Child abuse in most settings is significantly under-reported — even by the schools and community health services that have continuous contact with children. And there are widespread doubts as to whether the benefits of reporting child abuse to appropriate agencies outweigh the harms. In this second paper in The Lancet Child Maltreatment Series, Professor Ruth Gilbert, Centre for Evidence-based Child Health and MRC Centre of Epidemiology for Child Health, University College London Institute of Child Health, UK, and colleagues conclude that all professionals dealing with children have complementary roles in the recognition and response to child maltreatment.
Professionals contribute about half of the cases of child maltreatment reported to child protection services, with schools being the major contributor. One reason for under-reporting is failure to recognize maltreatment. When maltreatment is suspected however, professionals often do not report the case unless they have a high level of certainty that maltreatment has occurred. Even so, the proportion of child protection referrals that are substantiated by child protection services can be low (eg, 25% in USA, 52% in Australia). While recognition and reporting of child maltreatment to child protection services is important to promote safety, health and welfare, through the provision of effective interventions, additional ways of recording maltreatment, assessing need, and accessing therapeutic and supportive services should be considered.
The extent of uncertainty about maltreatment is illustrated by a recent prospective study of 434 doctors dealing with injured children in the USA. Doctors suspected around 10% of 15000 of child injury visits were maltreatment-related, but only reported 6% of them. Doctors reported three-quarters of the small number of children (1 in 25 of all those suspected to be maltreatment-related) with a high degree of suspicion and were more likely to report after consulting their colleagues. They were less likely to report if they were familiar with the child's relatives, or if they had low expectations of what reporting would achieve, or if they thought they themselves could work with the family to resolve the issue. And a study of reporting of child neglect in Ireland found that professionals most closely connected with the community were concerned about being 'found out' if they reported neglect. Poor communication with social services and negative perceptions about their effectiveness also discouraged reporting.
The authors say that in children with mental health problems, the key issue is the preparedness of doctors to contemplate the possibility that the child's mental problems could, at least in part, be explained by maltreatment, which, if ongoing , needs to be stopped, before the mental disorder can be effectively treated.
Although schools contribute most reports to child protection agencies, they are also responsible for failing to report the most cases. Two studies showed that schools reported only 30% to 37% of known child maltreatment, although reports were often made within the school to principals, counsellors and nurses. In a UK study of 43 schools, lack of access to qualified social workers, lack of feedback, and concerns about social services' ability to handle cases, were associated with not reporting.
A review of 106 maltreatment related deaths reported by all local authorities in England in 2003-2005 showed that 28% of deaths occurred in young people aged 11-19 years, of which 47% (11 cases) were from suicide.
The paper analyses policy approaches to child maltreatment particularly the extent to which provision of supportive and therapeutic interventions go hand in hand with assessment of whether maltreatment occurred or not and the need for protection. In a review of routine data from 6 countries the authors show that few children are removed from their home (0.2 to 0.4% of all children).** Provision of services to the remaining 1.5% to 5% of all children referred to child protection services each year appears to be higher in systems that operate a child and family welfare approach, such as in Sweden and New Zealand, where parents often self refer. The UK and most countries in western Europe operate a child and family welfare approach. In contrast, services are more limited in systems that focus on child safety, as in North America parts of Australia and France, unless the child is deemed to be at future risk of harm.
The authors argue that the scope for improvement in recognition and response to child maltreatment is likely to be greatest in services that have the closest ongoing contact with children and their families (schools and community services). General practitioners are in a key position to identify maltreated children as they see the child and parents but reports from GPs to child protection services are scarce. They are particularly well placed to respond to children exposed to intimate partner violence, which affects 5% to 17% of women seen by GPs each year and is itself a form of child maltreatment, strongly linked to other forms. Schools are well placed to recognise maltreatment by observing changes in behaviour and distress, and through children disclosing maltreatment. In some countries, the majority of mental health services for children are provided outside health care, linked to schools. Such services provide opportunities to detect and respond to child maltreatment, but studies suggest that school counsellors may lack the knowledge and skills to respond adequately.
Maltreated children may also be able to help themselves. An appendix to this paper also discusses the effectiveness of telephone helpline services such as ChildLine in the UK. ChildLine gives children to confidential advice and counselling, often at their time of greatest need. However, few children under 10 use services like this, and demand for other children often outstrips supply, with only 11-83% of calls worldwide being answered because of insufficient capacity (57% failing to be connected in the UK in 2007).
The authors conclude: "We suggest that all professionals dealing with children have complementary roles in the recognition and response to child maltreatment. Serious shortfalls exist at every step of the process in all sectors, but much more research has addressed these issues within paediatric services than elsewhere. Professionals who have continuous contact with children, such as people working in schools and community health services, can have a leading role in recognising, responding to, and supporting maltreated children. Their scarce reporting to child-protection agencies is a cause for concern, and we need to find out whether maltreatment is being recognised and dealt with in other ways. Doubts are widespread that the benefits of reporting suspected cases of maltreatment to child-protection services outweigh the harms."
Professor Ruth Gilbert, Centre for Evidence-based Child Health and MRC Centre of Epidemiology for Child Health, University College London Institute of Child Health, UK T) +44 (0) 207 905 2101; Press Office Stephen Cox – +44 (0) 20 7239 3126) r.gilbert@ich.ucl.ac.uk or coxs@gosh.nhs.uk
Notes to editors: *See panel, page 23 of full paper **see pages 29-30 of full paper
Full paper: http://press.thelancet.com/childmaltreatment2.pdf
Journal
The Lancet