Elsevier

The Lancet

Volume 373, Issue 9658, 10–16 January 2009, Pages 167-180
The Lancet

Series
Recognising and responding to child maltreatment

https://doi.org/10.1016/S0140-6736(08)61707-9Get rights and content

Summary

Professionals in child health, primary care, mental health, schools, social services, and law-enforcement services all contribute to the recognition of and response to child maltreatment. In all sectors, children suspected of being maltreated are under-reported to child-protection agencies. Lack of awareness of the signs of child maltreatment and processes for reporting to child-protection agencies, and a perception that reporting might do more harm than good, are among the reasons for not reporting. Strategies to improve recognition, mainly used in paediatric practice, include training, use of questionnaires for asking children and parents about maltreatment, and evidence-based guidelines for who should be assessed by child-protection specialists. Internationally, studies suggest that policies emphasising substantiation of maltreatment without concomitant attention to welfare needs lead to less service provision for maltreated children than do those in systems for which child maltreatment is part of a broad child and family welfare response.

Introduction

In the first paper in this Series, we reported the substantial shortfall between the occurrence of maltreatment and reports to child-protection agencies.1 For example, 1·5–5% of all children are reported to child-protection agencies every year for all types of child maltreatment in the UK, USA, Australia, and Canada. About 1% of children have maltreatment substantiated every year. By contrast, surveys of children, adolescents, or parents show that the annual frequency of maltreatment is much higher than is reported to child-protection agencies (physical abuse 4–16%; psychological abuse 10%; neglect 1–15%; and exposure to intimate-partner violence 10–20%).1 These data provide strong evidence that most child maltreatment is not reported. When child maltreatment is reported, professionals from public services, and members of the community and family contribute equally (figure).

National data from the USA show that schools contribute most reports from professionals (16·5%), whereas law-enforcement agencies (15·8%) and social services (10%) report slightly more than do medical personnel (8%).2 Patterns are similar in the UK and Spain.3, 4 These data suggest that, to understand the reasons for under-reporting, we need to know more about the patterns of presentation, recognition, reporting, and other responses to child maltreatment across different professions and within communities.5, 6 Here, we review patterns of recognition and response by professionals caring for children and their parents, and assess strategies to improve this process. We also discuss policies governing responses to child maltreatment in different countries and the extent to which they lead to service provision.

Section snippets

Evidence for under-recognition and under-response

Officially recognised maltreatment statistics substantially underestimate the annual prevalence of maltreatment based on self-reports in community surveys. This discrepancy could indicate failures to recognise maltreatment, failures to report, and failures of agencies to respond or substantiate maltreatment. Direct evidence that professionals in health and education under-report children they suspect of being maltreated comes from a growing number of studies.3, 7, 8, 9, 10, 11, 12, 13, 14, 15,

Benefits and harms of recognition of and response to child maltreatment

The rationale for any system that recognises and responds to child maltreatment is that overall, the harms of reporting to child-protection services are outweighed by the benefits of recognition, and therapeutic or protective responses. Concern that benefits might not outweigh harms, at least in some cases, inevitably reduces recognition and reporting. In health care, we endeavour to recognise asthma to treat children with bronchodilators and steroids. If we did not know that these treatments

Health care for children

Although health-care professionals contribute to a small proportion of reports to child-protection agencies, they are most likely to be responsible for reporting the minority of children who have been severely physically abused, and have injuries or symptoms as a result. According to a Canadian study,40 only 4% of 3780 children with substantiated child abuse had injuries needing medical attention. Recognition and response is especially urgent for these children to prevent further serious harm.41

Fatal maltreatment

Despite mandated systems needing multiagency investigation of unexpected child deaths in many countries,74, 75, 76 deaths due to child maltreatment are underestimated.77, 78, 79, 80, 81 WHO estimated that 0·6% of all deaths and 12·7% of deaths due to injury in children younger than 15 years were caused by abuse or neglect.82 Variations in mortality across different ages and countries are discussed in the first paper in this Series.1 Sidebotham and Fleming77 proposed five broad groups of deaths

Neglect

Despite minor variations between international and state definitions of neglect,39 there is agreement that neglect is a state of omission where, regardless of intention, carers fail to provide health, education, emotional development, nutrition, shelter, or safety for their child.1, 83, 91 Signs include scarce parental support or engagement with the child, lack of supervision, frequent absence from school, a child's begging or stealing, insufficient clothing, or nobody at home to provide care.

Maltreatment of children with mental-health problems

Various mental-health problems in children are associated with child maltreatment,1 including anxiety, depression, post-traumatic stress, dissociation, oppositional behaviour, suicidal and self-injurious behaviour, substance misuse, anger and aggression, and sexual symptoms and age-inappropriate sexual behaviour.97 The extent to which child maltreatment is recognised and addressed by clinicians seeing children for mental-health or behavioural problems is not well understood. Clinical studies

Schools

Of all the professions, teachers and school counsellors have the most interaction with children.3, 10 They are well placed to observe changes in behaviour and distress, to make comparisons with peer norms, and to be available for children who want to disclose maltreatment. However, although school professionals contribute most reports to child-protection agencies (figure), they are also responsible for failing to report most cases.3, 10, 103, 104, 105 One study of referrals in nursery schools

Training

The need for training of professionals to recognise and respond to child maltreatment is widely acknowledged. Within health care, primary-care or family doctors are of particular concern because they make few referrals to child-protection services despite their ongoing contact with families.38, 43, 114

A systematic review115 of training and procedural interventions for improving the management of child maltreatment by health professionals identified 22 studies, most being of poor quality and

Young offenders

Progression from maltreatment during childhood to antisocial and violent behaviour and criminality in childhood, adolescence, and adulthood has been defined by a growing body of research.117 Although early intervention to prevent these cycles of violence is likely to be most cost effective, young offenders need protection from maltreatment by caregivers and interventions to ameliorate the consequences. A review118 suggested that between a third and 90% of children in custody had some form of

Adult offenders and intimate-partner violence

When an adult is identified as a violent offender—whether as a result of violence or substance misuse—an opportunity exists to also identify a maltreated child.121, 122, 123 One manifestation of violent offending is intimate-partner violence. Although highly prevalent and strongly associated with other types of child maltreatment, intimate-partner violence might not be disclosed unless the victim is asked directly.123 General practitioners are in a key position to recognise and respond to

Family courts

Within the family-court system the no-fault, future-focused approach to divorce and separation, which operates in many high-income countries, discourages the investigation of allegations of child maltreatment. Professionals might be unaware of documented maltreatment or intimate-partner violence because of the lack of information sharing across child-protection public-law and private-law family cases.

Different approaches to tackle this issue have developed under different systems of family law.

Parents with mental-health problems

Strong associations between child maltreatment and parental mental-health conditions or substance misuse135 emphasise the need for professionals to consider the welfare of children when dealing with these problems in adults.1, 136, 137, 138, 139 One study140 investigated characteristics of mothers in a substance-misuse treatment programme according to whether their children were involved with child-welfare services (n=1939; 47% of all women with children admitted to the programme) or not

Policies governing responses to child maltreatment

Comparisons between countries and jurisdictions within countries suggest that rates of officially recognised maltreatment and provision of services are partly affected by policies governing recognition and response to child maltreatment.141, 142 Two broad, although overlapping, approaches for responding to child maltreatment can be discerned. We have defined these as a child and family welfare approach and a child-safety approach.30, 141 Table 3 lists examples of countries where these policies

Conclusion

The professional practices and policies discussed here are elements of a much broader agenda to tackle child maltreatment. We did not include important factors, such as the contribution of community support and development initiatives to the prevention, recognition, and support for children exposed to maltreatment and their families,158, 159 and strategies to empower children to address maltreatment for themselves. Confidential child helplines, which offer a worldwide service for children to

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