3. Significant Harm and Sources of Stress

3.1 The Concept of Significant Harm

3.1.1	The Children Act 1989 introduced the concept of Significant Harm as the threshold that justifies compulsory intervention in family life in the best interests of children, and gives local authorities a duty to make enquiries to decide whether they should take action to safeguard or promote the welfare of a child who is suffering, or likely to suffer, Significant Harm.
3.1.2	Section 47(1) of the Children Act 1989 states that: Where a local authority: Are informed that a child who lives, or is found, in their area is the subject of An Emergency Protection Order; or Is in Police Protection; or Has contravened a ban imposed by a curfew notice imposed within the meaning of Chapter 1 of Part 1 of the Crime and Disorder Act 1998; or Have reasonable cause to suspect that a child who lives, or is found, in their area is suffering, or likely to suffer Significant Harm, the authority shall make, or cause to be made, such enquiries as they consider necessary to enable them to decide whether they should take any action to safeguard or promote the child's welfare. In the case of a child falling within paragraph a.iii. above the enquiries shall be commenced as soon as is practicable and in any event, within 48 hours of the authority receiving the information.
3.1.3	Under section 31 of the Children Act 1989 a court may only make a Care Order (committing the child to the care of the local authority) or Supervision Order (putting the child under the supervision of a social worker, or a probation officer) in respect of a child if it is satisfied that: The child is suffering or is likely to suffer Significant Harm; The harm or likelihood of harm is attributable to a lack of adequate parental care or control.
3.1.4	Under section 31(9) of the Children Act 1989: Harm means ill-treatment or impairment of health or development; Development means physical, intellectual, emotional, social or behavioural development; Health means physical or mental health; Ill-treatment includes sexual abuse and forms of ill-treatment which are not physical.
3.1.5	The Adoption and Children Act 2002 amended the definition of Significant Harm to include the emotional harm suffered by those children who witness domestic abuse or are aware of domestic abuse within their home environment.
3.1.6	There are no absolute criteria on which to rely when judging what constitutes Significant Harm. Consideration of the severity of ill-treatment may include: The degree and extent of physical harm; The duration and frequency of abuse or neglect; The extent of premeditation; The degree of threats and coercion; Evidence of sadism, and bizarre or unusual elements in child sexual abuse.
3.1.7	Each of these elements has been associated with more severe effects on the child, and/or relatively greater difficulty in helping the child overcome the adverse impact of the ill-treatment.
3.1.8	Sometimes, a single traumatic event may constitute Significant Harm. In other circumstances significant harm is caused by the cumulative effect of significant events, both acute and long-standing, or the damaging impact of neglect which interrupt and change or damage the child's physical and psychological development.
3.1.9	When judging what constitutes Significant Harm it is necessary to consider: The family context, including the family's strengths and supports; The child's development within the context of the family and within the context of the wider social and cultural environment; Any special needs, such as a medical condition, communication difficulty or disability that may affect the child's development and care within the family; The nature of harm in terms of the ill-treatment or failure to provide adequate care; The impact on the child's health and development; The adequacy of parental care.
3.1.10	Under section 31(10) of the Children Act 1989: Where the question of whether harm suffered by a child is significant turns on the child's health and development, his health or development shall be compared with that which could reasonably be expected of a similar child. Note that 'significant harm' can also refer to harm caused by one child to another (which may be a single event or a range of ill treatment), which is generally referred to as 'Child-on-Child abuse.'
3.1.11	It is important always to take account of the child's reactions, and his or her perceptions, according to the child's age and understanding.

3.2 What is Abuse and Neglect?

3.2.1

Abuse and neglect are forms of maltreatment of a child. Somebody may abuse of neglect a child by inflicting harm, or by failing to act to prevent harm. Children may be abused in a family or in an institutional or community setting, by those known to them or, more rarely, by a stranger for example via the internet. They may be abused by an adult or adults, or another child or children.

3.3 Physical Abuse

3.3.1	Physical abuse may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating or otherwise causing physical harm to a child. Physical harm may also be caused when a parent or carer fabricates the symptoms of, or deliberately induces, illness in a child (see Perplexing Presentations and Fabricated or Induced Illness Procedure).
3.3.2	Physical abuse can lead to physical injuries, neurological damage, disability and death and can produce emotional or behavioural disturbance in children such as aggressive behaviour.
3.3.3	The range of injuries which may be caused by the physical abuse of children is varied. One injury to a child is not in itself an indication of physical abuse, as many children sustain accidental injuries. Certain injuries are less likely to have an accidental cause, and it is important that an appropriate medical opinion or assessment is obtained where there is suspicion about the cause of an injury.
3.3.4	In Knowsley such medical assessment should be conducted by a paediatrician at the Rainbow Centre, Alder Hey Hospital (see Local Contacts).
3.3.5	A number of factors may give rise to suspicion about the cause of an injury, the most obvious being a statement by the child and/or another person, that the injury has been caused deliberately or not accidentally. In addition, professionals working with children and families should be alert to situations where a child is injured and: The explanation provided by the parent or carer is apparently incompatible with the physical injury; There are conflicting or different explanations provided; There is no explanation provided or a lack of awareness of how the injury occurred; There is a reluctance on the part of the parent or carer to provide information about the current or previous injuries; There is a reluctance to agree to medical assessment; There is a delay or failure to seek appropriate medical attention for an injury; There are frequent minor injuries or presentations of the child at Accident and Emergency Departments; The parent or carer is impatient, angry or aggressive towards the child; The parent or carer is under the influence of alcohol or another substance.
3.3.6	The presence of any of these factors does not indicate that Physical Abuse has occurred but does indicate that the possibility of Physical Abuse should be considered.

3.4 Emotional Abuse

3.4.1	Emotional abuse is the persistent emotional maltreatment of a child such as to cause severe and persistent adverse effects on the child's emotional development. It may involve conveying to children that they are worthless or unloved, inadequate, or valued only insofar as they meet the needs of another person. It may include not giving the child opportunities to express their views, deliberately silencing them or 'making fun' of what they say or how they communicate. It may feature age or developmentally inappropriate expectations being imposed on children. These may include interactions that are beyond the child's developmental capability, as well as overprotection and limitation of exploration and learning, or preventing the child participating in normal social interaction. It may involve seeing or hearing the ill-treatment of another. It may involve serious bullying (including cyberbullying), causing children frequently to feel frightened or in danger, or the exploitation or corruption of children. Some level of emotional abuse is involved in all types of maltreatment of a child, though it may occur alone.
3.4.2	Emotional abuse can have a damaging effect on the child's mental health, behaviour or self-esteem.
3.4.3	One child in the family may be treated differently and emotionally abused by siblings as well as parents.
3.4.4	A child who lives in a household where domestic abuse, adult mental health problems or substance misuse by parents or carers are apparent, can suffer emotional harm.
3.4.5	A level of emotional abuse is involved in all other forms of abuse or neglect but may occur alone.

3.5 Sexual Abuse

3.5.1	Sexual Abuse involves forcing or enticing a child or young person to take part in sexual activities, not necessarily involving a high level of violence, whether or not the child is aware of what is happening. The activities may involve physical contact, including assault by penetration (for example, rape or oral sex) or non-penetrative acts such as masturbation, kissing, rubbing and touching outside of clothing. They may also include non-contact activities, such as involving children in looking at, or in the production of, sexual images, watching sexual activities, encouraging children to behave in sexually inappropriate ways, or grooming a child in preparation for abuse (including via the internet). Sexual abuse is not solely perpetrated by adult males. Women can also commit acts of sexual abuse, as can other children.
3.5.2	Perpetrators of Sexual Abuse are usually adults known to the child, or family members. Such abuse by a family member often occurs over an extended period of time and may develop in its form and severity over time.
3.5.3	The effects on a child vary and can be dependent on factors such as: The age of the child; The physical severity of the abuse; The extent of the period over which the abuse occurred; Threats or coercion which may be associated with the abuse.
3.5.4	Sexual Abuse can produce a range of disturbed behaviour in a child including: Self harm; Inappropriate sexualised behaviour; Regressive behaviour, such as soiling or wetting; Sadness or depression; Loss of self-esteem; Eating disorders; Sleep disturbance. Each of these types of behaviour can also be present in children where Sexual Abuse has not occurred.
3.5.5	Children who have been sexually abused may also sustain injuries or infections to the genital, anal or oral areas. Pregnancy can also be the result of Sexual Abuse. However in many cases of Sexual Abuse there is no physical sign or evidence of the abuse.
3.5.6	Children of either gender can be the victim of Sexual Abuse. Where a girl within a family has been sexually abused by a family member it is not safe to assume that boys within the household are not at risk of Sexual Abuse, or vice versa.
3.5.7	It is not possible to identify types of individuals who might be more likely to sexually abuse, although the majority are male. Females however can sexually abuse children or collude with males in such abuse.
3.5.8	Similarly it is not possible to identify a type of family where Sexual Abuse is more likely to occur.
3.5.9	Any report of Sexual Abuse made by a child should always be taken seriously and investigated.

3.6 Neglect

3.6.1	Neglect is the persistent failure to meet a child's basic physical and/or psychological needs, likely to result in the serious impairment of the child's health or development. Use of the Graded Care Profile is crucial at all stages of interventions to consider the neglect risks for families (see Knowsley Graded Care Profile 2).
3.6.2	Neglect may occur during pregnancy as a result of maternal substance abuse. Once a child is born, Neglect may involve a parent or carer failing to: Provide adequate food, clothing and shelter (including exclusion from home or abandonment; Protect a child from physical and emotional harm or danger; Ensure adequate supervision (including the use of inadequate care-givers); Ensure access to appropriate medical care or treatment. It may also include neglect of, or responsiveness to, a child's basic emotional needs. See Knowsley Safeguarding Children Partnership Multi-Agency Neglect Strategy (2023 - 2026).
3.6.3	In addition to a child's neglected appearance there may be other indicators of Neglect: Being significantly short and/or underweight for the chronological age; Cold mottled skin or poor skin condition; Swollen limbs; Cuts or sores which are slow to heal; Diarrhoea caused by a poor or inappropriate diet, irregular meals or tension. This list is neither exhaustive nor exclusive.
3.6.4	Severe Neglect in young children is associated with major impairment of growth and intellectual development. Persistent Neglect in children of any age can lead to serious impairment of health and development, and long-term difficulties with social functioning, relationships and educational progress. Neglect can also result in death.
3.6.5	Failure to thrive is a condition requiring a medical diagnosis. It can have an organic cause, but can also be a result of the persistent Neglect of the child's physical and/or emotional needs.
3.6.6	Children suffering Neglect may show dramatic changes in appearance and social functioning when placed in a different environment such as a hospital or foster placement.
3.6.7	Measuring Neglect is always difficult and requires close co-operation between Health and Children's Social Care. Inquiries into child deaths have placed great importance on the height and weight of very young children being plotted on the centile charts.
3.6.8	Neglect is often difficult to detect in that it is usually a slow ongoing process. Professionals may, out of familiarity, start to unknowingly tolerate lessening standards of child care, and each one of us has different standards with regards to what is acceptable or unacceptable. It is therefore essential that a regular, objective appraisal of the child's presentation and condition is made. Where there are concerns about the quality of care being provided to a child(ren) professionals should undertake the Graded Care Profile2 tool to determine what intervention/support is needed (see Knowsley Graded Care Profile 2).

3.7 Sources of Stress for Children and Families

3.7.1	Many families under stress are able to care for children and meet their needs in a warm, loving and supportive environment. For other families stress has a negative impact on the child's health, development and well-being either directly or because it affects the capacity of parents to respond to the child's needs. This is particularly the case where there is no other significant adult who is able to respond to the child's needs.
3.7.2	Social Exclusion and Poverty Many families are disadvantaged and lack a wage earner. Poverty may mean that children live in crowded or unsuitable accommodation, have poor diets, health problems or disability, be vulnerable to accidents, and lack ready access to good educational and leisure opportunities.
3.7.3	Racism Racism and racial harassment are additional sources of stress for some families and children. Although racism causes Significant Harm it is not, in itself, a category of child abuse. The experience of racism is likely to affect the responses of the child and family to assessment and enquiry processes. Failure to consider the effects of racism will undermine efforts to protect children from other forms of abuse.
3.7.4	Other sources of stress for children and families referred to in more detail in this manual include: Domestic Abuse (see Domestic Abuse and Reduction Strategy Procedure); Drug and alcohol misuse (see Children of Drug Misusing Parents Procedure); Mental illness (see The Mental Ill Health of a Parent or Carer Procedure).

3.8 Past Abuse

Sometimes referred to as 'historical abuse' - allegations of child abuse are sometimes made by adults and children many years after the abuse has occurred. There are many reasons for an allegation not being made at the time including fear of reprisals, the degree of control exercised by the abuser, shame or fear that the allegation may not be believed. The person becoming aware that the abuser is being investigated for a similar matter or their suspicions that the abuse is continuing against other children may trigger the allegation.

Reports of past allegations may be complex as the alleged victims may no longer be living in the situations where the incidents occurred or where the alleged perpetrators are also no longer linked to the setting or employment role. Such cases should be responded to in the same way as any other concerns including the referral procedures, etc. (see Multi Agency Safeguarding Hub (MASH)). It is important to ascertain as a matter of urgency if the alleged perpetrator is still working with, or caring for, children.

Organisational responses to allegations by an adult of abuse experienced as a child must be of as high a standard as a response to current abuse because:

There is a significant likelihood that a person who abused a child/ren in the past will have continued and may still be doing so;
Criminal prosecutions can still take place despite the fact that the allegations are historical in nature and may have taken place many years ago.

If it comes to light that the past abuse is part of a wider setting of institutional or organised abuse, the case will be dealt with according to the Organised/Multiple Abuse Procedure.