Recognising Abuse and Neglect

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					CHAPTER 2

RECOGNISING ABUSE AND NEGLECT

2.1 (This should be read in conjunction with Chapter 3 ‘Referrals to Social Services
Department’ and ‘The Protocol for Inter-Agency Working with Children in Need of
Support and Protection’).

INTRODUCTION

2.2 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 behaviors,
which are harmful to children, and interventions, which achieve the best outcomes for
children.

2.3 The guidance supports professional judgement and assessment of the individual
situation.



2.4 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.



2.5 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.



2.6 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.



2.7 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.



2.8 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 (see chapter 3).


2.9 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.



2.10 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

2.11 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.
2.12 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.

CHILDREN AT INCREASED RISK OF ABUSE

DISABLED CHILDREN

2.13 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.



2.14 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.



2.15 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.



2.16 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.



CULTURAL ISSUES

2.17 Evidence that suggests that black children may not receive the same level of
protection from those organisations responsible for their welfare as white children.
2.18 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.



2.19 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.

See also Practice Guidance ‘Culturally Appropriate Practice’.




                                                                      PHYSICAL ABUSE



DEFINITION

2.20 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 feigns the symptoms of, or deliberately causes ill
health to a child whom they are looking after. This is commonly referred to as Fictitious
Illness by Proxy or Munchausen Syndrome by Proxy"
2.21 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.



2.22 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.

2.23 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.

2.24 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.

2.25 Physical abuse of the child should also 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.

2.26 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.



2.27 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



2.28 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.

COMMON PRESENTATIONS IN CHILDREN

2.29 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

2.30 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.



2.31 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.

2.32 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.



2.33 Determining the age and nature of the bruising is ultimately a medical
responsibility. However, suspicion should be raised if a number of bruises have allegedly
been caused in a single incident but are of very different colouration (e.g. reddish blue
and yellow).



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.



BITES, SCRATCHES AND CUTS

2.34 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.


2.35 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.
2.36 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

2.37 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)

2.38 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.



2.39 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
       (eg 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

2.40 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.

2.41 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

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



INTRACRANIAL INJURY

2.43 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.



2.44 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.



POISONING/DROWNING/SUFFOCATING/STRANGLING
2.45 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 occured through lack of supervision.



2.46 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, eg drowsiness and a changed
       breathing pattern.



2.47 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.

2.48 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.



2.49 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.



2.50 FABRICATED AND INDUCED ILLNESS

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
      Alteration of charts or test samples
      Actually making the child ill.
2.51 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. Further details are in Chapter 11: Fabricated and Induced Illness



2.52 FEMALE GENITAL MUTILATION (COMMONLY REFERRED TO AS FEMALE CIRCUMCISION).
This involves the partial or total removal of the external female genitalia. The age of the
child is variable. Most often it is around 7 - 11 years, though may be delayed until 2
months before a woman gives birth.



2.53 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.



2.54 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.



2.55 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.



CLINICAL PRESENTATIONS IN LIFE THREATENING SITUATIONS

INTRACRANIAL INJURY

2.56 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.



2.57 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.



2.58 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.



2.59 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

2.60 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.



2.61 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)

2.62 The impact and damage sustained by the child will be influenced by the conditions
ie 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:

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



SUFFOCATION (SMOTHERING)

2.64 The presentation and symptoms are dependent on the length of time the
smothering persists.
2.65 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.



2.66 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.



2.67 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.



2.68 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

2.69 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.



2.70 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.



2.71 Amongst the more common substances are: salt, anti-depressants, painkillers,
sleeping tablets and alcohol.
2.72 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

2.73 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.



2.74 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.




EMOTIONAL ABUSE

DEFINITION

2.75 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. It may involve causing children 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".



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



2.77 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.



2.78 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.



2.79 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

2.80 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



Environment

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



COMMON PRESENTATIONS IN CHILDREN

2.81 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
2.82 The following identifies parental behaviours which, if persistent, may be emotionally
abusive. What is inappropriate will often depend on the child’s developmental stage.



2.83 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.



2.84 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.



2.85 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.



2.86 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.



2.87 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

2.88 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.



2.89 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.

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



SEXUAL ABUSE

DEFINITION

2.91 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 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."



2.92 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.



2.93 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.



2.94 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.



2.95 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.



2.98 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



2.99 Recognising inappropriate or over-sexualised behaviour in children

Things that should cause concern are detailed later under the 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



2.100 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



2.101 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.



2.102 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.




2.103 Common Presentations in Children

CHILD AGED UNDER 5
High                          Medium                         Low
Disclosure                    Developmental regression       Nightmares
Compulsive Masturbation       Genital injuries               Soreness of
Sexualised play, with                                        genitals/bottom
explicit acts                                                Excessive fear of being
Depicts sexual activity                                  bathed, changed or put to
(such as penetration, oral                               bed
sex, ejaculation)
Sexually transmitted
diseases
H.I.V. (unless from birth)
CHILD AGED 5 – 12 YEARS
High                         Medium                      Low
Disclosure                   Explicit sexual             Obsessive washing
Sexually transmitted         stories/poems               Abdominal pains
diseases                     Suicide attempts            Anorexia
Genital injuries             Alcohol and drug abuse      Depression
Compulsive masturbation      Bedwetting/enuresis         Developmental regression
H.I.V. (unless from birth)   Soreness of                 Nightmares
                             genitals/bottom             Running away
                             Soiling/Encopresis
                             Unexplained large sums of
                             money/gifts
CHILD AGED 12 – 16 YEARS
High                         Medium                      Low
Disclosure                   Self harm                   Running away
Genital injuries             Unexplained large sums of   Refusing to attend school
Prostitution                 money/gifts                 Depression
Self mutilation of                                       Hysterical symptoms
breasts/genitals                                         Anorexia
Sexual offending                                         Delinquency
Suicide attempts                                         Pregnancy (over 14)
Pregnancy (under 14)                                     Sexually transmitted
Sexually transmitted                                     diseases (over 14)
diseases (under 14)




RECOGNITION OF SEXUAL ABUSE CARRIED OUT BY CHILDREN AND YOUNG PEOPLE
2.104 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.



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



AGE DIFFERENCE

2.106 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

2.107 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

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



CONSENT OR COMPLIANCE

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



2.110 Full consent involves:

      Understanding the proposal
      Knowing the standard of behaviour
      Awareness of possible consequences
      Respect for agreement or disagreement.
2.111 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

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



DEVELOPING PATTERNS

2.113 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

2.114 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

2.115 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

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



HOW WAS THE ACTIVITY REVEALED
2.117 Was there a disclosure following upset or difficult behaviour? Or was it an
inadvertent comment which led to disclosure?



ANY ‘TARGET’ VICTIMS

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

NEGLECT

DEFINITION

2.119 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. 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’.



2.120 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.



2.121 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.



2.122 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
2.123 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

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



2.125 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.



2.126 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.



2.127 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.



2.127 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.

2.128 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



2.129 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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