Intended for healthcare professionals


Childhood matters

BMJ 1997; 314 doi: (Published 01 March 1997) Cite this as: BMJ 1997;314:622

Doctors have a vital role in identifying children at risk of abuse

  1. C J Hobbs, Consultant community paediatriciana,
  2. P L Heywood, General practitionerb
  1. a St James University Hospital, Leeds LS9 7TF
  2. b Street Lane Practice, Leeds LS8 1AY

    Britain is failing too many of its children. This is the bleak conclusion of the recently published report of the National Commission of Inquiry into the Prevention of Child Abuse (Childhood Matters).1 At some time, 10% of children are at risk of substantial harm. This could be prevented, and, rightly, few agencies or professional groups are spared the requirement to improve.

    The commission defines child abuse as “anything which individuals, institutions or processes do or fail to do which directly or indirectly harms children or damages their prospects of a safe and healthy development into adulthood.” Hence, the omissions of our professions and our tardiness in implementing change, from this perspective, are themselves abusive. This has already attracted criticism from the government, the key institution with parent-like responsibilities, which is presently considering a return to more brutal methods of child rearing.2

    Evidence was taken from over 10 000 people, including many who were abused as children. Despite greater attention to abuse in the past decade, children continue to be abused, usually by their carers, family members, or acquaintances. At least half of this abuse is not disclosed when it occurs. In most instances it is preventable since it is known, or strongly suspected, by a third party. Our systems frequently fail to prevent abuse from occurring or fail to recognise it at an early stage. Services respond when serious abuse is identified, at a cost of about £1bn ($1.6bn) a year. An expensive court system presides over the selected cases that reach it, unintentionally adding further damage to children and families. Children still fall through the net of agencies and local and national government structures.

    The goal of any civilised society must be to prevent child abuse. So how do we achieve this? The commission recognises that there is little evidence of what works or is cost effective. However, new ways must be sought within our existing knowledge of the causes and consequences of abuse, while further research is undertaken. Over four million of the country's 13 million children live in families receiving less than half the average national income. Poverty damages children's lives, and, when linked to other factors such as poor housing and diet, stress builds up and abuse often follows.

    Perhaps too much emphasis is given to investigating suspected cases of abuse at the expense of supporting families.3 The Children Act (1989) created a welcome shift in emphasis in the way professionals work with parents4; however, it fails to address the welfare needs of the large group of “children in need,” including those facing poverty, disadvantage, and social disruption. Simply redistributing limited resources from child protection to family support would leave more children unprotected. New resources are needed.

    Additional resources for social work training, improved handling of court cases, and a curb on increasing bureaucracy would help. There are over 80 specific recommendations in this 380 page report. Many reflect the need to give higher national priority to the issue of children's welfare. In government, children should be represented by a secretary or minister of state with enhanced ministerial responsibility for children. Close to the centre of government, a high profile children's commissioner, as exists in some other countries, would be a tangible expression of the will to address children's interests.

    Other recommendations underline the need to educate for parenting, to create child friendly communities, and to emphasise the fact that children are not possessions but individuals with rights and developing responsibilities. The commission calls for improved statistical information on the state of Britain's children, including more information about abuse; (there are fewer statistics than 10 years ago). Other recommended changes involve new legislation; improvement in the operation of current law; greater integration between social services, education, and health authorities; and improved regulation of staff who work with children to provide better safeguards. Children should receive the same protection as adults, which would mean removing from the statute book the defence of “reasonable chastisement.”

    Those commissioning and providing health services should give greater emphasis to preventing neglect and abuse. The importance given in this report to the general practitioner's role in identifying children at risk from abuse makes a sharp contrast to the BMA's Core Services: Taking the Initiative, which fails explicitly to mention it among general practitioners' core responsibilities.5

    The commission's findings must be welcomed and supported as a way to move forward in thinking and practice about children's welfare. Greater public involvement is required. Child abuse is everybody's responsibility not just that of professionals. We may give lip service to the importance of childhood; this must be converted into practical action. Only by action will we really demonstrate that childhood matters.


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