Head To Head

Has child protection become a form of madness? No

BMJ 2011; 342 doi: http://dx.doi.org/10.1136/bmj.d3063 (Published 18 May 2011) Cite this as: BMJ 2011;342:d3063
  1. Margaret Spinelli, associate professor of clinical psychiatry1,
  2. Louise M Howard, professor in women’s mental health2
  1. 1Columbia University College of Physicians and Surgeons, New York , USA
  2. 2King’s College London, London, UK
  1. Correspondence to: M Spinelli Mgs8@columbia.edu

Alain Gregoire and Simonetta Hornby (doi:10.1136/bmj.d3040) argue that child protection fails to detect many children in need of help while becoming ever more bureaucratic and unhelpful, while Margaret Spinelli and Louise Howard believe that child protection interventions are essential to prevent abuse

Abuse of children is a global problem. In the United States over three million reports of child abuse are made every year and almost five children die every day as a result of child abuse.1 In the UK, currently around 46 000 children are the subject of a child protection plan.2 But research indicates that abuse and neglect are both under-reported and under-recorded, so such figures underestimate the prevalence of child abuse. A recent survey found that 18.6% of secondary school children in the UK have been severely abused or neglected during childhood—equivalent to 973 000 children across the UK.2

Most abused and neglected children are not getting the help they need, and the consequences are potentially devastating. Physical abuse of children may result in death or serious physical injuries. Sexual abuse can lead to self harm, depression, and loss of self esteem into adulthood and is associated with being a victim of abuse as an adult and, in a minority of cases, a perpetrator of abuse. Emotional abuse has a similarly profound effect on mental health, behaviour, and self esteem, and neglect can lead to serious impairment of physical and mental health and development. The child does not have to be directly abused to be seriously harmed—witnessing domestic violence, for example, can lead to mental disturbance in childhood and adulthood.3

Role of health professionals

Child protection is an activity to protect children who are suffering, or are likely to suffer, serious harm. It has taken decades for healthcare professionals to understand that child abuse is common, and we are well placed to protect children as frontline staff who see injuries or signs of neglect. However, Lord Laming concluded in his report on the protection of children in England that “much more needs to be done to ensure that . . . services are as effective as possible at working together to achieve positive outcomes for children.”4 Ofsted’s evaluation of 50 serious case reviews highlighted the failure of all professionals “to see the situation from the child’s perspective.”5

Sadly, it will never be possible to detect all cases of child abuse and protect all children, and social care workers have a difficult task to identify which children need formal child protection procedures. Healthcare professionals therefore have a responsibility to work with social care to try to protect the most vulnerable in our society.

The risk of childhood abuse increases when parents have serious mental health or substance misuse problems, learning disabilities, or have been subject to domestic violence.5 It is therefore our responsibility as healthcare professionals when seeing parents, to consider whether parental difficulties may be affecting the child. Although healthcare professionals contribute to a small proportion of reports to child protection agencies, they are most likely to be responsible for reporting the minority of children who have been severely abused.6 Training of professionals to recognise and respond to child abuse is effective in increasing detection and reporting of child abuse,6 and the availability of such training in recent years throughout the NHS should help prevent recurrent abuse and improve long term outcomes for many children.

Evidence supports action

Evidence is growing on the importance of early intervention to prevent adverse long term outcomes, and robust evidence on the effectiveness of interventions such as the nurse-family partnership to prevent child abuse.7 Cognitive behavioural therapy can reduce symptoms of post-traumatic stress disorder, anxiety, and depressive disorders in children who have been sexually abused, and mother-child therapy can improve child behaviour in families with a history of domestic violence.7 There is also evidence that parent-child interaction therapy reduces recurrence of physical abuse reported to child protection service.7 Interventions such as resilient peer training and multisystemic therapy can lead to improved child outcomes after child neglect.7 Placement with foster parents and enhanced foster care can also lead to better outcomes for children.7 Interventions for psychological abuse are less well researched but a meta-analysis assessing the effectiveness of attachment based interventions, ranging from home visiting programmes to parent-infant psychotherapy, showed improvements in insensitive parenting and in infant attachment insecurity.8

Child abuse is a serious and common problem associated with adverse health outcomes which can be effectively detected and prevented. Far from child protection being mad, it is an evidence based rational response. It would be morally indefensible not to continue to develop and refine prevention, detection, and intervention strategies and thus curtail the incidence and prevalence of child abuse and murder.9


Cite this as: BMJ 2011;342:d3063


  • Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare no support from any organisation for the submitted work; LMH receives funding from NIHR for research into domestic violence. She was a member of the Department of Health implementation group on violence against women and children.

  • “Child protection has become a form of madness” will be debated in a Maudsley debate at the Institute of Psychiatry, King’s College London (www.iop.kcl.ac.uk/events/?id=1209) on 19 May.

  • Provenance and peer review: Commissioned; not externally peer reviewed.