Editorials

Diagnosing and responding to serious child abuse

Confronting deceit and denial is vital if children are to be protected 

Publishing recently in Pediatrics, Southall et al described their experience of using covert video recordings to diagnose life threatening abuse.¹ Of 39 children (median age 9 months) referred to two UK hospitals for investigation of suspicion of induced illness, including 36 with apparent life threatening events, the authors filmed evidence of abuse in 33. This included suffocation in 30, poisoning in two, and the breaking of an arm. The transcripts of the recordings make distressing, yet essential, reading. Risk of abuse extended to other children within these families: 12 out of 41 siblings had died suddenly and unexpectedly (suffocation was subsequently admitted for 8, and reinvestigation of another revealed salt poisoning), and abuse was documented in a further 15. 

Southall et al have revealed the grim world which has been intermittently explored over the past 100 or so years.^2-4 Now, however, the filmed evidence concretely exposes what was previously available only to professional imagination. These children were not damaged during bouts of anger but harmed coolly and callously by parents who appeared concerned and caring, yet when left alone with their children seriously harmed them. The added deception of the health professional increases the feeling of betrayal, not just on behalf of the child but also in relation to the trust doctors and nurses are accustomed to placing in the parent as the child's representative. What are the lessons from these disturbing data?

A crucial issue for doctors is the ability to distinguish cases of abuse from other causes of an acute life threatening event. Compared with controls, Southall et al found that the abused children were less likely to be prematurely born, more likely to present with bleeding from the nose or mouth, and more likely to have a history of sudden and unexpected death or abuse in siblings. In addition, 23 of the abusive parents were diagnosed as having personality disorders.

Intrafamilial child maltreatment is not a unitary, or easily definable, phenomenon but covers a wide range of ways in which parents harm their children. It ranges from neglect (the most common) through physical and emotional harm, to life threatening assault and rape of children. Most cases identified are not life threatening, and death from abuse is unusual. Professionals concerned with the majority can therefore be lulled into a sense of false optimism and assume circumstances will improve, even for the more problematic cases. Additionally, our training and professional calling to help the sick can encourage professional denial of such acts of harm.³ By contrast, those working in specialised units have to appreciate that milder, non-life threatening forms of maltreatment comprise most cases. Systems of child protection must be able to cope with the full range of child maltreatment.

The variety of child abuse that is factitious illness by proxy also incorporates a range of seriousness.⁵ In an epidemiological study in the United Kingdom McClure et al identified 128 cases.⁶ In 23 the perpetrator gave only a false history of illness and in a further 21, although both history and signs were fabricated, the parents did not inflict direct physical harm on the child. Thus, for a third of children harm resulted from the subsequent medical investigations. Of the remaining 84 children, 44 were poisoned and 32 suffered deliberate suffocation (3 children experienced both); 8 children died.

Southall et al suggest that "partnership" may not be feasible in cases of life threatening or serious harm. The term partnership has acquired a range of meaning, including professional style (mutual respect, communicative openness), sharing of power, as well as parental involvement in planning and decision making.⁷ Partnership as avoiding confrontation, or mere togetherness, is always dangerous in serious abuse. However, partnership is still possible, provided it is made explicit that the focus of all work is the child's welfare.⁸ A joint acknowledgment of maltreatment is mandatory, not merely desirable, and family reunification is not automatic. Indeed, partnership can exist around relinquishment of parental carethis being just as legitimate a therapeutic goal as reunification.⁸ Professional style should be mutually respectful and as inclusive of parents as possible while still maintaining the child's safety. Some interprofessional discussion must, however, remain confidential when parents are devious or seriously harmful.

What implications are there from this work for practitioners? Firstly, all professionals must remain alert to the possibility of serious, life threatening abuse. Secondly, the nature of the working partnership with abusive parents needs to be moulded by the requirements of child safety and welfare. Thirdly, child protection systems must encompass a range of responses, from family support to an ability to respond vigorously to prevent fatal abuse. One way of ensuring deaths from abuse are not overlooked would be the universal introduction of local child death reviews. ^{9 10} Covert video surveillance needs to be available as a tool for diagnosing some forms of factitious illness, though it must not replace a full child and family assessment, on which intervention should be based. Southall et al's work reveals important clues which may help to distinguish cases of acute life threatening events caused by abuse. Finally, the work which follows recognition is all important, for herein lies the potential for preventing further harm to children, and stopping escalation in less serious cases.