Classification of child abuse by motive and degree rather than type of injury.
ABSTRACT The protection of children may be enhanced if ill treatment is classified by motive and degree rather than by type of injury. Four categories are proposed: A, abuse: premeditated ill treatment undertaken for gain by disturbed, dangerous, and manipulative individuals; B, active ill treatment: impulsively undertaken because of socioeconomic pressures, lack of education, resources, and support, or mental illnesses; C, universal mild ill treatment: behaviour undertaken by all normal caring parents in all societies; and D, neglect: defined here as an unintentional failure to supply the child's needs. Such a classification could clarify the procedures for investigation and protection, and support the creation of a Special Interagency Taskforce on Criminal Abuse (SITCA) for those suspected of abuse (category A).
- SourceAvailable from: ncbi.nlm.nih.govArchives of Disease in Childhood 04/2000; 82(3):192-6. · 3.05 Impact Factor
- [show abstract] [hide abstract]
ABSTRACT: Munchausen Syndrome by Proxy (the fabrication of illness by a mother in her child) is often a serious form of child abuse that has been recognized increasingly over recent years. Approximately one-half of the mothers in this study had either smothered or poisoned their child as part of their fabrications. Lifetime psychiatric histories are reported for 47 of the mothers. Thirty-four had a history of a Factitious or Somatoform disorder, 26 a history of self harm, and 10 of alcohol or drug misuse. Nine mothers had a forensic history independent of convictions related to child abuse. Nineteen of these mothers were interviewed from 1-15 years after the original fabrications. The most notable psychopathology was the presence of a personality disorder in 17 of the mothers, which were predominantly Histrionic and Borderline types. Most subjects, however, met the criteria for more than one category of personality disorder.Child Abuse & Neglect 10/1994; 18(9):773-88. · 2.47 Impact Factor
Article: The physical punishment of children.Archives of Disease in Childhood 10/2000; 83(3):196-8. · 3.05 Impact Factor
Classification of child abuse by motive and degree rather
than type of injury
D P Southall, M P Samuels, M H Golden
Arch Dis Child 2003;88:101–104
The protection of children may be enhanced if ill
treatment is classified by motive and degree rather than
by type of injury. Four categories are proposed: A,
abuse: premeditated ill treatment undertaken for gain by
disturbed, dangerous, and manipulative individuals; B,
active ill treatment: impulsively undertaken because of
socioeconomic pressures, lack of education, resources,
and support, or mental illnesses; C, universal mild ill
treatment: behaviour undertaken by all normal caring
parents in all societies; and D, neglect: defined here as
an unintentional failure to supply the child’s needs. Such
a classification could clarify the procedures for
investigation and protection, and support the creation of
a Special Interagency Taskforce on Criminal Abuse
(SITCA) for those suspected of abuse (category A).
ment (abuse).1–3In the UK, despite “Working
Together”,4 5cases involving extreme suffering for
children continue to occur.6 7
Based on our experience,8we offer a new
classification of ill treatment. Category A is the
premeditated cruel abuse of children for gain;
category B is the impulsive active ill treatment of
children related to societal and personal pres-
sures; and category C is the universal mild hurts
inherent in all parenting. Our classification is dif-
ferent from that presently used and based on the
mode of ill treatment: physical, sexual, and
emotional.4 5 9
We define “neglect” as the unintentional
failure to supply the needs of the child—
differentiating it from what we now call “depriva-
tional abuse”, where withholding food, care, or
love is deliberate (see accompanying paper by
Golden et al in this issue).
Our classification is based on motive and
premeditation; it allows for “diminished respon-
sibility” resulting, for example, from mental
illness.The benchmark of abnormality is based on
the concept of what a “reasonable person would
do” given the circumstances. Nearly all judicial
systems have these same principles of natural
justice to underpin their determinations. Civil
society, the arms of the law and professional
agencies are familiar with these concepts that
date back millennia; the problems inherent in
making determinations are similar to those
applying to other forms of antisocial behaviour.
ven in many well resourced countries, there
appears to be inadequate protection for chil-
dren from the most serious forms of ill treat-
When abuse is classified according to current
divisions of mode of harm, many in a society can
develop fear of accusation for apparently normal
behaviours.This in turn can damage normal fam-
ily life; the father who does not hug his teenager
or bathe his young daughter and the person who
is inhibited from comforting the child who falls
over are also victims.The fear of a label of abuse is
changing the way we live.
CATEGORY A: DELIBERATE,
PREMEDITATED CHILD ABUSE
UNDERTAKEN FOR GAIN
This involves seriously harmful acts against chil-
dren and should be recognised in all countries as
one of the most serious of crimes.
Many notorious examples could be quoted.
Here is an example from the UK Independent
newspaper (21 November, 2000).
“The death of a little girl, beaten with a
bicycle chain and made to sleep in a bath
because she wet herself was blamed on the
police and social workers returning her to
her cruel ‘adoptive’ parents, the Old Bailey
was told yesterday ... Anna suffered 128
injuries caused by beatings with a belt
buckle, trainers and cigarette burns ... She
was often put in a bin liner with her hands
and feet tied and then made to sleep in the
bath ... Anna was admitted to hospital
twice during 7 months of neglect. But
despite the involvement of social services,
medical staff and the police, she was
returned to the care of Ms X and her
partner ... When she finally died, she had
not eaten for two days and had spent 5
which had deformed her legs. During the
last week she was naked in the bath. The
bathroom was cold and she was alone in
the darkness with the door closed.”
For the victim, abuse involves unimaginable,
unbearable suffering; for the perpetrator it is
deliberate and premeditated; it results in gain or
gratification for the perpetrator who may become
habituated to abuse, particularly sexual abuse.
The abuser is not mentally ill, as legally defined.
Some have untreatable psychopathic personality
disorders.10 11Those whose psychopathic disorder
(estimated population prevalence 0.5–1%) is
expressed in this way may be dangerous not only
to children but also to their partners. Abusers are
insensitive to the suffering they cause, may enjoy
See end of article for
Prof. D P Southall,
Academic Department of
Paediatrics, City General
Hospital, Stoke on Trent
ST4 6QG, UK;
17 October 2002
inflicting pain, and need to dominate and control. They are
people who, in the most extreme of ways, place their needs
Covert video and audio surveillance, used to investigate life
threatening abuse, has unequivocally demonstrated its exist-
ence, and shown the incredible suffering of the children and
the malevolence of the parents.8 12–14
Child abusers are fully aware of their actions; they know
they face retribution if detected. They establish plausible,
elaborate explanations for their children’s injuries to avoid
detection, weaving faint strands of truth into a lattice of lies.
When confronted with equivocal evidence their excuses may
seem reasonable.For example,“I sometimes put my hand over
my baby’s face to ease his crying—this always worked well
and did no harm—this time he died”. Such explanations are
incompatible with the pathophysiological changes of inten-
tional suffocation.8 12–14
Some members of the social, health, education, and judicial
services find it hard to believe that any parent could
deliberately inflict such terrible injuries or emotional damage
on their children. This professional reluctance or inability to
accept the harrowing reality is partially responsible for the
unacceptable delays that can occur before the victims are pro-
tected. Professionals are sometimes concerned about making
a false accusation that has such serious consequences. All too
often,this form of abuse only comes to light after the death of
one or several children.15–17Later inquiry then finds that
professionals have been “seduced” by a plausible abuser into
giving inappropriate support and failing the child.
Abusers are expert in manipulation. They “turn on the
charm” to entice professionals that show empathy with their
fabrications into becoming supporters. When confronted they
turn nasty, shout, and use drama to intimidate and isolate the
professional who is suspicious. They create doubt and dissent
within an overworked team to turn colleague against
colleague. Professionals sometimes unwittingly accept lies to
make their relationships with such abusers palatable.
Violence may be made more extreme by depression,or drug
or alcohol dependence.
Perpetrators may move from one child or family to another
reeking havoc. The deliberate abuse by parents18or, in some
countries, teachers and institutional “carers”, includes ciga-
rette burns, scalds, sexual abuse, ritual punishments, savage
beatings, prolonged physical isolation, and starvation. This
abuse includes the fabrication or induction of illness19–21to
gain attention and sympathy from doctors, nurses, friends,
and relatives. It also includes such severe and sustained emo-
tional abuse (deliberate belittling, repetitive threats, rejection,
terrorisation, and isolation) that children become perma-
nently emotionally disabled.22
The survivors of abuse often become seriously disturbed
and socially excluded. Many contemplate suicide—some suc-
ceed. In some parts of the world, victims run away to live as
“street children”,where they may be further abused.23As bru-
talised adults they may become abusers themselves, without
the ability to form relationships and give love, and so may
become part of an intergenerational cycle of familial abuse.
The cruelties inflicted interfere with the child’s emotional and
physical development and can result in a dysfunctional adult
with low self esteem, emotional immaturity, poor coping
strategies, and disturbed mental health that surfaces later.
Category A abuse occurs in all countries and cultures and
transcends all creeds.
Yet such abuse is widespread and is a worryingly hidden
reality. Enforced child labour within many countries is
category A abuse for obvious gain.24In West Africa children are
sold into slavery to work in cocoa plantations. There are many
examples of child trafficking for paedophilic sex; in Mumbai
alone 4000–10 000 Nepalese children are repeatedly raped,
beaten, and imprisoned in brothels.25Incredible abuse follows
kidnap to provide child soldiers and “wives” for irregular
armies,26 27where children are forced to perform sadistic mur-
ders as part of their “training”.In many countries children are
tortured28for collective punishment,to extract information on
parents/peers, to punish parents, and as entertainment; in
homes, prisons, and refugee camps.
There are more than 30 million children in the world (par-
ticularly Central and South America, Eastern Europe, Africa,
and South Asia)24driven to live on the streets by poverty and
in a proportion of cases by abuse. They live by scavenging,
stealing, begging, working like slaves, dealing in and taking
drugs, and prostituting themselves to survive. They are
frequently targeted by individual policemen and sometimes
killed by vigilante groups employed by local businessmen.29
Management of category A abuse
In our view,this must be the primary focus of child protection,
involving incisive action and receiving financial support from
all governments.Tragically most countries of the world do not
have any system in place to identify and protect children from
this abuse despite all but two countries being signed up to the
United Nations Convention on the Rights of the Child.30
We believe that the reasons for our collective lack of protec-
tion arise from: (1) the failure to make a clear distinction
between the deliberate, premeditated abuse of children and
the ill treatment described in categories B and C below;(2) the
inappropriate use of the term “abuse and neglect”.(Neglect in
our classification is unintentional and the term “deprivational
abuse” should be used when there is a deliberate withholding
of essential physical and emotional needs of the child—see
accompanying paper by Golden et al in this issue); and (3) the
lack of a powerful system to identify the perpetrators of these
crimes and protect children from them.
Although the differences between categories A and B
appear straightforward, in practice there can be many
difficulties in differentiating between them. As a society, we
have to reach a value judgement about whether it is better to
allow a few children to return to category A abusers to their
great peril and suffering,31–33or inappropriately to accuse and
stigmatise a larger number of families. Neither is satisfactory;
each individual diagnostic error, either way, involves harm to
the child and family. It is essential that we have both the
highest possible sensitivity and specificity when making
Nevertheless, the agencies themselves and the public must be
aware that some mistakes will inevitably be made.
We propose that a Special Interagency Taskforce on
Criminal Abuse (SITCA), which has its own operational
authority, be established. This is similar to the multidiscipli-
nary child protection teams proposed by the NSPCC in their
response to the inquiry into the death of Victoria Climbie.6
Each SITCA should be composed of child protection
specialists who have appropriate experience and technical
knowledge. They are likely to have been senior police officers,
senior social workers, paediatricians, psychiatrists, patholo-
gists, or lawyers trained in the forensic and childcare aspects
of their disciplines.
In the UK, all cases of potential abuse are initially referred
to Social Services,and this should continue.However,the first
step should be a strategy planning meeting, to which parents
are not invited, rather than a case conference. Once a case is
suspected of being category A abuse,a SITCA unit should take
Recent Part 8 inquiries in the UK (deaths resulting from
abuse) and other sources2 3indicate that there are insufficient
joint investigations with the necessary mix and degree of
expertise. We think that neither the social services nor the
police should take the lead when dealing with suspected cat-
egory A abuse. Both services are currently led by and provide
generalists, dealing with a heavy caseload of many types of
social need and crime respectively. In our experience, the
102 Southall, Samuels, Golden
development of an understanding relationship with the
perpetrator, or to use the euphemism “working together with
parents”, within the ethos of the 1989 UK Children Act4and
its guidelines (“Working Together”, 1991, 1999,5“Messages
from Research”, 199534), is inappropriate for managing any
form of category A abuse.Most social workers are ill equipped
to deal with criminals.
Those SITCA personnel with police training would be
accustomed to violence,less concerned about personal danger
from abusers,22trained to recognise deception,35and be aware
of the depths of depravity of many perpetrators. The SITCA
units would undertake a forensic analysis of all the social,
criminal, and medical data (including medical records of all
relevant family members) and interview family and wit-
This approach may be more acceptable to some disadvan-
taged countries where procedures to protect children are rudi-
mentary, often despite relevant legislation. Where police
forces are perceived to have little compassion, and protection
of children from abuse is rare,training a team of professionals
to initiate a SITCA system against category A abuse, could
improve the approach of the police force to the needs of chil-
CATEGORY B (IMPULSIVE ILL TREATMENT
RESULTING FROM ADVERSE SOCIETAL AND
Category B is where the ill treatment, although not premedi-
tated,would be regarded by “any reasonable person”as exces-
sive because of the degree of physical or emotional harm.
Characteristically, this occurs when parents are themselves
under great pressure or depressed, having difficulties with
relationships,and lacking family or other support.The actions
are impulsive, thoughtless, and selfish. The parent lashes out
at his/her child when the child is demanding attention,crying,
or screaming.The parent is frustrated and unable to cope with
the additional stress.Alcohol or drug dependence is often part
of the response of the parent to the stress and sometimes con-
tributes to the ill treatment. The act may cause very serious
injury, and occasionally death, especially in infants or young
Sometimes a parent is ignorant about the extent of damage
the impulsive act may cause. For example, in some societies it
is not generally known that shaking of a young infant can tear
veins around the brain.This is known within the UK,however,
as a result of the widespread publicity about shaken baby syn-
drome and in this setting, such injuries might best be first
considered under category A (especially as other injuries such
as rib fractures are often present).
This type of ill treatment is related to such emotional,social,
and economic pressures that the parent reaches “breaking
point”. The isolated, inexperienced, or poorly educated parent
is more likely to reach this stage before the established,
supported family. However, most normal parents can behave
in this way if sufficient pressures are applied.
Such ill treating parents may have been ill treated, abused,
or neglected in their own childhood to give a “learned”
response to stress and expressed in parenthood.However,with
repeated acts, it should become apparent, to even a stressed
parent,that the ill treatment is seriously damaging their child.
Subsequent failure to moderate their behaviour then becomes
deliberate and abusive (category A).
Management of category B abuse
The parent causing category B ill treatment is distressed when
they appreciate the impact their behaviour is having on their
child and show true remorse.They have shame that may cause
them to try to hide their ill treatment, and critically not to
repeat it. They cannot cope with their own lives, let alone care
for a child demanding care and attention. These parents des-
perately need professional help.
This is not the kind of ill treatment that in our view should
invoke criminal proceedings. However, systems that allow
timely identification, provide adequate support to protect the
child from further ill treatment, and ameliorate the under-
lying social problems are essential and widely known and
practised in many countries. In the UK, guidelines in 1991 to
the 1989 Children Act (updated in 1999)5provide an excellent
standard of care for children affected by this problem. Similar
systems should be installed in all societies to conform to the
United Nations Convention on the Rights of the Child.30Core
management involves family assessments, strategy discus-
sions, case conferences, child support registration, core
groups,and supportive measures,and has been well described
elsewhere.4 5 36
CATEGORY C (MILD ILL TREATMENT UNIVERSAL IN
All loving and caring parents occasionally ill treat their
Facing a degree of adversity is essential for development;
adverse experience equips children to cope with the realities of
life,and teaches caution and that everybody has failings.Chil-
dren need to emerge from the “Wendy House”. Even if we, in
so called “developed countries”, perceive other cultures as
being somewhat brutal, the child needs to learn to function
within that society. Thus, unlike the other categories of ill
treatment described above,category C is culturally dependent.
The defining feature for category C is for the ill treatment to be
mild, acknowledged, and mitigated by love and care.
Included are: (1) the “reflex” smack of the badly behaved
child; (2) the frustrated aggressive shout that stuns the child;
(3) the derogatory remark that demeans hurtfully; and (4)
conscious “disciplinary” acts accepted by some societies as
normal or necessary.
Although we disagree with any violence to children, we
accept that caring, loving parents often give “discipline” and
that its worldwide elimination is a utopian dream. The
campaigns of organisations like EPOCH37that advocate
against all violence to children are essential for civil society to
evolve. However, given that most countries are nowhere near
requiring non-violent interaction between parents and chil-
dren, sanctions against category C ill treatment might inhibit
wholehearted support for measures to address crimes against
children as in category A above.
Management of category C abuse
Category C active ill treatment requires enlightenment of civil
society and not intervention at the individual level. It should
be addressed through education (see fig 1).
Spectrum of ill treatment.
Classification of child abuse103
This paper would not have reached its present state without the inci-
sive and experienced input of Sarah Webb, David and Demelza Fore-
man, and Christopher Hobbs. We are extremely grateful to them for
adding so much to this manuscript.We also thank Annette Ball for her
help with the manuscript.
D P Southall, Honorary Medical Director, Child Advocacy International
www.childfriendlyhealthcare.org), Consultant Paediatrician, North
Staffordshire Hospital, and Foundation Professor of Paediatrics, Keele
M P Samuels, Consultant Paediatrician, North Staffordshire Hospital and
Senior Lecturer in Paediatrics, Keele University, UK
M H Golden, Emeritus Professor of Medicine, University of Aberdeen,
The views expressed in this article are those of the individual authors and
do not reflect the views of the organisations to which they are affiliated
1 Speight N, Wynne J. Is the Children Act failing severely abused and
neglected children? Arch Dis Child 2000;82:192–6. (Plus response from:
Hale B. In defence of the Children Act. Arch Dis Child 2000;83:463–7).
2 Hobbs CJ, Heywood PL. Childhood matters. Doctors have a vital role in
identifying children at risk of abuse. BMJ 1997;314:622.
3 National Commission of Inquiry into the Prevention of Child
Abuse. Childhood matters—the report of the National Commission of
Inquiry into the Prevention of Child Abuse, Vols 1 and 2. London: The
Stationery Office, 1996.
4 Home Office, Department of Health, Department of Education and
Science, Welsh Office. Working together (under the Children Act 1989).
A guide to inter-agency cooperation. London: HMSO, 1991.
5 Department of Health. Working together to safeguard children. ISBN
011 322309 9. London: HMSO, 1999.
6 The Victoria Climbie Inquiry. The independent, statutory inquiry set up
to investigate the circumstances leading to the death of Victoria Climbie
and to recommend action to prevent such a tragedy happening again.
7 NSPCC. Lauren Wright statement. www.nspcc.org.uk/html/home/
8 Southall DP, Plunkett MCB, Banks MW, et al. Covert video recordings
of life-threatening child abuse: lessons for child protection. Pediatrics
9 WHO. Child abuse and neglect. Fact Sheet N150, WHO information.
10 Hemphill JR, Hare RD, Wong S. Psychopathy and recidivism: a review.
Legal and Criminological Psychology 1998;3:139–70.
11 Frink PJ, O’Brien BS, Wootton JM, et al. Psychopathy and conduct
problems in children. J Abnorm Psychol 1994;103:700–7.
12 Samuels MP, McClaughlin W, Jacobson RR, et al. Fourteen cases of
imposed upper airway obstruction. Arch Dis Child 1992;67:162–70.
13 Southall DP, Stebbens VA, Rees SV, et al. Apnoeic episodes induced by
smothering—two cases identified by covert video surveillance. BMJ
14 Hall DE, Eubanks L, Meyyazhagan S, et al. Evaluation of covert video
surveillance in the diagnosis of Munchausen syndrome by proxy: lessons
from 41 cases. Pediatrics 2000;105:1305–12.
15 Creighton SJ. Fatal child abuse—how preventable is it? Child Abuse
16 Krugman RD. Special issue on fatal child abuse. Child Abuse Review
17 Browne KD, Lynch MA, eds. Spotlight on practice on child maltreatment
fatalities. Child Abuse Negl 1995;19:843–83.
18 Kempe CH, Silverman FN, Steele BF, et al. The battered child syndrome.
19 Bools C, Neale B, Meadow R. Munchausen syndrome by proxy: a study
of psychopathology. Child Abuse Negl 1994;18:773–88.
20 Royal College of Paediatrics and Child Health. Fabricated or
induced illness by carers. Report of the Working Party of the Royal
College of Paediatrics and Child Health. ISBN 190095463X. London:
21 Department of Health, Home Office, Department for Education and
Skills. Safeguarding children in whom illness is induced or fabricated by
carers with parenting responsibilities. London: DOH, 2001.
22 Stanley J, Goddard C, eds. In the firing line: violence and power in
child protection work. Chichester: John Wiley and Sons, 2002:224.
23 Human Rights Watch. Street children. www.hrw.org/children/
24 UNICEF. State of the world’s children, 1997. Focus on child labour.
25 Human Rights Watch/Asia. Rape for Profit. Trafficking of Nepali girls
and women to India’s brothels. New York: Human Rights Watch, 1995.
26 Machel G. Report by Ms Graca Machel, Expert of the
Secretary-General, on the impact of armed conflict on children. UN
document. A/51/306, 26 August 1996.
27 Amnesty International, Uganda. ‘Breaking God’s commands’: the
destruction of childhood by the Lord’s Resistance Army. Amnesty
International, 18 September 1997.
28 Welsh J. Children and torture. Lancet 2000;356:2093.
29 Casa Alianza. Covenant House report on the torture of street children in
Guatemala and Honduras, ISBN 9968-9834-3-8, 1997.
30 United Nations General Assembly. Convention on the Rights of the
Child. New York: United Nations, 1989. www.unhcr.ch.
31 Jellinek MS, Murphy JM, Bishop S, et al. Protecting severely abused and
neglected children. An unkept promise. N Engl J Med
32 Perry BD. Incubated in terror. Neurodevelopmental factors in the ‘cycle
of violence’. In: Osofsky J, ed. Children, youth and violence: the search
for solutions. New York: Guilford Press, 1997:124–48.
33 Oliver JE. Successive generations of child maltreatment. Br J Psychiatry
34 Department of Health. Child protection; messages from research.
London: HMSO, 1995.
35 Jones DPH, Lynch MA. Diagnosing and responding to serious child
abuse. Confronting deceit and denial is vital if children are to be
protected. BMJ 1998;317:484–5.
36 Department of Health, Department for Education and Employment, and
the Home Office. Framework for the assessment of children in need and
their families. London: The Stationery Office, 2000.
37 Elliman D, Lynch MA. The physical punishment of children. Arch Dis
104Southall, Samuels, Golden