Child protection

Maltreatment worldwide

Although there is international condemnation of child maltreatment, it remains a universal problem defined by culture and tradition. The lack of standardized data collection and variation in definitions of child maltreatment make worldwide comparisons difficult to draw. The UN Secretary General's report on violence against children estimates that in 2002 almost 53,000 children were murdered worldwide. The report also highlights the lack of governance and funding in poverty-stricken, fragile countries that provide the setting for widespread and serious forms of abuse and exploitation. Hundreds of millions of children are subject to child labour, sexual exploitation, female genital mutilation (FGM), honour-based violence and trafficking. Other abuses include child soldiers, feticide, abandonment, begging and orphans who are often institutionalized. A global action plan will address the determinants of abuse, which include poverty, family violence, culture and tradition, institutional care, discipline, armed conflict and treatment of girls.

Maltreatment in England

In England, a series of high-profile child deaths have shaped attitudes and legislation around child protection. Nomenclature is different in the other three countries of the UK, but the underlying principles are the same. Two particular cases were the tragic deaths of Jasmine Beckford and Victoria Climbié. Jasmine Beckford's death in 1984 shocked the nation and led to the Children Act of 1989. This established the principle that the welfare of the child (as opposed to the rights of the parents) is paramount in decisions made regarding their upbringing. Victoria Climbié's death in 2000 resulted in the Children Act 2004, which augmented established legislation emphasizing the integration of local services based around the needs of the child.

Since the inception of the first Children Act, there has been complex and frequently changing guidance published around child maltreatment, which is often challenging for the professionals involved ( Fig. 8.1 ).

Of approximately 11 million children across the UK, professional efforts are directed towards those subject to a Child Protection Plan and ‘looked after children’. As shown in Figure 8.2 , this represents only a small proportion of the ‘children in need’ and those defined as vulnerable, which includes disabled children and those living in poverty. Sadly, high-profile cases continue, with Peter Connelly in 2007 and Daniel Pelka in 2012 representing two of approximately 85 child deaths per year attributed to child maltreatment.

Case history

Daniel Pelka

• Date of birth: 15.7.07

• Date of death: 3.3.12

Daniel was murdered by his mother and stepfather in March 2012. For a period of at least six months prior to this, he had been starved, assaulted, neglected and abused. His older sister Anna was expected to explain away his injuries as accidental. His mother and stepfather acted together to inflict pain and suffering on him and were convicted of murder in August 2013, both sentenced to 30 years' imprisonment.

Daniel's mother had relationships with three different partners whilst living in the UK. All of these relationships involved high consumption of alcohol and domestic violence. The police were called to the address on many occasions and in total there were 27 reported incidents of domestic abuse.

Daniel had a spiral fracture of the humerus at the beginning of 2011 and abuse was suspected but the medical evidence was inconclusive. A social worker carried out an assessment concluding that there was need for intervention.

In September 2011, Daniel commenced school. He spoke very little English and was generally seen as isolated, though he was well behaved and joined in activities. As his time in school progressed, he began to present as always being hungry and took food at every opportunity, sometimes scavenging in bins. His mother was spoken to but told staff that he had health problems. As Daniel grew thinner, his teachers became increasingly worried and, along with the school nurse, help was sought from the GP and the community paediatrician.

Daniel also came to school with bruises and unexplained marks on him. Whilst these injuries were seen by different school staff members, they were not recorded, nor were they linked to Daniel's concerning behaviours regarding food. No onward referrals were made in respect of these injuries. At times, Daniel's school attendance was poor and an education welfare officer was involved.

Daniel was seen in February 2012 by a community paediatrician, but his behaviours regarding food and low weight were linked to a likely medical condition. The differential diagnosis of maltreatment, i.e. emotional abuse or neglect as a possible cause, was not considered.

The paediatrician was unaware of the physical injuries that the school had witnessed.

Three weeks after the paediatric assessment, Daniel died following a head injury. He was thin and gaunt. Overall, there had been a rapid deterioration in his circumstances and physical state during the last six months of his life.

(Extract above taken from Coventry Safeguarding Children's Board Serious Case Review.)

In child protection today, there is an emphasis on the importance of multi-agency information-sharing and communication along with early intervention. This is a change that has taken place over the last 30 years. According to the multi-agency document Working Together 2013 , the approach to child protection should be underpinned by two key principles:

• Safeguarding is everyone's responsibility

• A child-centred approach - ‘Think Family’ is a recent directive from the Department of Children, Schools and Families which emphasizes the importance of a whole family approach to safeguarding.

Why recognition and response is important

We all know that children may die from abuse. Less well recognized are the long-term sequelae in adulthood, that spare only the resilient minority. Outcomes include long-term health problems with poorer physical health, more risk taking, more medically unexplained symptoms and an increase in mental health problems including depression and suicide. Victims have lower educational attainment and difficulty parenting and thereby perpetuate the abusive cycle.

Sequelae have been shown to be both structural and functional. There is evidence from MRI studies that child maltreatment in the first two years of life, when brain growth is maximal, affects the developing brain. Persistent psychological maltreatment is a potent source of anxiety and stress, which disrupts the development of the neuroendocrine system. There is dysregulation of the hypothalamic–pituitary–adrenal axis, and parasympathetic and catecholamine responses which persist, so that the child either continues with a heightened response to stress or dissociates and withdraws.

During the first two years, there is also both synaptogenesis and synaptic pruning prior to myelination of the brain pathways. Studies have also shown that severe maltreatment can lead to alterations in this process and an overall reduction in brain volume. So, there is now increasing evidence that abuse and neglect, particularly in early infancy, can be extremely harmful, resulting in damage to the development and function of the child's brain, which later in life may lead to problems including aggression, depression, poor attention and concentration, social communication and relationship problems and anti-social behaviour. The importance of early intervention and attention to the chronicity of environmental adversity may indicate the need for permanent alternative care­givers, in order to preserve the development of the most vulnerable children.

The relatively new scientific field of epigenetics is also relevant to the cycle of child abuse and neglect. Its premise is that external influences can alter the way our DNA is expressed, and that this variability in expression is passed on in each generation.

Ever since the existence of genes was first suggested by Mendel in the 1860s and Watson and Crick described the double helix in 1953, science has developed the belief that DNA is nature's blueprint. Chromosomes passed from parent to child form a detailed genetic design for development. Recent research revolutionizes this idea and suggests that genes can be altered. There are millions of markers on your DNA and on the proteins that sit on your DNA. These have been termed the epigenome (literally ‘upon genetics’). DNA itself might not be a static predetermined programme, but instead can be modified by these biological markers. Chief among them are methyl groups, which bind to a gene and say ‘ignore this bit’ or ‘exaggerate this part’.

Methylation is how the cell knows it needs to grow into, say, an eyeball rather than a toenail. There are also ‘histones’ controlling how tightly the DNA is spooled around its central thread and therefore how ‘readable’ the information is. And it is these two epigenetic controls – an on–off switch and a volume knob – which give each cell its orders.

Darwin's central premise is that evolutionary change takes place over millions of years of natural selection, whereas this new model suggests characteristics are epigenetically ‘memorized’ and transmitted between individual generations.

Research on rats has identified changes in genes caused by the most basic psychological influence – maternal love. A 2004 study showed that the quality of a rat mother's care significantly affects how her offspring behave in adulthood – rat pups that had been repeatedly groomed by their mothers during the first week of life were subsequently better at coping with stressful situations than pups who received little or no contact.

You might think this is nothing new; that we already know from Bowlby and Rutter's work that a loving upbringing has positive psychological effects on children. But the epigenetic research suggests the changes are physiological as well as psychological. Epigeneticists also think socio-economic factors like poverty might ‘mark’ children's genes to leave them more prone to drug addiction and depression in later life, regardless of whether they are still poor or not.

This all bears weight when considering the outcome for the future generations of children exposed to traumatic life events and fits in well with the intergenerational cycle of abuse that is well documented.

Prevalence and relationship with medical conditions

Surprisingly, maltreatment is more common than many other medical conditions ( Table 8.1 ), but even these numbers are likely to be significant underestimates of the true prevalence. From interviewing adults, an NSPCC study found that 25% reported being subject to maltreatment in childhood. The changes in the number of children with a Child Protection Plan are shown in Table 8.2 .

The relationship between medical conditions and abuse is complex. Recent studies found that as many as 30–60% of maltreated children will have a coexisting medical condition. Therefore, as many abused children will be seen either routinely or for a medical condition, it should be part of the differential diagnosis for any childhood presentation.

In summary, recognition and response to maltreatment is important to prevent the psychological and physiological changes at structural, functional and genetic levels. This may go some way to preventing poor outcomes for the child in question and also to stop the intergenerational cycle of abuse and neglect.

Why is recognition and response difficult?

Historically, child protection has been taught as a separate topic in paediatrics, but no such separation exists. Child maltreatment is a differential diagnosis for every medical condition discussed in this textbook. Protecting children requires thinking of the possibility of maltreatment in any child who presents and having it on the list of differential diagnoses. Serious case reviews highlight the failure to ‘think the unthinkable’ when professionals accept parents' explanations too readily.

Although easy in theory, there are many barriers that prevent the professional from recognizing the possibility of abuse, including:

• Busy looking for rare medical condition to explain the symptoms

• Not wanting to open a can of worms

• Fear of being reported to the General Medical Council

• Fear of being wrong and missing a medical cause

• Reluctance to consider abuse

• Fear of parents' reaction to possibility

• Fear of loss of relationship with parents or carers.

Risk, vulnerability and resilience

We know that there are factors that impact on the likelihood of abuse occurring, such as drug and alcohol misuse, psychiatric illness in the parents and domestic violence. However, none of them have a causal link and there will be families who provide excellent parenting despite very difficult circumstances. It is therefore helpful to consider the risks, vulnerability, and resilience factors in a non-judgemental fashion.

Vulnerability

The common assessment framework ( Fig. 8.3 ) is a tool used initially by social workers but now by all professionals, and forms the basis of the Common Assessment Framework (CAF) form used to make referrals to social care. It is a shared assessment and planning framework for use across all children's services and all local areas in England. It aims to help the early identification of children and young people's additional needs and promote coordinated service provision to meet them. By looking at the themes listed, vulnerability factors can be identified and a thorough medical history will usually elicit them. They are listed in Table 8.4 .

Table 8.4

Vulnerability factors

Child's developmental needs
Premature and low birth weight
Separated from mother/primary caregiver
Disabled and/or chronic ill health, including physical and mental health
Unwanted/unplanned or different to expectations, for example the ‘wrong’ sex
Parenting capacity
Drug and alcohol misuse
Domestic violence
Mental health problems
Learning disability
Personal history of abuse and neglect
Family and environmental factors
Frequent moves, homelessness
Social isolation, weak supportive networks of family and friends
Socio-economic problems, such as poverty and unemployment
Living in a gang-associated area
Strong cultural beliefs leading to: Female genital mutilation Forced marriage Honour killing

Practical guidance in the assessment of a child with suspicion or allegation of maltreatment

Types of abuse and neglect – overview

Although a useful framework, in practice there is usually coexistence and overlap between the types of abuse. For simplicity, we will use the following categories:

• Physical abuse

• Sexual abuse

• Neglect

• Emotional abuse

• Fabricated illness

Evidence is increasingly moving away from the idea of certain injuries being classical or pathognomonic of child abuse. Instead, child maltreatment should be part of your differential diagnosis in any child presenting to medical services. However, an abused child can have a normal physical examination at any given time.

As children get older, the categories and perpetrators of abuse become less clear-cut and the young person thought to be a perpetrator may also be a victim of abuse and/or exploitation.

The WHO defines exploitation as a category of abuse, incorporating slavery, child labour and sexual exploitation. In the UK, we are increasingly recognizing the importance of sexual exploitation and trafficking as a child protection issue.

Physical abuse

This is defined as a form of abuse which 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.

Where physical signs are present, certain characteristics in the history should alert you to suspicion of child abuse. These include:

• A significant injury where there is no explanation

• An explanation that does not fit with the pattern of injury seen or motor-developmental stage of the child

• Injuries in infants who are not independently mobile

• An explanation that varies when described by the same or different parents/carers

• Unusual/inappropriate interaction between child and carer

• Aggression towards staff or the child or other relative/carer

• An inappropriate time delay in seeking appropriate medical assessment or treatment

• A history of inappropriate child response (e.g. did not cry, felt no pain)

• Presence of multiple injuries

• Child or family known to children's social care or subject to a Child Protection Plan

• Previous history of unusual injury/illness, e.g. unexplained apnoea

• Repeated attendance with injuries that may be due to neglect or abuse.