Child maltreatment is a major health and social problem that has recently been suggested to be the single biggest cause of morbidity in children (Hobbs 2003). For many abused children, the adverse effects on health and well-being will be life long. Furthermore, each week in the UK at least one child will die as a result of cruelty (National Society for the Prevention of Cruelty to Children (NSPCC) 2007). There is little doubt that caring for a child who has been maltreated is one of the most difficult challenges that those working with children and families will face. It is work that is fraught with uncertainties and complexities, yet it can also be rewarding (Hall 2003).

Safeguarding is an ‘umbrella’ term encompassing actions to promote and maintain the well-being of children and young people (Powell 2007). Child protection falls within this remit and refers specifically to actions that may be undertaken to protect children who are at risk of, or who are suffering, significant harm. The findings of a statutory inquiry conducted by Lord Laming into the untimely death of Victoria Climbié in 2000 (Laming 2003) have been pivotal in shaping safeguarding policy. The inquiry highlighted how ‘poor communication between agencies, a lack of attention paid to a child in her own right and failure to follow-up concerns can lead to disastrous consequences’Corby (2006 p 70).

Contemporary safeguarding policy aims to address these deficits, to promote the right of all children and young people to attain their potential and to recognise their particular vulnerability to different forms of abuse and neglect. The current framework for safeguarding children is based on ‘The Every Child Matters’ programme (DfES 2004) which has identified five key outcomes for all children and promotes the shared commitment of agencies in order to achieve them. The National Service Framework for Children, Young People and Maternity Services (DoH & DFES 2004) is an integral part of this programme and has promoted greater recognition of the need to protect children within the NHS. The Children Act (2004) introduced a statutory responsibility and formal structures within which a wide range of public services can work together to safeguard children. Statutory guidance for interagency working, including revised guidance for child protection procedures is detailed within the Government document ‘Working Together to Safeguard Children’ (HM Government 2006a).

The 3rd Chief Inspectors report (Ofsted 2008) identifies the many positive changes that have been made since the Laming inquiry and offers an invaluable review of safeguarding arrangements for Children’s Nurses. However, the reports recommendations identify areas in need of improvement, including consistency in applying thresholds for concern, recognition of the needs of vulnerable and ‘looked after’ children, and the need for all agencies to make lines of responsibility and accountability explicit. At the time of writing this chapter the death of ‘Baby P’ provides further focus on some of these concerns (Department for Children, Schools and Families (DCSF) 2008a).

This chapter aims to equip students of children’s nursing with the knowledge and understanding that will enable them to identify, and respond appropriately to, children who may be at risk of, or who are suffering from, harm. The chapter’s underpinning philosophy reflects the words of the UK’s best-known voluntary child welfare organisation, the NSPCC. This organisation acknowledges that the problem of child abuse and neglect will only be overcome when children’s rights to physical and emotional integrity are respected (NSPCC 1996). We share this sentiment and hope that our readers will join with us in promoting and securing the best interests of children at individual, community and societal levels.

Definition of key concepts

Working at all levels to safeguard children requires a critical understanding of the notion of some key concepts; childhood, children’s rights, child maltreatment and of child protection. This section considers these key concepts and encourages students of children’s nursing to challenge some mainstream ideas as to how children should be treated.

Childhood

Safeguarding children is based on a tacit belief that children are a distinct group of vulnerable individuals who have not yet reached a certain chronological age. However, the notion of childhood (and therefore child maltreatment) is largely socially constructed and influenced by historical, social and cultural change. Although Qvortrup (1994 p 3) simply states that childhood is ‘the life-space which our culture limits it to be’, an analysis of contemporary childhood is an important precursor to an understanding of child maltreatment.

Activity

Discuss the nature and meaning of contemporary childhood in the UK. It may help to consider the following trigger questions:

• When does childhood start and end?

• Is childhood the ‘golden age’ it is often said to be?

• Are public places such as shops, pubs and restaurants ‘child friendly’?

• Are school days really the ‘best days of your life’?

Safeguarding policy in the UK rests on the legal definition of childhood that is reflected in the various Children Acts: The Children Act 1989, The Children Act 2004 (England and Wales), The Children (Scotland) Act 1995, The Children (Northern Ireland) Order 1995. Although this definition states that childhood lasts from birth to 18 years, recognition is given to the fact that action may need to be taken where there are concerns about an unborn child. Furthermore, in certain circumstances (i.e. for people with learning difficulties) children’s services may incorporate provision for those aged up to 25 years (Children Act 2004).

Although attainment of a chronological age is a useful parameter for defining childhood, there is clearly much more to consider. Perhaps one of the most important aspects of contemporary childhood is that it is often circumscribed in negative terms (Archard 1993). A good illustration of this is the use of the term ‘childish’ in our society. The following quote, although being written more than 30 years ago, continues to reflect the subordinate and potentially damaging position of many children in the UK today:

The fact of being a ‘child’, of being wholly subservient and dependent on being seen by older people as a mixture of expensive nuisance, slave and super-pet, does young people more harm than good

(Holt 1975 p 15)

Children’s rights

Children’s rights theorists recognise the oppression of children as well as the lack of the constitutional rights that are accorded to others. Such oppression may be compared with the historical oppression of women, ethnic minorities and the proletariat. Franklin (1995) suggests that because children are politically disenfranchised they are frequently subjected to the sort of treatment that, if meted out to any other group in society, would be considered a moral outrage. The ongoing acceptance and use of corporal punishment in childhood, together with the readiness of the majority of adults to defend this practice, has been noted to be an ‘obvious sign’ of the low status of children (Newell 1995 p 215). In the UK children remain the only people who can in law be hit ‘as reasonable punishment’ (Children Act 2004, s 58).

Powell (2002) recognises that nurses’ views on the issue of corporal punishment reflect prevailing social and cultural practices. However, she also argues that the loss of extended family, community networks and increasing social isolation of young families, mean that nurses should be actively seeking opportunities to offer support, information and guidance to promote positive parenting practices.

Furthermore, Alderson (2008) suggests that child maltreatment may be encouraged by beliefs about the inherent willingness of children and young people to inflict harm on others. This maligns children and young people and stigmatises those with ‘problem behaviour’ who are often the most vulnerable. Camila Batmanghelidgh’s (2006) book ‘Shattered Lives’ bears witness to the lives of children who have experienced abuse and neglect and offers greater understanding for those confused by such hard-to-reach children.

Seminar discussion topic

At the current time, ‘reasonable chastisement’ remains legally acceptable in the UK. However, there is an increasing body of opinion among children’s organisations that supports the view that hitting children is wrong. It is notable that all forms of physical punishment of children have been outlawed in Austria, Croatia, Cyprus, Denmark, Finland, Germany, Iceland, Israel, Latvia, Norway and Sweden. While recognising the effects of the prevailing social expectations, debate the case for a change in UK policy.

The children’s rights movement is receiving support and global recognition following the inception of the United Nations (UN) Convention on the Rights of the Child, adopted by the General Assembly of the UN on 20 November 1989 (UN General Assembly 1989). The Convention, ratified by the UK in 1991, establishes a series of fundamental rights for children and young people and outlines the responsibilities of governments in ensuring that all services for children are offered in a child-centred, rights-based framework.

Article 19 of the Convention provides a clear message in relation to child protection activity:

State parties shall take all appropriate legislative, administrative, social and educational measures to protect the child from all forms of physical or mental violence, injury or abuse, neglect or negligent treatment, maltreatment or exploitation, including sexual abuse, while in the care of parent(s), legal guardian(s) or any other person who has care of the child

(UN General Assembly 1989)

Such protective measures should, as appropriate, include effective procedures for the establishment of social programmes to provide necessary support for the child and those who have care of the child, as well as for other forms of prevention and for identification, reporting, referral, investigation, treatment and follow-up of instances of child maltreatment. Progress towards the achievement of the UN articles is monitored periodically the most recent review identifies the attainments of the 4 countries which comprise the UK, continues to highlight the need to proactively seek out families experiencing difficulties and disadvantage (HM Government 2007).

Current policy developments that influence the provision of children’s services (including child protection services) are increasingly seeking to address the needs of, and represent the views of, children and parents. ‘Every Child Matters’ (DfES 2004) outlined a cohesive framework of integrated services to help to support parents and carers and improve outcomes for all children and young people. Children were consulted in the process of development and wanted the provision of services and support that would help every child reach his or her potential, rather than a narrow set of services that intervened at times of crisis or failure. The key outcomes in childhood that are said to ‘really matter’ to children include: ‘being healthy; staying safe; enjoying and achieving; making a positive contribution and economic well-being’ (DfES 2004 p 9).

The National Service Framework (DoH & DFES 2004) sets out a 10-year programme for long-term and sustained improvement in children’s health whilst The Childrens Plan (DCSF 2007) identifies ways in which strengthened support may be provided for all families during the formative years of children’s lives. ‘The Staying Safe Action Plan’ – produced following consultation with children, their parents, professional and members of the general public – makes explicit the scope of safeguarding practice and need for ‘universal, targeted and responsive provision’ (HM Government 2008b). Although ‘coal-face’ activity may sometimes seem far removed from the corridors of power, the safeguarding activities of children’s nurses will be pivotal in transforming these policies into tangible and empowering action for children and their families. Having considered how an understanding of the nature of childhood, children’s rights thinking and policy underpins child protection activity, the following section attempts to define child maltreatment.

Child maltreatment: defining the problem

Defining child maltreatment is challenging and rests on historical, cultural and social contexts and beliefs, as well as the interests and concerns of the definers. The consequence of this state of affairs is that differences of opinions are a key feature of child protection work. Differences of opinion can arise amongst health professionals, between health professionals and workers from other agencies (such as Children’s Social Care Services or the Police) and, perhaps more importantly, they can arise between professionals and families and within families themselves.

PROFESSIONAL CONVERSATION
Katy White is a qualified children’s nurse who has been working on an acute paediatric medical ward for a number of years.

Over the years that I have been staffing on this ward we have admitted a number of children who have raised concerns about possible child maltreatment. Sometimes the issues are difficult to disentangle. For instance, we had a baby in recently whose weight was a cause for concern. I think things had not been going well for a while.

The health visitor had had difficulty finding the family at home and they did not attend the Well Baby Clinic. I believe that grandma had called the clinic to say that she was worried that her daughter was not looking after the baby properly, but that she didn’t want her daughter to know about the call. In the end the Health Visitor got the baby seen by the GP, who referred him to us.

The paediatrician wanted to run some tests to see if there was an underlying cause for the poor weight gain, but we could see that the baby was simply underfed. It turned out that the mother was spending a lot of time out with her friends and leaving her baby son with a variety of babysitters, which in my mind is neglect. He also had a terrible nappy rash, which proves that he wasn’t being well cared for.

However, the younger staff on the ward felt sorry for the mother, who was their sort of age and had not wanted to be tied down by a child. She was also very reluctant to come into hospital with her son and I reckoned that she was grateful for some free babysitting. A number of us felt that a child protection referral should be made, but the Social Worker thought a family support route would be better. I think we’ll see that baby again. B9780702031830100190/rquote.jpg is missing

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One of the ways of approaching the difficulties in definition is to spend some time reflecting on what child maltreatment is not. ‘Good enough parenting’ is a term that can be used to describe the provision of child care that will help to ensure that the health, safety and developmental needs of children are met. Good enough parenting can be discussed in terms of the provision of care and control. Care involves anticipating children’s age-appropriate needs through prenatal care, adequate feeding, warmth and protection from harm. Control encompasses action to meet the child’s safety requirements, as well as the setting of consistent limits to behaviour. Although the notion of ‘control’ might seem antithetical to the notion of children’s rights, children must be treated as people in their own right and the parents able to put the child’s needs above their own.

Reflect on your practice

• Is your interpretation of ‘good enough parenting’ congruent with that of your colleagues?

• Do you sometimes find yourself (or notice others) making negative judgements about parents’ ability to parent their child?

• How can you ensure that the ‘welfare of the child is paramount’ when parents have a multiplicity of needs (e.g. they are trying to cope with financial difficulties, substance misuse, mental or physical health problems, domestic violence)?

Although it is helpful to consider the notion of ‘good enough parenting’ it is perhaps important to remember that, like child maltreatment, it is a concept that is heavily influenced by the prevailing social and cultural norms. Corby (2006 p 81) reminds us that professionals can become so accustomed to poor standards of parenting that they begin to accept them as normal, with potentially catastrophic consequences for children. Thus, although children’s nurses clearly have a remit to provide culturally sensitive care and support to families, the focus on deciding whether or not a child has been maltreated should remain on the daily lived experience of the child.

The contextual nature of child maltreatment suggests that a broad sociological definition is a good starting point for determining what child maltreatment may be. The following definition, taken from a research report on prevention of maltreatment, remains one of our favourites:

Child abuse consists of anything which individuals, institutions, or processes do or fail to do which indirectly harms children or damages their prospects of safe and healthy development into adulthood

(National Commission of Inquiry into the Prevention of Child Abuse (NCIPCA) 1996 p 2)

Activity

• Try and think of examples of how individuals, institutions and processes may cause significant harm in children.

• Was it difficult to reach agreement on some of the examples you raised?

Section 31-10 of the Children Act 1989 similarly recognises the importance of children’s health and development in ascribing a concept of ‘significant harm’ to denote the threshold that justifies compulsory intervention in family life (i.e. the initiation of statutory child protection procedures). Nevertheless, no detailed definition of what constitutes ‘significant harm’ is given. Indeed, it has recently been suggested that:

Decisions about significant harm are complex and should be informed by a careful assessment of the child’s circumstances, and discussion between the statutory agencies and with the child and family

(HM Government 2006b p 8)

The NCIPCA (1996) definition of child maltreatment and the legal concept of significant harm offer excellent vehicles with which to challenge the infringements of children’s rights to physical and emotional integrity. However, their scope may be too broad for everyday practice. A more practical definition of child maltreatment, which is broadly applicable throughout the UK, is provided by government guidance in the document ‘Working Together to Safeguard Children (HM Government 2006a). Such guidance describes four ‘categories’ of maltreatment: physical abuse, emotional abuse, sexual abuse and neglect (note: there is significant comorbidity of the different types of abuse).The document ‘What to do if you’re worried a child is being abused’ (HM Government 2006b) is a practitioner-friendly interpretation of the guidance providing the following definitions of each category: