CHILD PROTECTION AND SAFEGUARDING

Box 4.1 Clinical features suggestive of physical abuse

History

Delayed presentation (accident happened several days ago)

Story does not fit with the observed injuries. (Can you imagine what happened from the description you have been given? Does it sound likely or possible?)

Story inconsistent with the child’s level of development

Vague account of events or unwitnessed injury (may also indicate neglect)

Different versions of story given by different people/at different times

Disclosure from the child

Unconcerned or aggressive parents

Repeated attendance to hospital or previous unusual injury

No story at all – parents who say ‘I don’t know, doctor, you tell me what happened’

Examination

Linear marks (e.g. from a belt or cane)

Bruising on buttocks, trunk, cheeks and ears all highly suspicious (accidental bruising normally on front and on bony prominences; shins, forehead, etc.)

Any bruise on an immobile child

Fractures:

– The younger the child, the more likely a fracture is secondary to abuse

– Most humeral fractures are suspicious of abuse (spiral fracture highly suspicious)

– Multiple fractures are much more common in abused children

– Rib fractures (particularly posterior) highly specific for abuse in very young children (Crawford et al. 2006)

Bite marks (human bites are in a U shape and rarely break the skin)

Retinal haemorrhages

Fingerprint bruises

Burns:

– Cigarette burns (deep, circular pits)

– Immersion scalds (glove or stocking distribution)

– Bilateral burns and burns on face, feet and hands, legs and buttocks are commonly non-accidental

– Accidental scalds tend to be in a ‘splash’ pattern over face and chest (for example, where a child has pulled a cup of hot coffee onto themselves) but may also be a cause for concern as they may reflect inappropriate supervision and indicate neglect

Who? Physical punishment is illegal except if delivered by a parent, or someone acting on their behalf (e.g. grandparent).

‘Reasonable punishment’? Parents can use ‘mild’ physical force to discipline a child if this is felt to be ‘reasonable punishment’, although in practice this defence is rarely used (Singleton 2010). What constitutes ‘reasonable punishment’ and at what point does a parent’s actions become ‘excessive’? Anything which leaves a mark on the skin or any hitting involving an implement certainly requires referral to social services. Other, ‘milder’ forms of punishment should be taken in a broader context and other factors about the parent–child interaction considered.

Loss of control? Many parents use physical punishment at times when they are feeling stressed or frustrated and feel out of control at the time and then immediately feel guilty afterwards (Bunting et al. 2008). It is important to be aware of this as use of physical punishment may be a sign that parents are not coping and need extra support.

Top Tip

It is important to recognise that many things can stop people from raising concerns about abuse. Your own personal views on discipline of children can influence your decisions, as can fears of being culturally insensitive. Be aware of this and always have a low threshold for discussing with colleagues to gain a broader perspective.

Fabricated or induced illness (FII)

See Box 4.2 for clinical features suggestive of fabricated or induced illness.

This was previously also known as Munchausen syndrome by proxy and is often categorised under physical abuse. This type of abuse is very dangerous: research suggests that roughly 50% of children who have illness fabricated or induced experience long-term health problems as a result and 10% of these children die (Department for Children, Schools and Families 2008). It is most common in younger children (particularly the under-5s) but can occur in older children who may end up developing abnormal illness behaviour themselves and colluding with their carers in fabricating or inducing illness in themselves.

Box 4.2 Clinical features of fabricated or induced illness

It can be very difficult to distinguish between anxious parents responding to a child who has genuine symptoms and those who have grossly exaggerated, induced or fabricated symptoms in their child. A combination of the characteristics below can sometimes be suggestive of fabricated or induced illness.

The clinical features do not make sense or fit with any diagnosis

Symptoms only reported by carer (but never observed)

Symptoms only occur when carers are present

Carers intensively involved with children and don’t allow anyone else to care for them

Carers very involved with other families on the ward and hospital staff

Carers don’t appear to be appropriately concerned by abnormal results which may indicate serious illness in their child

The most commonly presenting features in cases of fabricated or induced illness are fits and apparently life-threatening events (Davis et al. 2009)

Feeding difficulties, reported allergies, poor growth

Record of poor school attendance

Extensive past medical history with investigation at multiple different hospitals

Unexplained failure to respond to treatment

As soon as one set of symptoms resolves, new ones are reported

Impact on child’s daily life (such as school attendance) far beyond what would be expected for a child with that diagnosis

Carers inappropriately seeking opinions from multiple different doctors

Fabricated illness can range from exaggeration of symptoms to completely fictitious accounts of past medical history, altering hospital charts or producing fake letters or documents. Parents may also tamper with samples of bodily fluids in order to give false results (such as dripping blood into a child’s urine sample). This fabrication of symptoms can result in the child missing a lot of school in order to attend hospital appointments. A lot of the harm caused comes from the medical profession as a result of the unnecessary and often unpleasant investigations the child has to undergo. In fact, the abuse can only continue with collusion from medical professionals; doctors can end up being complicit in the abuse. Commonly reported symptoms are those that are difficult to verify without directly observing them, such as fits, vomiting, pain and frequency of passing urine.

Some children with fabricated or induced illness may have been totally well, whilst others may actually have an illness (either current or previous), the symptoms of which are being exaggerated or exacerbated by the parent’s actions. Similarly, whilst some parents may be deliberately fabricating illness, others may genuinely believe that the child is unwell.

Induced illness is when the child’s symptoms arise as a result of something the parent has done – for example, deliberate poisoning or suffocation, or, in a child who does actually need medication, giving the wrong dose deliberately or withholding the treatment altogether. This is extremely dangerous and must be acted upon immediately if suspected as the child’s life can be in imminent danger.

Top Tip

Do not discuss your suspicions with the parent or carer if you are considering the possibility of fabricated or induced illness. You need to discuss your concerns with a senior (preferably the named doctor or nurse for child protection) first so that decisions can be made about how to gather evidence (sometimes with the involvement of the police) and who will discuss the issue with the parents and when. Similarly, in rare instances when you suspect it is a member of staff who is responsible for fabricating or inducing a child’s illness, do not confront them directly but raise your concerns with a senior colleague. If, after discussion with a senior colleague, you feel that they have not adequately responded to your concerns then check your local child protection guidelines to find out who you should talk to next.

Emotional abuse

See Box 4.3 for clinical features suggestive of emotional abuse.

Emotional abuse can occur in isolation but is also an inevitable consequence of all forms of abuse of children. It is prolonged and pervasive behaviour which has a negative effect on a child’s emotional development. Emotional abuse can involve:

being told that they are useless or not worthy of love

high criticism, low warmth

witnessing violence or aggression towards others (e.g. domestic violence)

unrealistic expectations of what a child can do at their age

overprotective and limiting of a child’s normal social interactions and learning

being made to feel afraid or in danger

exploitation of children.

It can be one of the most difficult forms of abuse to detect and you may need information from many different people about the interactions they have observed between the parent and child (e.g. health visitors, school teachers, GP).

Box 4.3 Clinical features suggestive of emotional abuse

Children who have been subject to emotional abuse can present in many ways but often with emotional or behavioural problems. Observing the interactions between parent and child and also the way in which a parent talks about their child can provide useful information. Suggestive features in the parent–child interaction may be as follows.

Parent hardly talks to the child except when telling them to do something

Child appears anxious when parent is critical or verbally aggressive

Parent fails to respond to child’s signals for help and does not appear concerned if the child is struggling with something

Parent offers little praise to the child

Parent does not play or interact with the child

The presenting features of a child who has been subject to emotional abuse can be very vague and vary between different age groups but can include the following.

Younger children

Language delay

failure to thrive

Sleep or feeding problems

Unconcerned by parent leaving them

Unable to play normally

School-age children

Poor school attendance and achievement

Angry, aggressive behaviour

Abnormal social interaction: this can range from an overly loud and ‘attention-seeking’ child who is inappropriately familiar with strangers, to a withdrawn and quiet child

Poor interactions with other children, few friends

Wetting and soiling

Adolescents

Depression, deliberate self-harm or eating disorders

Promiscuous or other risk-taking behaviour

Aggressive or antisocial behaviour

Box 4.4 Clinical features suggestive of neglect

History

Persistent, severe infestations such as head lice or scabies

Explanation for injury suggests poor supervision (e.g. ingestion of harmful substance or young child playing outside late at night)

Frequent attendance to A&E with injury (suggests consistently poor supervision)

Repeated failure to attend for outpatient appointments

Child has not received immunisations

DEVELOPMENTAL DELAY or learning difficulties may suggest emotional neglect

Poor school attendance

Examination

Smelly or very dirty child

Matted hair

Consistently wearing clothes inappropriate for the weather or the child’s size

Evidence of malnutrition including FAILURE TO THRIVE

Dental caries

Neglect

See Box 4.4 for clinical features suggestive of neglect.

Neglect is a persistent failure of a parent to meet their child’s basic emotional, psychological and/or physical needs. This can be deliberate or as a result of a parent’s own difficulties such as mental illness. Disabled children and those with chronic illnesses are particularly vulnerable to neglect as their needs are often much greater.

Sexual abuse

See Box 4.5 for clinical features suggestive of sexual abuse.

Sexual abuse is difficult to detect and often is only discovered following disclosure from the child. Sexual abuse can include contact abuse or involving children in looking at or producing pornographic material or encouraging them to behave in sexually inappropriate ways.

Top Tip

Take any disclosure made by a child or a young person very seriously and bear in mind that often the abuse will have been happening for many years before a child has the courage to tell someone about it.

Box 4.5 Features suggestive of sexual abuse

There are many, non-specific physical symptoms which may occasionally be indicative of sexual abuse but have a broad medical differential diagnosis such as:

vaginal bleeding in a prepubertal child

recurrent vulvo vaginitis with or without dysuria

rectal bleeding

soiling or wetting in previously toilet-trained child (particularly soiling).

Certain behaviours may also point towards sexual abuse such as foreign body insertion into the anus or vagina, masturbation in public or a major unexplained change in the child’s behaviour (anxiety, REGRESSION, poor school performance).

Certain ‘sexualised’ behaviours are normal in children of different ages and understanding these will help you to know when there is cause for concern. Sexualised behaviour in children is concerning if it is compulsive (i.e. you can’t distract them or stop them from doing it), inappropriate for their stage of development or if it is affecting other areas of their life such as their school work or interaction with others. The following outline of normal sexual behaviour at different ages is adapted from an NSPCC factsheet (NSPCC 2010).

Preschool child (0–4 years)

Is curious about other people’s body parts