tiny blood spots resulting from very small blood vessels breaking under the skin), which gives a mottled bluish red appearance, may be seen between the fingers of a slap mark, or where the child has been held tightly, or smothered
• A small circular bruise, with skin sometimes broken; this may be due to finger poking
• Bruising on forearm, face, ears, abdomen, hip, upper arm, back of leg, hands or feet could be as a result of defending themselves
• Suspicion should be raised where a group of bruises occur close together (may present on the upper arm, outside of the thigh, or on the body)

3.31 Typical bruising from the use of implements includes:

• Circular abrasions around limbs: may be ligatures or ties
• Abrasions to the corners of the mouth: may be from a gag
• Parallel-sided marks that curve with the outline of the body: may be from belts/straps
• Less clear linear marks, seen over prominent areas, usually narrower: may be from a stick
• Bruising with a looped outline: may be from the use of flex
• Bruising which reflects the imprint from an implement such as a shoe shape, a buckle, etc.

3.32 Conditions which may be mistaken for bruising include:

• Birth marks, natural pigmentation of the skin such as ‘blue spots’, commonly present in children whose parent(s) Have black or dark skin
• Bleeding disorders
• Infection
• Meningitis septicaemia
• Allergy
• Skin disease
• Ink, paint, dyes, dirt.

Determining the age and nature of the bruising is ultimately a medical responsibility.  However, the evidence is that we cannot accurately age a bruise from an assessment of colour – either from a clinical assessment or a photograph.

3.33 Babies who are not yet mobile, i.e. are unable to move on their own, cannot bruise by themselves. Bruises and other injuries must be adequately explained before being accepted as accidental.

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Bites, scratches and cuts

3.34 Human bites:

• Bruising is crescent shaped, and individual teeth can be identified if a recent bite
• Bite marks may be distorted in shape depending on where on the body the child is bitten
• Broken skin indicates a bite with some force
• May be confused with skin eruptions

3.35 The distance between the canine teeth on either side of the mouth, is greater than 3cms in bites from adults and older children. Dog and cat bites are distinctive from human bites, as their teeth are designed to puncture, cut and tear skin.

3.36 Scratches and cuts may also be inflicted injuries. Minor bruising, scratches or petechial bruising may also be the only visible sign of more serious assaults on a child, such as attempted strangulation or suffocation.

Swelling

3.37 This can occur at any site on the body and may initially be the only apparent injury. It can be minor or extensive and may be indicative of a more serious underlying injury, such as:

• Skull or other fracture sites
• When present on the scalp with tenderness and bruising (without a fracture) and sometimes with a bald patch, may indicate pulling of the hair or lifting a child by the hair
• Swelling of the face (usually with other symptoms), can indicate smothering or strangulation

Burns and scalds (thermal injury)

3.38 Non-accidental burns and scalds are found more frequently in children under 3 years old. They may be inflicted to discourage the child from playing with hot objects, in anger, or as a sadistic form of punishment.

3.39 Burns which should arouse suspicion include those where:

• There are scalds to hands, feet and buttocks but splash marks are absent. Clear demarcation lines can be seen between the scalded and unscalded skin : indicating a dip or forced immersion
• The soles of the feet or buttocks are unharmed; indicating having been pressed against a cooler base
• Scalds in unusual areas e.g. genitals or face, and a pattern of separated burned areas: suggestive of splashed or thrown scalds
• Scalds to the back of the hand : suggestive of the hand being held under hot water tap
• Burns in the mouth/centred round the mouth and face: may result from hot food or liquid forced on the child
• A pattern of contact burns that leave an imprint of the hot object: may suggest that a hot object has been pressed against the child or the child pressed against it (e.g. a radiator)

Cigarette burns

• May be single or multiple
• May be scarring from previous burns (shallow crater)
• Usually deep, cratered, circular, full skin thickness burns
• Common sites are the hand, foot, limbs, neck, breast or back
• Skin conditions such as impetigo, can be mistaken for cigarette burns

Fractures

3.40 Fractures should be suspected if there is sudden loss of function. Pain may be significant immediately, but may lessen. Swelling, bleeding and bruising take longer. There may be no bruising or indication at the site of the fracture. Where there is dislodgement of the bone or an incomplete break, there may be few outward signs. Seemingly minor bruising may mask a more serious injury, particularly in a very young child.

3.41 Abuse is highly indicative where there are:

• Fractures of the thigh bone in children under 13 months
• Rib fractures (unless there is a history of direct trauma, such as a road traffic accident, bone disease or surgery): these are frequently multiple and on both sides and often caused during violent shaking of the child
• A combination of healed and fresh fractures
• Explanations of a fall, which, although common in childhood, do not usually result in fracture
• Delays in seeking medical attention
• A spiral fracture in a young child, without a medically feasible explanation

Skull Fractures

3.42 These are common in the severely abused child. Swelling over the scalp may suggest the possibility of a fracture.

Intracranial injury

3.43 Injury to the brain is the most common cause of death from physical abuse. In the first year of life 95% of serious head injuries result from abuse. There are 2 main types:

• Impact injury occurs when a child is thrown violently against a wall, floor etc, or is struck, causing injury to the brain, skull and scalp
• Injury by shaking. Child is often held by the chest and repeatedly violently shaken back and forth

3.44 Both types may be present. There may be no superficial injury and the first indication of a problem may be that the child becomes unwell.

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Poisoning/Drowning/Suffocating/Strangling

3.45 All are very serious forms of abuse, as, whether or not the intention is to do so, the potential to cause serious harm is high. Where the incident may appear accidental, it could have occurred through lack of supervision.

3.46 Deliberate poisoning mainly occurs in children under 2 years 6 months. It usually presents as:

• Reported accidental poisoning. It will be important to confirm the account is credible
• The child having inexplicable signs and symptoms
• The child having recurrent unexplained illnesses, e.g. drowsiness and a changed breathing pattern

3.47 It is important to bear in mind that:

• It is a feature of induced illness
• Where parents misuse substances they may seek to involve their child at an early age
• Drugs may be used to keep children quiet, or make them compliant, and to allow sexual abuse to occur

3.48 Suffocation/Strangulation is more likely to involve children under 3 years, most being under 1 year old and:

• May be difficult to detect in spite of the violence involved as there may be no signs of injury, particularly If a pad of material/pillow is used
• It is also a feature of induced illness. The child may be repeatedly smothered just long enough to induce unconsciousness, then taken to a doctor

3.49 Deliberate Drowning is uncommon and also tends to occur in pre-school age children. Accounts of what happened may change, and are usually inconsistent with the child’s stage of development.

Fabricated and Induced Illness (FII)

3.50 This is a comparatively rare form of child abuse, which consists of the fabrication or induction of illness in a child that would not normally be present. The child is subsequently presented to health professionals for diagnosis and/or treatment. The deception may be done in three ways:

• Fabrication of symptoms and/or signs of illness: i.e. inventing a story of illness/fabrication of past medical history
• Alteration of charts or test samples
• Actually making the child ill

3.51 Abuse may continue in hospital. The child may also have a real illness that has been diagnosed and needs treatment. This may make diagnosis of the fabricated illness extremely difficult. It is important not to confuse this form of abuse with the actions of an over-anxious or challenging parent/carer who frequently seeks advice or confronts medical personnel.

Please refer to Chapter 14: Fabricated or Induced Illness (FII)

Female Genital Mutilation (commonly referred to as female circumcision).

3.52 This involves the partial or total removal of the external female genitalia. The age of the child is variable. The procedure is typically performed on girls aged between 4 and 13 years, in some cases Female Genital Mutilation is performed on newborn infants or young women before marriage or pregnancy.  Female Genital Mutilation may also be delayed until 2 months before a woman gives birth.

3.53 The practice is based on culture rather than religion. It is illegal in the United Kingdom under the 1985 Prohibition of Female Circumcision Act, though it may still be carried out, using crude and makeshift instruments, with no medical facilities or anaesthetic, and in less than hygienic conditions.

3.54 Incidents in the UK involve families coming from countries where it is routinely practiced, primarily in North and East Africa. Children may be returned to those countries, including on ‘holiday’ and have the procedure carried out there.

3.55 The practice can have a range of damaging consequences. The focus of intervention should be on prevention involving community education, but the practice constitutes child abuse and should be responded to as such.  

Please refer to: Practice Guidance on Female Genital Mutilation.

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Clinical Presentations in Life Threatening Situations

Intracranial injury

3.56 Injury to the brain is the commonest cause of death from physical abuse. Apart from a number of rare conditions, and in an otherwise healthy child, these injuries are invariably traumatic in origin.

3.57 The presenting symptoms can be acute or chronic dependent on the growth of the blood mass. In some cases, both can be present when the child has a previous injury, and then sustains further trauma.

3.58 Chronic presentation includes:

• Failure to thrive, with a history of poor feeding and sporadic vomiting. There may be unexplained anaemia, and raised temperature
• Fits will be of late onset, and accelerated head growth may occur

3.59 Acute presentation includes:

• Irritability with decreased responsiveness, fits and coma, and the fontanel may be tense
• Irregular breathing and apnoea, and the child will appear shocked and distressed

Retinal haemorrhage

3.60 The presence of retinal haemorrhages may be the first clue to the diagnosis of an intracranial injury, and the association with abuse is documented. They can occur in other conditions, but confusion with abuse is considered unlikely.

3.61 Outcomes for the child are dependent on the severity of the episodes. If the intracranial injury is the result of a violent shaking episode, there may be evidence of bruising on the chest. X-rays may identify rib and long bone fractures. There may be evidence of external injury to the head or skull fracture, or no external injuries.

Inflicted submersion injury (drowning)

3.62 The impact and damage sustained by the child will be influenced by the conditions i.e. water temperature, pond, bath or seawater, flowing or stagnant water. It may be the presence of other signs, or inconsistencies in the history that confirms the diagnosis of abuse. The accounts of those who were around at the time of incident are crucial.

Presentation may include:

3.63 Hypothermia, asphyxia and fits. Submerging a child’s head in water may also be an extreme form of physical control.

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Suffocation (Smothering)

3.64 The presentation and symptoms are dependent on the length of time the smothering persists.

3.65 The child’s physical appearance may include:

• Petechial haemorrhages of the face, neck and chest, and particularly the eyelids, anterior chest and abdomen
• The face may have a swollen, congested appearance
• There may be finger and thumb bruising around the mouth, and bruising of the lips and gums. If a pillow or pad of soft material is used, there may be no facial marks
• There may be scratches or nail marks on the face and evidence of bleeding or dried blood in and around the mouth and nose

3.66 The parent may report that the child has gone ‘blue and floppy’ at home, or have stopped breathing, or had fits. There may be no objective witnesses to this, but blood oxygen saturation levels may be reduced. A parent can continue to smother a child even when being observed.

3.67 There are a number of warning features that may indicate suffocation. These include:

• Previous unexplained episodes with similar symptoms
• Unexplained child deaths in the family
• Older babies in the family who have presented with the same symptoms
• Attendances at hospital emergency department, with apparently very trivial injuries, or the parent may give some prior warning that they are going to harm the child

3.68 Careful consideration should be given to all sudden unexplained child deaths. Suffocation is a feature of induced illness, and repeated suffocation may be inflicted to induce symptoms, creating a confused or bizarre clinical picture.

Poisoning

3.69 A child can be poisoned with almost any substance, which can be introduced in food, drink, or by other means such as absorption through the skin.

3.70 Deliberate poisoning may be difficult to diagnose. It may be the result of one single act or a series. Poisoning may also be the result of neglect.

3.71 Amongst the more common substances are: salt, anti-depressants, painkillers, sleeping tablets and alcohol.

3.72 The presentations will be variable, but may include:

• Vomiting, diarrhoea and dehydration
• Blistering of the mouth, if the substance was corrosive
• Drowsiness and poor responses to stimulation, or the child may be hyperactive
• He/she may be incoherent, confused and have hallucinations
• Breathing patterns may be abnormal or he/she may be apnoeic. respiratory or cardiac arrest may ensue
• Bio-chemical results may be abnormal or bizarre

Repeated poisoning may be indicative of neglect, or be a feature of induced illness.

Abdominal injuries

3.73 These may result from a kick or punch to the abdomen, or from crushing against the spine or rib cage, or the child being swung or thrown onto a solid object. The major organs may be perforated or lacerated, and they may be serious bleeding of the major vessels. These injuries are a serious threat to life particularly if there has been delay in presentation, diagnosis or surgery, increasing the risk of death.

3.74 Types of injuries:

• Perforation of the stomach and intestines
• Serious bleeding of the major abdominal vessels
• Laceration, injury and bleeding, involving the liver, spleen, pancreas, kidneys and other structures

There may be no signs of external injury, or there may be other injuries to the head or limbs.

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Emotional Abuse

Definition

3.75 Within these procedures emotional abuse is defined as:

"the persistent emotional ill-treatment of a child such as to cause severe and persistent adverse effects on the child’s emotional development. It may involve conveying to the child 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 ill treatment of a child, though it may occur alone".

3.76 The impact of all other forms of abuse is compounded by emotionally abusive relationships between parents and children.

3.77 Occasionally there are situations where no other obvious signs of abuse or neglect are present but the emotional relationship between the parents/carers and child appears so damaging that this may amount to emotional abuse. Very occasionally, this may involve a single act by a parent/carer which is extremely hostile, rejecting or induces fear in a child. In most instances, concern about emotional abuse will develop, based upon observation of the relationship between a parent and child.

3.78 The difficulty most often experienced by those with concerns is that each individual incident may appear insignificant and "a matter of individual judgement" about how to respond to the child. It is often helpful to cluster together those interactions which have caused concern, and also those which have been positive, in order to form an overall picture.

3.79 What makes the parental behaviour abusive is that it typifies their relationship with the child. It is likely to be recognised by what is observed over time This involves making judgements about how a parent/carer should manage a child’s behaviour, and clarity about what puts this parental behaviour beyond an acceptable threshold. Key questions will be:

• How persistent is this way of treating the child?
• How severe/inappropriate is it?

Factors increasing the likelihood of abuse

3.80 The following factors may increase the likelihood of emotional abuse:

Child

• Is unwanted
• Is the "wrong" gender
• Suffered from poor early attachment
• Is a step-child
• Is disabled
• Is of dual heritage within a white family when their needs are not taken seriously
• Is perceived as different

Parents/carers

• Serious physical or psychiatric illness
• Breakdown in parental relationships with chronic, bitter conflict over contact or residence
• Parental drug and/or alcohol addiction
• Parental involvement in seriously deviant lifestyles, including persistent offending behaviour
• Domestic violence
• Postnatal depression which affected the capacity to make an early attachment

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Environment

• Major and repeated family changes
• Isolation and social exclusion
• Families under persistent stress

Common presentations in children

3.81 Emotional ill treatment is involved in all forms of abuse and many of the behaviours and responses listed below may be indicators of abusive relationships in which there is also physical abuse, sexual abuse or neglect. Some presentations could be as follows:

• Very low self esteem, often with an inability to accept praise or to trust others
• Lack of any sense of fun - over serious or apathetic
• Excessively clingy or attention seeking behaviour
• Over anxious, either watchful and consistently checking or over anxious to please, or to achieve
• Developmental delay, especially in speech. In serious cases the child may be mute, or may fail to grow
• Substantial failure to reach potential in learning, linked with lack of confidence, poor concentration and lack of pride in achievement
• Self harming, compulsive rituals, repetitive behaviour
• Unusual patterns of response to others showing emotions

Common presentations in parents/carers

3.82 The following identifies parental behaviours which, if persistent, may be emotionally abusive. What is inappropriate will often depend on the child’s developmental stage.

3.83 Behaviour which appears persistently rejecting of the child:

• A negative view of the child, particularly a view that the child is inherently bad: this is often combined with "deserved" harsh punishment
• Treating the child very differently from other children in the family, e.g. scapegoating
• Open ridicule of the child
• Never valuing the child’s success; being hyper-critical
• Ignoring the child; extreme unresponsiveness or unavailability

3.84 Behaviour which is inconsistent over time.

• Extremely inconsistent and unpredictable responses to the child, particularly where this includes the threat of rejection. What is okay one day is punished the next day

3.85 Seriously unrealistic expectations which either inhibit the child or are unachievable.

• Expectations of what the child can/should do which are very inappropriate for the developmental stage of the child. This can be either much too high or much too low, and can involve parenting which is extremely over-protective or under-protective
• Interpreting the behaviour of a small baby as deliberately naughty

3.86 Drawing the child into lifestyles or beliefs which will damage his/her development.

• Involving the child directly in bizarre parental beliefs
• Involving the child in significant anti-social or criminal behaviour

3.87 Poor boundaries between adult and child:

• Having no respect for personal boundaries
• The child not being seen as an individual but as there to meet the parents’ needs
• The child is enmeshed in the adults concerns
• The needs of parent/carer consistently being put before the child
• Involving the child in battles within adult relationships
• Child witnesses domestic violence

Impact of Emotional Abuse on the child

3.88 Some children are more resilient than others and appear to cope better. It is known that factors such as supportive important attachments to other adults can reduce the impact of emotional abuse. Poor outcomes for children are predicted in those situations where there is persistent low warmth and high criticism.

3.89 There is increasing evidence of the long term consequences for children’s development where they have been subject to sustained emotional abuse. It can be especially damaging in infancy. It may be as significant as other more visible forms of abuse, if not more so.

3.90 It is important to appreciate that the damage caused by emotional abuse may not surface until later in life.

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Sexual Abuse

Definition

3.91 Within these procedures sexual abuse is defined as:

"Sexual abuse involves forcing or enticing a child or young person to take part in sexual activities, 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, pornographic material or watching sexual activities, or encouraging children to behave in sexually inappropriate ways."

3.92 Adults and adolescents, both male and female, abuse both male and female children. There remains a deep reluctance to accept that such abuse exists. Whilst sexual abuse can continue for a number of years, one single incident can be profoundly harmful.

3.93 Sexual abuse often occurs against a background of other family problems. It is linked with other forms of abuse and neglect, and with bizarre forms of punishment, particularly those that involve the genitals.

3.94 The extent and nature of touching and affection between parents and children differs between cultures, but abuse in all cultures occurs where the boundaries between affection and sexual stimulation or exploitation have been breached. Sexual abuse crosses all cultural and social groups, and involves children in every age group, including the very young. It is most frequently carried out by parents or carers, other family members, including siblings and by those in a position of trust. Older children represent a significant proportion of those who abuse.

3.95 Features of sexually abusive behaviour

• It is rarely an impulsive act, and can have compulsive features
• It is often carefully planned and executed
• It involves a degree of coercion, force, and/or persuasion
• It is carried out within an unequal power relationship
• Children and families are targeted and rarely randomly picked
• The process of grooming may be of a short duration or may span years
• The bigger the part which offending plays in the abuser’s life the more difficult it is to break the cycle of abusing behaviour
• The closer the relationship between child and abuser, the less likely the child is to tell
• The longer the abuse lasts, the greater is the likelihood of penetration, and also that the non-abusing parent will not believe the child.
• Where the non abusing parent is intimidated or abused by the abuser
• Where there are sadistic or bizarre approaches to discipline
• Where the family is closed, chaotic or socially isolated
• Where the daughter takes over the role of mother

3.96 Families who are vulnerable to being targeted by abusers from outside the family:

• The family is isolated
• Family boundaries on or about sexual activities are inconsistent
• The family does not provide appropriate supervision of the child
• The family does not control access to abusers in the family or community

3.97 Recognising inappropriate or over-sexualised behaviour in children

Things that should cause concern are detailed later under the following section "Common Presentations in Children"

A child’s sexual knowledge is influenced by:

• The child’s age
• The presence of an older sibling or one of the opposite gender
• Discussions in the family about sexual matters
• The family’s view about nudity and family bathing
• The acceptance by parents of their child’s sexuality, self exploration, and their questions and curiosity about sexual matters
• Whether they are punished, chastised or humiliated for their sexuality

3.98 Children are more vulnerable to sexual abuse where:

• They are isolated, unsupported and have poor relationships with their parents or carers
• Their strong need for attention, affection and dependency may make them more vulnerable to grooming via bribes, attention and affection
• They are unable to communicate their concerns, either because they are too young and lack vocabulary, or have specific communication difficulties
• Disbelief or rejection of their attempts to tell puts them off trying again or makes them delay telling. They do not want to cause trouble for the family, particularly if they have witnessed the impact on the family of other disclosures
• They have previously retracted an allegation and this undermines their credibility at the next attempt to tell (Retraction is a common feature of sexual abuse even where that abuse is later shown to have taken place)
• Others see the child as willing, or that he/she initiated or maintained the activity

Common presentations in children

3.99 The significance of the indicators is dependent on the age and development of the child. Some carry a much higher index of suspicion. A combination of a number of features should also raise the level of concern.

3.100 The following chart provides some of the presentations but is not exhaustive. H (high), M (medium), and L (low) indicate the level of suspicion each indicator should arouse

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3.101 Common Presentations in Children

 

Recognition of Sexual Abuse Carried out by Children and Young People

3.102 What follows is intended to help differentiate between sexual behaviour that can be considered as being age appropriate and non-abusive (and which therefore does not require intervention), and sexually abusive behaviour which requires action under these procedures.

3.103 It is important, when using the following guidelines, not to consider individual factors in isolation.

Age difference

3.104 The greater age difference, the more likely it is that the behaviour is abusive. There should be concern if the age difference is greater than two years. If the abuser is post-puberty and the victim is pre-puberty, this is also cause for concern.

Power difference

3.105 An imbalance of power should raise the possibility of abuse. Indicators are differences in:

• size
• strength
• level of assertiveness
• peer group status
• relative levels of development and cognitive ability

Nature of activity

3.106 If the activity involves behaviour beyond what would be considered to be age appropriate this should raise concern.

Consent or compliance

3.107 Co-operation and compliance are not the same as consent. Did both parties fully consent or was one co-operating or compliant because of other factors (such as age differences or threats)?

3.108 Full consent involves:

• understanding the proposal
• knowing the standard of behaviour
• awareness of possible consequences
• respect for agreement or disagreement

3.109 There is a continuum of control in sexual acts, ranging from:

• normal – no coercion, activity done in fun
• manipulation/peer pressure at a subtle, non-physical level
• coercion through use of threats and bribes
• physical force, weapons and other direct physical threats

Persistence of activity

3.110 How often, and for how long does/did this happen? Persistence may suggest abuse – but not always.

Developing patterns

3.111 If a pattern of behaviour is developing over time (e.g. Are there regular patterns with several partners?) there may be evidence that the child is progressing into an entrenched pattern of sexually abusive behaviour.

Overt aggression

3.112 If there is suggestion that the child has used their size strength, actual or threatened violence to engage in sexual activities, then the behaviour should be considered abusive.

Child’s perception

3.113 If either person experiencing the behaviours perceives them as abusive then this should be of concern. Even if they are not stating any concerns, the nature of the behaviour may still suggest that it is abusive.

Attempts to secure secrecy

3.114 If there have been any attempts to secure secrecy, the reasons for this have to be explored.

How was the activity revealed

3.115 Was there a disclosure following upset or difficult behaviour? Or was it an inadvertent comment which led to disclosure?

Any ‘target’ victims

3.116 Are there common characteristics of age, gender or vulnerability in a young person’s sexual partners?

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Neglect

Definition

3.117 Within these procedures neglect is defined as:

‘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 or development.  Neglect may occur during pregnancy as a result of maternal substance abuse. It may involve a parent or carer failing to provide adequate food, shelter and clothing, failing to protect a child from physical harm or danger, or the failure to ensure access to appropriate medical care or treatment. It may also include neglect of, or unresponsiveness to a child’s basic emotional needs’.

3.118 Children have the right to develop healthily, and to do this their basic needs must be met. Severe neglect of children is associated with major impairments of their health, cognitive and intellectual development, and with long-term difficulties with social functioning, relationships and educational progress. The risk of disease, ill health and death increases for neglected children, particularly for those under five.

3.119 Neglect does occur in families living in poverty, but they are not one and the same. The greatest risk to children are from those parents whose own emotional impoverishment is so great, that they do not know how to parent their children.

3.120 Many children experience temporary neglect due to family breakdown, parental illness, loss of employment or family crisis. However neglect that is most harmful is that which is:

• persistent
• cumulative
• chronic or acute episode
• resistant to intervention

3.121 The following is not an exhaustive list, and elements of neglect may be present to a greater or lesser degree. The lack of parental care may have a different impact on individual children in the same family. Neglect of any sort involves an element of emotional maltreatment.

Common presentation in children

3.122 The age and development stage of the child during the period of neglect indicates those aspects of their development which may be adversely affected.

3.123 Babies

• Recurrent diarrhoea and vomiting due to poor hygiene
• Poor growth and weight loss and conditions associated with protein and vitamin deficiency
• Tired and lethargic, but may cry for long periods due to hunger/pain/discomfort, further increasing risk of negative interaction with parents
• Often look anxious and unhappy and are difficult to comfort or pacify leading to increased level of family stress which may result in physical abuse of the baby
• The child may be left in wet and soiled clothing and have severe nappy rash causing scarring and infection
• Recurrent infections with hospital admissions as a result of being in wet and cold conditions
• Poor physical appearance may affect social interaction with others. The baby may not try to attract attention and may become withdrawn
• Lack of stimulation may cause development delay in sitting, walking, crawling
• Frequent minor injuries - (may also be due to physical abuse particularly if non-mobile)
• The child has ingrained dirt on skin and under nails, which has implications for the spread of infection/infestation

3.124 Pre-school child

• Poor growth – height and weight
• Recurrent minor unexplained injuries
• Lack of stimulation and social interaction affects development of receptive and expressive language development. May be made worse by recurrent inadequately treated middle ear infection
• Limited attention span probably results from lack of attempt to engage child’s attention at home. May indicate profound anxiety
• Social immaturity affects their ability to play co-operatively. Relationships with other children characterised by aggression and withdrawal - other children may avoid interaction with them
• Lack selective attachments - indiscriminately friendly with strangers and crave intimate physical contact, even in the presence of parent(s)
• Child is reported to be a ‘bad feeder’ or eater, but objective observations indicate baby/child is very hungry. The child may be reported to steal food from other children
• Food available is not nutritionally adequate or is inappropriate for the child’s needs
• Young child is allowed to wander the streets
• Child is exposed to dangerous or aggressive animals
• Child has easy access to medication/drugs and associated equipment
• Child may be involved in fire setting
• Small child left alone
• Young child frequently left with comparative strangers or in the care of a young baby-sitter
• The child has ingrained dirt on skin and under nails, which has implications for the spread of infection/infestation
• Persistent poor oral hygiene
• Hair is persistently tangled, dirty, and un-groomed.

3.125 School Child

• Short stature
• Poor social and emotional adjustment with behaviour and learning difficulties
• Poor hygiene and unkempt appearance may further impact on development of friendships. (Coping strategy may be to interact with adults)
• Persistent poor oral hygiene
• Disorders of attachment may be evident
• Chronic infestation e.g. head lice or scabies, despite attempts by others to advise, administer, provide appropriate treatment
• Lack of boundary setting leading to sexual exploitation
• The school may be unable to compensate for the long term lack of cognitive stimulation at home and they may require a ‘Statement of Educational Need’
• Low self-esteem. A child may feel worthless and display feelings of guilt for their behaviour. They may appear depressed
• Difficulty exercising self-control or regulating emotional behaviour, resulting in school exclusion
• Poorly developed self-care skills
• They may have unusual patterns of urination and defecation
• Self-stimulating behaviour (including sexual) and self-harm
• Child may have no clothes of their own
• Clothing/shoes may be poorly fitting to the point where this impedes the child's mobility
• Child is not involved in or is denied access to social events

3.126 Teenager

• Many of the above, but may also have poor general health and delayed puberty
• Frequent exclusions from school due to anti-social behaviour
• Easily influenced and exploited by others including sexual exploitation
• May be unaware of their hygiene needs during menstruation
• May have very poorly developed self-care skills
• May be sexually promiscuous, self-destructive and be involved in alcohol or substance misuse
• May be involved in delinquent or criminal acts and be well known to local police and community
• Pregnancy
• Running away
• There are no boundaries set between adult and child relationships
• Disorders of attachment may be evident

3.127 Common Presentation in Parents

• Failure to obtain advice or treatment when the child is ill
• Poor compliance with recommended treatment or medication (even when the child has a serious condition) including prescriptions for spectacles or hearing aids
• Chronic failure to have child attend for immunisation and developmental assessments having previously consented to do so and in spite of attempts to arrange this
• A disregard for advice on smoke pollution when the child has repeated chest infections
• Physical and emotional unavailability for the child
• Quality and quantity of available food and other material resources may be far superior to that provided for the child
• Delegating the responsibility for the child to others and holding them responsible when things go wrong
• Failure to show concern when the child is distressed or in pain
• Mothers often have poor health and low self-esteem
• One or both parents may have a history of abuse or neglect in childhood
• Violence and aggression in front of the child, and involving the child in inappropriate adult behaviour and discussion
• Responses to child’s behaviour is often unpredictable
• Child’s achievements’ or abilities are either ignored or scorned
• Child left in the care of those who are considered to be a risk to children, and the parent(s) are aware of this information
• Parent(s) do not know the whereabouts of their young child
• There are no boundaries set between adult and child relationships
• Parent(s) fail to recognise the need to promote the child’s positive self-identity and esteem
• Failure to recognise that the child’s neglected appearance impacts on acceptance by peers and the child may become socially isolated

3.128 Home environment

• Insufficient beds/bedding for each child and bedding may be persistently wet and/or infested
• Doors and gates are missing or broken, which gives access to hazardous environments
• Window panes may be broken and left un-repaired for long periods of time
• Gardens contain hazardous/discarded equipment or machinery
• Fireguards are either absent or not in use
• Evidence of inadequate or non-existent washing facilities
• Toilets do not work, evidence that they continue to be used
• Persistent smell of urine and faeces, (animal or human), with evidence in the home or garden
• Rotting scraps of food on the floor, with particular implications for the younger child
• No floor coverings or curtains, particularly where the child sleeps, and no source of heating or lighting
• Essential services may regularly be cut-off due to non-payment of bills

Neglectful families may well stand out and be unaccepted within their communities, including those where there is significant poverty and deprivation.

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