4.3 Recognition of Significant Harm

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Contents

• 1. Definition of Significant Harm(Jump to)
• 2. Physical Abuse(Jump to)
• 3. Emotional Abuse(Jump to)
• 4. Sexual Abuse and Exploitation(Jump to)
• 5. Neglect(Jump to)
• 6. Risk Indicators(Jump to)
• Further information(Jump to)

1. Definition of Significant Harm

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

There are no absolute criteria on which to rely when judging what constitutes Significant Harm but consideration should be given to the following:

• The severity of ill-treatment which may include the degree and extent of physical harm including, for example, impairment suffered from seeing or hearing the ill-treatment of another;
• The duration and frequency of abuse and neglect;
• The extent of premeditation.

Child abuse and neglect is a generic term encompassing all ill treatment of children including serious physical and sexual assaults as well as cases where the standard of care does not adequately support the child's health or development.

Children may be abused or neglected through the infliction of harm, or through the failure to act to prevent harm.

Abuse can occur in a family or an institutional or community setting. The perpetrator may or may not be known to the child.

Working Together to Safeguard Children 2018 sets out definitions and examples of the four broad categories of abuse which are used as a basis for determining that a child should be subject to a Child Protection Plan:

• Neglect;
• Physical abuse;
• Sexual abuse and exploitation;
• Emotional abuse.

These categories overlap and an abused child does frequently suffer more than one type of abuse. They are dealt with in the sections below.

2. Physical Abuse

Physical Abuse is a form of Significant Harm which may involve including 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.

Recognising physical abuse

The following are often regarded as indicators of concern:

• An explanation which is inconsistent with an injury;
• Several different explanations provided for an injury;
• Unexplained delay in seeking treatment;
• The parents / carers are uninterested or undisturbed by an accident or injury;
• Parents are absent without good reason when their child is presented for treatment;
• Repeated presentation of minor injuries (which may represent a 'cry for help' and if ignored could lead to a more serious injury);
• Family use of different doctors and A&E departments;
• Reluctance to give information or mention previous injuries.

Bruising

All bruising in non mobile children should be considered to be non accidental and should be referred for an assessment. See A Multi-agency Protocol for the Management of Actual or Suspected bruising in Infants who are Not Independently Mobile.

Bite Marks

Bite marks can leave clear impressions of the teeth. Human bite marks are oval or crescent shaped. Those over 3cm in diameter are more likely to have been caused by an adult or older child.

A medical opinion should be sought where there is any doubt over the origin of the bite.

Burns and Scalds

It can be difficult to distinguish between accidental and non-accidental burns and scalds, and will always require experienced medical opinion. Any burn with a clear outline may be suspicious e.g.:

• Circular burns from cigarettes (but may be friction burns if along the bony protuberance of the spine);
• Linear burns from hot metal rods or electrical fire elements;
• Burns of uniform depth over a large area;
• Scalds that have a line indicating immersion or poured liquid (a child getting into hot water of its own accord will struggle to get out and cause splash marks);
• Old scars indicating previous burns/scalds which did not have appropriate treatment or adequate explanation.

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

Fractures

Fractures may cause pain, swelling and discolouration over a bone or joint.

Non- mobile children rarely sustain fractures.

There are grounds for concern if:

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

Scars

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

Further information about this unusual and potentially dangerous form of abuse is set out in the Fabricated or Induced Illness Procedure.

3. Emotional Abuse

Emotional abuse is a form of Significant Harm which involves the persistent emotional maltreatment of a child such as to cause severe and persistent adverse effects on the child's emotional development.

It may involve conveying to children that they are worthless or unloved, inadequate, or valued only insofar as they meet the needs of another person. It may include not giving the child opportunities to express their views, deliberately silencing them or "making fun" of what they say or how they communicate. It may feature age or developmentally inappropriate expectations being imposed on children.

These may include interactions that are beyond the child's developmental capability, as well as overprotection and limitation of exploration and learning, or preventing the child participating in normal social interaction. It may involve seeing or hearing the ill-treatment of another. It may involve serious bullying (including cyberbullying) causing children frequently to feel frightened or in danger, or the exploitation or corruption of children.

Some level of emotional abuse is involved in all types of maltreatment of a child, though it may occur alone.

Recognising emotional abuse

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

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

The following may be indicators of emotional abuse:

• Developmental delay;
• Abnormal attachment between a child and parent/carer e.g. anxious, indiscriminate or no attachment;
• Indiscriminate attachment or failure to attach;
• Aggressive behaviour towards others;
• Scapegoated within the family;
• Frozen watchfulness, particularly in preschool children;
• Low self esteem and lack of confidence;
• Withdrawn or seen as a 'loner' - difficulty relating to others.

4. Sexual Abuse and Exploitation

Sexual abuse and exploitation is a form of Significant Harm which involves forcing or enticing a child or young person to take part in sexual activities, not necessarily involving a high level of violence, whether or not the child is aware of what is happening. The activities may involve physical contact, including assault by penetration (for example rape or oral sex) or non-penetrative acts such as masturbation, kissing, rubbing and touching outside of clothing. They may also include non-contact activities, such as involving children in looking at, or in the production of, sexual images, watching sexual activities, encouraging children to behave in sexually inappropriate ways, or grooming a child in preparation for abuse (including via the Internet). Sexual abuse and exploitation is not solely perpetrated by adult males. Women can also commit acts of sexual abuse and exploitation, as can other children.

See also Allegations Against Staff, Carers and Volunteers Procedure.

Recognising sexual abuse and exploitation

Boys and girls of all ages may be sexually abused and exploited and are frequently scared to say anything due to guilt and/or fear. This is particularly difficult for a child to talk about and full account should be taken of the cultural sensitivities of any individual child / family.

Recognition can be difficult, unless the child discloses and is believed. There may be no physical signs and indications are likely to be emotional / behavioural.

Some behavioural indicators associated with this form of abuse are:

• Inappropriate sexual conduct;

• Sexually explicit behaviour, play or conversation, inappropriate to the child's age;

• Continual and inappropriate or excessive masturbation;

• Self-harm (including eating disorder), self mutilation and suicide attempts;

• Indiscriminate choice of sexual partners;

• Children who associate with other young people involved in exploitation;

• Children who have older boyfriends or girlfriends;

• An anxious unwillingness to remove clothes for - e.g. sports events (but this may be related to cultural norms or physical difficulties);
• Children who go missing for periods of time or regularly come home late;
• Children who regularly miss school or education or do not take part in education;
• Children who appear with unexplained gifts or new possessions;
• Children who misuse drugs and alcohol.

Some physical indicators associated with this form of abuse are:

• Pain or itching of genital area;
• Blood on underclothes;
• Pregnancy in a younger girl where the identity of the father is not disclosed;
• Physical symptoms such as injuries to the genital or anal area, bruising to buttocks, abdomen and thighs, sexually transmitted infections, presence of semen on vagina, anus, external genitalia or clothing.

Cases of underage sexual activity which present cause for concern are likely to raise difficult issues and should be handled particularly sensitively.

A child under 13 years is not legally capable of consenting to sexual activity. Any offence under the Sexual Offences Act 2003 involving a child aged under 13 years is very serious and should be taken to indicate that the child is suffering, or is likely to suffer, Significant Harm. Cases involving children under 13 years old should always be discussed with a nominated child protection lead in the organisation. Under the Sexual Offences Act 2003, penetrative sex with a child under 13 years old is classed as rape. Where the allegation concerns penetrative sex, or other intimate sexual activity occurs, there would always be reasonable cause to suspect that a child, whether girl or boy, is suffering, or is likely to suffer, Significant Harm. There should be a presumption that the case will be reported to Surrey Children's Services and that a Strategy Discussion will be held. All cases involving children under 13 should be fully documented including detailed reasons where a decision is taken not to share information. These decisions should be exceptional and only made with the documented approval of a senior manager.

Sexual activity with a child aged under 16 years is also an offence. Where it is consensual it may be less serious than if the child were aged under 13 years but may, nevertheless, have serious consequences for the welfare of the young person. Consideration should be given in every case of sexual activity involving a child aged 13-15 as to whether there should be a discussion with other agencies and whether a referral should be made to Surrey Children's Services. The considerations in the following checklist should be taken into account when assessing the extent to which a child (or other children) is suffering, or is likely to suffer, Significant Harm and therefore whether a Strategy Discussion should be held in order to share information:

• The age of the child. Sexual activity at a young age is a very strong indicator that there are risks to the welfare of the child (whether boy or girl) and, possibly, others;
• The level of maturity and understanding of the child;
• What is known about the child's living circumstances or background;
• Age imbalance, in particular where there is a significant age difference;
• Overt aggression or power imbalance;
• Coercion or bribery;
• Familial child sex offences;
• Behaviour of the child i.e. withdrawn, anxious;
• The misuse of substances as a disinhibitor;
• Whether the child's own behaviour because of the misuse of substances places him/her at risk of suffering harm so that he/she is unable to make an informed choice about any activity;
• Whether any attempts to secure secrecy have been made by the sexual partner beyond what would be considered usual in a teenage relationship;
• Whether the child denies, minimises or accepts concerns;
• Whether the methods used are consistent with grooming; and
• Whether the sexual partner(s) is known by one of the agencies.

In cases of concern when sufficient information is known about the sexual partner(s), the agency concerned should check with other agencies, including the police, to establish whatever information is known about that person(s). In appropriate cases the police may share the required information without beginning a full investigation if the agency making the check requests this.

Sexual activity involving a 16 or 17 year old, even if it does not involve an offence, may still involve harm or the likelihood of harm being suffered. Professionals should still bear in mind the considerations and processes outlined in this guidance in assessing whether harm is being suffered, and should share information as appropriate. It is an offence for a person to have a sexual relationship with a 16 or 17 year old if they hold a position of trust or authority in relation to them.

See also Children Displaying Harmful Sexual Behaviour Procedure.

5. Neglect

Neglect is a form of Significant Harm which involves the persistent failure to meet a child's basic physical and/or psychological needs, likely to result in the serious impairment of the child's health or development.

Neglect may occur during pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer failing to:

• Provide adequate food, clothing and shelter (including exclusion from home or abandonment);
• Protect a child from physical and emotional harm or danger;
• Ensure adequate supervision (including the use of inadequate care-givers); or
• Ensure access to appropriate medical care or treatment.

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

Recognising Neglect

Evidence of neglect is built up over a period of time and can cover different aspects of parenting. Indicators include:

• Failure by parents or carers to meet the basic essential needs e.g. adequate food, clothes, warmth, hygiene and medical care;
• A child seen to be listless, apathetic and unresponsive with no apparent medical cause;
• Failure of child to grow within normal expected pattern, with accompanying weight loss;
• Child thrives away from home environment;
• Child frequently absent from school;
• Child left with adults who are intoxicated or violent;
• Child abandoned or left alone for excessive periods.

Despite being the most prevalent type of child maltreatment, neglect is complex and difficult to identify, assess and respond to. SSCP promotes the use of the Graded Care Profile 2 (GCP2) in recognising and responding to concerns about the quality of care a child is receiving. Practitioners from across health, education and children’s services should use the GCP2 with families where there are concerns about the quality of care to help to measure this and put in place targeted interventions. The GCP2 should also be used to support practitioners when making a Request for Support to Surrey Children’s Services.

The GCP2 is a licensed tool from the NSPCC and practitioners must attend training prior to using the tool (bookings via Olive).

For those who have time limited contact with children and their families, SSCP have also developed a briefer Neglect Screening Tool. This tool supports practitioners who are unable to complete a GCP2, to identify signs of neglect at an early stage and to help them to discuss their concerns with their Manager or Safeguarding Lead, in order to decide the next appropriate steps.

6. Risk Indicators

The factors described in this section are frequently found in cases of child abuse. Their presence is not proof that abuse has occurred, but:

• Must be regarded as indicators of the possibility of Significant Harm;
• Justifies the need for careful assessment and discussion with Designated Professional /Named Professional / Lead Professional, manager, (or in the absence of all those individuals, an experienced colleague);
• May require consultation with and/or referral to Surrey Children's Services under the Contacts and Referrals Procedure.

The absence of such indicators does not mean that abuse or neglect has not occurred.

In an abusive relationship the child may:

• Appear frightened of the parent(s);
• Act in a way that is inappropriate to her/his age and development (though full account needs to be taken of different patterns of development and different ethnic groups).

The parent or carer may:

• Persistently avoid child health promotion services and treatment of the child's episodic illnesses;
• Have unrealistic expectations of the child;
• Frequently complain about/to the child and may fail to provide attention or praise (high criticism/low warmth environment);
• Be absent;
• Be misusing substances;
• Persistently refuse to allow access on home visits;
• Be involved in domestic abuse;
• Have a recognised psychiatric condition;
• May allow an individual previously known or suspected to have abused children, move into the household (see Risk Management of Individuals who Pose a Risk of Harm to Children Procedure).

Further information

National Institute for Health and Care Excellence, Child abuse and neglect (October 2017)