A Unique Child - Abuse: Warning signs

Child abuse is a tragic reality of life. Sadly, physical, sexual or emotional abuse or childhood neglect often go unnoticed. The consequences of these acts may be far and long-reaching, leading to significant psychological disturbance throughout childhood and adulthood.

Professionals may fail to act on signs of abuse out of inexperience, perhaps looking but not seeing. In some instances, however, failure to alert the authorities may be deliberate, in order to avoid being the whistleblower and facing complaint or harassment from the family, damaging the relationship with the child or parent and in fear of making a false accusation. Deliberately turning a blind eye to child abuse can have serious consequences not only for the child, but also the individual professional involved.

Children particularly at risk are those already on the at-risk register and those with parents/carers who misuse drugs or alcohol, who have mental illness or who have a history of violence. Parents or carers who have harmed children in the past or who have been violent towards animals are considered more likely to abuse. Disabled children or those looked after by vulnerable adults may also be at risk.

SIGNS

It is crucial to be aware of the signs of abuse in order to raise the alarm when a child is in danger. Physical maltreatment is the most apparent form of child abuse. The nature of the injury as well as its physical location offer important clues as to the cause.

Bruises, if in the shape of a hand grip or instruments, particularly if located in areas of the body that can't be explained by a plausible accident, should raise serious concerns. Large bite marks, unexplained or symmetrical cuts, or ligature marks around wrists or ankles, could all point to abuse. Unusually located burns, for example at the back of the hand, back, buttocks or soles of the feet, should be treated as sinister.

Multiple fractures that cannot be explained by medical conditions, particularly if the fractures occurred at different times, unexplained head or spinal injury, or bleeds in the back of the eye may all reflect physical maltreatment.

The age of a fracture may be determined by X-ray analysis. Some children may be poisoned. Harm for personal gain should raise suspicion of Munchausen's syndrome by proxy, where a parent fabricates or deliberately induces an illness or injury.

Parents or carers who abuse often offer explanations inconsistent with the injury, usually without a witness to corroborate their story. They may appear uneasy, aggressive or cold toward their child.

SEXUAL ABUSE

It is not uncommon to read in the press about child pornography internet sites. In many cases, photos are taken and sent or even sold to site ringleaders. Sadly, thousands of children are sexually abused each year and it is likely the majority go undetected.

Sexual abuse, whether or not for the purposes of pornography, should be considered in children who complain of recurrent episodes of pain when passing urine, or vaginal or anal discharge once plausible medical causes, such as a benign urinary tract infection, have been excluded. Hepatitis B, genital or anal warts, or bacterial sexually transmitted diseases in children is highly suspicious. Anal or genital injury without clear explanation should always ring alarm bells.

Children who have suffered abuse may become withdrawn, tearful and aggressive, or display inappropriate sexualised behaviours. In some instances, children use sexualised language. They may be silenced by bribery or blackmail from their abusers.

NEGLECT

Children who do not receive the emotional or physical care they need are considered to be suffering from neglect. Neglect may not be deliberate but reflect a parent's illness, vulnerability or innocent inability to parent.

Neglect may also be a manifestation of overt poverty. Signs that may suggest neglect include scabies or head lice, though this should be put into context. Others are failure to attend school or medical appointments or to adhere to treatment offered by healthcare workers, including immunisations.

Tight shoes and clothes, clothing inappropriate for the weather, and poor development or growth all warrant investigation. Of particular concern are children who suffer medical ailments without intervention from a carer, persistent uncleanliness, overwhelmingly smelly children, apparent malnourishment, stealing and hoarding food, or scavenging and eating quickly.

Medical conditions such as coeliac disease should be considered in children who are apparently malnourished. Coeliac disease, which tends to be underdiagnosed, leads to malabsorption of dietary nutrients and failure to thrive. Lactose intolerance, diabetes, thyroid disease, TB and cystic fibrosis are just some of many other medical conditions that should be considered by a medical professional.

Once conditions such as ADHD or autistic spectrum disorders have been ruled out, if children begin to behave in an unusual way then parental separation anxiety, emotional abuse or indeed abuse of any form should be considered. Suspicious behaviour would include social withdrawal, aggression or rages, rocking, over-friendliness, clinginess, nightmares, distress, self-harm (such as cutting, scratching, picking), repeatedly running away, incontinence or deliberate wetting or defecation.

Abuse is a sad fact of life. Parents or carers try to conceal it, and it is the duty of professionals who work with children to be vigilant for signs of abuse, and to raise the alarm when a child is being harmed.

There may be situations that require immediate action - for example, if the child has suffered obvious harm and the presumed offending person is on the premises to take the child home. Where immediate child protection is required, the police should be called. When concerned about child abuse, it is in the best interests of the child to refer the case to the authorities, and let them determine whether the child is indeed at risk.

Dr Raj Thakkar BSc (Hons) MBBS MRCGP MRCP (UK) is a full-time GP in Buckinghamshire

LEGAL REQUIREMENTS

Under the Statutory Framework of the Early Years Foundation Stage (3.8-3.9), providers are legally obliged to have a written safeguarding policy and procedure, which should be given to staff as part of their induction.

Providers must ensure that all staff members:

- understand the safeguarding policy and procedure and are able to implement it appropriately, including knowing who to approach if they suspect any cases of abuse

- are able to respond appropriately to any significant changes in children's behaviour; deterioration in their general well-being; unexplained bruising, marks or signs of possible abuse; signs of neglect.

- have an up-to-date understanding of safeguarding issues.

For information, visit: http://nationalstrategies.standards.dcsf.gov.uk/node/83921

Providers should follow the guidance set out in What to do if you are worried a child is being abused, published by the DCSF and available at: www.dcsf.gov.uk/everychildmatters/resources-and-practice/IG00182.

See Policy Q&A, page 24