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Recognition of Child Abuse and Neglect

The Circumstances

Explanations may be inconsistent, vague or not compatible with what you know. There may have been a delay in reporting an injury or in seeking treatment. There may be no explanation.

The Background

The child may have already been taken to hospitals or doctors on a number of past occasions. There may be a known history of unexplained or suspicious incidents or neglect. Parents may not mention previous injuries known to have occurred.

The Parents

Home may be a violent, stressful place and parents may feel at odds with the world. The family may have moved several times and may be socially isolated. Parents may perceive the child as naughty, demanding. difficult, dull, stupid or ungrateful. They may have unrealistic expectations of their children and difficulty in putting their children's needs before their own. They may have been abused themselves in the past and this may be a contributory factor. There may be issues of drug and alcohol abuse and mental health problems.

The Child

On the one hand, the child may appear hyper-vigilant yet unresponsive, regarding all adults with a look of frozen watchfulness (awaiting the next blow). On the other hand, (s)he may act in an indiscriminate or impulsive way with grown ups. The child could be aggressive, unusually eager to please or may want to take care of adults. The child could simply present as being annoying, constantly irritable or apparently taking no pleasure in play. Frequent unexplained absences from school may be significant. Behaviour may indicate inappropriate sexual knowledge.

A child's statement about the allegation of abuse, whether in confirmation or denial, should always be taken seriously. A child's testimony should not be viewed as inherently less reliable than that of an adult. However, professionals need to be aware that a false allegation may be a sign of a disturbed family environment and an indication that the child may need help. Similarly, it should be remembered that a retracted statement may be an indication of the child's fear of consequences rather than necessarily meaning that the allegation was false.

Types of Abuse

For the purposes of the Child Protection Register, child abuse is divided into emotional abuse, neglect, physical injury and sexual abuse. These categories are not mutually exclusive; all abuse involves some emotional damage.

Emotional Abuse

Emotional abuse is the persistent emotional ill-treatment of a child such as to cause severe and continuing 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 involve inappropriate age or developmental expectations being imposed on children. It could also be frequently causing a child to fee frightened or in danger which can lead to the exploitation or corruption of children. 

The sense of security that enables children to thrive and enjoy the outside world is obvious and easily recognisable. Once this is withdrawn, a child's delicate self esteem can be grossly undermined and can lead to compulsive or disturbed behaviours, physical or psychological developmental impairment, or even suicide.

Emotional abuse may be difficult to quantify and have no physical signs. Great diligence may be necessary to obtain sufficient evidence to protect the child before irreparable damage is done.

Emotional abuse may take the form of a basic failure to respond to a child's fears and worries, or a deliberate form of harm involving frightening, bullying or scapegoating of a child.

A child, who despite receiving adequate material and physical care, may be the subject of emotional neglect or rejection, which in some ways is even more difficult for children to bear. Children who appear depressed or withdrawn, who have difficulty making friendships or simply present as passive and apathetic may be having to deal with enormous yet hidden hostility, denigration and rejection at home.

Children may also be deemed to be suffering emotional abuse if the demands placed upon them, such as looking after young children or adults, preclude their own social activities and their right to play.

Behaviours which are emotionally abusive include the following:

The effects of such abuse are not always immediate and children even in the same household are likely to respond in very different ways. Many of the responses to emotional abuse are included in the section entitled "Symptoms of Sexual Abuse".

Neglect

Neglect is the persistent failure to meet a child's basic physical and/or psychological needs and is likely to result in the serious impairment of a child's health or development. It may involve a parent or carer failing to provide adequate food, shelter, clothing or appropriate medical treatment. It may also include neglect of, or unresponsiveness to, a child's basic emotional needs.

Child neglect is a serious condition that can result in retarded physical and emotional development. Coupled with physical abuse it can have fatal consequences. A child's development is highly sensitive to both physical and psychological stress.

The judgement of the degree of neglect we may find tolerable accords with social values, but at the point where insufficient care or protection leads to actual or potential impairment then child abuse can be said to have occurred.

Physical Neglect

This type of neglect may be the consequence of lack of concern and/or poverty. Children who receive an inadequate diet, lack clean hygienic conditions and severe infestations are examples of physical neglect. Children allowed to live in dangerous conditions or who are left to harm themselves must also be considered.

Child supervision is an issue subject to wide sub-cultural variability. Factors include the age of the child and his or her maturity as well as the length of time the carer is away. A further consideration is often the age and maturity of the temporary carer.

Medical Neglect

Medical neglect means failure on the part of the parent or carer to take reasonable steps to prevent injury or disease and/or failure to seek medical/psychological treatment or advice within a reasonable length of time when it is clear that medical intervention is necessary. Failure to identify injury, disease or to follow essential medical advice may also be neglectful.

Non-organic 'Failure to Thrive'

Non-organic Failure to Thrive is a phrase applied to infants or children who fail to develop adequately, drop away from their expected growth centile or grow erratically for reasons that have no medical or organic basis.

A parent can fail to adequately nourish a child for a variety of reasons: inexperience of childcare, lack of knowledge of how to feed, lack of care or feelings of hostility. Alternatively, some infants are difficult to feed and there may be a more complex psychological problem related to a child's hostile or stressful environment such as attachment difficulties.

Explanations related to the small stature of parents should always be carefully scrutinised. Many children otherwise regarded as simply small have been observed to have rapidly gained weight following an admission to a hospital or to care.

Children undernourished in their early years can be disadvantaged for life as their brain growth may be affected. This, in turn, affects all aspects of development and general health.

Physical Abuse

Physical abuse may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating or otherwise causing physical harm to a child. Physical harm may be also caused when a parent or carer feigns the symptoms of or deliberately causes ill health to a child whom they are looking after.

Bruises

Falls and accidents often produce only a single bruise which is usually on a bony prominence. Even a child who falls downstairs can sometimes only sustain one or two bruises. Conversely, a fall may often produce bruises on several surfaces such as a knee, a forearm and hand. Children usually run and therefore fall forwards which can lead to bruises on the front of the body and marks on their forehead, knees, and shins as well as on their hands if they managed to break their fall.

Bruises are virtually universal in the mobile child. Bruising on the less mobile child should always be a cause of concern and bruising in a young baby or a child with severe learning or physical disability should be viewed with deep suspicion.

Children are commonly struck on the head, ears, cheeks, mouth, chest, upper arms, stomach, thighs and buttocks. Any bruising to the lips or gums, ears, genital or rectal area, neck or buttocks should arouse particular suspicion and indicate the need for an expert paediatric opinion as such bruising is rarely caused accidentally.

To produce finger marks, bruising to the pinnae of the ears, outline marks (such as from a belt or strap), or grasp marks requires considerable force. Suspected bruising may turn out to be a symptom of a bleeding disorder, a birthmark, skin pigmentation or a skin disease but these distinctions are for medical practitioners to make.

Black Eyes

Bruises around and to the eyes are not uncommon and can be accidental if children have had an injury to the forehead or nose. In this instance, the bruising will be underneath the eyes. However bruising to the upper lids of the eyes and around the orbital ridge and surrounding tissue will need a medical opinion.

Easy Bruising

Parents often claim their child 'bruises easily'. In most cases this claim is incorrect and should be investigated by blood tests.

Burns and Scalds (Thermal Injury)

Scalds and burns are common accidents in children. A child who presents with any burn should be comprehensively medically examined.

It can be difficult to distinguish between accidental and inflicted burns but, generally, non-accidental burns are characterised by their regular outlines and their location. (eg, "glove" and/or "stocking" injuries to the extremities) whereas a child who pulls a saucepan of boiling water over themself suffers diffuse scalds to the facial and chest area. Burns to the buttocks and groin are rarely accidental.

Accidental burns or scalds should always lead to questioning the amount of supervision and protection offered to the child and should raise the issue of child neglect.

A common burning object, readily to hand at moments of stress or anger, is the cigarette. Although children can sustain very superficial burns by accident if parents smoke, brushing against the tip does not cause the characteristic circular punched out area of skin loss. Multiple cigarette burns are more readily diagnosed as non-accidental injury than single burns that heal rapidly without the need for any medical attention. However, such burns usually produce very typical scars. (NB-Impetigo/skin infection can be confused with cigarettes burns).

Friction burns are relatively common when children suffer playground accidents but these are usually associated with contact areas such as buttocks, stomach or chest and back.

Bites and Scratches

Bites inflicted by peers or siblings are common in childhood. Children can also suffer bites and scratches from pets.

Human bite marks are usually distinctive as a circle of two discontinuous semi-circles corresponding to the upper and lower teeth. There is usually no central bruising although this area may be swollen. 'Love bites' to a child may be signs of a sexual abuse. Bite marks may be associated with serious or sadistic abuse and are of forensic importance. An expert should always examine them.

The random movements of newborn infants frequently cause scratch marks, especially on the face. However, extensive and deep scratches are unlikely to be self-inflicted.

Lesions and Cuts

A torn frenulum (the web of skin joining the upper gum and the upper lip) is usually the result of a shearing force that requires specialist interpretation and investigation.

Restraining children by applying bands and ropes to wrists and ankles can lead to straight-edged lesions, which should arouse suspicion.

Children can be beaten with a variety of instruments and repeated blows may result in a series of marks.

Children whose Illness is Fabricated or Induced by Carers

Child welfare concerns may arise when:

There may be a number of explanations for these circumstances and each requires careful consideration. The characteristic of fabricated or induced illness is that there is a lack of the usual symptoms or signs or, in circumstances of proven organic illness, lacks the usual response to proven effective treatments. It is this puzzling discrepancy which alerts the medical clinician to possible harm being suffered by the child.

The following list of behaviours exhibited by carers when fabricating or inducing illness in a child is not exhaustive but can include the following:

Other Indicators of Physical Abuse

Sexual Abuse

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 (eg, rape or buggery) 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.

A child's verbal allegations must always be treated with the greatest respect. Children are entitled to be listened to and to have their allegations treated seriously. Although there can be occasions when children invent allegations, as a result of adult pressures or for a variety of other reasons, research suggests that such fabricated allegations are rare and that children are, in fact, more likely to claim they are not being assaulted when they are than vice versa.

Once concerns are reported it is important that the indicators are weighed in terms of significance and in the context of the child's life, before the assumption is made that the child is or has been sexually assaulted. Some indicators take on greater or lesser weight depending on the child's age. It is essential you do not question the child but record carefully what is said and contact Social Services. Do not discuss with a suspected abuser.

Less than half of victims of sexual abuse will present any forensic or medical evidence or any sign of neglect or physical abuse. Nevertheless, many commonly exhibit behavioural or emotional symptoms which will give some clue to their private suffering and confusion.

It is important to note that these symptoms are not specific to sexually abused children and can have a number of causes.

Symptoms of Sexual Abuse

These effects present singly or in clusters of behaviours, depending on each child's environment and specific situation.

For the pre-school child, the effects may show in:

In children between the ages of 6 and 12 years, the above effects may be recognisable with further elaborations:

For the older child, the effects may include any of the above-mentioned patterns with further escalations:

If a child is showing signs of emotional or behavioural stress, then the possibility of sexual abuse must be considered, particularly where there are sudden changes with no apparent explanation.

Self-destructive Behaviour

Many victims of sexual abuse will in some way act out their distress. Common amongst adolescent behaviour is self-mutilation, drug abuse, alcohol abuse and prostitution. Attempts at suicide are often the result of self-loathing and the inability to betray the abuser, who may be quite close.

Children have commonly been known to cut or burn themselves, have themselves tattooed and to make themselves ill.

They will seek the attention they desperately need by committing offences or by running away from home or absconding after getting themselves placed in care. Sexual abuse should always be considered as a possible explanation.

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