Recognition of Significant Harm

When we talk about parental alienation and emotional harm and when experts link the two together there is a reasonable expectation that the authorities will recognise what’s going on and act against the alienating parent.

What our research (and personal experiences) is showing us is that these authorities themselves do not recognise what is happening, and certainly do not take action. We’re working on educating them but for now here are the core definitions that you may find useful in your own cases:

Significant Harm

In relation to children:

The Children Act 1989 introduced Significant Harm as the threshold that justifies compulsory intervention in family life in the best interests of children.

Physical Abuse, Sexual Abuse, Emotional Abuse and Neglect are all categories of Significant Harm.

Harm is defined as the ill treatment or impairment of health and development. This definition was clarified in section 120 of the Adoption and Children Act 2002 (implemented on 31 January 2005) so that it may include, “for example, impairment suffered from seeing or hearing the ill treatment of another”.

Suspicions or allegations that a child is suffering or likely to suffer Significant Harm should result in an Assessment incorporating a Section 47 Enquiry

Assessments

Assessments are undertaken of the needs of individual children to determine what services to provide and action to take. They may be carried out:

• To gather important information about a child and family;
• To analyse their needs and/or the nature and level of any risk and harm being suffered by the child;
• To decide whether the child is a Child in Need (Section 17) and/or is suffering or likely to suffer Significant Harm (Section 47); and
• To provide support to address those needs to improve the child’s outcomes to make them safe.

Working Together 2013 removed the requirement  for separate Initial Assessments and Core Assessments. One Assessment may be undertaken instead.

The maximum timeframe for the assessment to conclude, such that it is possible to reach a decision on next steps, should be no longer than 45 working days from the point of referral. If, in discussion with a child and their family and other professionals, an assessment exceeds 45 working days the social worker should record the reasons for exceeding the time limit.

Assessments should be conducted in accordance with Chapter 1 of Working Together 2015, and the Local Protocol for Assessment.

There are no absolute criteria on which to rely when judging what constitutes significant harm. Sometimes a single violent episode may constitute significant harm but more often it is an accumulation of significant events, both acute and longstanding, which interrupt, damage or change the child’s development.
 

The impact of harm upon a person will be individual and depend upon each person’s circumstances and the severity, degree and impact or affect of this upon that person.

Section 47 Enquiries

Under Section 47 of the Children Act 1989, if a child is taken into Police Protection, is the subject of an Emergency Protection Order or there are reasonable grounds to suspect that a child is suffering or is likely to suffer Significant Harm, a Section 47 Enquiry is initiated. This is to enable the local authority to decide whether they need to take any further action to safeguard and promote the child’s welfare.

This normally occurs after a Strategy Discussion.

Section 47 Enquiries are usually conducted by a social worker, jointly with the Police, and must be completed within 15 days of a Strategy Discussion.

Where concerns are substantiated and the child is judged to be at continued risk of Significant Harm, a Child Protection Conference should be convened.

 

Strategy Discussion

A Strategy Discussion (sometimes referred to as a Strategy Meeting) is normally held following an Assessment which indicates that a child has suffered or is likely to suffer Significant Harm.

The purpose of a Strategy Meeting is to determine whether there are grounds for a Section 47 Enquiry.

 

Initial Child Protection Conference

An Initial Child Protection Conference is normally convened at the end of a Section 47 Enquiry when the child is assessed as either having suffered Significant Harm or to be at risk of suffering ongoing significant harm.

The Initial Child Protection Conference should be held within 15working days of the Strategy Discussion, or the last strategy discussion if more than one has been held.

The Definition 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.

Section 47(1) of the Children Act 1989 states that:

Where a local authority… have reasonable cause to suspect that a child who lives, or is found, in the area and is suffering, or is likely to suffer, Significant Harm, the authority shall make, such enquiries as they consider necessary to enable them to decide whether they should take any action to safeguard or promote the child’s welfare… the enquiries shall be commenced as soon as practicable and, in any event, within 48 hours of the authority receiving the information.

Under Section 31 of the Children Act 1989 a court may only make a Care Order (committing the child to the care of the local authority) or Supervision Order (putting the child under the supervision of a social worker, or a probation officer) in respect of a child if it is satisfied that:

• The child is suffering or is likely to suffer Significant Harm;
• The harm or likelihood of harm is attributable to a lack of adequate parental care or control.

Under Section 31(9) of the Children Act 1989, as amended by the Adoption and Children Act 2002:

• Harm means ill-treatment or 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;
• Ill-treatment includes sexual abuse and forms of ill-treatment which are not physical.

*The Adoption and Children Act 2002 broadens the definition of Significant Harm to include the emotional harm suffered by those children who witness domestic violence or are aware of domestic violence within their home environment.

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 extent of physical harm;
• The duration and frequency of abuse or neglect;
• The extent of premeditation;
• The degree of threats and coercion;
• Evidence of 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 ill-treatment.

Sometimes, a single traumatic event may constitute Significant Harm. In other circumstances Significant Harm is caused by the cumulative effect of significant events, both acute and long-standing, or the damaging impact of neglect which interrupt and change or damage the child’s physical and psychological development.

When judging what constitutes Significant Harm it is necessary to consider:

• The family context, including the family’s strengths and supports;
• The child’s development within the context of the family and within the context of the 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 the ill-treatment or failure to provide adequate care;
• The impact on the child’s health and development;
• The adequacy of parental care.

Under Section 31(10) of the Children Act 1989:

Where the question of whether harm suffered by a child is significant turns on the child’s health and development, his health or development shall be compared with that which could reasonably be expected of a similar child.

It is important always to take account of the child’s reactions, and his or her perceptions, according to the child’s age and understanding.

Categories of Abuse and Neglect

Someone may abuse or neglect a child by inflicting harm or by failing to act to prevent harm. In the context of child protection, abusive or neglectful behaviour is behaviour towards a child or young person which has the deliberate intention of causing harm or is so reckless to the consequences that harm is caused.

The following definitions are taken from Appendix A of Working Together to Safeguard Children, 2015.

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

Physical Abuse

A form of abuse which may involve hitting, shaking, throwing, poisoning, 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.

Emotional Abuse

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 cyber 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.

Sexual Abuse

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.

Neglect

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, clothing and 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); or
• Ensure access to appropriate medical care or treatment.

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

Indicators of Significant Harm

A number of factors may give rise to suspicion about the cause of an injury, the most obvious being a statement by the child and/or another person that the injury has been caused deliberately or not accidentally.

The following guidance is intended to help all professionals who come into contact with children. It should not be used as a comprehensive guide, nor does the presence of one or more factors prove that a child has been abused, but it may however indicate that further enquiries should be made. The following factors should be taken into account when assessing risks to a child. This is not an exhaustive list.

Professionals should be alert to situations where a child is injured and:

• The explanation provided by the parent or carer is apparently incompatible with the physical injury;
• There are conflicting or different explanations provided;
• There is no explanation provided or a lack of awareness of how the injury occurred;
• There is a reluctance on the part of the parent or carer to provide information about the current or previous injuries;
• There is a reluctance to agree to medical assessment;
• There is a delay or failure to seek appropriate medical attention for an injury;
• There are frequent minor injuries or presentations of the child at Accident and Emergency Departments;
• The parent or carer is impatient, angry or aggressive towards the child;
• The parent or carer is under the influence of alcohol or another substance;
• A child reacting in a way that is inappropriate to his/her age or development;
• The parent indicates difficulties in coping with the child;
• There is evidence of domestic abuse or parental mental ill health

Many families under stress are able to care for children and meet their needs in a warm loving and supportive environment. For other families, stress has a negative impact on the child’s health, development and well-being either directly or because it affects the capacity of parents to respond to the child’s needs. This is particularly the case where there is no other significant adult who is able to respond to the child’s needs.

Many families are disadvantaged and lack a wage earner. Poverty may mean that children live in crowded or unsuitable accommodation, have poor diets, health problems or disability, are vulnerable to accidents, and lack ready access to good educational and leisure opportunities.

Racism and racial harassment are additional sources of stress for some families and children. Although racism causes Significant Harm it is not, in itself, a category of child abuse. The experience of racism is likely to affect the responses of the child and family to assessment and enquiry processes. Failure to consider the effects of racism will undermine efforts to protect children from other forms of significant harm.

Other sources of stress for children and families referred to in more detail in this Manual include:

• Domestic Violence
• Drug and Alcohol Misuse
• Mental Illness

Recognising Physical Abuse

The range of injuries which may be caused by the physical abuse of children is varied. One injury to a child is not in itself an indication of physical abuse, as many children sustain accidental injuries. Certain injuries are less likely to have an accidental cause, and it is important that an appropriate medical opinion or assessment is obtained where there is suspicion about the cause of an injury.

Bruising

Children can have accidental bruising, but it is often possible to differentiate between accidental and inflicted bruises. It may be necessary to do blood tests to see if the child bruises easily.

The following must be considered as non-accidental unless there is evidence or an adequate explanation provided:

• Any bruising to a pre-crawling or pre-walking baby;
• Bruising in or around the mouth, particularly in small babies, for example 3 to 4 small round or oval bruises on one side of the face and one on the other, which may indicate force feeding;
• Two simultaneous bruised eyes, without bruising to the forehead, (rarely accidental, though a single bruised eye can be accidental or abusive);
• Repeated or multiple bruising on the head or on sites unlikely to be injured accidentally, for example the back, mouth, cheek, ear, stomach, chest, under the arm, neck, genital and rectal areas;
• Variation in colour possibly indicating injuries caused at different times – it is now recognised in research that it is difficult to age bruises apart from the fact that they may start to go yellow at the edges after 48 hours;
• The outline of an object used e.g. belt marks, hand prints or a hair brush;
• Linear bruising at any site, particularly on the buttocks, back or face;
• Bruising or tears around, or behind, the earlobe/s indicating injury by pulling or twisting;
• Bruising around the face;
• Grasp marks to the upper arms, forearms or leg or chest of a small child;
• Petechial haemorrhages (pinpoint blood spots under the skin). These are commonly associated with slapping, smothering/suffocation, strangling and squeezing.

Fractures

Fractures may cause pain, swelling and discolouration over a bone or joint. It is unlikely that a child will have had a fracture without the carers being aware of the child’s distress.

If the child is not using a limb, has pain on movement and/or swelling of the limb, there may be a fracture.

There are grounds for concern if:

• The history provided is vague, non-existent or inconsistent with the fracture type;
• There are associated old fractures;
• Medical attention is sought after a period of delay when the fracture has caused symptoms such as swelling, pain or loss of movement;
• There is an unexplained fracture in the first year of life;
• Non mobile children sustain fractures.

Rib fractures are only caused in major trauma such as in a road traffic accident, a severe shaking injury or a direct injury such as a kick.

Skull fractures are uncommon in ordinary falls, i.e. from three feet or less. The injury is usually witnessed, the child will cry and if there is a fracture, there is likely to be swelling on the skull developing over 2 to 3 hours. All fractures of the skull should be taken seriously.

Subdural haematoma is a very worrying injury, seen usually in young children; it may be associated with retinal haemorrhages and fractures particularly skull and rib fractures. The cause is usually a severe shaking injury in association with an impact blow. There may or may not be a fractured skull. The baby may present in the Accident and Emergency Department with sudden difficulty in breathing, sudden collapse, fits or as an unwell baby – drowsy, vomiting and later an enlarging head.

Joints

A tender, swollen “hot” joint with normal x-ray appearance may be due to infection in the bone or trauma. There may be both. A further x-ray will usually be required in 10 to 14 days. Where there is infection, this of course will require treatment.

Mouth Injuries

Tears to the frenulum (tissue attaching upper lip to gum) often indicates force feeding of a baby. There is often finger bruising to the cheeks and around the mouth. Rarely, there may also be grazing on the palate. Blunt trauma to the mouth causes swelling and damage to the inner aspect of the lips.

Internal Injuries

There may be internal injury e.g. perforation or a viscous with no apparent external signs of bruising to the abdomen wall.

Poisoning

Ingestion of tablets or domestic poisoning in children under 5 is usually due to the carelessness of a parent or carer, but it may be self harm even in young children.

For more information google: “Fabricated and Induced Illness Procedure”.

Bite Marks

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.

Burns and Scalds

• It can be difficult to distinguish between accidental and non-accidental burns and scalds, and will always require experienced medical opinion. Any burn with a clear outline may be suspicious e.g.:
• Circular burns from cigarettes (but may be friction burns if along the bony protuberance of the spine or impetigo in which case they will quickly heal with treatment);
• Linear burns from hot metal rods or electrical fire elements;
• Burns of uniform depth over a large area;
• Scalds that have a line indicating immersion or poured liquid (a child getting into hot water of its own accord will struggle to get out and cause splash marks);
• Old scars indicating previous burns/scalds which did not have appropriate treatment or adequate explanation.

Scalds to the buttocks of a small child, particularly in the absence of burns to the feet, are indicative of dipping into a hot liquid or bath.

The following points are also worth remembering:

• A responsible adult checks the temperature of the bath before the child gets in;
• A child is unlikely to sit down voluntarily in a hot bath and cannot accidentally scald its bottom without also scalding his or her feet;
• A child getting into too hot water of his or her own accord will struggle to get out and there will be splash marks.

Scars

A large number of scars or scars of different sizes or ages, or on different parts of the body, or unusually shaped, may suggest abuse.

Recognising Emotional Abuse

Emotional abuse may be difficult to recognise, as the signs are usually behavioural rather than physical. The manifestations of emotional abuse might also indicate the presence of other kinds of abuse.

The indicators of emotional abuse are often also associated with other forms of abuse.

The following may be indicators of emotional abuse:

• Developmental delay;
• Abnormal attachment between a child and parent/carer e.g. anxious, indiscriminate or no attachment;
• Indiscriminate attachment or failure to attach;
• Aggressive behaviour towards others;
• A child scapegoated within the family;
• A child’s frozen watchfulness, particularly in pre-school children;
• A child’s low self esteem and lack of confidence;
• A child appearing withdrawn or seen as a ‘loner’ with difficulty relating to others.

Recognising Sexual Abuse

Children of either gender can be the victim of sexual abuse. Where a girl within a family has been sexually abused by a family member it is not safe to assume that boys within the household are not at risk of sexual abuse, or vice versa.

It is not possible to identify types of individuals who might be more likely to sexually abuse, although the majority are male. Females however can sexually abuse children or collude with males in such abuse.

Similarly it is not possible to identify a type of family where sexual abuse is more likely to occur.

Any report of sexual abuse made by a child should always be taken seriously and investigated.

Some behavioural indicators associated with this form of abuse are:

• Inappropriate sexualised conduct;
• Sexual knowledge inappropriate for the child’s age;
• Sexually explicit behaviour, play or conversation, inappropriate to the child’s age;
• Continual and inappropriate or excessive masturbation;
• Self-harm (including eating disorder), self mutilation and suicide attempts;
• Running away from home;
• Poor concentration and learning problems;
• Loss of self-esteem;
• Involvement in prostitution or indiscriminate choice of sexual partners;
• An anxious unwillingness to remove clothes for – e.g. sports events (but this may be related to cultural norms or physical difficulties).

Some physical indicators associated with this form of abuse are:

• Pain or itching of genital area;
• Recurrent pain on passing urine or faeces;
• Blood on underclothes.

Pregnancy can also be the result of sexual abuse.

However in many cases of sexual abuse there is no physical sign or evidence of the abuse.

Recognising Neglect

In addition to a child’s neglected appearance there may be other indicators of neglect:

• Being significantly short and/or underweight for the chronological age;
• Cold mottled skin or poor skin condition;
• Swollen limbs;
• Cuts or sores which are slow to heal;
• Diarrhoea caused by a poor or inappropriate diet, irregular meals or tension;
• Patchy hair or bald spots.

This list is neither exhaustive nor exclusive.

Failure to thrive is a condition requiring a medical diagnosis. It can have an organic cause, but also can be a result of the persistent neglect of the child’s physical and/or emotional needs.

Children suffering neglect may show dramatic changes in appearance and social functioning when placed in a different environment such as a hospital or foster placement.

Neglect is often difficult to detect in that it is usually a slow ongoing process. Professionals may, out of familiarity, start to unknowingly tolerate lessening standards of child care, and each one of us has different standards with regards to what is acceptable or unacceptable. It is therefore essential that a regular, objective appraisal of the child’s presentation and condition is made.

Measuring neglect is always difficult and requires close co-operation between health and social care services. Inquiries into child deaths have placed great importance on the height and weight of very young children being plotted on the percentile charts.

Impact of Abuse and Neglect

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.

Physical abuse can lead to physical injuries, neurological damage, disability and death and can produce emotional or behavioural disturbance in children such as aggressive behaviour.

The effects of sexual abuse on a child vary and can be dependent on factors such as:

• The age of the child;
• The physical severity of the abuse;
• The extent of the period over which the abuse occurred;
• Threats or coercion which may be associated with the abuse.

Sexual abuse can produce a range of disturbed behaviour in a child including:

• Self harm;
• Inappropriate sexualised behaviour;
• Regressive behaviour, such as soiling or wetting;
• Sadness or depression;
• Loss of self-esteem;
• Eating disorders;
• Sleep disturbance.

Each of these types of behaviour can also be present in children where sexual abuse has not occurred.

Severe neglect in young children is associated with major impairment of growth and intellectual development. Persistent neglect in children of any age can lead to serious impairment of health and development, and long-term difficulties with social functioning, relationships and educational progress.

Neglect can also result in death; either directly or through the suicide of a child.

Every school, local borough and county council, NHS trust, and government department (including Cafcass) have a safeguarding policy that specifically provides them each with a pathway to recognise and act when they suspect significant harm. It also makes it clear that it is compulsory for them to follow the pathway, policies and procedures.

So why aren’t they?