Child maltreatment

Child maltreatment (abuse and neglect) is recognised to be a major contemporary public health issue.

Any child can be at risk of abuse, however there are a number of factors that can increase a child’s vulnerability to abuse and neglect (NICE, 2017):

  • Socioeconomic factors such as poverty, poor housing and deprivation.
  • Child factors: disabled children are more vulnerable to abuse or neglect.
  • Family factors such as parental/carer substance misuse problems, parental/carer mental health problems and domestic abuse. These factors may be compounded if the parent/carer lacks support from family or friends (social isolation).
Vulnerability factors for recurring or persistent child abuse and neglect (be aware that neglect and emotional abuse may be more likely to recur or persist than other forms of abuse):
  • The parent or carer does not engage with services.
  • There have been one or more previous episodes of child abuse or neglect.
  • The parent or carer has a mental health or substance misuse problem which has a significant impact on the tasks of parenting.
  • There is chronic parental stress.
  • The parent or carer experienced abuse or neglect as a child.

Other important risk factors include:

  • A family history of maltreatment.
  • Being in care (looked-after child).
  • A history of offending (parent or child).

Prevention and early identification of child maltreatment, which is key, may depend on the early recognition of risk factors and warning signs, including those related to parents and the environment.

Preventing abuse requires promoting family well-being and resilience and fostering strong, stable relationships between parents and child. Planning positive intervention involves assessing and addressing parental risk factors, preferably before a child is conceived, and certainly in early pregnancy. Practitioners need to retain awareness that most parents in families with risk factors do not maltreat their children, and some parents in families with no identified risk factors do maltreat their children.

How common is child maltreatment?

A UK-wide survey of young people, carried out in 2009, found that almost one in five young people aged 11-17 years reported experiencing high levels of maltreatment during their childhoods (Radford et al., 2011).

More recent statistics point to a year on year increase in the numbers of children who are referred to statutory services and those subject to child protection proceedings (e.g. child protection plans). This may, in part, reflect greater professional and public awareness and response to child maltreatment, but there is a continuing need to be vigilant and responsive to concerns.

The NSPCC How Safe are our Children? Annual Conference and report provides a useful analysis of various sources of child protection data from across the UK. The research and resources site links to the How Safe initiative and provides links to UK government child protection returns on numbers of children subject to statutory intervention, for example being subject to a child protection plan

Types of child maltreatment

Abuse is a form of maltreatment of a child. 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 institutional or community setting by those known to them or, more rarely, by others. Abuse can take place wholly online, or technology may be used to facilitate offline abuse. Children may be abused by an adult or adults, or another child or children.

(Working Together To Safeguard Children 2018)

Statutory guidance across the four countries of the UK describes four main categories of abuse, and these definitions will normally be reflected in local organisations’ policies and procedures. The four categories are; physical abuse, emotional abuse, sexual abuse and neglect (definitions of abuse taken from Working Together 2018 ).

Reference to one (or sometimes more than one) category of abuse is made for the purposes of child protection planning. Government statistical returns show that the most common reason for child protection intervention reflects concerns about neglect, closely followed by concerns about emotional abuse. Physical abuse and sexual abuse feature in significantly fewer cases subject to statutory intervention, however, it should be noted that in most local authorities, only one category can be ticked on a child protection plan. So, while physical abuse and sexual abuse might be ‘ticked’ less often, that doesn’t mean they don’t feature in the plans.

Presentation of child maltreatment can take many forms. A child may present with physical or behavioural signs of abuse and/or neglect, which are incidental to the reason for attendance at the GP practice. Alternatively, they may attend with mental health or behavioural issues as a result of abuse/neglect.

Children and young people may disclose maltreatment, although disclosure to professionals is rarely a sudden or one-off event. Young people describe it as going on a journey, with trust and confidence in the process growing over time.

Abuse and neglect should always be considered when seeing children and young people of any age for any presentation. If practitioners don’t consider it, they may not ask about it and may not see the signs. It is important that abuse is asked about directly in age appropriate language, bearing in mind that children and young people may not recognise that they are victims of abuse.

Practitioners should be very clear with children and young people about confidentiality and its limits.

Concerns that a child may be at risk of, or may be suffering, abuse or neglect may arise from consultations with adults rather than with the children. In these situations, it is equally important that practitioners are very clear with the adult about confidentiality and its limits, and also their professional duty to safeguard children and young people. Professional curiosity is also very important (refer to the Introduction section of the toolkit for a further explanation).

Other types of child maltreatment and contextual safeguarding

In addition to the four main categories of abuse, which generally reflect harm from family members, or those known to the child or young person, there are other forms of child maltreatment that GPs and their practice staff should be alert to. These threats which have been referenced as contextual safeguarding, can also arise from within the family but might arise at school, from within peer groups, or more widely from within the local community. It may include threats ranging from online safety, exploitation, honour-based violence, forced marriage, criminal gangs and organised crime groups to the influences of extremism leading to radicalisation and trafficking.

More details can be found in the sections below and on the NHS England safeguarding pages.

Where concerns are raised about presentations that are indicative of contextual or specialised forms of abuse, it is likely that the practitioner will want to seek additional advice, for example from local safeguarding and child protection leads. National helplines, such as those provided by the NSPCC, include dedicated helplines for specialised forms of abuse.

More details of contextual forms of abuse can be found on the NSPCC website.