Special Circumstances Guidance
Children - Special Circumstances
Domestic abuse describes any behaviour that involves exerting control over a partner or ex-partner’s life choices and that undermines their personal autonomy. It is an assault on their human rights. Although most victims are women, men can also suffer domestic abuse, and it can also occur in same-sex relationships. Children and young people living with domestic abuse are at increased risk of significant harm both as a result of witnessing the abuse and being abused themselves. Children can also be affected by abuse even when they are not witnessing it or being subjected to abuse themselves. Domestic abuse can profoundly disrupt a child’s environment, undermining their stability and damaging their physical, mental and emotional health.
The impact of domestic abuse on a child will vary, depending on factors including the frequency, severity and length of exposure to the abuse and the ability of others in the household (particularly the non-abusive parent/carer) to provide parenting support under such adverse conditions. If the non-abusive parent/carer is not safe, it is unlikely that the children will be. Indeed, children frequently come to the attention of practitioners when the severity and length of exposure to abuse has compromised the non-abusing parents/carers ability to nurture and care for them.
The best way to keep both children and non-abusive parents/carers safe is to focus on early identification, assessment and intervention through skilled and attentive staff in universal services. Domestic abuse is widely under-reported to the police. Given the reticence of victims to come forward, it is crucial that staff are aware of the signs of domestic abuse and routinely make appropriate enquiries.
The impact of domestic abuse on a child should be understood as a consequence of the perpetrator choosing to use violence rather than of the non-abusing parents/carers failure to protect. Every effort should be made to work with the non-abusing parent/carer to ensure adequate and appropriate support and protection is in place to enable them to make choices that are safe for both them and the child. At the same time, staff should be maintaining a focus on the perpetrator and monitoring any risk resulting from ongoing abuse. The ultimate aim should be to support the non-abusing parent/carer in re-establishing a stable and nurturing home for the child; in the meantime, protecting the child may mean them having to live apart from the non-abusing parent/carer for a time. In such circumstances, staff should work to ensure as much stability and continuity for the child as possible. Agencies should always work to ensure that they are addressing the protection of both the child and the non-abusing parent/carer.
Protection should be ongoing, and should not cease if and when the abuser and the non-abusing parent/carer separate. Indeed, separation may trigger an escalation of violence, increasing the risk to both the child and their non-abusing parent/carer. One area of critical concern is the child’s contact with the perpetrator, which can provide a channel for continuing and even increasing the domestic abuse. Any decisions made in regard to contact by both social work services and/or the civil courts should be based on an assessment of risk to both the non-abusing parent/carer and the child.
More detailed information about the impact of domestic abuse on children and young people and the need to address this from a child protection perspective can be found in the following documents:
Domestic abuse is the reason for around one third of non-offence cause for concern reports. There is a very high incidence of repeat victimisation which means children are likely to be repeatedly exposed to domestic abuse within their family. In 90% of incidents children and young people are in the same or next room. 40% to 60% of children whose mother is abused are also directly abused by the perpetrator.
Children and young people living with domestic abuse may suffer from stress-related illnesses and conditions, and experience feelings of guilt, shame, anger, fear and helplessness.
FDASAP is an independent partnership that reports directly to the Community Safety Partnership Group. Fife Domestic and Sexual Abuse Partnership (FDASAP) develop Fife's strategy in relation to domestic abuse including voluntary and statutory sectors. FDASAP forms part of the MARAC process. MARAC is a forum where multiple agencies get together to provide a co-ordinated response. It identifies very high risk victims of domestic abuse.
Substance misuse can involve either alcohol or drug misuse (which can include prescription as well as illegal drugs). The risks and impacts on children of substance-misusing parents and carers are known and well-researched.
Parental drug abuse – the facts in Scotland:
- Parental drug abuse is at least as prevalent in Scotland as in England and Wales, with 11 percent of fathers and nearly six percent of mothers in Scotland found to have taken drugs during 2009 (Millennium Cohort Study).
- 60,000 children are affected by parental drug misuse in Scotland, according to the most recent figures (Audit Scotland’s Drug and Alcohol Services in Scotland, March 2009).
- One third of those who died a drug-related death in 2009 were parents, or a parental figure of children, and almost 1 in 10 were living with a child, theirs or otherwise, at the time of death (Statistical Publication Notice: Drug Related Deaths, January 2011).
The Scottish Government guidance “Getting Our Priorities Right” (2003) outlined the expectations on a range of agencies in respect of referral, information-sharing and service provision for families where parents or carers misuse substances including alcohol. This has been further supported by the Hidden Harm report.
Substance misuse during pregnancy can have a particularly significant health impact on the unborn and the new born child (infant drug dependency, Foetal alcohol syndrome , Neo-natal alcohol syndrome). Ante-natal and post natal services working with other key agencies are critical to ensure the risks to babies affected in this way are reduced. In Fife, the NHS Vulnerable in Pregnancy Service working with the relevant agencies effectively addresses issues of substance misuse in pregnancy and post birth.
Parental substance misuse can result in sustained abuse, neglect, maltreatment, problematic behaviour, disruption in primary care-giving, social isolation and stigmatisation of children. Substance-misusing parents/carers often lack the ability to provide structure or discipline in family life. Poor parenting can impede child development through poor attachment and the long-term effect of maltreatment can be complex. The capability of parents/carers to be consistent, warm and emotionally responsive to their children can be overwhelmed by the preoccupation of substance misuse.
It is important that all practitioners working with drug or alcohol abusing parents/carers know the potential effects that substance misuse can have on a child, both in terms of the indirect impact on the care environment as well as direct exposure to the use of these substances. For staff in all agencies dealing with substance misusing parents/carers the best interests of the child should always be of paramount concern.
Foetal Alcohol Syndrome (FAS) is a serious health problem that tragically affects children and their families whose mother’s have misused alcohol during pregnancy, but is completely preventable. Alcohol crosses from the mother’s bloodstream through the placenta into the baby’s blood.
Babies born with FAS tend to weigh less and be shorter than normal. They usually suffer from smaller heads; deformed facial features; abnormal joints and limbs; poor coordination; problems with learning; short memories.
Victims of foetal alcohol syndrome often experience mental health problems, disrupted school experience, inappropriate sexual behaviour, alcohol and drug problems, difficulty caring for themselves and their children, and homelessness.
The severity of the condition depends how much alcohol was consumed during pregnancy.
Many parents/carers are not open about their substance dependencies and the impact it has on their lives and their ability to care for children. It is vital that agencies have effective information sharing processes that allow, legitimately, the sharing of appropriate information relating to children’s safety. However, more important is the creation of a culture of shared values and understanding between practitioners from different agencies that will encourage individual workers to be willing to more openly share information in their daily work. As this openness develops, the value of this sharing will become apparent and will lead to more accurate assessments and subsequently better outcomes for children and their parents.
All agencies providing a service for substance misusing adults should:
- ensure that staff understand the impact of parental or carer drug misuse on children and young people, and are able to identify children and young people who may be at risk of harm (whether from abuse or neglect) as a result of parental drug misuse, or from associates of drug misusing parents;
- adopt policies that ensure child protection issues are considered as an integrated part of each assessment undertaken by the agency;
- establish procedures to ensure that local children and young people’s services are informed of:
- any concerns that a child cared for by their service users may be at risk of harm or neglect; and
- the potential need of children and young people cared for by their service users for additional family support; also
- ensure that staff are aware of and can help parents access services designed to support parents in caring for their children.
All practitioners should be aware that the needs of the child must take precedence over the need of the substance-misusing adult.
The focus is firmly on early action, before any problem escalates and reinforcing the message to all practitioners that ‘doing nothing is not an option’.
More detailed information about the impact of parental substance misuse on children and young people and the need to address this from a child protection perspective can be found in the following documents:
The definition of 'disabled children' includes children and young people with a comprehensive range of impairments with physical, emotional, developmental, learning, communication and health care needs. Disabled children are defined as a child in need under section 93(4) of the Children (Scotland) Act 1995.
Disabled children are not only vulnerable to the same types of abuse as other children. Particularly vulnerable are those children with communication or sensory impairments, behavioural disorders or learning disabilities. Abuse of disabled children is more likely to start at an earlier age and repeated multiple abuses are evident. Neglect is most frequently reported, followed by emotional abuse.
Disabled children are more likely to be dependent on support for communication, mobility, manual handling, intimate care, feeding and/or invasive procedures. There may be increased parental stress, multiple carers, care in different settings (including residential) and often reluctance among adults to believe that disabled children are abused. Disabled children are also likely to be less able to protect themselves from abuse and limited mobility can add to their vulnerability. In addition, the network of carers around the child is likely to be larger than for a non-disabled child, which can be a risk factor in itself.
Abuse of disabled children is significantly under-reported. Services need to ensure their systems for collecting information about disabled children are sufficiently robust. When responding to concerns about a disabled child, expertise in child protection and disability should be brought together to ensure the child receives the same standard of service as a non-disabled child. It is important that services consider and develop ways that allow disabled children to communicate with staff. This is particularly relevant when a child is being interviewed as part of a joint investigation, is subject of a medical examination or attending a Child Protection Case Conferences. The use of trusted carers (if they are not suspected perpetrators) and services that specialise in communicating; including non-verbal communication, with disabled children should be engaged wherever possible.
Disabled children can progress into adult protection. The Protection of Vulnerable Groups (Scotland) Act 2007 recognises the vulnerability of disabled adults. Transition to adult services for disabled children can be traumatic. Fife has a transitions team that addresses the issue of transition between child and adult care. For further details contact Social Work Services Contact Centre on 01383 441177.
Children can also be affected by the disability of those caring for them. Disabled parents/carers/siblings may have additional support needs relating to physical and or sensory impairments, mental illness, learning disabilities, serious or terminal illness, or degenerative conditions. These may impact on the safety and well-being of their children, resulting in delay to their education, physical and emotional development.
Further helpful information can be found in the following publications or on the links noted below.
- "Safeguarding Disabled Children: Practice Guidance, Department for Children Schools and Families, 2009.
- Triangle is an independent organisation that works directly with children and their families but also offers training and consultancy to practitioners and agencies.
- Capability Scotland is a third sector agency which provides education, employment opportunities and support for disabled people.
- K Stalker et al Child Protection And The Needs And Rights Of Disabled Children And Young People: A Scoping Study, University of Strathclyde, 2010.
- Scottish Good Practice Guidelines for Supporting Parents with Learning Disabilities
Evidence shows that some adults will deliberately evade practitioner interventions aimed at protecting a child. In many cases of child abuse and neglect, this is a clear and deliberate strategy adopted by one or more of the adults with responsibility for the care of a child. It is also the case that the nature of child protection work can result in parents and carers behaving in a negative and hostile way towards practitioners.
The terms 'non-engagement', 'non-compliance' and ‘disguised compliance’ are all terms used to describe a range of deliberate behaviour and attitudes, that amount to an underlying resistance to accepting support, or in more serious cases wilfully deceiving protective agencies to continue the abuse of children. The behaviours below indicate some of the behaviours that would heighten concerns:
- failure to enable necessary contact, e.g. missing appointments, or refusal to allow access to the child or to the home;
- active non-compliance with the actions set out in the Child's Plan (or Child Protection Plan);
- disguised non-compliance, where the parent/carer appears to co-operate without actually carrying out actions or enabling them to be effective; and
- threats of violence or other intimidation towards practitioners.
- Consideration needs to be given to determining which family member(s) is or are stopping engagement from taking place and why.
Non-engagement and non-compliance, may point to a need for compulsory or emergency measures. In these often challenging situations, staff may need access to additional or specialist advice to inform their assessments and plans. As well as access to specialist advice every agency in Fife should as a priority provide support to staff to ensure their safety. This support should be explicitly expressed in single agency policy and procedures and should lead to practical measures to ensure that risk is minimised for staff and effective debriefing is available.
If a family fails to engage by missing appointments, not responding to letters etc., this failure should be recorded. In addition, records should be kept of the extent and seriousness of this resistance to engage and what are the potential risks to children. Decisions following this assessment should also be recorded.
For children subject to multi-agency child’s plans there is an onus on all agencies that contribute to the plan to think flexibly and innovatively, ensuring that those best placed to achieve engagement are utilised to address the resistance to contact. Decisions on the individual or agency given the role of addressing non-engagement should be agreed at multi-agency meetings (e.g. Child Protection Case Conference, Core Group) and predicated on the likelihood of that individual being successful in engaging the family.
In circumstances where families continue to resist contact, agencies should inform the Reporter for children subject to supervision requirements and if a child is on the CPR this should be highlighted to social work management and the Reviewing Service.
There are two separate but not unconnected issues which should be considered within the context of identifying, assessing and managing the risks faced by children affected by mental health problems:
- children and young people who themselves are experiencing mental health problems; and
- children and young people whose lives are affected by parental mental illness or mental health problems.
Stigma is a particular issue causing many people not to admit to experiencing mental health problems or seeking help for themselves or their children.
The emotional well-being of children and young people is just as important as their physical health. Most children grow up mentally healthy, but certain risk factors, poor attachment, loss, domestic abuse, parents/carers misusing substances and parents experiencing mental health problems and children can make some children more likely to experience mental health problems. Events that happen to children will not usually lead to problems with their mental health on their own, but some extremely traumatic events can trigger mental health problems (Post Traumatic Stress Disorder) for children and young people.
Changes of environment can act as triggers, such as moving home or school. Teenagers often experience emotional turmoil as sexual maturation develops through the stressful period of adolescence. Adolescence is often described as a period of storm and stress where teenagers attempt to define their own identity. During this period of identity formation many children particularly those with other difficulties will experiment with alcohol, drugs or other substances that can alter how they feel. This experimentation with substances can often contribute to mood swings either exacerbating or camouflaging mental health problems. Self-harm, parasuicide and suicide is a significant risk for young people during adolescence.
For some young people, this will not be a transitory issue and mental health problems will severely limit their capacity to participate actively in everyday life and will continue into adulthood. Some will develop severe difficulties and behaviour that challenges families and services, including personality disorders and sexually-predatory behaviour. A small number of children with mental health problems may pose risks to themselves and others. For some, their vulnerability, suggestibility and risk levels may be heightened as a result of their mental illness. For others, their need to control, coupled with lack of insight or regard for others, feelings and needs, may lead to them preying on the vulnerabilities of other children. It is imperative that services work in close partnership to address the difficulties and mitigate the risks for these children and for others.
There are certain ‘risk factors’ that make some children and young people more likely to experience problems than other children, but they do not necessarily mean difficulties are bound to come up or are even probable. Some of these factors include:
- having a long-term physical illness;
- having a parent or carer who has had mental health problems, problems with alcohol or been in trouble with the law;
- experiencing the death of someone close to them;
- having parents who separate or divorce;
- having been severely bullied or physically or sexually abused;
- living in poverty or being homeless;
- experiencing discrimination, perhaps because of their race, sexuality or religion;
- acting as a carer for a relative, taking on adult responsibilities;
- having long-standing educational difficulties; and
- insecure attachments with primary carer.
- For children and young people experiencing such difficulties, it is extremely important that they are able to access the right support and services and that their issues are taken seriously, a focus on children's welfare is paramount. The need to work collaboratively across services to ensure effective responses that take account of the child's or young person's family and wider social circumstances is fundamentally important. Effective risk assessment is required as part of this response. Child and adolescent mental health services can provide an important resource in helping children and young people overcome the emotional and psychological effects of abuse and neglect. It is important that children and young people's mental health is not seen as only the preserve of psychiatric services, as the causes of mental ill-health are bound up with a range of environmental, social, educational and biological factors.
Further helpful information can be found in the following publications or on the links noted below.
The SCIE Report, Think child, think parent, think family (published July 2009) identifies the need for a multi-agency approach with senior level commitment to this strategy and includes recommendations for practice in relation to assessment, care planning /provision and reviewing this at a practitioner, organisational and strategic level.
See Me - Scotland's national campaign to end the stigma and discrimination of mental ill-health.
Scottish Good practice Guidelines for Supporting Parents with Learning Disabilitiesis aimed at providing practical guidance to agencies that support people with learning disabilities who become parents.
Practitioners' ability to determine if a child's sexual behaviour is developmentally normal, inappropriate or abusive will be based on healthy and problematic behaviour and issues of informed consent, power imbalance and exploitation.
Where abuse of a child is alleged to have been carried out by another child or young person, such behaviour should always be treated seriously and be subject of a child concern notification to relevant agencies, both in respect of the victim and the perpetrator. In all cases where a child or young person presents problem sexual behaviour, immediate consideration should be given to whether action requires to be taken under child protection procedures, either to protect the victim or because there is concern about what has caused the child/young person to behave this way.
Children who have displayed harmful or problematic sexual behaviour often require a coordinated multi-agency response from social work, health, education, the reporter and in more serious cases the procurator fiscal. The multi-agency response can be co-ordinated through MAPPA, YPSRAG or through less formal risk management meetings.
Fifepartners that address the risk posed by serious sexual and violent offenders have been conscious of the close relationship between YPSRAG and MAPPA and have attempted to ensure that there is no public protection gap existing between the two. We have carefully developed and structured the attached framework clarifying the reporting structure between both areas.
There will be occasions where individuals who are managed through YPSRAG also require to be considered by the MAPPA Group. Young people who are considered to be most serious risks for the community will generally be those who are referred on to MAPPA for their consideration.
Where the Fife Forensic Learning Disability Team (FFLDT) or the Fife Community Forensic Mental Health Team (FCFMHT) identify ongoing public protection issues for an individual who is not managed through MAPPA, details about the individual will be passed to the MAPPA Co-ordinator for information and discussion and a decision regarding the requirement for a full MAPPA referral even if it is a young person.
Criteria for referral to the Learning Disability and Mental Health SRAG should relate to individuals who:
- are current registered sex offenders or alleged to have sexually offended;
- are people required to register as sex offenders;
- have previously been registered as sex offenders but the period has expired;
- are violent offenders/potential violent offenders;
- are dangerous offenders/potential dangerous offenders; and
- present in a dangerous way and pose a significant risk to the community.
Female Genital Mutilation
The Prohibition of Female Circumcision Act 1985 which first made female genital mutilation (FGM) an offence, except on specific physical and mental health grounds, was repealed in 2003 in England and Wales and replaced by the Female Genital Mutilation Act 2003, which strengthens and amends the 1985 legislation. It makes it an offence for the first time for UK nationals or permanent UK residents to carry out FGM abroad, or to aid, abet, counsel or procure the carrying out of FGM abroad, even in countries where the practice is legal. In order to apply the principles from this Act throughout the UK, the Scottish Parliament has passed the Prohibition of Female Genital Mutilation (Scotland) Act 2005. Zero Tolerance have compiled a comprehensive briefing detailing resources and research on FGM.
Female Genital Mutilation (FGM) is a collective term for procedures, which include the partial or total removal of the external female genital organs for cultural or other non-therapeutic reasons. It is typically performed on girls aged between 4 and 13, although in some cases it is performed on newborn babies or young women prior to marriage or pregnancy. FGM is extremely harmful, causing long-term mental and physical suffering, difficulty in giving birth and infertility, and can be fatal. It violates the most basic human rights.
Fife Child Protection Committee recognises that whilst there may be no intent to harm a child through FGM, the practice can directly cause serious short and long-term medical complications. Consequently, the practice of FGM is seen as a physically abusive act. It is the aim of Fife Child Protection Committee to prevent the practice of FGM in a way that is culturally sensitive and with the fullest consultations with community representatives and professional agencies.
Any information or concern that a child is at risk of, or has undergone FGM, should result in a child concern notification either to the Police or Social Work Service as FGM places a child at risk of significant harm and will therefore be subject to a child protection investigation.
Where the child appears to be in immediate danger of mutilation and parents cannot satisfactorily guarantee that they will not proceed with it, a Child Protection Order should be sought. A Child Protection Order should also be sought if the child's parents are intent on sending their daughter out of the country, and it can be shown that mutilation is likely if she goes.
Honour-based violence and forced marriage
Honour-based violence (HBV) is a crime or incident, which has been committed to protect or defend the perceived honour of the family and/or community. Such violence can occur when perpetrators perceive that a relative/community member, who may be a child, has shamed the family and/or the community by breaking their honour code. The punishment for transgressing the code of behaviour may include assault, abduction, confinement, threats and murder. Incidents that may seem like a trivial transgression to others may be sufficient motivation for a child to be punished, including:
- inappropriate make-up or dress;
- the existence of a boyfriend/girlfriend;
- inter-faith relationships;
- kissing or intimacy in a public place;
- pregnancy outside of marriage; and
- rejecting a forced marriage.
A forced marriage is defined as a marriage conducted without the full and free consent of both parties and where duress is a factor. Duress can include physical, psychological, financial, sexual and emotional pressure. Clear distinctions must be made between a forced marriage and an arranged marriage. An arranged marriage is one in which the families of both spouses are primarily responsible for choosing a marriage partner for their child or relative, but the final decision as to whether or not to accept the arrangement lies with the potential spouses. Both spouses give their full and free consent. The tradition of arranged marriage has operated successfully within many cultures and communities for generations.
In Scotland, a couple cannot be legally married unless both parties are at least 16 on the day of the marriage, and both must be capable of understanding the nature of a marriage ceremony and of consenting to the marriage. Parental consent is not required.
The Scottish Government will introduce legislation which will protect people from being forced to enter into marriage without their free and full consent and protect those who have been forced to enter into marriage without such consent. The Forced Marriage etc. (Protection and Jurisdiction) (Scotland) Bill will be introduced into the Scottish Parliament in the autumn of 2011.
The Government believes that all people in Scotland who are eligible to marry or enter into a civil partnership have a right to do so freely. The Bill will empower and protect vulnerable women and men against serious abuse, involving violence, threats of violence and other forms of improper coercion.
The consequences of forced marriage can be devastating to the whole family, but especially to the young people affected, with them often becoming estranged from their families and wider communities; losing out on educational opportunities as they are taken prematurely from school; suffering domestic abuse; and/or having a high rate of self-harm and suicide rates. Potential indicators of HBV and forced marriage can include combinations of a number of signs and the list below is not exhaustive:
- absence and persistent absence from education;
- request for extended leave of absence and failure to return from visits to country of origin;
- decline in behaviour, engagement, performance or punctuality;
- being withdrawn from school by those with parental responsibility;
- being prevented from attending extra-curricular activities; and/or from going onto further/higher education;
- self-harm, attempted suicide, depression, eating disorders;
- accompanied to doctors or clinics and prevented from speaking to health practitioner in confidence;
- female genital mutilation;
- reports of domestic abuse, harassment or breaches of the peace at the family home;
- threats to kill and attempts to kill or harm; and/or
- truancy or persistent absence from school.
If agencies become aware of young females going abroad they should contact the Home Office/Foreign and Commonwealth Office Forced Marriage Unit. A level of discretion will be required to ensure that young person is not placed at additional risk. In some circumstances Forced Marriage Unit may require Fife Council to support the young person returning from abroad. Fife Council should afford the support normally given to children that have been abandoned in these circumstances.
Cases of forced marriage may initially be reported to social work services as cases of domestic abuse. Spouses forced into marriage may suffer domestic abuse but feel unable to leave due to a lack of family support, economic pressures and other social circumstances - some may fear losing their own children. In all cases, the social worker needs to discuss the range of options available to the child or young person and the possible consequences of their chosen course of action. A spouse who is the victim of a forced marriage can initiate nullity or divorce proceedings to end the marriage. The child or young person should be informed that a religious divorce would not end the marriage under UK law.
The Forced Marriage etc (Protection & Jurisdiction)(Scotland) Act 2011 will make it a criminal offence to breach new laws leading to a two year prison sentence, a fine of up to £10,000, or both.
Scottish courts will have the power to issue Forced Marriage Protection Orders, to ensure people are taken to a place of safety or help those in danger of being taken abroad for marriage.
Existing powers to annul a forced marriage will be clarified to streamline the process.
Further helpful information can be found in the following publications or on the links noted below:
- A Choice by Right, Report of the UK Working Group on Forced Marriage, 1999.
- Forced marriage: A wrong not a right.
- Forced Marriage (Civil Protection) Act 2007.
- Forced marriage: A civil remedy.
- Safer Lives: Changed Lives: A shared approach to tackling violence against women in Scotland,Scottish Government, 2009.
- Handling cases of forced marriage: follow link on victims of forced marriages.
- The Forced Marriage etc (Protection & Jurisdiction)(Scotland) Act 2011
- www.karmanirvana.org.uk national honour support line foe practitioners and service users 0800 5999 247
Fabricated and induced illness, previously known as Munchausen's Syndrome by Proxy is described as:
- a parent or someone who is in a position of childcare, fabricating or inducing illness in a child, including fabricating the child’s past medical history, hospital charts, records and specimens of body fluids. This may also include falsification of letters and documents;
- presenting the child for medical assessment and care, usually persistently, often resulting in multiple medical procedures; and
- denying the causes of the child's illness.
Acute symptoms and signs of illness cease when the child is separated from the perpetrator. Children and young people affected may present with a variety of symptoms, some of which may seem bizarre, including:
- seizures - including, in small babies, apnoeic cyanotic episodes caused by partial suffocation;
- bleeding disorders - especially haematuria (blood in urine) and haematemesis (vomiting up blood);
- rashes - usually caused by direct skin trauma;
- unexplained fevers; and
- alleged psychological illness in a child.
The perpetrator is often the mother. The mother in 20% of cases may have a history herself of fabricated and induced illness.
This syndrome is extremely complex and difficult to diagnose. Medical and psychiatric advice should be sought when managing all such cases. It is important that the various health professionals involved with the child and the parent/carer, have an opportunity to jointly overview the family situation and pull their combined knowledge and expertise to accurately assess if the FII condition is a factor in the case.
For those children who are suffering, or at risk of suffering significant harm, joint working is essential both to protect the child and where necessary to take action. All agencies and practitioners should:
- be alert to potential indicators of illness being fabricated or induced in a child;
- be alert to the risk of harm that individual abusers, or potential abusers, may pose to children in whom illness is being fabricated or induced;
- share, and help to analyse, information so that an informed assessment can be made of the child’s needs and circumstances;
- contribute to whatever actions (including the cessation of unnecessary medical tests and treatments) and services are required to safeguard and promote the child’s welfare;
- regularly review the outcomes for the child against specific planned outcomes;
- work co-operatively with parents/carers unless to do so would place the child at increased risk of harm; and
- assist in providing relevant evidence in any criminal or civil proceedings, should this course of action be deemed necessary.
The majority of cases of fabricated or induced illness in children are confirmed in a hospital setting. The first task for the paediatrician is to find out whether a child’s illness and individual symptoms and signs can be accounted for by natural causes. If not, the possibility that the illness has been fabricated or induced must be considered. CAMHS may be called in to look at the effects on the child and establish whether the parent/carer suffers from an underlying disorder. Police must investigate a possible crime. Social workers will co-ordinate the assessment of concerns about the child’s welfare or the risk of harm and support to parent/carers during the assessment. Co-ordinated planning and assessment is essential in the investigation of fabricated or induced illness. Some methods, such as the use of covert video surveillance, should be discussed and agreed by all services involved before being implemented.
Parents who may have the FII condition can often avoid engaging with agencies or be hostile towards staff involved. It is important that agencies support staff who challenges parents where FII is suspected. This support should include access to legal support if required. In very complex cases legal sections from different agencies should consult on courses of action that are consistent with putting the child’s needs first. During this consultation legal representatives from all agencies should consider all legal avenues available which will reduce the risks to the child.
A sudden unexpected death in infancy (SUDI) is deemed to have occurred where there is no known pre-existing condition which would make the death predictable. Only a small number of children die during infancy in Scotland and while the majority of such deaths are as a result of natural causes, physical defects or accidents, a small proportion are avoidable, having been caused by the commission or omission of an act i.e. through neglect, violence, malicious administration of substances or by the careless use of drugs.
Since the cause of death is not known, a death certificate cannot be issued and the death is not able to be registered. It is therefore routing practice that all SUDIs are reported to the Procurator Fiscal on whose behalf the police will act. This practice is well established and the police will automatically be informed of the death by the Scottish Ambulance Service or Emergency Department. Investigations which include a post-mortem examination may take several months and begins with the gathering of information from health workers and police. On the rare occasion when death appears to be the result of a criminal act, the police will work sensitively to collect detailed information from the outset.
Child Protection underpins all investigations following SUDI. It is standard practice for a child protection team to be contacted in all cases to make them aware of the infant’s death. The degree of involvement of a child protection team will vary for each SUDI, from maintaining a very peripheral role and concluding their part in the investigation as soon as the initial post-mortem findings are known, to providing ongoing support to the family and staff involved, if child protection issues are raised. Child Protection teams include professionals from health care, social work and police.
It is important that police, social work and hospital/medical staff establish a collaborative approach to any such investigation to allow clear procedures to be followed, accurate assessment and appropriate support to children and families.
For further guidance please refer to NHS Fife Guidance on SUDiC.
When a death of a child is reported to the police a Senior Investigating Officer (SIO) should always be appointed to oversee the investigation, whether or not there are any obvious suspicious circumstances.
Trained police officers from the Public Protection Unit or equivalent should be used for more specialist tasks during an investigation, such as:
- interviewing child witnesses;
- obtaining other background information from specialist police databases and other agency records; and
- liaison with the relevant social work services to ensure their records are checked, including the Child Protection Register (and previous registrations if possible), and involve them in a strategy discussion, if appropriate.
On occasions when the infant/family was not resident in or had recently moved to the area in which the death occurred, the SIO will ensure that enquiry is made with other police forces and partner agencies in the area the child resided or is known to have recently resided.
Actual or attempted physical injury to a child, including the administration of toxic substances, where there is knowledge, or reasonable suspicion, that the injury was inflicted or knowingly not prevented is physical abuse.
Physical abuse may include a serious incident or a series of minor incidents involving bruising, fractures, scratches, burns or scalds; deliberate poisoning; attempted drowning or smothering; fabricated and induced illness (previously known as Munchausen Syndrome by Proxy); physical chastisement deemed to be unreasonable; and serious risk of actual injuries resulting from parental lifestyle prior to birth, for example, substance misuse or domestic violence. It is however important to remember that injuries may have occurred for reasons other than deliberate harm and genuine accidental injuries are common.
Most falls or accidents produce one bruise on a single surface, usually on a bony protuberance. A child who falls downstairs generally has only one or two bruises. Accidental bruising is usually on the front of the body as children and young people generally fall forwards. In addition, there may be marks on their hands if they have tried to break their fall.
Fractures should be suspected if there is pain, swelling and discoloration over a bone or joint. The most common non-accidental injuries are to the long bones (e.g. arms, legs, ribs). It is very rare for a child under one year to sustain a fracture accidentally. Fractures normally cause pain and it is difficult for a parent to be unaware that a child has been hurt.
A tear to the frenula of the lips and tongue often indicates force feeding of a baby. There is often finger bruising on the cheeks or in and around the mouth. In addition there may be linear grazing on the palate. A blow to the face may cause frenula injuries to an older child.
Bites can leave clear impressions of marks of individual teeth, or sometimes a more general crescent shape mark. Human bites are oval or crescent shaped. If the distance is more than 3cm across, an adult or older child with permanent teeth may have caused them.
Burns and Scalds
It can be very difficult to distinguish between accidental and non-accidental burns, but as a general rule burns or scalds with clear outlines are suspicious, e.g. a glove or sock effect. So are burns of uniform depth over a large area. Also splash marks above the main scald area (caused by hot liquid being thrown). Remember: a child is unlikely to sit down voluntarily in too hot a bath, and cannot scald his/her bottom accidentally without also scalding his/her feet; and a child getting into too hot water of its own accord will struggle to get out again and there will be splash marks.
Small round burns may be cigarette burns (but may be friction burns and accidental, if along the bony protuberance of the spine). It is sometimes difficult to differentiate between impetigo and cigarette burns, but generally impetigo is multiple and spreads evenly during early stages of treatment. Cigarette burns tend to have a characteristically dark thick base.
Many children and young people have scars. Notice should be taken of an exceptionally large number, particularly of different ages and if accompanied by current bruising. Unusually shaped scars (e.g. old cigarette burns) or large scars (indicating burns that did not receive treatment) should be given careful assessment.
Shaken Baby Syndrome
Shaken Baby Syndrome is a collective term for the internal head injuries a baby or young child sustains from being violently shaken. It is a descriptive term of how injuries may have occurred and not a medical diagnosis. Violent shaking can cause a range of serious injuries to a baby or small children, which are often fatal. These injuries are mainly to the head but there may also be injuries to the body.
“Any child below the age of 16 may be deemed to have been sexually abused when any person(s), by design or neglect, exploits the child, directly or indirectly, in any activity intended to lead to the sexual arousal or other forms of gratification of that person or any other person(s) including organised networks”. This definition holds whether or not there has been genital contact and whether or not the child is said to have initiated or consented to the behaviour.
Sexual abuse may include activities such as incest, rape, intercourse with children and young people; inappropriate sexual behaviour towards children and young people; indecent assault of children and young people; taking indecent photographs of children and young people or encouraging children and young people to become prostitutes or witness sexual behaviour or pornographic materials.
Sexual abuse is now known to be more common than was previously recognised. Boys and girls of all ages can be victims. Perpetrators may be male or female, may range from the very young to the very old, but most commonly are known to their victims. Abuse within a family is rarely an isolated event; it sometimes lasts for months and years and may involve more than one child. Perpetrators often ‘groom’ children and young people, for example by offering positive attention and treats. Perpetrators of sexual abuse may target vulnerable children and young people and families and may seek out work or recreational situations where they have access to children and young people.
Victims may disclose their situation to adults in whom they have confidence and rarely fantasise or make up stories of sexual abuse. Children and young people's alleg