Defining ‘child’

Throughout its history, health visiting has been associated with the health and well being of children as the main group and focus for professional practice. This is not without reason, as the promotion of health and the prevention of ill health (CETHV, 1977) are dependent upon the roots for a long and healthy life being established at an early age. It has been argued (e.g. Symonds, 1991) that if health visitors focus on children and families, this detracts from the broader, whole population approach. It is important to recognise, however, that children form a distinct population within the general population. A population of children has its own distinct health and social characteristics, and needs that vary according to age, developmental stage, and a range of genetic, social, and environmental factors. Furthermore, focusing on the health of families with young children means that not only is the health of the current population of children enhanced, but so too is the health of the future adult population (along with the health of the current population of adult family members).

Current legislation, such as the Children Act 1989 and the Children Act 2004, is informed by the UNCRC (UNICEF, 1989) and defines a child as ‘anyone who has not yet reached their 18th birthday’. However, within the UK, tensions exist within law and policy on how chronological age and developmental capacity vary as a marker for childhood. Take as an example the unborn child. Policy sets out procedures and timescales for addressing safeguarding concerns regarding unborn children. For example 1010 unborn children in England were the subject of child protection plans in the year ending March 2014 (DfE, 2014); such plans only come into place at birth, as the foetus has no legal rights to protection in respect of even the most extreme of circumstances. In utero, however, the foetus may be subjected to a range of harmful exposures and abuses, such as domestic abuse, tobacco smoke, alcohol, and drugs, all of which are known to cause potential harm to foetal health and development.

Just as the beginning of childhood is an ambiguous and contested concept, so too is the point at which childhood ends. In the UK, this may be illustrated by differences in legislation passed as a result of devolution. Although in law a child is a child until they are 18, 16-year-olds can legally have a sexual relationship with a member of the same or opposite sex of the same age or older. In England, Wales, and Northern Ireland, 16 and 17-year-olds may marry or enter a civil partnership with their parents’ consent; however, in Scotland, parental consent is not required at 16. Throughout the UK, young people cannot purchase alcohol or cigarettes until 18 or learn to drive a car or motorbike until they are 17. Under current legislation, a person must be 18 or over to vote in the UK, but 16- and 17-year-olds in Scotland were empowered to vote in the referendum on independence in 2014 and proposals to give the Scottish Parliament powers to reduce the voting age were brought in time for its elections in 2016 (White, 2015). In contrast, there are no plans in the legislative proposals for allowing under-18s across the UK to vote in the forthcoming EU referendum. Further tensions exist within specific pieces of legislation and policy. The Sexual Offences Act 2003, for example, deems that sex for children and young people under 16 years of age is illegal. However, young people under the age of 16 may request and be prescribed contraception if they are deemed competent to do so, in line with guidance produced by the National Institute for Health and Care Excellence (NICE, 2014).

Similarly, in respect of decision making for medical treatment, children may give or withhold their consent to that treatment if they are deemed as competent. Increasing importance is given to the child’s wishes with increasing age and evolving capacity for understanding. Courts can and do, however, override these wishes when they are deemed not to be in the best interests of the child or young person. Other tensions in respect of service provision and the chronological age of children exist. For example, young people aged 16 or above requiring hospital admission may be considered too old for admission to a paediatric ward and consequently be exposed to adult environments and services which do not cater appropriately for their needs and may potentially be harmful. Whilst analysis of society’s use of chronological age in determining when particular behaviours (healthy or not) may be considered legal falls outside the scope of this chapter, the discussion reflects the ambiguities and contentious nature of society’s attempts to determine the age at which childhood begins and ends, demonstrating that childhood is frequently used as a political hostage. Activity 5.1 may help you explore the concept of ‘child’ further and clarify the ambiguities surrounding the definition of ‘childhood’, which presents challenges for health visitors in their day-to-day practice.

Defining ‘childhood’

Difficulties in reaching a consensus in respect of defining ‘childhood’ are evidenced by contested concepts within the literature. Different forms and sources of literature offer different perspectives on what constitutes a ‘child’ and are influenced by political, temporal, spatial, and cultural factors. Smith (2010) presents an analysis of the concept of childhood in contemporary society and suggests that perspectives on childhood are subject to disparate positions, with little to support childhood as a ‘clear and coherent entity’ (Smith, 2010: 194). He suggests that there may be certain universal features of childhood that act as determinants of children’s lives, which are:

• physical growth;
  
• increasing competencies;
  
• inexperience;
  
• vulnerability.

He further argues that these features should be considered as principles in relation to the variations of experiences and the child’s context, which may be heavily influenced by such factors as history, culture, and genetics. Nevertheless, these features expose the extent to which childhood is commonly viewed in adult terms; that is, as a deficit in preparation for adulthood and, as Smith (2010: 5) suggests, ‘a means to an end’. In contrast to these features, Smith considers other perspectives on childhood that recognise the importance of the child’s view, the need to understand the child’s lived experience, and how the child formulates their own sense of the world in their own terms. Children draw from the source material of the adult world around them; however, their behaviour through play and interaction with others helps them to create their own roles and identities and develop relationships.

These different perspectives on childhood present dilemmas for health visitors, who are often required to draw on their own professional and personal values, as adults, to make judgments based on a biopsychosocial model reflecting the immaturity of children, who are seen as having limited rights and interests. In addition, health visitors need to develop an understanding of the world through a child’s eyes and ensure they give a clear priority to the views of children within families and do not rely upon traditional perspectives of childhood, which view children – as Prout (cited in Smith, 2010) sees it – from a standpoint of immaturity and incompleteness (in relation to children and adulthood). For health visitors to be successful in working with children and understanding their needs and experiences, they need to be able to see them and to engage fully, directly, and empathically with them, by utilising their higher-level communications skills and using observation and active listening. This will enable the health visitors to develop robust assessments of children’s needs and of the extent to which they feel safe from harm.

A focus of early intervention and practice with those families and children deemed particularly vulnerable has become known as progressive universalism (or, as it is referred to by Marmot et al. (2010), proportionate universalism). This is thought to make a more significant impact on the reduction of health inequalities affecting the lives of children. Progressive universalism has been defined as a ‘universal service that is systematically planned and delivered to give a continuum of support according to need at neighbourhood and individual level in order to achieve greater equity of outcomes for all children’ (DH, 2007: 8). However, a consultation with Community Practitioners and Health Visitors Association (CPHVA) members found that the concept had not been easily embraced by some health visitors (CPHVA, 2007). It was suggested that the term ‘regressive’ universalism could be more appropriate, to reflect the fact that not everyone would get an adequate standard of service. If health visitors were denied the opportunity to build a relationship with all families, they would feel it impossible to provide a service based on progressive universalism. Indeed, other major charitable organisations suggested that the term ‘progressive universalism’ was just another means to justify the cutting of health visitor numbers at that time (FPI, 2007). Whilst the concept of progressive universalism assists health visitors in focusing services on those with the most recognised need, in the context of safeguarding children, it presents a challenge, as child abuse occurs across all social classes, involves children of all ages, and is likely to be hidden and not easily recognised. Focusing health visiting practice only on those perceived as vulnerable at a neighbourhood or an individual level means that opportunities for identifying and responding to abuse across the population as a whole will be reduced. Indeed, Lord Laming, in his report to the House of Commons (Laming, 2009), highlighted the tensions between health visitors supporting families with complex needs and the health visitor’s role in offering a universal service to all. It is through experience and effective supervision that health visitors are able to determine the point at which concerns should be elevated and responsibilities shared. Laming (2009) made the point that the majority of children in the population do not have – or, indeed, need – a child protection plan, and emphasised the universal role of health visitors as crucially important in developing strong relationships with all families and the value of all children being seen in their home environment. This approach underpins the delivery of the universal Healthy Child Programme (HCP) (DH, 2009), which requires a core offer of mandated contacts with the transfer of the commissioning of health visiting to local authorities in October 2015.

Defining ‘safeguarding’

Before reading on, it may be useful to consider your own perceptions of the meaning of ‘safeguarding’ and begin to complete Activity 5.2. Over recent years, the term ‘safeguarding children’, coined in Section 17 of the Children Act 1989, has increasingly replaced that of ‘child protection’. Whilst ‘safeguarding’, as a term, is now widely represented in the mainstream language of policy and practice, it represents a multifaceted concept that may be open to interpretation by many different groups, agencies, professionals, and individuals. The literature offers various perspectives on ‘safeguarding children’, but the importance of professionals sharing an agreed definition of what constitutes safeguarding cannot be overstated. Agreed definitions are vital in terms of understanding the aims of safeguarding practice and simultaneously forming a basis for more specific procedural policy that details how safeguarding practice should be carried out. A current definition of safeguarding and promoting the welfare of children is:

Protecting children from maltreatment; preventing impairment of children’s health or development; ensuring that children are growing up in circumstances consistent with the provision of safe and effective care; and taking action to enable all children to have the best life chances.

(DfE, 2015a: 92)

Whilst this definition does not offer any detail on the activities associated with the safeguarding role, or how effective safeguarding practice might be achieved, it does have a number of strengths. One of the most significant is that it reflects the five outcomes identified as being most important to children and young people in the consultation of Every Child Matters (DfES, 2004) and subsequently embedded in the Children Act 2004:

• be healthy;
  
• stay safe;
  
• enjoy and achieve;
  
• make a positive contribution;
  
• achieve economic well being.

The process of consulting with children and young people and allowing them to express their views is compliant with Articles 12 and 13 of the UNCRC. In addition to the process being respectful of children’s rights, the content of the five outcomes is also compliant with the rights of children.

In incorporating the five outcomes, this broad definition of safeguarding represents a holistic view that safeguarding children is much more than protecting them from abuse. Defining safeguarding in a holistic way effectively widens the scope of practice, increasing the opportunities for health visitors and school nurses to work proactively in partnership with children and families in order to safeguard and promote all children’s welfare. However, as indicated by the placement of the term ‘protecting children from maltreatment’, child protection is nevertheless a very important part of the work undertaken to safeguard and promote the welfare of children. Equally, protecting children from harm demands much more than just having systems in place to manage child maltreatment. Suggestions highlighted by Puffett (2010) that the term ‘safeguarding’ be replaced with the term ‘child protection’ would have been a retrograde step, although, as Parton (2014) acknowledges, in real terms a framing of policy and practice in terms of child protection has re-emerged. Political attempts to manipulate the discourse and subsequent direction of policy detract from the fact that for children, the issue of preventing child maltreatment remains. Therefore, whilst child protection per se refers to the activities undertaken to protect those children who are suffering or likely to suffer significant harm (DfE, 2015a), the concept of safeguarding enables a wider, more holistic understanding of the need to protect all children from harm and subsequently aim to reduce the need for child protection activities. A proactive, preventative approach such as this reflects an early intervention approach, which is defined as:

targeted, preventive activity which supports people who are at risk of experiencing adverse and costly life outcomes, in order to prevent those outcomes from arising. The activity is not early in terms of a particular stage of life, but early in the onset of problems – before the occurrence of such outcomes in order to prevent the costs associated with them.

(EIF, 2015: 19)

Such an approach reinforces the value of prevention, albeit in secondary prevention terms. Whilst primary prevention is at the heart of the health promoting public health role of health visitors, they nevertheless have a major role to play in identifying needs and providing early help and support.

A robust legislative and policy framework underpins the role of the health visitor in safeguarding children and incorporates a range of global, national, professional, and local policies and procedures. This reflects society’s recognition of the seriousness of child abuse and neglect as public health issues, and also the value that health visitors bring to a safeguarding role.

According to the World Health Organization (WHO, 2014), the maltreatment of children is a major global issue. Each year, millions of children worldwide are the victims of and witnesses to physical, sexual, and emotional violence. It is estimated that globally 41 000 deaths in children under the age of 15 are attributed to homicide, with those under 4 and those in their adolescent years at greatest risk (WHO, 2014). The WHO goes on to acknowledge that this number underestimates the true extent of the problem, as a considerable proportion of child deaths due to maltreatment are wrongly attributed to falls, burns, drowning, and other causes. For children who survive abuse, there are likely to be lifelong physical and emotional health consequences for their well being and development, not only through childhood but into adulthood too.

Safeguarding children requires a global political response. The development of policy at a national and international level for the protection of children against abuse has, in recent decades, become increasingly child-centred, with a growing recognition of the rights of children. Global safeguarding policy is underpinned by the UNCRC (UNICEF, 1989), which has become the world’s most ratified human rights convention, with only one UN member state, the USA, having declined to ratify it (at the time of writing, Somalia remains in the process of finalising ratification). This international treaty consists of 54 articles that detail a range of civil, political, economic, social, and cultural rights which every child is deemed to require in order to live a safe, happy, and fulfilled childhood. The convention was clearly a significant undertaking by the UN, which challenged its member states to recognise the importance of the state in supporting children, meeting their health and development needs, and, if necessary, intervening to protect them from harm. However, without any significant level of accountability, the UK government has ratified the convention but not incorporated it into UK law in the form of a specific Act of Parliament.

Consequently, there may be some difficulty in enforcing children’s convention rights. Whilst the UNCRC places emphasis on the rights and needs of children and on the aim of ensuring an optimum state of child well being, UK policy has continued to wrestle with the rights of children and the rights and wishes of parents. Health visitors therefore find themselves working within a policy framework that, on the one hand, espouses the rights and interests of children and, on the other, sees parental choice as key to how children are parented. A health visitor’s access to a child is through the parent, who is the gatekeeper to observation and communication with the child.

Although the fact that the UNCRC has not been incorporated into English law by an Act of Parliament may be considered a limitation on the value placed on children’s rights in England, there is other evidence concerning the extent to which the seriousness of children’s rights are taken. The government for example, is bound to making regular reports to the Committee on the Rights of the Child, a UN monitoring body. In court settings, children’s convention rights are referred to and used in legal arguments and decision making, whilst in policy in respect of children, reference is often made to the fact that such policy and guidance reflects the principles of the UNCRC. An example of this in respect of a child-centred approach to safeguarding may be seen in Working Together to Safeguard Children: A Guide to Inter-Agency Working to Safeguard and Promote the Welfare of Children (DfE, 2015a: 10).

The UNCRC is clearly a very important document that holds great relevance for health visitors. It can be explored further in Activity 5.3. Of particular significance to the health visitor’s safeguarding role is Article 19, which requires that states parties take appropriate measures to protect children from all forms of physical and mental violence, injury, abuse, and neglect. Article 19 therefore acts as a mandate for national safeguarding legislation and policy, which encompass the roles of public sector employees and professionals such as health visitors. Other articles found within the UNCRC may also be considered directly relevant to the health visitor’s role in safeguarding children.

Newell (cited in Martell, 1999: 121) stated that health visitors need to see themselves as part of a new ‘movement to build a human rights culture for children’. In respect of health visiting practice and children’s rights per se, this is a laudable goal, and one which health visitors should strive for. However, in the context of the health visitor’s role in safeguarding and protecting the most vulnerable children, it becomes an urgent element of essential practice. Parton (2014) argues that combining a children’s rights orientation with a broad public health approach to child maltreatment provides the most positive framework for developing future policy and practice. This reinforces the value of the role of specialist community public health nurses and their contribution to safeguarding children. Health visitors therefore need a fundamental awareness and working knowledge of the convention rights that underpin their work with children, families, and the communities in which they live, as well as the ability to act as advocates for children in spite of the challenges they face within everyday practice. Prior to the Health Visitor Implementation Plan 2011–15 (DH, 2011), challenges in health visiting included those brought to light by Unite/CPHVA’s (2008) Omnibus survey and subsequently emphasised by Lord Laming (2009), such as large and complex caseloads, staff shortages, and resultant time pressures, which may reduce the effectiveness of child and family interactions and assessment. Despite the recent increase in health visitor numbers as a result of the Health Visitor Implementation Plan, a current major challenge for health visitors is working in a child protection system stretched to its financial limits. The National Society for the Prevention of Cruelty to Children (NSPCC, 2014: 4) recently described the system as ‘buckling under pressure’, with expenditure for the main areas of public spending relating to child protection and safeguarding in all four nations of the UK relatively unchanged in the financial years from 2006/07 to 2012/13. Furthermore, it should be acknowledged that despite the growth in health visitor numbers, a great proportion of the health visiting workforce is fairly recently qualified and may therefore, even with good quality supervision, still be developing the knowledge, skills, and confidence required to undertake its safeguarding role effectively. This, together with evidence that the demand for child protection services is outgrowing expenditure, means that in respect of their safeguarding and child protection responsibilities, challenges for health visitors remain.

Health visitors face other issues within the context of health visiting practice and the safeguarding of children, too, such as the problem of balancing the needs and rights of children with the competing rights of parents. The European Convention on Human Rights (ECHR) was incorporated into English law through the Human Rights Act 1998. This important piece of legislation confers a range of human rights on all UK citizens and requires all public authorities, including health authorities and therefore health visitors, to perform their duties and enact their roles in accordance with these rights. The Conservative government (Conservatives, 2015) has pledged to replace the Human Rights Act with a British Bill of Rights. Health visitors therefore need to embed their safeguarding practice within their knowledge and understanding of any changes to human rights legislation in the context of their safeguarding and child protection roles. Of particular relevance to – and sometimes causing tension within – child protection activity is Article 8 of the ECHR: the right to respect for private and family life, home, and correspondence. Whilst it is generally unlawful for public authorities to behave in a way that is incompatible with this right, there are a number of exceptions, including activity which is in the interests of public safety, for the prevention of crime, for the protection of health or morals, or for the protection of the rights and freedoms of others. All the exceptions specified are relevant to the role of professionals in protecting children. The challenge for health visitors and other professionals, however, is to ensure that the degree of interference with families’ rights under Article 8 is proportionate. It is important to recognise that the rights conferred by the ECHR and Human Rights Act extend not only to adults but to children, too. They therefore add impetus to the UNCRC and to the requirements of health visitors as public servants.

The emphasis on safeguarding children within contemporary society justifies, underpins, and guides the health visitor’s role in safeguarding children. Major shifts in national child protection and safeguarding policy generally occur reactively, precipitated by high profile child deaths or scandals involving children and subsequent inquiries. For example, the death of Dennis O’Neill, beaten and starved aged 12 whilst in foster care in Shropshire, precipitated the Monckton Inquiry (Home Office, 1945) and the Children Act 1948. Later, the 1987 crisis in Cleveland, where 121 children were removed from their families following dubious diagnoses of sexual abuse, was detailed in the Cleveland Report (Butler-Sloss, 1988) and gave impetus to the Children Act 1989, which is described as having radically affected all aspects of legal practice concerning children (White et al., 2008); consequently, the practice of all professionals working with children – especially those defined by the Act as being ‘in need’ of support and/or protection – was also affected. The death of Victoria Climbié in 2000 from severe physical abuse and neglect at the hands of her great-aunt and her partner led to an inquiry (Laming, 2003) and a range of policy and organisational changes, including Every Child Matters: Change for Children (DfES, 2004) and its legislative spine, the Children Act 2004. Subsequently, the death of Peter Connelly in 2007 precipitated the commissioning of a report by Lord Laming (2009) on the progress made to implement effective arrangements for safeguarding children and, later, a revision of Working Together to Safeguard Children (DCSF, 2010). Such policy changes impact on and present a challenge to the professional practice of health visitors when considered alongside the raft of other policy initiatives being introduced at regular intervals. Activity 5.4 will allow you to explore this further, taking into account local policy initiatives. Keeping an up-to-date working knowledge of policy changes presents a challenge to health visitors, who need to be able to identify new learning needs on a regular basis and access the knowledge and support required to fulfil their safeguarding role.

National policy also informs professional policy. The Standards of Proficiency for Specialist Community Public Health Nurses include the safeguarding of children and specify that specialist community public health nurses need ‘in depth knowledge of child protection’ (NMC, 2004: 15). Driven from a high level by both the NMC as a professional regulator and central government departments, there is no shortage of professional policy and guidance around safeguarding children. Clearly, professional practice and the policy that guides that practice should reflect the principles contained within The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives (NMC, 2015). Recently updated, section 17 of The Code is explicit in respect of registrants’ professional responsibilities to protect all those at risk of harm, neglect, and abuse. Furthermore, it contains a range of other, core professional values that may be applied to health visitors’ safeguarding practice. Crucially, this document represents the minimum standard against which professionals are measured in relation to the NMC’s function of protecting the public. Thus, it is vital that health visitors have a working knowledge of The Code and its application within a safeguarding and child protection context.

Defining ‘child abuse’

Although children have been exposed to harmful acts and behaviours from the beginning of time, an understanding of what society considers as child abuse today only began to emerge during the 19th century. At that time, children were seen as the property of adults and not as individuals in their own right. They were often subjected to all manner and types of abuse and neglect. Indeed, a measure of society’s value of children was their utility as small individuals who could perform dangerous roles by virtue of their size as factory and mill workers, coalminers, and chimney sweeps. During this time, there was growing political pressure to tackle this and other forms of exploitation of children for economic gain. Legislative change ensued with a series of Factory Acts that increasingly excluded younger children from working and limited the hours that older children could work.

A number of Education Acts gradually introduced compulsory education, whilst legislation such as the Infant Life Protection Act 1872 was designed to tackle the barbaric practice of baby farming. This was the term used to describe the taking in of children for a commercial fee, many of whom subsequently lived in overcrowded conditions, were subjected to abuse and neglect, and were frequently murdered. Although baby farming as such no longer exists in contemporary English society, informal, private arrangements between parents and other family members or friends are sometimes still made and may put children at risk. Whilst this practice is not confined to any one ethnic group, in today’s multicultural society it is important to acknowledge that in some countries entrusting children to relatives in Europe who can offer educational and other opportunities not available to them at home is not uncommon (Laming, 2003). Where private, unregulated care arrangements are made in an abusive context, children may be used primarily as a mechanism to gain access to financial support, housing, and other benefits, may not have their needs met, and may be at risk of harm. Health visitors need to be alert to these possibilities, and be prepared to share their concerns in a procedurally appropriate manner. Accounts of relevant 19th-century legislation such as those outlined earlier are relevant to society in the 21st century. They show a clear marker for the birth of law and other forms of policy that we would now consider reflect the ethos of safeguarding children in a holistic sense; that is, taking account of the wider socioenvironmental factors that impact upon the lives of children. They also illustrate the fact that despite legislation and policy, abuse and neglect for financial gain still occur.

Despite society’s attempts to address the welfare of children, there are also accounts during the 19th century of serious injuries sustained by children as a result of acts of physical abuse and neglect (Kempe & Kempe, 1978). Such accounts were predominantly recognised and interpreted within a medical discourse, through autopsy findings and epidemiological analysis of population data on injuries sustained by children. These data presented a picture of the extent to which children were abused and neglected. The first UK Act of Parliament to recognise the need to address the extent of physical abuse was the Prevention of Cruelty to Children Act 1889, which for the first time allowed the state to intervene between parents and children. This Act was amended in 1894 to acknowledge mental cruelty, create an offence where a sick child was denied medical attention, and allow children to give evidence in court. This can be interpreted as the beginnings of society’s recognition of the rights of children to voice their thoughts and opinions, as well as their right to protection from emotional abuse and neglect. It would be many years, however, before the rights and interests of children would be considered more fully, with firmer legislation and stronger penalties for the perpetrators of abuse.

The association of health visiting with child protection arose during the mid–late 19th century, as it became aligned with the maternal and child welfare movement as a result of appalling poverty and insanitary conditions (Robinson, 1982). Indeed, Robinson notes that in 1867, the Ladies Sanitary Reform Association set out the duties of its visitors to include ‘teaching’ hygiene, child welfare, and mental and moral health and providing social support. These activities clearly align health visiting with an interest in the welfare of children. However, caution needs to be applied in interpreting the drivers for this ‘teaching’. Smith (2004) challenges the altruistic and romanticised perception of the origins of health visiting with reference to middle-class fears over the spread of epidemics (Wohl, 1986), concerns over the fitness of the workforce and army recruits (Caraher & McNab, 1997), and a desire for a source of occupation among middle-class women (Cowley, 1996). Whatever the drivers were, health visiting became increasingly aligned with maternal and child welfare, and the basis for what we would now consider a ‘safeguarding’ role was recognised in legislative terms through the Children Act 1908, where health visitors were appointed as Infant Life Protection Visitors.

According to Robinson (1982), the development of health visiting in the 20th century was influenced both by the development of the National Health Service (NHS) and its relation with other occupational groups. The Children Act 1948 was heavily influenced by the Monckton Inquiry (Home Office, 1945) into the death of Dennis O’Neill, which highlighted how divided administrative responsibilities across departments increased the risk of errors (Robinson, 1982). Robinson presents an analysis of the influence of the Children Act 1948, the development of new children’s services, and the NHS Act of 1946 for health visiting, and highlights the degree of ambiguity over its development and the parallel development of the social work profession, both of which were based within local authorities, but with an overlapping set of skills and functions. The point here for health visitors is that, to this day, we continue to see a blurring of the interface between the preventative and reactive roles of both professions. This was highlighted by Lord Laming (2009), who underlined how social workers’ caseloads had risen and how, as a result, health visitors were increasingly carrying child protection issues that would previously have been referred on to children’s social care services. This demonstrated that the threshold for accepting referrals of children at risk of suffering abuse was not consistent and was dependent in part on resourcing. Whilst Lord Laming acknowledged that this situation was both inappropriate and unmanageable for health visitors, it remains a challenge to be addressed. The situation also serves to illustrate the impact that the under-resourcing of one professional group has on another.

The term that first articulated the concept of child abuse in modern society was ‘battered-baby syndrome’, which emerged in 1961, having been coined by Kempe (Kempe & Helfer, 1972). The term was emotive and deliberatively provocative, designed to shock paediatricians and society in general out of complacency. Although it succeeded in its aim, it was acknowledged to have several limitations: it was open to interpretation, lacking in clarity, and a cause of confusion. For some, the term represented a narrow interpretation of only the severest forms of physical abuse, whereas for the authors it encompassed the total spectrum of abuse. Whilst the term ‘syndrome’ was used in the context of referring to a set of symptoms, it also presents connotations of a disease process, which may detract from the often premeditated and deliberate nature of child abuse. Clearly, however, the early recognition of the phenomenon of child abuse was not confined to one particular person, place, or time. Recognising the issue and naming it took a number of intellectuals and professionals from a variety of countries just short of a century.

Different sources of literature offer different terms, definitions, and perspectives on what constitutes child abuse. It is important that health visitors work with definitions of child abuse that are agreed across professional groups, so that a common consensus is reached in working together to prevent, identify, and respond to behaviours, contexts, situations, and settings that may be abusive. The current definition of child abuse aimed at the interagency workforce and offered by recent statutory guidance 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 (e.g. via the internet). They may be abused by an adult or adults, or another child or children.

(DfE, 2015a: 92)

This is a contemporary definition, and is key for practitioners working with and coming into contact with children. Although neglect is recognised as one of the forms of child maltreatment, it is clearly differentiated in this definition from other forms, which may be further categorised as physical, emotional, and sexual. Highlighting and giving prominence to neglect in this way reflects its significance in terms of its being the most common reason for children being subjected to a child protection plan in England or for being on a child protection register in Northern Ireland, Scotland, and Wales (NSPCC, 2014), as well as increasing recognition of the deleterious impact of neglect on the health and well being of children. Indeed, neglect is often considered as separate from abuse, as it relates to acts of omission rather than commission; that is, it is based on shortfalls in meeting the needs of children, rather than specific acts they are subjected to. This can be seen in the Department for Education (DfE) definition of neglect, which refers to a ‘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 and development’ (DfE, 2015a: 93). Highlighting neglect in this way may counteract the problem that it is often not perceived as abuse or maltreatment. That said, it is important to also acknowledge that whilst neglect may be referred to as a passive form of maltreatment by some authors, this does not reflect cases where neglect appears to have been premeditated and actively pursued as a form of child abuse, as for example in the case of Khyra Ishaq (Radford, 2010). Health visitors need to be mindful that differentiating neglect from physical, emotional, and sexual abuse does not diminish its significance, and, indeed, it could be argued that neglect is likely to have the greatest impact on a health visitor’s workload.

Defining child abuse and neglect is only the first step for health visitors in applying these concepts to real situations in practice; you can explore this further in Activity 5.5. However, there is a broader context here relating to the formative nature of child abuse and neglect that practitioners need to consider. The concept of child abuse becomes problematic when trying to determine whether an action (or omission) should be considered abusive or not, given that how child abuse is defined and refined is subject to change over time and across different societies in different parts of the world. When we attempt to define child abuse and neglect, we do so at a given point in time and within the broad context of what society considers constitutes satisfactory parenting and what behaviours towards children are considered acceptable.

Different forms of child abuse receive different prominence in different forms of literature (e.g. policy, research, the media) at different times, often as a result of specific child abuse cases or scandals which become highlighted due to various aspects of their shocking nature. The emergence of hundreds of allegations of child sexual abuse perpetrated by Jimmy Savile in 2012 and the subsequent launch of Operation Yewtree, the criminal investigation into Savile and other alleged perpetrators, is one example. The sexual exploitation of at least 1400 children in Rotherham between 1997 and 2013 (Jay, 2014) is another. Child abuse cases and scandals emerge and lie within the broader context of an ever-increasing knowledge and evidence base around child abuse theory, safeguarding, and child protection practice, as well as improvements in investigation techniques. Technological advances, in particular, have had a paradoxical influence on how child abuse is defined. On the one hand, improvements in forensic techniques such as those used by the National Crime Agency’s Child Exploitation and Online Protection (CEOP) Centre have underpinned a ‘pathologisation’ of child abuse by providing a medium for more sophisticated diagnosis and intervention. On the other hand, 21st-century technology, in the form of the Internet, tablets, and mobile phones, has been increasingly used as a vehicle for accessing children: both in grooming and abusing them directly (Jay, 2014) and as a means of sharing information relating to the abuse of children in the form of still or moving images or the written word. Unsurprisingly, it is not only adults who use technology to abuse children. Cyber bullying, recognised as a form of emotional abuse (DfE, 2015a), generated an 87% increase in ChildLine counselling sessions between the years 2011/12 and 2012/13 (NSPCC, 2014). In addition, there is increasing recognition and concern over the growing trend of young people taking and sharing indecent photographs of themselves, their friends, and their partners via mobile phones. Known as sexting, the impacts of this behaviour may be ‘extremely damaging’ and have been associated with suicide (CEOP, n.d.). Whilst such images may not be produced as a result of grooming, CEOP states it is aware of cases where images have found their way on to paedophile chat sites and forums. A further issue for children and young people engaging in sexting is that the behaviours associated with it make them vulnerable not only to sexual abuse and emotional harm, but also to prosecution and criminalisation. Section 45 of the Sexual Offence Act 2003 amended the Protection of Children Act 1978 to make it a criminal offence to take, make, distribute, show, and possess such photographs of any person below the age of 18. Up until recently, such technology did not exist, and this type of activity could not have been imagined as a form of child abuse. Some accepted behaviours and practices, such as allowing children access to social networking sites, may on face value appear harmless, yet they clearly pose known risks in respect of adults accessing and grooming children for the purposes of abuse. These examples illustrate an ever-expanding societal and technological context in which forms and understandings of child abuse continue to evolve. It is important that health visitors remain alert as to what constitutes both existing and newly emerging forms and definitions of child abuse as they seek to interpret behaviours and practices within families and communities. Such behaviours and practices include female genital mutilation (FGM), forced marriage (FM), and so-called ‘honour based violence’ (scHBV), which have been recognised as abusive and of concern to those seeking to safeguard and protect children from diverse communities in the UK. These issues will be commented on later in this chapter. It is important also to recognise that incidents of abuse, whatever form they take, do not occur in a vacuum within the lives of children, and that survival of abuse has lifelong impacts upon the health and well being of the victim (see Box 5.1).

Whilst the quality of these studies may vary, there is a clear and consistent pattern that makes the association between child abuse and health issues explicit. This is more so with forms of abuse that are easier to measure/observe (e.g. physical abuse) and less so with sexual abuse, neglect, and emotional maltreatment, which can be more challenging to research. Evidence from various inquiries may be useful in this respect; for example, the Independent Inquiry into Child Sexual Exploitation in Rotherham 1997–2013 (Jay, 2014) found that in just over a third of cases, children affected by sexual exploitation were previously known to services because of child neglect and the need for child protection. There was also a history of domestic violence in 46% of cases, as well as high levels of truancy and school refusal. This points to comorbidity in respect of forms of child sexual exploitation and possible compounding of impacts on children’s physical, emotional, and social well being. Despite the variance across the studies, the wealth of evidence to date suggests an association between child abuse and poor health that could be readily applied to Bradford Hill’s criteria for causation (Bradford Hill, 1965).

This evidence demonstrates that the health visitor’s role in safeguarding is not only to seek to protect a child from harm in the short term, but also to optimise and promote the child’s future trajectory for health into adulthood. It is also important to consider when working with parents/adults experiencing the health problems mentioned in this box that they may have been exposed to adverse childhood experiences, or indeed be survivors of child abuse themselves.

Defining ‘significant harm’

The concept of ‘significant harm’ represents a legal definition of child abuse, and was first introduced in Section 31(9) of the Children Act 1989. The concept reflects a threshold that legitimises state intervention into the lives of children and families to safeguard and promote child welfare. Under Section 47 of the Children Act 1989, social workers, as employees of ‘local authorities’, have a duty to ‘make enquiries’ or begin investigations, undertaking assessments and gathering information to inform decision making regarding actions that may need to be taken to protect a child who is suffering, or at risk of suffering, significant harm. As part of this process, where the age of the child is relevant to the recent or current work of health visitors, social workers will communicate with health visitors in the investigation process and may draw from health or other assessments. As a result of such activities led by social workers, courts may subsequently make a care order (whereby the child is committed to the care of the local authority) or supervision order (whereby the child is put under the supervision of a social worker or probation officer) where the threshold criterion is reached.

The term ‘significant’ is not defined in the Children Act 1989, but in deciding what is significant, provision is made for courts to compare the health and development of the child concerned ‘with that which could reasonably be expected of a similar child’ (Children Act 1989, §31:10). A ‘similar child’ was defined by the Lord Chancellor at that time as a child with the same physical attributes as the child concerned, and not simply a child of the same background. This notion was contested by Freeman (1992), who argued that whilst the goal of the ‘similar child’ notion was to be applauded because it emphasised the unique needs of children with disabilities, it overlooked the essential individuality of families and their problems. Health visitors have the opportunity of forming assessments that reflect the individuality of children and families, and courts may use these assessments to decide for themselves what constitutes significant harm. ‘Harm’ is clearly defined in the Children Act 1989 as ‘ill-treatment or the impairment of health or development’. This definition was later extended by Section 120 of the Adoption and Children Act 2002 to include impairment suffered by hearing or seeing the ill treatment of another, in recognition that children exposed to the domestic abuse of others suffer harm. The Children Act 1989 considers ‘ill treatment’ to mean sexual abuse and abusive actions that are not physical (thus implicating both physical and emotional abuse as abuse). In addition, ‘health’ is deemed to mean both physical and mental health, and ‘development’ is taken to include dimensions such as physical, emotional, behavioural, intellectual, and social development. It is essential that health visitors have an understanding of the concept of the risk of significant harm and recognise the value of their contributions to child protection processes. Such contributions include using their knowledge to make appropriate referrals and sharing their well-documented assessments of children’s circumstances and experiences, their physical and mental health, and all aspects of their development: physical, emotional, behavioural, intellectual, and social.

The concept of significant harm is, however, ambiguous, subjective, and open to interpretation by individual practitioners and representatives of various authorities. Its effectiveness in protecting the right children at the right moment in time will thus be inconsistent, as individual cases will, by their very nature, vary, as will the knowledge, experience, skills, and confidence of practitioners working with them. Health visitors should be aware that there are no absolute criteria on which professionals can rely when judging what constitutes significant harm. The interpretation of significant harm as a threshold for intervention is not static and depends on a number of factors; you can explore these further in Activity 5.6.

A clear example of the sometimes acutely volatile nature of the threshold for intervention may be seen in response to the case of Peter Connelly, who died in 2007 as a result of extreme physical abuse and neglect. Following Peter’s death, there was an unprecedented rise in applications for neglected and abused children to be taken into care (Cafcass, 2010). The demand for care applications has climbed steadily since 2008–09, and applications during 2014–15 were recently described by the Children and Family Court Advisory and Support Service (Cafcass, 2015) as having been at an all time high, with July 2014 producing eleven thousand one hundred and thirty five. Cafcass (2015) suggests that the 2014–15 data may be attributable to a number of factors, including increased awareness of child sexual exploitation leading to a greater number of referrals to local authorities, greater public and professional awareness of child protection issues, and more rigorous reviewing and greater scrutiny of plans within local authorities.

Variations in the threshold for removing the most vulnerable children at risk of – or actually suffering from – significant harm from their families present challenges in practice. When the threshold for intervention is high, it may be difficult for professionals to succeed in getting very vulnerable children into care. Such children may be exposed to continuing risk of abuse and neglect and are more dependent on higher levels of support and supervision within the community. Clearly, this has an impact on health visiting and other family support services.

The concept of significant harm as a threshold for intervention thus presents challenges, both in theory and in practice. Nettleton (1998) and Appleton (1994) both identified the stress on health visitors when working with families in which there are significant concerns about the harms that children may be subjected to, but where a threshold has not been reached to trigger formal intervention by child protection services. The key here is for health visitors to access supervision and to underpin their carefully and clearly written referrals, assessments, and reports with reference to research and the evidence base. Such an approach will help to form the basis of collaborative, critical, evidence-based decision making and so determine whether or not a child is being subjected to significant harm. Despite its ambiguities, Harwin & Madge (2010) acknowledge that the concept of significant harm has largely stood the test of time and that the absence of a clear operational definition is both its strength and its weakness. They consider that it allows for necessary professional discretion, but acknowledge that its vulnerabilities are associated with external pressures that affect its interpretation and suggest that a more confident workforce and greater resources are required.

One advantage of the legal concept of significant harm not being static is of particular interest to health visitors working with families in which there is domestic abuse. As already mentioned, the legal definition of harm includes harm suffered by seeing or hearing the ill treatment of others. This amendment occurred in recognition of society’s growing awareness of both the scale of domestic abuse and its negative impact on women, children, and young people. Based on statistics from the 2013/14 Crime Survey for England and Wales, the Office for National Statistics (ONS, 2015) estimates that 1.4 million women aged 16–59 in England and Wales suffered domestic abuse in the years 2013 to 2014. It should be acknowledged that domestic abuse is also perpetrated by women against men – there were an estimated 700 000 male victims in the same time period (ONS, 2015) – and that it also occurs in same-sex relationships. However, it is recognised that the vast majority of acts of gender-based violence are perpetrated by men against women and girls (HM Government, 2011). Furthermore, women are more likely than men to have experienced intimate violence across all headline types of abuse when asked (ONS, 2015). The Department of Health (DH, 2013b) acknowledge that domestic abuse often starts or intensifies during pregnancy, and it has been estimated that at least 750 000 children witness domestic abuse each year (DH, 2002) and that in homes where domestic abuse occurs, children witness approximately three-quarters of incidents (RCPsych, 2014). Hughes (1992) found that in 90% of cases, when domestic abuse occurs, the children are in the same or next room. Thus, even when children do not directly see violent or abusive incidents, they are likely to be exposed to them through hearing both the abuse itself and the reaction of the victim. Furthermore, they will subsequently be exposed to its physical and emotional impact. Being exposed to domestic abuse can cause children harm in a number of ways; for example, seeing and hearing a parent (most likely their mother) being abused can cause children emotional distress; children may sustain physical injuries during violent physical assaults when they attempt to intervene to protect a parent; and children may be forced to take part in various forms of abuse or to witness it (DH, 2009b). Forcing children to take part in or witness abuse reduces them to being used as tools; this behaviour dehumanises children and increases both their own and their mother’s suffering. Threats are often made to harm or kill children in an attempt to exert power and control over women. In 30–60% of cases where women are being abused, children are also being physically and/or sexually abused (Edelson, cited in DH, 2009b). This is significant when working with families where domestic abuse occurs; health visitors need to consider that children may be at risk of suffering or may actually be suffering significant harm through both their exposure to the domestic abuse and through other forms of abuse. Likewise, when working with families where there is suspected or known child abuse, the possibility that domestic abuse may be occurring should be considered and explored. Effective identification of domestic abuse remains a challenge, with many women reluctant to disclose their situation (BMA Board of Science, 2014). A literature review conducted by Litherland (2012) reinforced the value of the health visitors’ role in the identification of domestic abuse and concluded that the use of routine enquiry using a screening tool increased disclosure rates. Furthermore, Litherland found that recurrent enquiry, giving information to all women following enquiry, knowledgeable and caring practitioners, and supportive environments were all important in eliciting disclosure of abuse. Health visitors therefore need to embrace these approaches so that they may safeguard and promote the well being of women and children alike.

Amendments to the Children Act 1989 in respect of domestic abuse demonstrate the importance of updating legislation to reflect society’s growing understanding of concepts of abuse. Updates to policy also chart shifts in understanding. For example, the definition of domestic abuse itself was recently revised to acknowledge findings from various sources that young people aged 16 and 17 may be victims of domestic violence and abuse:

The cross-government definition of domestic violence and abuse is:

any incident or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse between those aged 16 or over who are, or have been, intimate partners or family members regardless of gender or sexuality. The abuse can encompass, but is not limited to:

• psychological
  
• physical
  
• sexual
  
• financial
  
• emotional

(Home Office, 2015)

Assessment of children in need and their families