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Contents

1. The Definition of Significant Harm
2. Categories of Abuse and Neglect
3. Recognising Physical Abuse
4. Recognising Emotional Abuse
5. Recognising Sexual Abuse
6. Recognising Neglect
7. Impact of Abuse and Neglect
8. Risk Factors in all Forms of Harm

1. The Definition of Significant Harm

1.1	The Children Act 1989 introduced the concept of significant harm as the threshold which justifies compulsory intervention in family life in the best interests of children.
1.2	Section 47 of the Act places a duty on local authorities to make enquiries, or cause enquiries to be made, where it has reasonable cause to suspect that a child is suffering, or is likely to suffer Significant Harm.

Under Section 31(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; ‘Development’ means physical, intellectual, emotional, social or behavioural development; ‘Health’ means physical or mental health; and ‘Ill-treatment’ includes sexual abuse and forms of ill-treatment that are not physical.

1.3	There are no absolute criteria on which to rely when judging what constitutes significant harm. Consideration of the severity of ill-treatment may include: The degree and the extent of physical harm, The duration and frequency of abuse and neglect, The extent of premeditation, The degree of threat, coercion, sadism, and Bizarre or unusual elements in child sexual abuse 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.
1.4	Sometimes a single traumatic event may constitute Significant Harm, e.g. experiencing or witnessing a violent assault, suffocation or poisoning. More often, Significant Harm is a compilation of significant events, both acute and long-standing, which interrupt, change or damage the child's physical and psychological development. Some children live in family and social circumstances where their health and development are neglected. For them, it is the corrosiveness of long term emotional, physical or sexual abuse and/or neglect that causes impairment to the extent of constituting Significant Harm. In each case, it is necessary to consider any ill-treatment alongside the family's strengths and supports.
1.5	To understand and establish Significant Harm, it is necessary to consider: The family context, including protective factors The child’s development within the context of his or her family and wider social and cultural environment Any special needs, such as a medical condition, communication difficulty or disability that may affect the child’s development and care within the family The nature of harm, in terms of ill-treatment or failure to provide adequate care The impact on the child’s health and development; and The adequacy of parental care
1.6	A court may only make a Care Order or Supervision Order in respect of a child if it is satisfied that: The child is suffering, or is likely to suffer Significant Harm; and That the harm or likelihood of harm is attributable to a lack of adequate parental care or control (section 31, Children Act 1989).

2. Categories of Abuse and Neglect

The abuse or neglect of a child can be caused by inflicting harm or by failing to act to prevent harm. Children may be abused in a family, in a community or institutional setting, by those known to them or, much more rarely, by a stranger.

The following definitions are taken from Chapter 1 of Working Together to Safeguard Children, 2010.  When a decision is made at a Child Protection Conference that a child should be subject to a Child Protection Plan, one of these categories will be used to identify the primary source of harm– see Section 11.4, Initial Child Protection Conference Procedure.

They have been included to assist those providing services to children in assessing whether the child may be suffering actual or potential harm.

2.1 Physical Abuse

Physical abuse may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating or otherwise causing physical harm to a child. 

Physical harm may also be caused when a parent or carer fabricates the symptoms of, or deliberately induces illness in a child.  Further information about this form of abuse is set out in the Fabricated or Induced Illness Procedure.

2.2 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 include not giving the child opportunities to express their views, deliberately silencing them or "making fun" of what they say or how they communicate. 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 (including cyberbullying) 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.

2.3 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, not necessarily involving a high level of violence, whether or not the child is aware of what is happening. The activities may involve physical contact, including assault by penetration (for example rape or oral sex) or non-penetrative acts such as masturbation, kissing, rubbing and touching outside of clothing.. They may also include non-contact activities, such as involving children in looking at, or in the production of, sexual images, watching sexual activities, encouraging children to behave in sexually inappropriate ways, or grooming a child in preparation for abuse (including via the Internet). Sexual abuse is not solely perpetrated by adult males. Women can also commit acts of sexual abuse, as can other children.

2.4 Neglect

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 and development.

Neglect may occur during pregnancy as a result of maternal substance misuse. 

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)
• Protect a child from physical and emotional harm or danger
• Ensure adequate supervision (including the use of inadequate care-givers)
• Ensure access to appropriate medical care or treatment

It may also include neglect of, or unresponsiveness to, a child’s basic emotional needs.

3. Recognising Physical Abuse

3.1 Introduction

Physical abuse may be the result of sudden, uncontrolled or premeditated assault or exposure to physical harm and may include:

• Injury knowingly inflicted, including bruising, bites, burns, scalds, unexplained or repeated lacerations or abrasions, fractures, head and/or facial injuries, brain injury and concussion, suffocation and fabricated or induced illness
• Ingestion of or exposure to poisonous or harmful substances
• Domestic violence – see Domestic Abuse Procedure
• Infanticide

For details in relation to fabricated or induced illness in children, see also Fabricated and Induced Illness Procedure

Accidental injuries normally have a clear and credible history and are consistent with that history and with the development and abilities of the child.

It may be due to a medical condition

3.2 Possible indicators of abuse

It can be difficult to identify physical abuse and the following factors should be considered:

• Repetitive pattern of injury (but parents may use different GP’s/hospitals to avoid detection);
• Injuries not consistent with the history;
• Explanations which vary, are contradictory or implausible;
• Pattern of injuries which without satisfactory explanation might suggest abuse;
• Bruising to a young baby - there are few reasonable explanations;
• Multiple injuries;
• Severe head injuries;
• Rib fractures;
• Subdural haematoma ;
• Retinal haemorrhage;
• Cigarette burns;
• Fractures in infants and toddlers;
• Presence of other signs of abuse e.g. neglect, failure to thrive, sexual abuse
• Unusual behaviour in the parents e.g. delay in seeking medical advice;
• Refusal to allow proper treatment or admission to hospital;
• Unprovoked aggression towards staff;
• Behaviour in the parent and child interaction which indicates poor attachment/bonding;
• Frequent injuries of different ages and/or in unlikely places e.g. symmetrical bruising to the eyes (although this may occur where there is injury to the head/nose) or ears;

3.3 Bruising

Bruises are collections of blood under the skin or in the tissues.  It may be faint or severe.  The colour of bruises depends on the depth and age of the injury.  Bruises fade from red, blue purple and yellow over a period of days.  The exact dating of bruises is notoriously difficult as it depends on the individual, the tissues affected and the depth of the bruise.  Only a medical practitioner should give an opinion on the age of a bruise.

Petechial bruises are tiny spots of blood under the skin caused by increase in pressure in the tiny blood vessels causing them to break.  They are very significant in the areas around the neck, face, eyes and ears, and disappear very quickly.

Repeated or multiple bruising may have a medical cause but this can only be excluded by a full medical examination and blood tests. 

Bruising in accidents is usually on the front of the body as children generally fall forwards, and there may be marks on their hands where they have tried to break the fall.  Unusual sites for accidental bruising are:

• The back, back of the legs, buttocks (except occasionally along the bony surface of the spine)
• Mouth, cheeks, behind the ear
• Stomach, chest
• Under the arm
• Genital, rectal area
• Neck

Bruising to the breasts, buttocks, lower abdomen, thighs and genital/rectal area could be an indicator of Sexual Abuse.

Bruising caused by a hand slap can leave a characteristic pattern of stripes representing the imprint of fingers.  Forceful gripping can leave small round bruises corresponding to the position of the finger tips, e.g. on upper arms or cheeks.

“Tramline” bruising is caused by a belt or a stick and shows as lines of bruising with a white patch in between.

Bruises can be mimicked by paint or pen marks, dye from clothes, birthmarks or blue spots.  Blue spots are irregularly shaped areas of bluish-black pigmentation on the buttocks, back and possibly other parts of the body.  They are birth marks and appear on more than 50% of new born babies of African, Chinese and Japanese parentage and sometimes in the children of dark haired European families.  Their edges are usually clearly defined and their colouring even.  They are not indicators of abuse and should not be confused with bruising.  However their presence and location on the child’s body should be clearly recorded by health professionals on a body map.

See also NSPCC Leaflet "Bruises on Children"

3.4 Bite Marks

Bites result in small bruises forming part or all of a circle. 

Bite marks can leave clear impressions of the teeth when seen shortly after the injury has been inflicted.  The shape then becomes a more defused ring bruise or oval or crescent shaped. Those over 3cm in diameter are more likely to have been caused by an adult or older child. 

A medical/dental opinion, preferably within the first 24 hours, should be sought where there is any doubt over the origin of the bite.  The diameter may provide evidence as to the identity of the perpetrator.

See also NSPCC Leaflet "Oral Injuries and Bites on Children"

3.5 Burns and Scalds

Burns are caused by the application to the skin of dry heat and the depth of the burn will depend on the temperature of the object and the length of time it is in contact with the skin.

It can be difficult to distinguish between accidental and non-accidental burns.  Non-accidental burns are usually deep and may show the outline of the object whereas accidental burns rarely do because the child’s immediate response is to pull away e.g. the burn of the whole sole-plate of an iron is unlikely to be accidentally caused.

Flame burns are usually less deep and have a less definite outline and may be fan shaped.

Friction burns, accidental or not, may be similar in appearance to a flame burn; they are seen on the prominent areas of the body such as the nose, chin, heels, elbows, back or shoulders of children.

Cigarette burns are not common.  They are round, can be deep and have a red flare round a flat brown crust.  They can be difficult to distinguish from impetigo.  Such burns usually leave a scar, which should not be confused with chickenpox scars.

Indicators of non-accidental burns include:

• Delay in presenting the child for treatment
• Presentation after a delay if a complication sets in
• Presence of other injuries, old and new
• Pattern of repeated burns/scalds to children in the family
• Evidence of neglect including non-organic failure to thrive
• Reports from the parents or carers that there were no witnesses to the ‘accident’ and that the child was merely discovered to be burned, thus hoping to discourage any further enquiry
• Scalds attributed to action of sibling or other child (this can be a false explanation for abusive scalds but if found to be true, then the wider implications require careful consideration)
• Child reported to experience little pain at the time of injury
• Child shows unusual response to the injury/treatment
• A history of previous abuse or neglect

Scalds are caused by steam or hot liquids. 

Accidental scalds may be extensive but show splash marks unlike the sharp edges of damage done when the child is ‘dunked’ in hot water.  The head, face, neck, shoulders and front of the chest are the areas classically affected when a child pulls over a kettle.  If the child turns on the hot water in the bath the soles of the feet are in contact with the bath and will be less affected than the tops.

Indicators of inflicted scalds include:

• “Glove” or “stocking” distribution of scalds to one or both hands/feet or clear ‘tide mark’ may be present
• Absence of splash marks may imply restraint of the child
• Soles may be spared if feet pressed on to cooler base of bath - presence of shoes and clothes may modify pattern of injury
• Scalds to the buttocks and/or feet either isolated or associated with immersion in hot water
• Poured or thrown pattern which may involve unusual sites e.g. back of hand, genitalia, face
• Age of scald inconsistent with history given
• Explanation does not fit with developmental ability of the child (e.g. 10 month old unable to climb into sink)
• Pattern or degree of injury is not consistent with the history
• Bath water temperature from ‘scene of crime investigation’ inconsistent with account by carer.

See also NSPCC Leaflet "Thermal Injuries on Children"

3.6 Scars

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

3.7 Fractures

Children’s bones bend rather than break and require a considerable force to damage them so there must be a clear history of injury and of prolonged upset to the child immediately afterwards.  Below are listed some common sense points relating to fractures -

• Fractures are sudden, painful and can lead to immediate loss of function
• If children are said not to cry or express pain, ask why.  Abused children are sometimes too frightened to complain and the “watchful” child can be recognised in the hospital.
• Children do not continue to walk or play normally with a fracture, but parents who have abused may ignore the injury.
• Pain is at a maximum at the beginning and swelling, bleeding and bruising take a while to develop in full.  As these develop, pain may lessen.  However pain continues until the fracture has healed.
• Many fractures show no bruising
• As many of the fractures in abused children involve areas of bone dislodged from the main shaft or incomplete (greenstick) breaks, all the classic signs of fractures are not always present.  Loss of function is the most important sign of a recent fracture.  Once healing is underway there may be no clinical signs of fracture detectable, but radiology will reveal the old injury.  In abuse, this is especially important because fractures of different ages may be evident on a skeletal survey.

Fractures are of various kinds depending on the direction and strength of the force which caused them;

Greenstick

The bones bend rather than break.  This is very common accidental injury in children.

Transverse

The break goes across the bone and occurs when there is a direct blow or a direct force on the end of the bone e.g. a fall on the hand will break the forearm bones or the lower end of the humerus.

Spiral or Oblique

The fracture line goes right round the bone or obliquely across, this is due to a twisting force.

Metaphyseal

Occur at the extreme ends of the bone and are rarely seen accidentally.  They too are caused by a strong twisting force.

Skull Fractures

If accidental they are usually a single long line on one side of the head.  Complex (branched), depressed or fractures at the back of the skull are more suspicious.

Rib Fractures

Do not occur accidentally except in a severe crushing injury e.g. in a road traffic accident.  Any other cause is highly suspicious of non accidental injury.

As with all unusual injuries the history and context of the injury are vital to any assessment regarding the possibility of Non Accidental injury.

See also NSPCC Leaflet "Fractures in Children"

3.8  Injuries in relation to the age of the child

i. Babies Under 1 Year Old

Any injury, no matter how minor, in a non-mobile child must be considered carefully; it must have a credible explanation if it is to be considered accidental.  Healthy babies do not bruise or break their bones easily, they do not usually:-

• Bruise themselves with their fists, a rattle or other toy
• Bruise themselves by lying against or through the bars of a cot
• Acquire bruises on the feet when they are held for a nappy change.

Bruising on the ears, face, neck, trunk and buttocks is particularly suspicious of abuse.  Petechial spots, which disappear very rapidly, may indicate attempted smothering, and should be assessed as quickly as possible.

A torn frenulum (behind the upper lip) in babies must be referred for medical investigation as it may be an indicator of abuse.

Fractures are not always obvious clinically and so a skeletal survey would always be advisable in a small baby with suspected non-accidental injury.  Fractures of the ribs, metaphyseal fractures and spiral fractures of the limbs should raise concerns about the possibility of non-accidental injuries.

A fracture of the clavicle (collarbone) can occur after a difficult birth but if further fractures occur an expert opinion should be sought.

Minor injuries in infants which are not necessarily serious in their nature can still be very significant and warrant investigation.

Fractures in babies under a year old should always be investigated.

When small babies are shaken their head and limb movements cannot be controlled, and this can result in a severe brain injury from haemorrhaging inside the skull.  It may also cause metaphyseal fractures of the limbs as a result of the rotary movement.  Carers often do not understand how dangerous such behaviour can be.  Finger bruising on the chest well may indicate that the child has been held tightly and shaken and can result in fracture to the ribs.

Accidental burns and scalds may be seen in older babies (over 6 months).  Burns which may be deep due to grabbing hold of hot objects e.g. hair tongs, irons etc. are found on the palm not the back of hands.  Scalds, caused by pulling over hot liquids are usually on the front of the face, neck, chest and legs.  The injury would normally be witnessed and the explanation clear.

ii. Toddlers under 4 Years

All toddlers have a few accidental bruises on their shins, elbows and forehead.  They usually fall forward so that bruises on the back or buttocks are suspicious.  A single event cannot result in bruising on both sides of the body or bruising around a curved surface of the body.

Two bruised eyes may appear after an accidental blow in the middle of the forehead when the bruise begins to resolve and must not be considered to be another injury.  They are, however, significant if they occur without a forehead swelling or other evidence of related trauma.

A torn frenulum at this age may occur when the child fall flat on a carpet when running but there are usually friction burns of the nose and chin at the same time.

Once the child becomes verbal, s/he is more able to say how the injury was sustained.

iii. Older Children

Here the question of over chastisement is important – chastisement that causes bruising is physical abuse.

If the injury is accidental, most children  can give a very clear and detailed account of how it happened.  A child may not be able to freely give an explanation.  A child who has been coached to give a false explanation will not be able to give additional detail.  Careful consideration needs to be given as to how best communication can be facilitated with children who have speech, language or communication difficulties and may require specialist assistance or for whom English is not their first language.  See Guidance for Work in Child Protection with Deaf Children or Children who Communicate in other ways, and their Families.

Fractures are usually accidental.

4. Recognising Emotional Abuse

Emotional abuse alone is difficult to recognise as the child may be physically well cared for and the home in good condition and the signs are usually behavioural rather than physical.  The manifestations of emotional abuse might also indicate the presence of other kinds of abuse – it may be a warning sign of other forms of neglect or ill-treatment.

It may consist of adverse effects on a child’s behaviour or emotional development caused by persistent or severe:

• Rejection or indifference in environments that are high in criticism and low in warmth
• Isolation
• Inducing fear
• Lack of affection
• Scapegoating
• Inappropriate demands upon a child by virtue of their age
• Verbal hostility
• Subjection of a child to ridicule or threats
• Parental inconsistency or unpredictability
• The impact of domestic abuse
• The impact of a parent’s poor mental health or substance misuse
• Racial abuse

Children suffering from emotional abuse may:

• Exhibit excessively clingy or attention-seeking behaviour
• Be fearful, distressed, withdrawn or emotionally flat
• Constantly seek to please
• Behave indiscriminately to anyone, even strangers
• Have impaired ability for enjoyment or play
• Lack curiosity and natural exploratory behaviour
• Lack fear of physically dangerous situations
• Be delayed in any or all areas of development
• Have low self-esteem and feelings of worthlessness
• Show eating disturbances, faltering growth or lack of body tone

5. Recognising Sexual Abuse

Child sexual abuse covers a wide range of activities of varying severity.  It includes the sexual exploitation of children involved in prostitution and electronically via the electronic media.

Although some children are abused by complete strangers, the majority are abused by someone known to them, either adults holding positions of trust with respect to the child (e.g. family friends, baby sitters, professionals, etc.) or family members.

A high percentage such abuse is thought to be committed by children and young people – see Children who Abuse Others Procedure. The majority of abusers are male.  Women also abuse children sexually or co-operate with men in perpetrating such abuse.

All children can be vulnerable to such abuse but the majority of victims are girls.  Both girls and boys of all age groups are at risk and there is evidence of the sexual abuse of babies and toddlers as well as older children.  Disabled children may be particularly vulnerable to such abuse and professionals should consider the specific difficulties such as those relating to communication – see also Abuse of Disabled Children Procedure.

The sexual abuse of a child is often planned and chronic.

A large proportion of sexually abused children have no physical signs.  It is therefore also necessary to be alert to behavioural and emotional factors that may indicate abuse.  Absence of physical signs does not indicate the absence of abuse.

5.1 Allegation of abuse

A child making an allegation of abuse is an important indicator and should always be taken seriously and further enquiries made.

It is important to note that most children will only tell a small part of their abusive experience initially.  Adult responses can influence how able a child feels to reveal the full extent of her or his abuse.

5.2 Physical Signs and Symptoms

Only a minority of sexually abused children will present with a physical complaint.  The following symptoms should give cause for concern and further assessment.

• Vaginal bleeding in prepubescent girls
• Soreness, discharge and unexpected bleeding in the genital area
• Abnormal dilation of the vagina, anus or urethra
• Chronic urinary tract and other genital related infections
• Bruising, lacerations, grazes or bites to the genital or breast areas
• Sexually transmitted diseases
• Pregnancy especially where the identity of the father is vague
• A change in bowel habit such as soiling or constipation
• Genito-urinary abnormalities such as enlarged vaginal opening or scarred hymen
• Rectal abnormalities such as anal fissures or scars

Such symptoms will require specialist investigation by a Consultant Paediatrician to establish the likelihood of abuse.

5.3 Behavioural and emotional indicators

• Explicit sexual preoccupation in talk, play
• Hinting at sexual activity or secrets in talk, play or drawings
• Excessive sexual awareness or inappropriate sexual knowledge for the child’s age
• Inappropriate displays of affection between fathers/daughters or mothers/sons
• Extreme compulsive masturbation in an inappropriate setting
• Extreme exposure of or preoccupation with genitalia
• Overt sexually inappropriate behaviour in relation to other children and adults
• Fear of particular people or situations e.g. bath-time, toileting and bedtime
• Sleep disturbance with fears or nightmares perhaps with sexual context
• Sudden extreme changes in mood
• Changes in eating pattern and eating disorder
• Inability to concentrate, sudden change in school performance
• Reluctance to participate in physical activity or to change clothes for PE, swimming etc.
• Regular avoidance and/or fear of medical examinations
• Drug and alcohol abuse (older children)
• Suicide attempts and self harm
• Persistent running away
• Unexplained large sums of money/gifts
• Psychosomatic conditions e.g. unexplained abdominal pain or headaches

It is important to remember that sexual abuse is just one of a number of factors that can adversely affect a child’s behaviour.  It is necessary during any monitoring or assessment to explore with the child’s cares possible reasons for the child’s behaviour.

Some indicators take on greater or lesser importance depending on the child’s age.

Suspicion increases when several factors are present together and when the behaviour contains sexual elements.

See also Children who Abuse Others Procedure for further guidance of what constitutes Sexual Abuse.

6. Recognising Neglect

6.1  Introduction

Neglect is more difficult to define, and sometimes to recognise, than physical abuse yet its effects can be life long and detrimental.  Neglect refers to a situation where a child’s basic needs are not met to a minimum standard.  It comprises both a lack of physical care and supervision and a failure to  meet the developmental needs of a child in terms of their emotional, physical and educational development. 

When assessing neglect it is important to consider the norms for the area in which the child lives, the parental circumstances and cultural customs. 

Neglect may consist of:

• Exposure to danger, cold or starvation
• Significant impairment of health and development
• Non-organic failure to thrive – see 6.5
• Children left unattended or unsupervised
• Persistent evasion of health services
• Significant under-stimulation

6.2  Babies

Babies are by definition extremely dependent and it is essential that their basic needs are met.  If they are  cold and wet they will contract recurrent infections; if they do not have their nappies changed regularly they will develop nappy rash, which if left untreated may cause scarring; if they are not fed adequately they will fail to thrive.  Failure to thrive or faltering growth is usually defined as an exceptionally poor rate of growth in which weight and often length/height becomes increasingly divergent from the normal age standardised in the population.  In many cases it has an organic cause and should be investigated by a paediatrician to eliminate this in order to conclude that it is due to neglectful parenting.  It can also be contributed to lack of emotional care i.e. critical, negative or hostile parenting.  This should always be assessed along with weight loss/gain etc. (see also Section 6.5).

A neglected or abused infant may show signs of poor attachment, usually the signs of inconsistent and insensitive parenting.  They may lack the sense of security to explore, appear unhappy and whining.  Alternatively, there may be few signs of secure attachment behaviour where the child moves aimlessly around a room or creeps quietly into a corner.

Possible Indicators of Neglect

• Thin and scraggy - the skin may be looser and the limbs softer than you would expect
• Grubby body and clothing - look for dirt in the neck folds, under the arms, in the groins and under the nails
• Severe nappy rash amounting to ulceration in some cases with sores on other parts of the body
• Dull expression with little interaction
• Sparse and coarse hair
• Lack of distress when separated from parent

NB Beware of reliance on weights taken at different times with different clothes and on different scales

6.3  Preschool children

The main indicators of neglect in preschool children are behavioural, such as poor attention span and aggression towards peers and caretakers.  Cooperative play is often poor, as the skills have not been learnt at an earlier age.  Overt indiscriminate friendly behaviour to unknown adults may be a feature of children who are deprived of emotional affection.

The physical consequences of persistent neglect often include poor growth in height, weight and head circumference and can lead to developmental delay.

Possible Indicators of Neglect

• Dirty and unkempt - maybe with skin infections
• Clothing dirty and unsuitable for weather conditions
• No bowel or bladder control
• Low weight and height for age (although overweight children are also often neglected too)
• Voracious appetite when offered food
• Withdrawn or aggressive behaviour

NB Be aware of the environmental factors and be sure to exclude a medical cause for the findings

6.4 School children

In most cases the main indications of neglect are to be found in poor social and emotional adjustments; behavioural problems and learning difficulties.  Many abused and neglected children have poor attention for learning tasks and there is subsequent poor educational attainment.  Failure in concentration is often coupled with physical over activity of such a degree that a child is regarded as disruptive.  Other behaviour includes repetitive rocking or other self-stimulating behaviour.  Personal hygiene may be poor because of the physical neglect and rejection by peers is common.

Possible Indicators of Neglect

• Dirty, unkempt and smelly
• Low weight and height for age
• Poor school attendance and time keeping
• Poor attention span
• Behavioural problems
• Frequent accidents and minor injuries which may not receive appropriate attention.

6.5 Failure to thrive/faltering growth

All forms of abuse but especially neglect and emotional abuse can lead to faltering growth.  This may be the only alerting sign and any medical cause must be excluded first.  This will require a clear medical, social and family history and may need investigation in hospital.  Faltering growth occurs when an infant or child fails to achieve the expected growth as assessed by measurements of weight and height.  The child may also fail to achieve full potential in other parameters of development, thus indicators of poor development may be observed when;

• A child does not reach the expected height and weight – as demonstrated on centile charts
• S/he fails to reach the normal milestones in physical, social or behavioural development
• There is a rapid improvement in weight when the child’s environment is changed
• A child has perverse eating habits – gorging or stealing food or has an enormous appetite

In assessing whether a child is failing to thrive and assuming medical causes have been excluded, consideration must be given to the following;

• Ethnic origins and culture
• Hereditary factors, i.e. size and shape of parents and siblings
• The parents ability to cope and their beliefs about diet, feeding, discipline etc.
• Growth pattern rather than single weights.  Thus it is important to chart weight, height and head circumference frequently (Refer to the PCHR ‘Red Book’)
• Intermittent illness and its effect on growth
• The effect of family upsets e.g. bereavement, parent in hospital etc.
• The possibility of other forms of abuse e.g. sexual abuse.
• The meaning of the child for the parent/carer

Thus, although growth charts are important in assessing failure to thrive in children, they must be used with care and all other factors taken into consideration. 

7. Impact of Abuse and Neglect

7.1	The sustained abuse or neglect of children physically, emotionally, or sexually can have long-term effects on the child’s health, development and well-being. It can impact significantly on a child’s self esteem, self image and on their perception of self and of others. The effects can also extend into adult life and lead to difficulties in forming and sustaining positive and close relationships. In some situations it can affect parenting ability and lead to the perpetration of abuse on others.
7.2	The context in which the abuse takes place may also be significant. The interaction between a number of different factors can serve to minimise or increase the likelihood or level of significant harm. Relevant factors will include the individual child’s coping and adapting strategies, support from family or social network, the impact and quality of professional interventions and subsequent life events.
7.3	In particular, Physical Abuse can lead directly to neurological damage, as well as physical injuries, disability or at the extreme, death.  Harm may be 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.  Physical abuse has been linked to aggressive behaviour in children, emotional and behavioural problems and educational difficulties.
7.4	There is increasing evidence of the adverse long-term consequences for children’s development where they have been subject to sustained Emotional Abuse.  Emotional abuse has an important impact on a developing child’s mental health, behaviour and self-esteem.  It can be especially damaging in infancy.  Underlying emotional abuse may be as important, if not more so, than other more visible forms of abuse in terms of its impact on the child.  Domestic abuse, adult mental health problems and parental substance misuse may be features in families where children are exposed to such abuse.
7.5	Sexual Abuse can lead to disturbed behaviour including self-harm, inappropriate sexualised behaviour and adverse effects which may last into adulthood.  The severity of impact is believed to increase the longer the abuse continues, the more extensive the abuse and the older the child.  A number of features of sexual abuse have also been linked with the severity of impact, including the extent of premeditation, the degree of threat and coercion, sadism and bizarre or unusual elements.  A child’s ability to cope with the experience of sexual abuse, once recognised or disclosed, is strengthened by the support of a non-abusive adult or carer who believes the child, helps the child to understand the abuse and is able to offer help and protection.
7.6	Severe Neglect of young children is associated with major impairment of growth and intellectual development.  Persistent neglect can lead to serious impairment of health and development, intelligence, physical ability and long term difficulties with social functioning, relationship and educational progress.  Neglect can also result in extreme cases in death.

8. Risk Factors in all Forms of Harm

Certain characteristics have been found to be associated with all forms of harm.  They include:

• A history of abuse in the childhood of one or both parents
• Violent behaviour of the parents towards each other, or other signs of stress in the adult relationships
• Immature parents often feeling socially isolated
• Parents who abuse drugs or alcohol
• Parents who have significant mental health problems
• Children born prematurely or with low birth weight or with disabling conditions
• Unwanted children
• A recent pregnancy
• Parents who have previously abused a child or where there has been suspicion of previous abuse
• Situations of stress such as poor housing and financial difficulty
• Situations where there appears to be a lack of bonding between the parent and child often associated with separation for some period shortly after the birth of the child.

NB None of these indicators may exist but a child may still have been abused or neglected.

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