Child Abuse Review Vol. 5: 145-148 (1996)

Do We Value Our Children?

question could be posed ‘do we value our children?’ or A even ‘what position do they play in the scheme of things?’

It is an interesting concept that abuse and infanticide have occurred over the centuries but even at the end of the last century Lord Shaftesbury when trying to improve the working conditions for children stated that ‘The House could not contemplate abuse’. It is noteworthy that even this was 70 years after an Act to protect animals.

A century later most developed countries are well able to identify abuse. Questions now arise as to whether some government agencies are too diligent in this process, over- stretching the scarce resources available for social welfare. At the same time however, skills have increased in the recognition of child maltreatment. Two aspects of this are dealt with in the first two articles of this Issue.

Ever since the early 1980’s Emery has drawn attention to the relationship between child abuse and sudden infant death. In the first article, Hobbs and Wynne highlight the fact that the highest incidence of child death is in the first year of life although the incidence of sudden infant death has decreased markedly during the last decade. This is probably the result of attention being paid to the child’s environment and the fact that research has linked sudden infant death to smoking and drug taking in pregnancy. Overheating and sleep position have also been emphasised. Sudden infant death can only be diagnosed if no organic cause can be identified and this aspect needs to be considered further. The article by Hobbs and Wynne clearly states that a significant number of the remaining non-organic sudden infant death cases are the result of abuse.

Any child dying unexpectedly, when there is no clear immediate cause, must be investigated in a sensitive manner and the cause of death (on death certificates) must be accurately recorded if the size of the problem is to be truly comprehended and tackled appropriately. Those involved in such investigations must always keep the possibility of child abuse in their minds as it is all too easy to dismiss or too abhorrent to contemplate. Sudden infant death is a seductive diagnosis which absolves both the parents and professionals

Editorial Jean Price Chair BASPCAN and Consultant Community Paediatrician Southrnead Health Services

June 1996

‘Skills have increased in the recognition of child maltreatment’

‘Any child dying unexpectedly must be investigated in a sensitive manner’

@ 1996 by John Wiley 8 Sons, Ltd.

146 Price

‘All too often the non abusing parent is rendered impotent in protecting other children in the family’

‘Potentially fatal forms of abuse cause us to carefully consider our practice’

of guilt but what of the risk to subsequent children in the families involved? Parents should be helped to appreciate the risk and consequences of their behaviour. All too often the non abusing parent is rendered impotent in protecting other children in the family and in misdiagnosed cases the perpetrators may think or convince themselves that they are innocent.

The CESDI (Confidential Enquiry into Still Births and Deaths in Infancy) enquiries have brought together various health professionals to examine medical aspects of sudden infant deaths but the emphasis is on health professionals’ practice and there is variable quality in post mortem reports. Such enquiries are not multi-disciplinary and are too focused on medical issues.

The second article by Yeo vividly describes Munchausen syndrome by proxy as a form of child abuse. This more than any other form of child abuse demands a very careful and co-ordinated approach with all agencies contributing to its assessment. As medical conditions are mimicked, Yeo especially identifies the need for all medical specialties to work closely together and share all essential information.

Whilst much effort has gone into debating issue around confidentiality since the inception of the Children Act, 1989 there are still incidents where some doctors are confused as to where their responsibilities lie. It is essential that confi- dentiality is always viewed in the context of child protection. The fact that the General Medical Council expects doctors to justify their actions when breaking confidentiality appears to make those doctors not routinely dealing with child abuse very nervous, to the extent that occasionally they may with- hold vital information. It must be emphasised that ‘the interests of the child are paramount’. Y eo also highlights that Munchausen syndrome by proxy

is a life threatening condition. Viewing it in this way may allow the use of legal processes to safeguard a child’s life or, as in this case, the use of video surveillance as in other life threatening illnesses.

Potentially fatal forms of abuse cause us to carefully consider our practice, as might the current British child protection procedures. Firstly, professionals in child protec- tion are criticised for not recognising or identifying serious cases of child abuse, as in the case of Maria Colwell (HMSO, 1974) but when procedures are developed and implemented, criticisms turn to too many children being identified, as in the Cleveland Enquiry, 1988 and later in the Orkney Enquiry, 1992. Increasingly field workers, managers and politicians have realised that identification is one thing but

Editorial 147

counselling, treatment and therapy is another and these latter aspects are a scarce resource. Increasingly the pres- sures are coming to bear on practitioners to reverse the process, thus spending less on identification and transferring resources to more therapeutic services. This message is certainly a strong underlying theme that has emerged from research.

Freeman’s contribution to this Issue provides a very interesting paper addressing how Strathclyde has stemmed the tide of increased numbers on the child protection register through careful training and debate around what truly constitutes a child at risk of serious, abuse and therefore requires to be registered. This was done against the back- ground of the Scottish law which emphasises the need for meeting the welfare needs of the child. It would appear that through careful monitoring of their child protection system they are managing to keep the numbers down but still meet the welfare needs of the children and their families. There must be some lessons here for all practitioners but can communities truly afford the therapeutic services that some of the very damaged and dysfunctional families require?

In their article, Essex, Gumbleton and Luger provide a very exciting and innovative way of approaching families where serious abuse has occurred and where it is unclear as to where the responsibility lies. It is difficult to engage families where there is denial but by using hypothetical constructs these workers are helping the abusers take responsibility for their future actions within their family. This is a refreshing move away from the psychodynamic approach of needing acceptance of responsibility. This approach highlights the dilemmas that most child protection workers witness; where children disclose because they want the abuse to stop but without the total disruption to them and their family. However, the child protection procedures have tended to bring total disruption to the lives of many children who would wish those relatively good aspects of their parenting to continue. Nevertheless, the perpetrator often has too much to lose to accept responsibility for the abuse such as; power, position within the family and society, sexual gratification and possibly the loss of freedom.

Essex and her colleagues offer a refreshing and welcome approach to dysfunctioning families by developing trust and acknowledging the need for change, mutually acceptable boundaries and some form of gatekeeping by all concerned. The whole environment becomes a safer place, which may not only produce the required safety for the child (and so reduce the stress and anxiety for the innocent parent) but

‘Pressures on practitioners to reverse the process, thus spending less on iden t z .ca t ion and transferring resources to more therapeutic services”

The perpetrator often has too much to lose to accept responsibility for the abuse’

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1 Fee: €80.00 (Includes lunch and refreshments)

Price

1

‘Professionals are increasingly identzyying adolescent perpetrators’

also may provide enough security for the perpetrator to acknowledge his guilt and responsibility. Whilst this approach is laudable, the great cost in personnel time to reach these goals must also be noted.

The upsurge in knowledge and awareness of the abuse process now means that professionals are increasingly identi- fying adolescent perpetrators. This group of young people cause professionals considerable concern, particularly as they may be victims themselves and require help in their own right. McGarvey and Lenaghan offer another challenging and therapeutic approach to adolescent perpetrators. They, however, emphasise the need for careful selection, planning, consultation and sharing of information at all stages. There- fore, it is essential to accurately estimate the resources required to produce the desired outcomes of interventions with perpetrators.

The articles in Volume 5, Issue 3 encompass a wide spectrum of abuse and therapies, repeating well documented messages of working together and the need for sharing of information. However, within the prevailing financial climate, it is important to constantly question and evaluate priorities, to ensure the protection and treatment of children in need comes first.

Accident and Emergency

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1 CHILDRENINCRISIS I A One Day Multidisciplinary Conference

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THURSDAY 14TH NOVEMBER. 1996