Classification of child abuse by motive and degree rather than type of injury

Article (PDF Available)inArchives of Disease in Childhood 88(2):101-4 · March 2003with34 Reads
DOI: 10.1136/adc.88.2.101 · Source: PubMed
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).

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Available from: Martin Philip Samuels
PERSONAL PRACTICE
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).
..........................................................................
E
ven in many well resourced countries, there
appears to be inadequate protection for chil-
dren from the most serious forms of ill treat-
ment (abuse).
1–3
In the UK, despite “Working
Together”,
45
cases involving extreme suffering for
children continue to occur.
67
Based on our experience,
8
we 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.
459
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.
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
months restrained with masking tape,
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 m ay become
habituated to abuse, particularly sexual abuse.
The abuser is not mentally ill, as legally defined.
Some have untreatable psychopathic personality
disorders.
10 11
Those 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
authors’ affiliations
.......................
Correspondence to:
Prof. D P Southall,
Academic Department of
Paediatrics, City General
Hospital, Stoke on Trent
ST4 6QG, UK;
davids@doctors.org.uk
Accepted
17 October 2002
.......................
101
www.archdischild.com
inflicting pain, and need to dominate and control. They are
people who, in the most extreme of ways, place their needs
before others.
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.
15–17
Later 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
char m” to entice professionals that show empathy with their
fabrications into becoming supporters. When confronted they
tur n 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.
Per petrator s may move from one child or f amily to another
reeking havoc. The deliberate abuse by parents
18
or, 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 illness
19–21
to
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,
ter rorisation, 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.
23
As 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 countr ies is
category A abuse for obvious gain.
24
In 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.
25
Incredible abuse follows
kidnap to provide child soldiers and “wives” for irregular
ar mies,
26 27
where children are forced to perform sadistic mur-
ders as part of their “training”. In many countries children are
tortured
28
for 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 Amer ica, Eastern Europe, Africa,
and South Asia)
24
driven 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,
31–33
or 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
assessments. This requires highly trained specialists.
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
active control.
Recent Part 8 inquiries in the UK (deaths resulting from
abuse) and other sources
23
indicate 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
www.archdischild.com
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 Act
4
and
its guidelines (“Working Together”, 1991, 1999,
5
“Messages
from Research”, 1995
34
), is inappropriate for managing any
for m 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,
22
trained to recognise deception,
35
and 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 member s) and interview family and wit-
nesses.
This approach may be m ore 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-
dren.
CATEGORY B (IMPULSIVE ILL TREATMENT
RESULTING FROM ADVERSE SOCIETAL AND
PERSONAL PRESSURES)
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
children.
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)
5
provide 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.
30
Core
management involves family assessments, strategy discus-
sions, case conferences, child support registration, core
groups, and supportive measures, and has been well described
elsewhere.
4536
CATEGORY C (MILD ILL TREATMENT UNIVERSAL IN
ALL SOCIETIES)
All loving and caring parents occasionally ill treat their
children.
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
nor mal 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 EPOCH
37
that 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).
Figure 1 Spectrum of ill treatment.
Classification of child abuse 103
www.archdischild.com
ACKNOWLEDGEMENTS
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.
.....................
Authors’ affiliations
D P Southall, Honorary Medical Director, Child Advocacy International
(www.childadvocacyinternational.co.uk and
www.childfriendlyhealthcare.org), Consultant Paediatrician, North
Staffordshire Hospital, and Foundation Professor of Paediatrics, Keele
University, UK
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,
UK
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
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    • Table (3) show, that there's a relationship between different factors affecting patients' adherence , patient's factors, disease and therapy factor, and social economic factors, this result may come in agreement with (11), and relationship between social support and patient's adherence. The Punishment for the student of his interests is failure this result agree with (Southall et al 2016) the study Classification of child abuse by motive and degree rather than type of injury, Also the School violence is causing to escape from the school is failure this result agree with the Gender Differences in Long-term health Consequences of physical abuse of children data from a nationally representative survey, The violence affects educational attainment for students failure this result agree with of the study child abuse and neglect.(10)
    [Show abstract] [Hide abstract] ABSTRACT: Objective: To determine the impact of physical abuse on Behavior of School Age Children in Al-Najaf Al- Ashraf city and to find out association between the School age Children Behavior and their demographic characteristic (age, gender, Residence, educational level and parents' occupation) Methodology: A cross-sectional descriptive approach was designed to meet the previously mentioned objectives of the current study the period of the study is from March 4/3/ 2016 to Apr 28/4/2016 April. Conclusion The majority of the study (95%) are the city center. Regarding with gender the results of majority of the study (80%) are the male. the age was nine above is (96.9%). Concerning of the family income was the barely sufficient (61.3%). This result study for father education and mother education the majority of the study (30.6%) are the graduate college or institute. And the seemingly of the study father occupation and mother occupation was the result together explained proportion highest the unemployed (58.8%) father occupation, and unemployed (78.1%) for the mother occupation. Recommendation: Educate parents through parenting workshops and other sources of information and encourage them to begin talking to their children about The study, dealing with others and respect for the teacher. Typically, school counselors and school psychologists provide such information. Learn how to communicate with children. Notice if there is a decline in a child’s performance in school, Abuse may affect all aspects of a child’s life, including their grades. Notice if there is an unexplained drop in a child’s attendance at school, Children may be unable to attend school due to bad behavior from their teacher or other child. You must provide a suitable study environment and give enough time to study. Early education for children and their entry to kindergartens to increase their level of scientific. The correlation between demographic characteristics and mean score of physical abuse not significant expect age and parent education are significant.
    Article · Oct 2016 · Archives of Disease in Childhood
    • Neglect is the absence of a desired set of conditions or behaviors, as opposed to the presence of an undesirable set of behaviors. A definition of neglect, therefore, implies a certain set of desired behaviors as well as a designation as to who should be responsible for meeting the needs or performing the desired behaviors (Golden, Samuels, & Southall, 2003).
    [Show abstract] [Hide abstract] ABSTRACT: This study examined the relationship between child experiences identified conceptually as "neglectful" prior to age 4 and child outcomes at age 4. This was done using measures from two sites collected as part of LONGSCAN. Child needs were included within categories of physical and psychological safety and security. Problems with residence safety or cleanliness and untreated behavioral problems predicted child impairments in language. CPS reports of failure to provide shelter predicted impairments in several developmental outcomes. A stimulating home environment predicted less impairment in cognitive development. Multiple changes in residence predicted externalizing behavior problems. Exposure to verbally aggressive discipline predicted more behavioral problems overall. Conversely, some indicators (such as caregiver transitions and lack of medical care) predicted less developmental impairment or fewer behavior problems in certain domains. The approach supports a conceptualization of neglect based on child developmental needs. Implications for practice and future research are discussed.
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  • [Show abstract] [Hide abstract] ABSTRACT: Despite there being a lack of direct evidence of the effectiveness of providing emergency inhalers to schools, the balance of evidence at present suggests the benefits outweigh any possible harm. However, unless UK prescribing law or its interpretation is changed, this will remain an action which opens teachers, nurses, and doctors to possible legal and professional sanctions, and may nullify their institutional or professional indemnity. As a consequence, provision will remain patchy and research into the value of emergency inhalers will be inhibited. A position statement from one or more responsible organisations such as the Royal College of Paediatrics and Child Health, the British Thoracic Society, or the British Paediatric Respiratory Society could persuade a reassessment from the Medicines Control Agency. This is also an issue which could be addressed in the forthcoming National Service Framework for children.
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  • [Show abstract] [Hide abstract] ABSTRACT: "Child protection training is essential for all health professionals engaged in services for children. It is not an optional extra" (Barry Capon, Chair of Independent Inquiry into Death of Lauren Wright).
    Article · Aug 2003
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