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Children at risk: Identifying the signs of abuse

In 2012, beacons burnt to mark the Queen's Diamond Jubilee; the Olympic flame blazed as the UK hosted the Olympic Games; and before the year ended, a powerful spotlight shone on the sexual abuse of children. The prosecutions of alleged members of child grooming gangs in Lancashire and Yorkshire revealed the extent to which children had been failed. Sexual exploitation of girls as young as 11 occurred, despite awareness of their plight by agencies that could have intervened. An inquiry into the sexual exploitation of children by gangs and groups highlighted the fact that “each year thousands of children in England are raped and abused...the often devastating”.1

As 2012 drew to a close, numerous allegations of historic sexual abuse were made against the late TV presenter and celebrity fundraiser Jimmy Savile, triggered by the accounts of five women in a programme broadcast that autumn.2

By December, several hundred allegations had been made to the police about Jimmy Savile and others, by adults who felt empowered to reveal childhood abuse that had been ignored or suppressed, often for decades. Once revered and knighted for his charitable work, Savile is now regarded as “one of the UK's most prolific known sexual predators.”3

The scandal involving Savile has heightened public awareness of child abuse and prompted an increase in calls to both the police and the NSPCC. Sustaining community engagement and profes- sional vigilance is vital, as children continue to be at risk of physical abuse and neglect as well as sexual exploitation.

February 2013 marked the thirteenth anniversary of the death of eight-year-old Victoria Climbié. Yet despite the child protection procedures that were put in place following her death, Peter Connelly ('Baby P') died in the same London borough some seven years later. He was seventeen months old. Like Victoria, he was subjected to horrific abuse and like Victoria, subsequent investiga- tions highlighted missed opportunities by professionals that might have saved him.4,5

The stark facts are that in England: Abuse or neglect is implicated in the deaths of around three children every week.6,7 The group most at risk are infants (a third of all Serious Case Reviews conducted between 2007 and 2011 related to children under one year).8 In many of the cases involving infants, the only agency engaged with the family is health.8

Primary care professionals are on the front line when it comes to preventing and detecting child abuse, since most families with children are registered with a general practice. Nurses, midwives, health visitors and mental health nurses are among those whose role is crucial. Whether contact arises during the ante-natal or post-natal period, all nurses need to be alert to the risks that may be posed to an unborn child or a vulnerable infant, as well as to an older child. This includes nurses whose work may be concerned mainly with issues affecting the physical or mental health of adult members of the family. A home visit undertaken for whatever reason provides a unique opportunity to increase understanding of a family's circumstances and to identify issues that may impact adversely on a child's wellbeing.

Careful observation of a family's domestic situation could include taking note of:

General provision made for the child or children including accommodation, food, clothing and age-appropriate toys. The level of cleanliness and hygiene in relation to the child as well as the home. Environmental risks such as unguarded fires. The interaction with adults in the home including relatives and adult friends. Signs of self-harming by the child (even toddlers can exhibit self-harming behaviour). A child showing fearful or aggressive behaviour towards a particular person.

Any injuries on a child that might give cause for concern. The presence of a seemingly well school-age child at home during term time.

Early assessment and intervention may enable appropriate support to be provided for a vulnerable family by the relevant agencies and avert harm to a child.

Children have been put at risk of possible injury or neglect when professionals have:

  • Failed to share crucial information with each other and/or other relevant agencies; for example, the presence in the home of adults with serious mental disorders, substance misuse, or a history of violent offences including cruelty to animals.
  • Prioritised support for the parents above the needs of the child.
  • Underestimated the risks posed by parental lifestyles and behaviours; for example, a chaotic household in which a child is exposed to hazards whether deliberately or accidentally.

Good record-keeping is essential even if you have only limited contact with a family. Seemingly disparate pieces of information can highlight child abuse; your information may be a crucial piece of the jigsaw.9

You are not expected to investigate your suspicions before reporting them, and anxiety about your own professional relation- ship with the parents should not deter you from seeking advice if you suspect a child may be at risk. Serious Case Reviews all too often show that a child's needs have not been regarded as paramount, and children have been left in situations where they have suffered daily from either deliberate or unintentional harm and neglect. If you think a child or young person is at immediate risk of harm, this has to be treated as an emergency and may require you to summon police and/or ambulance services as well as informing social services. 

The Nature of Abuse: Key Facts

Working Together 2010 defines child abuse and neglect as follows: “Abuse and neglect are forms of maltreatment of a child. Somebody may abuse or neglect a child by inflicting harm, or by failing to act to prevent harm. Children may be abused in a family or in an institu- tional or community setting, by those known to them or, more rarely, by a stranger for example, via the internet. They may be abused by an adult or adults, or another child or children.”10

All types of ill-treatment of a child involve some level of emotional abuse, but it may exist in isolation; for example, in the form of constant humiliation, verbal bullying, or cyber bullying. For many forms of abuse, expert medical assessment is crucial: it can be hard to distinguish plausible from implausible explanations for some injuries, especially burns and scalds; sore or swollen limbs may be the only outward sign of long bone fractures; and the diagnosis and management of sexual abuse requires an expert team. The forms of abuse covered below focus on those for which nurses in primary care need particular awareness. (For more details about these and other forms of abuse, see Resources).

Physical abuse can take many forms, and features to note include:

  • Bruising. This is important, especially if it could have potentially been caused by teeth or fingertips. Any kind of bruising in pre-mobile infants is suspicious of non-accidental injury, especial- ly in uncommon sites such as the ears or back. Toddlers commonly have forehead and nose bruising, but bruising in other places is a potential 'red flag'.
  • Burns and scalds. These require expert medical assessment. There are differences in the appearance between scald marks that are inflicted and those that are accidental; cigarette burns are a significant inflicted injury that can be mistaken for other lesions such as scabies.

Neglect may be deliberate or may be the unintended result of a chaotic lifestyle; in either case, intervention is necessary.

Examples include:

  • Very poor domestic hygiene.
  • Persistence of untreated medical problems such as severe nappy rash, dental caries, scabies, or eczema.
  • Failure to thrive in infancy; malnutrition in an older child.
  • Developmental delay.

Sexual abuse is generally very difficult to ascertain without disclosure by the child, and the examination of sexually abused children is a highly specialised skill. However certain 'red flag' signs may come to the attention of primary care staff:

Trauma to, or discharge from, the genitalia of infants or young children. Older children may show signs of inappropriate or sexualised behaviour or language; complaints of anal or genital pain or soreness should also raise suspicions.

Fabricated and induced illness can present to nurses or GPs; for example, when a parent insists on the existence of symptoms (eg, seizures or episodes of lifelessness) which are reported to be frequent but which are never independently corroborated.11

Culture-related abuses may occur, and primary care profession- als should be aware of these if they work in practices with relevant ethnic, religious or cultural groups. Examples are:

  • Forced marriage of children.
  • Female genital mutilation.
  • Child abuse arising out of extremes of religious belief.

Professional Training Requirements

Whatever your role you have a duty to ensure that you are trained to the appropriate level with regard to safeguarding and that you update your training as required.10

In summary: All nurses, whether in regular or infrequent contact with children, need to know about normal child development; maintaining a child focus; the nature, signs and indicators of child abuse; what to do in response to concerns; appropriate documentation and mechanisms for sharing concerns, and the use of the Common Assessment Framework. For health visitors, and others working constantly with children, these requirements extend to understanding the principles in Working Together (2010); the impact of parental mental health problems, drug misuse and domestic abuse; and the ability to work with children and families.

You should be in no doubt about who to contact for advice and support. As well as familiarising yourself with the processes in your own organisation, you need to be conversant with the procedures and protocols created by your Local Safeguarding Children Board.

For most people in Britain, the highlights of 2012 will have been the Queen's Jubilee and the Olympic and Paralympic Games. For a small but significant minority, 2012 will also be seen as a watershed in relation to child abuse. Nurses share in the responsibility of maintaining a child-centred focus, so that through early detection and intervention, vulnerable children are protected from harm and abuse.



HM Government. Working Together to safeguard children. A guide to inter-agency working to safeguard and promote the welfare of children. (book)

Royal College of Nursing. safeguarding children and young people - every nurse's responsibility. guidance for nursing staff .

RCGP & NSPCC. Safeguarding Children & Young People. A toolkit for general Practice 2011 

Cardiff Child Protection systematic reviews



1. “I thought I was the only one. The only one in the world”. The Office of the Children's Commissioner's Inquiry into Child Sexual Exploitation In Gangs and Groups. Interim Report, November 2012.

2. ITV 'Exposure' documentary, screened Wednesday 14th November 2012.

3. Gray D, Watt P. Giving Victims a Voice. A joint MPS and NSPCC report into allegations of sexual abuse made against Jimmy Savile under Operation Yewtree. London: NSPCC; 2012.

4. The Lord Laming. The Victoria Climbié enquiry. Command paper CM 5730, HMSO; 2003.

5. Haringey Local Safeguarding Children Board. Serious Case Review: Baby P. Executive summary. London: Haringey LSCB; 2009.

6. OFSTED. Annual report 2007/08. London: OFSTED; 2008. 7. Gilbert C. Questions 296-300. In: Uncorrected transcript of oral

evidence: taken before the Children, Schools and Families Committee: the work of OFSTED - 10 Dec 2008. London: House of Commons Children, Schools and Families Committee; 2008.

8. Ages of concern: learning lessons from serious case reviews. A thematic report of OFSTED's evaluation of serious case reviews from 1 April 2007 to 31 March 2011. London: OFSTED; 2011.

9. The Lord Laming. The Protection of Children in England: A Progress Report. London: The Stationery Office; 2009.

10. HMGovernment.Working Together to Safeguard Children. A guide to inter-agency working to safeguard and promote the welfare of children. London: Department for Children, Schools and Families; 2010. HM Government. Safeguarding children in whom illness is fabricated or induced. Supplementary guidance to Working Together to Safeguard Children. London: Department for Children, Schools and Families; 2008.