Development of current concepts

The sanctity and privacy of the Western family and its unfettered authority over its children was not challenged by society as a whole until the late 19th and the first half of the 20th century. For example, in Australia, legislation against neglect of children was enacted in the early 1920s.

Subsequently, state child welfare departments were created and their officers authorized to intervene on behalf of neglected children through the state Children’s Courts. The action often led to children being removed from their family, being made state wards and placed in state institutions.

The impetus for the introduction of specific child protection legislation was led by US paediatrician Henry Kempe, who coined the term ‘battered baby syndrome’ to describe the physically abused infant. Such legislative provisions, related initially to physical or psychological harm and subsequently to sexual abuse, were introduced first in the USA and then, beginning in the 1970s, in other Western countries including Australia, New Zealand and the UK.

Child protection legislation asserts the right of children to be free of harm from abuse or neglect caused by their parents or carers. Most child protection legislation states that the safety of children in their family environment is of paramount importance and must always be considered above the rights or opinions of the parents or carers.

A web link to the various Australian states’ child protection legislation is: http://www.aifs.gov.au/nch/pubs/issues/issues22/issues22.html.

Significant psychosocial adversity is present in all families where abuse occurs. The adversity includes poor education, poverty, young parental age, single parenthood, mental ill-health, intellectual disability, substance abuse and intrafamilial violence. Premature and complicated birth is also over-represented in abused or neglected children, as well as poor development of the primary attachment relationship between infant and carer (usually the mother).

The concept of the ‘continuum of child protection’ has been developed to incorporate the prevention, early intervention, recognition and management of children who might need child protection or who have been harmed through abuse or neglect. The ‘continuum of child protection’ links together families who are experiencing adversity (which implies there is a potential for abuse to occur) with those in which abuse or neglect has been established. Therefore, even though there is no predictable causal relationship between the presence of adversity and the occurrence of abuse or neglect, the population of families suffering significant adversity will contain the majority of children who will experience such harm. Consequently, child protection from the health professional’s perspective begins with the identification of family adversity in pregnancy or early childhood leading into the provision of services to assist in the eradication of the adversity or the minimizing of its effects. Such services are generally community-based and are equivalent to secondary prevention strategies. Their focus is to lessen a family’s social isolation, strengthen the interpersonal relationships of the parents, assist the parents’ understanding of the developmental demands of young children and provide practical home-based parenting advice. There is evidence to support the efficacy of such preventative programmes in families where adversity is present but abuse has not occurred, but no clear evidence that indicates similar programmes reduce the recurrence of incidents of abuse or neglect once they have occurred. Hence, to maximize successful intervention, it is critical to identify and address adversity before children are harmed.

Once children have been harmed through abuse or neglect, tertiary level services must become involved; these include statutory welfare agencies, the police and often tertiary forensic health services.

This primary, secondary and tertiary approach to child protection has been called the public health model of child protection intervention.

Similar patterns of psychosocial adversity are prevalent in families whether or not abuse has occurred. There is no reliable way of predicting which children are likely to become victims of abuse or neglect; therefore, the early identification of adversity, even in the antenatal period, is an important strategy. Identification of family adversity can lead to the provision of services to address and ameliorate its presence and effects. This is a child abuse primary prevention strategy.

The Australian National Child Protection Framework represents the public health approach as a pyramid (Fig. 3.9.1).

Fig. 3.9.1 Pyramid approach to public health.

Child protection and the concept of mandatory reporting

When child protection legislation was introduced in the USA, Canada and Australia it contained the requirement for mandatory reporting, which refers to the legal requirement placed on specified individuals to notify the designated statutory authority (usually the statutory welfare authority) when the individual has reasonable grounds to suspect that a child has been harmed by abuse or neglect.

Each state in the USA and each of the Canadian provinces has the mandatory reporting requirement. Each Australian state and territory has some level of legislation requiring mandatory reporting to the state or territory statutory agency of a suspicion of harm owing to child abuse or neglect. The breadth of professionals mandated to report varies widely across the states and territories in Australia; medical practitioners are always specified as mandated notifiers.

There is no mandatory reporting requirement in the UK or in New Zealand, but an expectation that the authorities will be informed of children suspected of being abused. The mandatory reporting requirement varies throughout continental Europe; generally, reporting is not mandatory.

Mandatory reporting was introduced when child abuse was considered to be manifest primarily as physical abuse. It was reasoned that physically abused children would usually be brought to medical attention and the abuse would be suspected by the doctor. It allowed a doctor to make a notification to the statutory authority and not be in breach of patient confidentiality, and when a doctor suspected abuse then the legal requirement for notification did not require the doctor specifically to challenge the responsibility of the parents in relation to the suspicion.

Most child protection legislation requires that the anonymity of notifiers be maintained and provides protection of notifiers against legal action that might be initiated by parents or carers.

The value of mandatory reporting in the management of suspected child abuse is still debated. Those regions in which it is not present argue against its introduction. No region that has mandatory reporting has withdrawn it.

A useful summary of the issues related to the mandatory reporting of child abuse was published by the Australian Institute of Family Studies in 2005 (web reference: http://www.aifs.gov.au/nch/pubs/sheets/rs3/rs3.html).

Physical, sexual and psychological abuse: a general overview

Physical abuse is injury inflicted on a child by a caregiver, including injury from physical discipline. The intent to injure is not relevant when considering physical abuse.

Psychological abuse is a repeated pattern of caregiver behaviour or extreme incidents that convey to children that they are worthless, flawed, unloved, unwanted, endangered or of value only in meeting another’s needs. Such behaviour has significant effects on the developing brains of children, its consequences being manifest in behaviour and developmental problems in preschool children, learning problems in older children, and antisocial and criminal behaviour in adolescents.

Sexual abuse has occurred whenever dependent, developmentally immature, children and adolescents are involved in any sexual activities that they do not fully comprehend, to which they are unable to give informed consent or that violate social taboos or family roles.

Sexually abusive behaviour may have serious psychological consequences for the child. It is particularly harmful when it occurs on multiple occasions over a period of time, when it is associated with physical injury, threats of physical harm if others are told, bribery or coercion, or when family members become aware of the allegations but don’t believe the child.

Psychological harm is of primary concern as a consequence of both physical and sexual abuse. For example, it can cause problems in children’s personality development, their ability to self-regulate their behaviour and to interact socially.

Prevalence of child abuse in Australia

The Australian Institute of Health and Welfare (www.aihw.gov.au) is responsible for collecting and collating child protection data from throughout Australia. The total number of notifications made nationally, reflecting the number of children in whom child abuse or neglect is suspected, has increased annually from 107 134 in 1999–2000 to 339 454 in 2008–2009. New South Wales contributed 63% of the total notifications. The increase reflects changes in child protection policies and practices, and an increased public awareness of child abuse. It is not clear whether the increased rate of notification is due to an increase in child abuse. In Australia, estimates of the current incidence of child abuse range between 10 and 20 cases per 1000 live births.

In Australia a large proportion of investigations of suspected child abuse are not substantiated. The proportion of finalized investigations that were substantiated varied from 29% in New South Wales to 62% in Victoria. Overall, emotional abuse was the most common type of substantiated abuse, and sexual abuse the least common.

Accurate national data on death due to child abuse are not available in Australia. The most vulnerable are those less than 2 years of age, with most deaths occurring in infants aged under 12  months.

Child protection systems – the interagency child protection process

This refers to the systems and the services contained within them that are specifically responsible for child protection at either a state or country level.

The provision of services to children anywhere on the child protection continuum (as described above) occurs through the cooperation and collaboration of different agencies, within both the government and non-government sectors. No single professional or agency can adequately provide fully comprehensive services across the whole continuum.

Principles of interagency practice in relation to the management of suspected child abuse or neglect

This refers to the tertiary level statutory system that is responsible for the management of children who enter the child protection system because of a suspicion that they have been abused or neglected and in whom abuse or neglect is established.

The agencies that comprise the tertiary level system are the statutory welfare agency, the police and, often, tertiary forensic health services. The important principles that support and enable tertiary interagency practice are:

The health services, community services and the police have specific roles and responsibilities in managing suspected child abuse and neglect.

Health

• Recognition of adversity in families and ensuring its active resolution

• Recognition of children in whom abuse/neglect may have occurred

• Ensuring that the child’s situation is properly assessed in relation to health and safety needs

• Complying with local legal notification requirements for suspected abuse/neglect

• Determining the ongoing role of the health agency according to agreed interagency practice

• Working to maintain an ongoing professional relationship with families after abuse has been suspected

• Provision of specialist forensic health services to children suspected of having been abused or neglected, complementing community services and the police. These include forensic medical and psychosocial assessment and therapeutic services.

Community services

• Investigation of notifications/reports of suspected child abuse/neglect

• Coordination with health units and police of each agency’s respective role

• Facilitation of the assessment of children in whom abuse/neglect is suspected

• Establishment of the level of danger/safety of children who have been abused or neglected

• Seeking of court child protection orders, when considered necessary, for abused/neglected children, particularly for those who remain in unsafe circumstances

• Optimal placement of children removed from their families because of abuse/neglect

• Ensuring that adequate therapy is provided to children in whom abuse/neglect has been substantiated.

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