4.14 Significant Harm and Recognising Abuse Guidance

Contents

1. The Concept of Significant Harm
2. Recognising Significant Harm
3. Child Abuse as a Form of Significant Harm
4. Neglect
5. Physical Abuse
6. Sexual Abuse
7. Emotional Abuse
8. Bullying
9. Who Causes Abuse (Significant Harm)

1. The Concept of Significant Harm

The Children Act 1989 introduced the concept of 'Significant Harm' as the threshold that justifies compulsory intervention in family life in the best interests of children and gives local authorities a duty to make enquiries to decide whether they should take action to safeguard or promote the welfare of a child who is suffering, or is likely to suffer significant harm.

There are no absolute criteria to rely on when judging what constitutes significant harm. Working Together to safeguard Children 2006 (p7) gives the following definition:

"Consideration of the severity of ill-treatment may include the degree and the extent of physical harm, the duration and the frequency of abuse and neglect, the extent of premeditation, and the presence or degree of threat, coercion, sadism, and bizarre or usual elements. Each of these elements has been associated with more severe effects on the child, and/or relatively greater difficulty in helping the child overcome the adverse impact of the maltreatment.

Sometimes, a single traumatic event may constitute significant harm, e.g. a violent assault, suffocation or poisoning. More often, significant harm is a compilation of significant events, both acute and longstanding, which interrupt, change or damage the child's physical and psychological development. Some children live in families and circumstances where their health and development are neglected. For them, it is corrosiveness of long-term emotional, physical or sexual abuse that causes impairment to the extent of constituting significant harm. In each case, it is necessary to consider any maltreatment alongside the family's strengths and supports."

Under s31(9) of the Children Act 1989 as amended by the Adoption and Children Act 2002 'harm' means ill-treatment or the impairment of health or development, including for example, impairment suffered from seeing or hearing the ill-treatment of another; 'health' means physical or mental health; and 'ill-treatment' includes sexual abuse and forms of ill-treatment which are not physical. Under s31(10) of the Act: Where the question of whether harm is suffered by a child is significant turns on the child's health and development, his/her health or development

2. Recognising Significant Harm

In making your judgment about whether or not the concerns you have  about a child and their family meet the criteria for likely or actual suffering of significant harm, it is more then likely you will have some information but not the whole picture.

Abuse or neglect is not always easy to identify.

The first indications that a child is being abused may not necessarily be the presence of a severe injury. Indicators can present in numerous ways to the public and professionals alike:

• by remarks made by the child or his/her parents or friends;
• by changes in a child's behaviour or demeanour which may indicate abuse;
• by indications that the family is under extreme stress;
• by a series of events which, whilst not necessarily of concern in themselves, are significant if viewed in their entirety.

Initially, the situation may not seem serious but it should be remembered that prompt help to a family in trouble may prevent minor abuse escalating into something more serious.

3. Child Abuse as a Form of Significant Harm

In 'Working Together to Safeguard Children', 2006 the Department for Children Schools and Families  defines four categories of child abuse, which are assumed to be forms of 'Significant Harm':

• Neglect
• Physical Abuse
• Emotional Abuse
• Sexual Abuse

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 institution or community setting; by those known to them or, more rarely, by a stranger.  They maybe abused by an adult or adults or another child or children.

4. Neglect

Neglect is a form of Significant Harm which involves 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. Once a child is born, neglect may involve a parent or carer failing to provide adequate food and clothing, shelter including exclusion from home or abandonment, failing to protect a child from physical and emotional harm or danger, failure to ensure adequate supervision including the use of inadequate care-takers, 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.

Neglect may occur/involve:

• During pregnancy as a result of maternal substance abuse
• Parent/carer failing to provide adequate food and clothing, shelter including exclusion from home or abandonment,
• Failing to protect a child from physical and emotional harm or danger
• Failure to ensue adequate supervision including the use of inadequate care-takers,
• Failure to ensure access to appropriate medical care or treatment.
• May also include neglect of, or unresponsiveness to a child's basic emotional needs
  
  

Warning signs include:

• non-organic failure to thrive, i.e. where there is poor growth for which no medical cause is found, especially with a dramatic improvement in growth on a nutritious diet away from home;
• a consistently unkempt, dirty appearance;
• unmet medical needs, e.g. failure to seek medical advice or attend appointments for illness, severe untreated nappy rash, missed immunisations where they have not been refused on other grounds;
• developmental delay without any other clear cause;
• lack of social responsiveness;
• self-stimulating behaviours such as head banging or rocking (note that some special needs children may exhibit this behaviour due to their disability but this should also be evaluated for context);
• repeated failure by parents/carers to prevent injury;
• consistently inappropriately clothed for the weather;
• hazardous living conditions.

5. Physical Abuse

Physical Abuse is a form of Significant Harm which may involve including hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating or otherwise causing physical harm to a child, including fabricating the symptoms of, or deliberately causing, ill health, to a child.

Harm maybe caused to children both by the abuse itself, and by the abuse taking place in a wider family or institutional context of conflict and aggression, including inappropriate or inexpert use of physical restraint. Physical abuse has been linked to aggressive behaviour in children, emotional and behavioural problems, and educational difficulties. Violence is pervasive and the physical abuse of children frequently coexists with domestic violence. It may involve hitting, shaking, scolding, suffocating or poisoning and it may cause the following injuries:

Bruises

Symmetrically bruised eyes are rarely accidental, although they may occur where there is a fracture of the head or nose and blood seeps from the injury site to settle in the loose tissue around the eye. A single bruised eye may be the result of an accident or abuse. Careful consideration is required whenever there is an injury around the eye. It should be noted whether the lids are swollen and tender and if there is damage to the eye itself.

• Bruising in or around the mouth (especially in small babies)
• Grasp marks on legs and arms - or chest of a small child
• Finger marks (e.g. you may see three or four small bruises on one side of the face and one on the other)
• Symmetrical bruising (especially on the ears)
• Bruising behind the ears
• Outline bruising (e.g. belt marks, hand prints)
• Linear bruising (particularly on the buttocks or back)
• Bruising on soft tissue with no obvious explanation, e.g. inner aspect of thigh
• Bruising of different ages
  
  

The following are uncommon sites for accidental bruising:

• back of legs, buttocks, except occasionally along the bony protuberances of the spine
• mouth, cheeks, behind the ear
• stomach, chest
• under the arm
• genital, rectal area
• neck

Babies or others who are not yet mobile, i.e. are developmentally unable to move on their own, should not get bruises or other injuries. If they have bruises or other injuries, these must be adequately explained before they are accepted as accidental.

Note Seemingly trivial injuries should not be ignored because abuse can and does sometimes escalate against a child if it goes unchecked. They should be noted and collated in the child/ren's records. Most falls or accidents produce one bruise on a single surface - usually on a bony protuberance. A child who falls downstairs generally has only one or two bruises. Children who fall usually fall forwards and therefore, bruising is most often found on the front of the body. In addition, there may be marks on their hands if they have tried to break their fall. Bruising may be difficult to see on a dark skinned child. Mongolian blue spots are natural pigmentation on the skin which may be mistaken for bruising. These purplish-blue skin markings are most commonly found on the backs of children whose parents are darker skinned.

Scars

Children may have scars, but notice should be taken of a large number of differing age scars (especially if coupled with current bruising), unusual shaped scars (e.g. round ones from possible cigarette burns) or of large scars that are from burns or lacerations that did not receive medical treatment.

Fractures

These should be suspected if there is pain, swelling and discoloration over a bone or joint. Fractures should be suspected if the child is not using a limb, especially in younger children. The most common non-accidental fractures are to the long bones in the arms and legs, and to the ribs. It is very rare for a child under one year to sustain a fracture accidentally. Fractures also cause pain and it is very difficult for a parent to be unaware that a child has been hurt.

Burns/Scalds

It can be very difficult to distinguish between accidental and non-accidental burns; however, burns or scalds with clear outlines are suspicious as are burns of uniform depth over a larger area.

Note a responsible adult checks the temperature of the bath before a child gets in; a child is unlikely to sit down voluntarily in too hot a bath and cannot accidentally scald its bottom without also scalding its feet; a child getting into too hot water of its own accord will struggle to get out again and there are likely to be splash marks; small round burns may be cigarette burns (but may be friction burns, and accidental, if along the bony protuberances of the spine). Small round marks can sometimes be due to a skin condition - medical assessment will assist with differential diagnosis

Bites

These can leave clear impressions of the teeth. Human bites are oval or crescent shaped. If the impression of the bites is more than 3 cm across its width, they must have been caused by an adult or older child with permanent teeth.

Other injuries which may be deliberately caused

• poisoning
• ingestion or other application of damaging substances, e.g. bleach
• administration of drugs to children where they are not medically indicated or prescribed
• female genital mutilation, which includes female circumcision, excision and infibulation, is physical abuse and an offence regardless of cultural or other reasons. The only exception is if surgery takes place for medical reasons.

Injuries may also be caused as a result of a parent fabricating or inducing illness in a child. 

6. Sexual Abuse

Sexual abuse is a form of Significant Harm which involves forcing or enticing a child or young person to take part in sexual activities, including prostitution, 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.

These activities are usually kept very secret and are damaging to children, both in the short and in the long term.

Most child victims are sexually abused by someone they know - either a member of their family or someone well known to them or their family. The children are likely to have been put under considerable pressure not to reveal what has been happening.

Both boys and girls of all ages are abused and the abuse may carry on for many years before it comes to light.

Abusers may be both male and female.

It is important to note that children/young people are also capable of sexually abusive behaviour.

Sexual abuse often presents itself in a veiled way. Although some child victims have obvious genital injuries, a sexually transmitted disease or are pregnant, relatively few show such obvious signs.

Recognition of sexual abuse generally follows either a direct statement from the child (or very occasionally from the abuser), or more often, suspicion based on the child's circumstances, behaviour, or physical symptoms or signs.

The following list of commonly observed indicators is not exhaustive and there may be situations where none of them is present, even though a child is known to have been abused sexually. Equally, even if some are present it may also not be definitive of sexual abuse. These physical signs should alert professionals to the possibility of abuse. Suspicion increases where several features are present together.

Physical manifestations

• sexually transmitted diseases
• pregnancy (especially in younger girls or when identity of father is uncertain)
• genital lacerations or bruising
• vaginal bleeding in prepubescent girls
• abnormal dilation of vagina, anus or urethra
• Additional physical signs

Although these signs are not on their own indicative of sexual abuse, they include:

• itching, redness, soreness
• unexplained bleeding from vagina or anus
• daytime wetting
• faecal soiling or retention

Emotional and behavioural manifestations

Behaviour with sexual overtones (depending on age and understanding):

• explicit or frequent sexual preoccupation in talk and play
• sexual relationships with adults or other children
• hinting at sexual activity or secrets through words, play or drawings

Children may also behave in the following ways:

• withdrawn, fearful or aggressive behaviour to peers or adults
• running away from home
• suicide attempts and self mutilation
• child psychiatric problems, including behaviour problems, withdrawal from social contact, onset of wetting or soiling when previously dry and clean, severe sleep disturbances, arson (fire setting)
• learning problems which do not match intellectual ability, or poor concentration (NB: for some sexually abused children, school may be a haven -  they will arrive early, are reluctant to leave and perform well)
• marked reluctance to participate in physical activity or to change clothes for PE, etc.

7. Emotional Abuse

Emotional abuse is a form of Significant Harm which involves the persistent emotional maltreatment of a child such as to cause severe and persistent adverse effects on the child's emotional development. It may involve conveying to children that they are worthless or unloved, inadequate, or valued only insofar as they meet the needs of another person. It may feature age or developmentally inappropriate expectations being imposed on children. These may include interactions that are beyond the child's developmental capability, as well as overprotection and limitation of exploration and learning, or preventing the child participating in normal social interaction. It may involve seeing or hearing the ill-treatment of another. It may involve serious bullying causing children frequently to feel frightened or in danger, or the exploitation or corruption of children. Some level of emotional abuse is involved in all types of maltreatment of a child, though it may occur alone.

It is not usually indicated by a specific incident, but is observed in the interaction with the child. One child may be scapegoated or treated completely differently to their siblings.

Some level of emotional abuse is involved in all types of ill-treatment of a child although it may occur alone.

Parental behaviours associated with emotional abuse

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

• a persistently negative view of the child, particularly as inherently bad, often combined with "deserved" harsh punishment
• inconsistent and unpredictable responses particularly where there is threat to or rejection of the child
• expectations which are inappropriate for the developmental stage of the child, either too high or too low, over protective or under protective
• a lack of emotional availability or responsiveness to the child
• no respect for personal boundaries of the child; not seeing the child as an individual
• promoting mis-socialisation or poor social adaptation
• contradictory, confusing or misleading messages in communicating with the child which seriously distort reality for the child or promote confusion
• serious physical or psychiatric illness of a parent including periods of hospitalization
• induction of a child into bizarre parental beliefs
• breakdown in parental relationship with chronic, bitter conflict over contact or residence (this would also include situations where there is domestic violence)
• major emotional rejection of the child and parental inability to perceive his/her needs with any objectivity
• major and repeated familial change, e.g. separations, reconstitution of families
• parental drug and/or alcohol addiction or involvement in seriously deviant lifestyles
• entrenched offending behaviour which may be criminal and which might also lead to a term of imprisonment

Behavioural signs in children

Behaviour in a child which may indicate emotional abuse includes:

• very low self esteem, often with an inability to accept praise or to trust
• lack of any sense of fun, over-serious or apathetic
• excessive clingy or attention seeking behaviour
• over-anxiety, either watchful and constantly checking or over-anxious to please
• developmental delay, especially in speech
• substantial failure to reach potential in learning, linked with lack of confidence, poor concentration and lack of pride in achievement
• self harming; compulsive rituals; stereotypic repetitive behaviour
• unusual pattern of response to others showing emotions

There are separate procedures in Part III of this manual which describe other potential areas of concern; for example, on matters relating to Domestic Violence or Fabricating or Inducing Illness.

8. Bullying

Severe or persistent forms of bullying can result in Significant Harm, which is why those providing services for children should have adequate policies, procedures and training to counter bullying.

Bullying occurs when a person or group of people behave in ways which are designed cause distress or to hurt a person or group of people. 

Some times whole organisations can bully.

Bullying can be overt and plain for all to see.  It can be subtle and insidious.

Bullying can become part of the culture, recognised or believed by all or a significant number of people as 'acceptable'; it can even be encouraged and rewarded.

Bullying can include:

1. Name calling, being sarcastic and spreading hurtful rumours;
2. Assault or physical violence;
3. Threats & intimidation;
4. Spitting;
5. Incitement of others to harass and intimidate;
6. Destruction or taking property without permission;
7. Extortion or undue pressure;
8. Emotional aggression like tormenting and excluding people;
9. Racial harassment, taunts, graffiti and gestures;
10. Sexual aggression or harassment, unwanted physical contact or comments;
11. Comments, threats or actions relating to people's disability;
12. Comments, threats or actions relating to people's sexual orientation.

9. Who Causes Abuse (Significant Harm)

There is no 'typical' situation or environment in which child abuse may occur although many children are abused by parents. 

Parental responses to allegations of abuse which directly implicate them are very varied.  The following do not indicate either that abuse has taken place or that no abuse has taken place, but should raise concern.

• There may be an unequivocal denial of abuse and possibly non-compliance with enquiries or requests, for example, for the child to be medically assessed.
• Sometimes parents may react aggressively to a suggestion that they may be responsible for harm to their child.
• There may be reluctance to give information or explanations may be incompatible with the harm suffered by the child or explanations may be inconsistent over time.
• Parents may display a lack of awareness that the child has suffered harm or that their actions may be harmful.
• Parents may seek to minimise the severity of the abuse or not accept that their actions constitute abuse at all.
• Blame or responsibility for the harm may be projected on to the child (i.e. the victim) or a third party.
• Parents may seek help from any of the statutory or relevant voluntary agencies on matters unrelated to the abuse or its causes. This may be to draw attention to concerns other than those being presented.
• The parents may disappear.

Children may also be abused in an institution or community setting; by those known to them or, more rarely, by a stranger.  For example, children may be subject to ill treatment or abuse in the following settings:

• where they are looked after by independent residential or foster homes;
• whilst 'in care' children may be abused or mistreated by staff, visitors and by other children;
• by teachers in day or residential schools in the public, private voluntary or charitable sector;
• when placed in secure accommodation, prison or custody,
• when participating in clubs or associations;
• at leisure or sporting facilities, events or activities;
• children may also be coerced into prostitution, sexual exploitation or pornography;
• they may be severely bullied or abused by other children at school, whilst playing, at clubs or in residential or foster care;
• they may be enticed or befriended by 'strangers' whilst away from home;
• which can include children who have run away or are missing from home or care;
• they can be subject to organised abuse by groups of adults who may be relatives, friends of the family or professionals;
• they may be placed at risk resulting from domestic violence or from parental drug and alcohol use;
• children may also be subject to risk caused to the mental illness of parents.

End