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Next Lesson - Child Immunisations
Core
It is important to note that safeguarding issues surrounding children can be distressing. Please seek help from an organisation in your area if you have any worries or concerns.
Safeguarding is the practice of promoting welfare of people and protecting them from harm. This particularly applies to anyone deemed as vulnerable and dependent, i.e. the elderly, children, and disabled people. This article will focus specifically on child safeguarding, but it is always important to consider the safeguarding of other vulnerable people. It is everyone’s responsibility to look out for the wellbeing of children. Healthcare workers have a key role in spotting and raising concerns for child safeguarding due to their privileged access to the child’s medical information and familial circumstances.
Child safeguarding is described as a “jigsaw of risk”. Each individual organisation only sees certain aspects of the child’s life, meaning it can sometimes be hard to ‘see the whole picture’. This often leads to abuse being missed.
When we look at child safeguarding and welfare we use the assessment framework triangle, looking at the child’s developmental needs, family and environmental factors, and the capacity of the parents/carer. Each of these areas are comprised of multiple elements as demonstrated in the diagram below.
Diagram - The Assessment Framework Triangle, a tool used to assess the development of a child, their familial environment, and the capacity of their parents
SimpleMed original by Tom Bradley
When all the needs in each category are met, a very suitable environment is created for a child to grow up happy and healthy. However, if concerns exist about whether these needs are being met, a social worker will become involved in the child’s life and determine the best situation for that child’s needs to be met. If the child’s welfare is deemed at great risk, they will be taken into social care by the care workers. This can happen when the child is at significant risk of neglect, harm, and any of the types of abuse described later on in this article. Note that in general this is a last resort, and social workers will work with families to try and resolve issues.
If you suspect any form of abuse is occurring then always seek advice from your manager or supervisor.
Physical abuse is the action of purposefully, physically harming a child through any method. Examples of actions include, but are not limited to hitting, slapping, kicking, shaking, poisoning, burning, biting, mutilating, or drowning. Parents can sometimes fabricate symptoms or deliberately cause illnesses in the child – the treatment of which can cause harm.
Physical abuse can present with marks to the skin, (e.g. bruises, burns, or scarring), but children presenting with sudden unexplained exacerbations of medical conditions (e.g. asthma) and any unexplained drowsiness, vomiting, or breathing difficulties should also be considered for abuse.
New-born babies who are unable to crawl, pull to stand, or toddle are particularly vulnerable to abuse due to the frustration of the caregiver. Because of this, any bruise or mark on these babies should be investigated and duly noted.
The hitting of children by parents for discipline is a complicated area and the law is changing. At time of writing it is illegal in Scotland and Wales to hit a child, but legal in England where the smack is defined as “reasonable punishment”. Reasonable punishment depends on factors such as the age and the location of the smack. Any excess of this punishment causing wounding or actual bodily harm will be classified as physical abuse.
Sexual abuse of children falls into three different categories: Child sexual exploitation, direct sexual abuse, and female genital mutilation.
The child may not understand that it is happening, especially if they have been groomed by a caregiver to assume that this is normal. It is important to remember that it can happen anywhere, by anyone to any child at any time. In the past, most children were sexually abused by someone who they know in person, but the internet places children at risk to those they do not know. Children who are disabled are more likely to be abused as they are less likely to come forward with it.
Child sexual exploitation occurs when children and young people are exploited into taking part in sexual activities. It can be achieved through gaining the child’s trust or threatening them with violence or blackmail. Some children are given gifts or attention in exchange for performing sexual activities, and so can often think that this is part of a normal or even loving relationship with the abuser. This is known as grooming. It can happen in person, or more commonly online through the sharing of photos and videos. Note that adults often disguise themselves as children the same age as the victim to gain access to them.
Often once an abuser has images they can blackmail the child into taking part in other activities against their will. Young people can be invited to gatherings and given drugs/alcohol to make them more susceptible to being abused.
Signs of child sexual exploitation include, but are not limited to a dramatic change in the child’s mood or character, being secretive, alcohol/drug misuse, being frightened of particular people/places, or having unexplained new things/money.
Direct sexual abuse is separated into contact and non-contact abuse.
Contact abuse involves physical contact being made with the child, be it in the form of sexually touching them with a body part or object, regardless if they are clothed or not. This includes forcing children to undress and touch people or forcing them to take part in sexual activities. Contact abuse does not have to be penetrative to classify as contact abuse: sexual touching, kissing, oral sex, and inappropriate touching are all forms of this.
Non-contact abuse is where abuse occurs without the abuser touching the child, it can be both online or in-person and can include showing pornography to children, flashing them, forcing a child to masturbate, or take part in any videos of child abuse or take part in online sexual activities.
Physical signs of sexual abuse include unexplained bruises, sexually transmitted diseases, or any bleeding or soreness at their genitals or anal area. More emotional signs can include using sexual language inappropriate for their age, being inexplicably afraid of someone, self-harm, alcohol/drug misuse, or any changes in eating habits. If they are being abused online then they may spend an abnormal amount of time online or on social media, be secretive about their activities online or appear upset/angry after using the internet or social media.
It is important to know that children under the age of 13 are unable to consent to any form of sexual activity and that any sexual activity under the age of 16 is illegal. However, adolescents of similar ages having consensual sex aged 13-15 will be unlikely prosecuted.
The Fraser Guidelines relate to the prescription of contraception to an adolescent under 16 without parental consent. It is legal under the Fraser guidelines as long as it is deemed by the healthcare professional that the patient is both mature enough to understand the implications, and that the treatment is in the best interests of the patient (e.g. an unplanned pregnancy would be a risk without it).
Female genital mutilation (FGM) is the deliberate alteration or removal of the female genitals for non-medical purposes. It is completely illegal within the UK as it is defined as “a form of violence against women and girls” by the crown prosecution service. This can also be known as female circumcision. It is carried out in some African and Indonesian cultures with the intent of preparing the girls for marriage and childbirth or as part of becoming a woman. It can occur at any age in the girl’s life from just after birth to before marriage and during pregnancy. It is more common if any female relative has themselves had FGM.
There is no evidence of any health benefits of FGM and the process can cause significant harm, including severe pain, infections, infertility, dyspareunia (pain when having sex), incontinence, mental health issues, and even death from severe blood loss during the practice.
The process is often carried out by someone from the community who has no medical training and uses non-sterile instruments such as traditional knives or even razor blades. The girls are often left without analgesia and are pinned down during the practice. This leads to a very high rate of infection and complications.
There are four different grades of severity of FGM, and all of these stages are illegal and have different lasting affects upon the girl. Reconstructive surgery can now be offered to anyone who has been affected.
For more information about FGM, please see the second article of the Reproductive series entitled Anatomy of the Woman.
Male infant circumcision for religious reasoning is not deemed as genital mutilation, however, this is a topic under debate at the moment in the courts.
Emotional abuse occurs when there is long-term emotional mistreatment of a child, a practice that can have hugely adverse effects on the child’s cognitive and emotional development and psychological wellbeing. It can involve making children feeling that they are useless, worthless, and unloved or only there to serve a purpose. This can be done through making fun of things the child is trying to say or preventing them from speaking their views or imposing inappropriate expectations on the child. It can also be done through neglecting the child.
Children brought up in houses with domestic abuse, parents with substance abuse, and mental illness can have an increased likelihood of being emotionally abused as traumatic events known as adverse childhood experiences are more common place. This has an ongoing effect on the child and can lead to more health problems further on in their life.
Overprotecting children can be a more minor form of emotional abuse, and can involve preventing them from participating in social interactions and limiting them from exploring as it will leave the child emotionally and socially stunted, despite there being no malicious intention.
Emotional abuse is involved in every type of child abuse in some way as every type will affect the child for the rest of their lives emotionally – note that it can still occur on its own.
Signs of emotional abuse in children include an unexplained extreme lack of confidence, struggling in controlling their emotions, and difficulties in maintaining relationships. Younger children may be overly affectionate to people they don’t know or be more aggressive and jealous of other children. Older children may have few friends, struggle to control their emotions, and lack social skills.
Mental health problems are very common in children growing up with emotional abuse.
Neglect is defined as a persistent failure to meet the basic physical and psychological needs of a child and can come in many forms. It commonly results in poor health and stunted development of the child.
Examples of neglect include;
- Maternal substance abuse during pregnancy, i.e. alcohol.
- Failure to provide adequate food and shelter for the child.
- Failure to keep the child clean and appropriately clothed, i.e. not wearing a jacket during winter.
- Failure to protect the child from harm, both physical and emotional.
- Failure to give the child access to any appropriate medical treatment.
- Failure to supervise the child adequately, i.e. leaving a child home alone when they are too young to look after themselves.
Medical neglect is a subset of neglect where the child’s medical needs are ignored, required medication is not administered, or medical attention is not sought when needed. It also covers mothers who do not prepare appropriately for childbirth and take part in activities that will place the newborn at risk, such as substance abuse. This is why any child who has an appointment at a hospital or GP practice that does not attend for their appointment has "was not brought written" on their notes instead of "did not attend", as it is the parent/carers duty to ensure that the patient attends their appointment.
Every death of a child in the UK is investigated and reviewed to establish the cause of death, any factors which may have contributed to the child’s death, to learn from it in order to prevent future child deaths from similar scenarios, and to support the family as they go through a traumatic experience.
Every child's death is recorded on the national child mortality database for this reason. This review is done through a joint agency response when any death is sudden, the cause is either unknown or under suspicious circumstances, it is due to external causes or any stillbirth without a healthcare worker present. Different groups involved in these reviews include social workers, coroners, and health care workers.
Edited by: Dr. Maddie Swannack
Reviewed by: Dr. Thomas Burnell
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