Chapter Twelve. Safeguarding children from physical abuse
Dianne Watkins and Judy Cousins
KEY ISSUES
• Defining child physical abuse
• Macrotheoretical perspectives on the causation of child physical abuse
• Microtheoretical perspectives on the causation of child physical abuse
• A framework for prevention
Introduction
There is an explicit expectation in contemporary British healthcare systems that all healthcare professionals, regardless of their expertise or the context of their practice, should possess the knowledge and skills to enable them to recognize and respond appropriately to concerns about a child’s safety. Roles and competencies for healthcare staff have been jointly developed by the Royal Colleges of nursing, midwifery and medicine with advice from ‘Skills for Health’. These have been published by the Royal College of Paediatrics and Child Health (2006) and are in accordance with statutory government recommendations outlined in Working Together to Safeguard Children (Department for Education and Skills (DfES) 2006). These roles and competencies are aimed at all healthcare professionals who come into contact with children and young people, reiterating how all have a duty to safeguard and promote child welfare. This chapter specifically focuses on safeguarding children at risk of physical abuse. For those who wish for more comprehensive information on all categories of child abuse, guidance on further reading is provided at the end of the chapter.
This chapter will define child physical abuse and explore macrotheoretical and microtheoretical perspectives, which attempt to explain the possible contributing factors associated with the physical abuse of children. Macrotheory includes reference to cultural and sociological factors, structural characteristics of the family and stress attributed to the environment. Microtheory incorporates parental biological and lifestyle factors, biological differences in the child and the socialization experience of parents. The chapter will conclude by presenting a framework to inform primary preventive nursing practice in the field of child maltreatment.
Background
Society’s focus on child abuse as a uniquely contemporary issue, both in terms of numerical prevalence and social/moral intolerance, is an erroneous one. Awareness of this issue was initiated by an American, Henry Kempe, who first diagnosed the ‘battered baby syndrome’ in the 1960s (Kempe et al 1962). Since this time there has been a growing realization that children are meaningfully abused by their parents and others in society. Although many of the studies which attempt to explain the reasons why child abuse occurs are retrospective and lack the rigour associated with randomized control studies, there is agreement that the causes of child abuse are multifaceted, and in most instances cannot be isolated to one determinant (Browne and Hamilton-Giachritsis 2007). Studies in the 1980s tended to focus on a positivist approach which blamed the perpetrator, placing child abuse within a medical framework (Parton 1985). However, more recent literature reflects a paradigm shift away from a ‘cause and effect’ model towards an ‘ecological’ model, which incorporates a complexity of interactions between the individual, family, community and society (Belsky and Stratton 2002).
Physical abuse: definitions, effects and prevalence
Definitions currently used in England and Wales for children recorded on child protection registers can be found in the categories outlined in Working Together to Safeguard Children (DfES 2006: 37). These include physical abuse, emotional abuse, sexual abuse and neglect. Physical abuse is defined as:
Hitting, shaking, throwing, poisoning, burning or scalding, 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.
The National Society for the Prevention of Cruelty to Children (NSPCC; 2008), and Hanks and Stratton (2007) inform on the type of injuries that physically abused children present with. The most common external injuries include bruises from beatings and kicks, cuts, torn frenulum from rough feeding practices, black eyes and broken bones. Common internal injuries consist of brain injuries, retinal haemorrhages and internal injuries of the abdomen. Signs which the NSPCC (2008) state are a cause for concern include:
• injuries that the child cannot give an explanation for or the explanation provided is unconvincing
• untreated or poorly treated injuries
• injuries where accidents are unlikely, such as the abdomen, back and thighs
• bruising that looks to incorporate hand or finger marks
• human bite marks and cigarette burns
• burn and scald injuries.
Behavioural signs exhibited by children experiencing physical abuse may include:
• being sad, withdrawn or depressed
• having difficulty sleeping
• behaving aggressively or becoming disruptive
• showing fear towards certain adults
• lacking confidence and having low self-esteem
• using drugs or alcohol.
Creighton (2007) explains how child abuse statistics are obtained from the numbers of children placed on child protection registers in England and Wales. Each social service department in the United Kingdom holds a central ‘child protection register’ and children’s names are placed on the register as the result of a child protection conference, where a decision is made that the child is at risk of significant harm and therefore in need of an interagency child protection plan. The primary purpose of the child protection register is to assist in the protection of children, and the statistics it generates are of a secondary benefit. Figures collated from the register should be viewed with caution, as under-reporting is a constant feature discussed in literature pertaining to child abuse (Creighton 2007). In 2007 there were 27 900 children in England who were the subject of a child protection plan (registered), representing 25 children per 10 000 of the population aged under 18 years. This rate has increased from 26 400 in 2006 and 25 900 in 2005 (Department for Children, Schools and Families 2007). Of the children registered in 2007, 44% were included under the category of neglect, 25% under the category of emotional abuse and 15% under the category of physical abuse.
This distribution is very different from that of 20 years ago. Of the children included on child protection registers between 1980 and 1990, those who had experienced physical abuse formed the largest group, followed by sexual abuse, neglect and finally emotional abuse. However, by 2004 children registered for emotional abuse nearly equalled those registered for physical abuse and registrations for neglect far exceeded any other of the three categories. Changes in child characteristics are also evident; the average age of a child on a child protection register for physical abuse rose from just over three and a half years of age in 1975 to seven years in 1990. Other characteristics remain static, such as the persistent over-representation of boys versus girls registered for physical abuse (Creighton 2007).
The Welsh Child Protection Systematic Review Group at Cardiff University, the NSPCC and the Department for Children, Schools and Families have produced a range of evidence-based information leaflets on physical child abuse that health professionals will find invaluable (Box 12.1).
Box 12.1
Information resources for professionals
Oral injuries and bites on children (2007)
Thermal injuries on children (2006)
Fractures in children (2005)
Bruises on children (2005)
Safeguarding children in whom illness is fabricated or induced (2008)
Safeguarding children who may have been trafficked (2007)
A macrotheoretical perspective on child physical abuse
A macrotheoretical perspective allows a broad approach to examining contributing factors associated with the physical abuse of children, one that moves away from a focus on blaming the perpetrator. It includes reference to cultural and sociological reasons and stress attributed to the environment (Watkins and Cousins 2005).
The influence of culture on child physical abuse
Authors discuss cultural norms as a possible theory to explain violence in families and punitive patterns of discipline (Browne and Hamilton-Giachritsis 2007, Korbin 2007). Intertwined with this is the ‘privacy’ of the family regarded as a cultural value in Britain, which often inhibits society from becoming involved in family affairs (Lyon 2007). However, while much discipline may not be regarded as a deliberate act of cruelty, it becomes difficult to differentiate between that which is considered ‘tolerable’ and that which is ‘abusive’ (Frude 1991: 176).
Historically, the physical punishment of children has been an accepted cultural norm in British society and continues to influence child-rearing patterns in many families in the 21st century. Smith et al’s (1995) findings confirmed this where, of 403 socially diverse families with children, 97% of 4-year-olds had experienced physical punishment, 16% had experienced a blow that would have fitted the criteria for physical abuse and 75% of infants aged under 1 year of age had been smacked, with 38% being smacked more than once a week. More mothers than fathers smack their child at 79% versus 58% respectively, probably reflecting the greater time mothers spend with children (Cawson et al 2000). More recently, Ghate et al (2003) found that nearly 60% of parents reported slapping or smacking their child during the previous 12 months and 9% stated they had used severe physical punishment. Hobbs (2003) estimates that 150 000 children a year experience physical punishment of a degree likely to cause them physical harm. This supports Cousins and Watkins’ (2005) belief in a continuum between child physical punishment and child physical abuse.
Escalation theory offers one explanation for the association between physical punishment and physical injury. Quite simply, as children grow, parents are invariably required to increase the force they use when administering physical punishment. What starts as little ‘taps’ may escalate into smacks or even worse, and where this occurs, so does the risk of injury (Phillips 2007). Indeed, many parents prosecuted for physically injuring their child state how their intention was never to injure, just to discipline. Intentionality is discussed by Krug et al (2002), highlighting how an individual’s violent behaviour against another, such as a parent shaking a crying baby to quieten it or smacking an infant for perceived bad behaviour, can have unintended consequences. Force is used, not necessarily with an intention to cause harm. However, such actions can result in serious injuries or even death; especially where parental perception of the fragility of infants and children is underestimated.
For those children who experience frequent, intentional and harsh physical punishment the associated outcomes are the poorest. Worst case scenarios involve the death of a child and the younger the child the greater the risk of death (Krug et al 2002). As a measure or indicator of children’s life experience, homicide rates may be considered the absolute tip of the iceberg, or at one end of a continuum where ‘taps’ used to instil discipline are at the other. Bridging the two are behaviours ranging from smacks, slaps, shakes, scaldings, burns, kicks, thumps and beatings and at any one time an infant or child may experience one, some or all of these reactions from a caregiver. The morbidity associated with physical punishment and violence experienced behind the closed door of the home must never be underestimated. Frequent harsh physical punishment is also associated with a range of psychological effects including evoking feelings of rejection, provoking feelings of anger towards the perpetrator, engendering low self-esteem and inhibiting the development of self-worth, as well as socializing children in the use of physical force against others, and perpetuating long-term aggressive and delinquent behaviours (Gershoff 2002, Ghate et al 2003).
As well as the risk of injury from physical punishment, evidence suggests that children living in violent environments also face increased risk of physical abuse (Hester et al 2007). The Royal College of Psychiatrists (2004) report that in families where there exists domestic violence, approximately three-quarters of children witness the event and about half experience being badly hit or beaten themselves. At least one-third of children are injured when trying to protect their mothers, and in a quarter of cases, abusive men also exhibit violence towards children (Mullender 2004, Royal College of Psychiatrists 2004, NCH Action for Children 1994). Apart from the obvious risk of physical injury, witnessing violence in these situations can result in anxiety, tummy-aches, temper tantrums, sleep difficulties and bedwetting in younger children. In older children, boys may exhibit aggressive and disobedient behaviour and girls exhibit tendencies to become withdrawn and depressed (Royal College of Psychiatrists 2004).
The influence from living in violent conditions appears to influence disciplinary choices. Kanoy et al’s (2003) longitudinal study found an association between high rates of hostility and marital conflict and more frequent and severe use of physical punishment of children. McGee (2000) found violent men less involved in childcare, less affectionate to their children and more likely to use physical punishment, and Kerker et al (2000) reported that mothers experiencing domestic violence were significantly more likely to report hitting their children hard enough to leave a mark, compared with those not experiencing violence. Of concern, where both parents use physical punishment, children in two-parent families could experience significantly more physical punishment than those in single parent families.
From a legal and constitutional perspective Lyon (2007) discusses the absurdity behind the decision of the government to enact section 58 of the Children Act 2004 which legally allows parents to physically discipline children, while in the same year they also passed the Domestic Violence Crime and Victims Act to protect women from domestic violence. Perhaps even more remarkable is how women figure significantly among those who support parental right to continue to use physical punishment. However, it must be remembered that questions used to assess public views on smacking are often couched in terms of removal of personal rights and few individuals vote to have their rights curtailed, making it difficult to accurately ascertain public opinion.
Feminism also informs the cultural theory of child abuse, and maintains that violence by men against women and children in the family reaffirms the male position of power in society. This patriarchal view stems from a belief that men are of a higher order, which allows them greater power and control over women, who are lower in the social hierarchy (Browne and Hamilton-Giachritsis 2007). Feminists maintain that society condones these attitudes, and warns that ignoring family violence, particularly abuse towards women, may well perpetuate the cycle of family violence.
The influence of sociological factors on child physical abuse
Social and economic factors play a crucial role in child abuse, and are closely related to degrees of poverty, in that the more extreme poverty families are subjected to, the greater the likelihood of child abuse occurring (Corby, 2005 and Corby, 2005). Generally, studies find stronger correlations between poverty and physical abuse than sexual or emotional abuse, and when considering there are approximately 3.8 million children currently living in poverty in the UK, this is of concern (Dyson 2008). Choices are constrained for people on a low income, which in turn reduces opportunities for social contact. This can result in social isolation and poor social contacts for families who live on the ‘bread line’, increasing a family’s vulnerability to child abuse (Browne and Hamilton-Giachritsis 2007).
Although it is known that the most severe injuries to children occur in the poorest families, the research base to support a single cause-and-effect relationship in the absence of other factors is sparse. Studies have found a positive correlation between factors such as poverty, unemployment, poor housing, low educational levels, lower social class and the abuse of children (Bentovim 2007). However, other authors suggest the relationship between socioeconomic status and child maltreatment is inconclusive (Browne and Hamilton-Giachritsis 2007). Ultimately, poverty environments do tend to be chaotic, more highly stressed and lack resources; however, an assumption cannot be made that all children from lower socio-economic groups will be abused (Dyson 2008). Other social factors associated with an increased vulnerability to child maltreatment include social isolation, out of home placements, step-parents and spiritual possession.
Social isolation
Social isolation and lack of a supportive network have been recognized as risk factors and the nuclear isolated family identified as being at greater risk of abusing their children (Corby, 2005 and Corby, 2005). The ‘quality’ of social support is probably more important than the quantity, as a protective factor for parents. Social isolation may be more common in single female parents, who tend to be at greater risk of abusing their children, with over 40% of single parents represented in British studies of abused children (Browne and Saqi 1988).
Out of home placements
A retrospective survey by Hobbs et al (1999) of children in care requiring paediatric report for suspected, probable or confirmed physical or sexual abuse, provided details on a series of disturbing findings. Of 103 fostered children, 51 were diagnosed as suspected, 66 as probable or confirmed and 40 as having experienced physical and sexual abuse. Boys experienced greater levels of physical abuse whereas girls experienced greater levels of sexual abuse. One 2-year-old child died after being shaken by a foster parent. The authors’ records indicated that children in foster care were 7–8 times more likely to be assessed by a paediatrician for abuse than a child in the general population.
Step-parents
Physical abuse of children is more common by step-parents, particularly fatal abuse, compared with that of natural parents. Egan-Sage and Carpenter (1999) cites step-fathers as being responsible for abuse of the child in 14% of referrals to social services, and 16% of those entered on the child protection register. The reason for this may relate to an inability of the step-parent to form an attachment relationship with the step-child.
Spiritual possession
Physical child abuse is associated with carers’ belief in spirit possession of a child. Belief in spirit possession is defined as ‘the belief that an evil force has entered a child and is controlling him or her’ (Department of Health 2007: 5). A child may also be perceived as a witch and this is defined as ‘the belief that a child is able to use an evil force to harm others’ (Welsh Assembly Government 2007: 5). Alternative terminology and labels include black magic, kindoki, ndoki, the evil eye, djinns, voodoo, obeah and child sorcerers. The number of confirmed cases of this type of abuse is small; however, it is likely that a significantly larger number of cases remain undetected. Where it is present the impact on the child is considerable and the child faces risks which could result in significant harm. The most common forms of physical abuse include beating, burning, cutting, stabbing, semi-strangulating, tying up the child, or rubbing chilli peppers or other substances on the child’s genitals or eyes. The abuse normally takes place in the child’s home but it also occurs in places of worship where ‘exorcisms’ are conducted (Welsh Assembly Government 2007). The physical experience of abuse may be severe. However, such children also suffer psychologically, especially if ostracized by their family or community.
The influence of structural characteristics and environmental stress on child physical abuse
The United Nations Childrens Fund (UNICEF; 2003) reminds how the transition to parenthood is an overwhelming experience for the majority of parents, who suddenly find themselves faced with the responsibility for the well-being of a small, often demanding and dependent infant. Adjusting to a new social role, while feeling exhausted, and add to that the stress from any financial and/or relationship difficulties, compounds feelings of inadequacy and can contribute to anxiety and depression. For the majority of parents, such feelings are transitory, aided by a social environment that is warm, supportive and which helps to instil confidence and raise self-esteem. Others, however, already familiar with a life characterized by emotional and environmental poverty, now face a mountain of new pressures ‘ill-equipped, ill-prepared and unsupported’ (UNICEF 2003: 11).
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