1.1.2 Recognising Abuse and Neglect

1. The Definition of Significant Harm

The Children Act 1989 introduced the concept of significant harm as the threshold which justifies compulsory intervention in family life in the best interests of children.

Section 47 of the Act places a duty on local authorities to make enquiries, or cause enquiries to be made, to decide whether to take action to safeguard or promote the welfare of a child who is suffering, or likely to suffer, significant harm.

'Harm' is defined as the ill treatment or impairment of health and development. This definition was clarified by section 120 of the Adoption and Children Act 2002 to include 'impairment suffered from seeing or hearing the ill treatment of another' for example, where there are concerns of domestic abuse.

Additionally, a court may only make a Care Order or Supervision Order in respect of a child if it is satisfied that:

• The child is suffering, or is likely to suffer significant harm; and
• That the harm or likelihood of harm is attributable to a lack of adequate parental care or control (Section 31).

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 the extent of physical harm, the duration and frequency of abuse and neglect, the extent of premeditation, the degree of threat, coercion, sadism, and bizarre or unusual elements. 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 maltreatment.

Sometimes a single traumatic event may constitute significant harm, e.g. a violent assault, suffocation or poisoning. More often, significant harm is cumulative, and follows a series of events, both acute and long-standing, which interrupt, change or damage the child's physical and psychological development.

Some children live in family and social circumstances where their health and development are neglected. For them, it is the corrosiveness of long term neglect, emotional, physical or sexual abuse that causes impairment to the extent of constituting significant harm. In each case, it is necessary to consider any ill-treatment alongside the family's strengths and supports.

To understand and establish significant harm, it is necessary to consider:

• The family context, including protective factors;
• The child's development within the context of their family and wider social and cultural environment;
• Any additional 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 ill-treatment or failure to provide adequate care;
• The impact on the child's health and development; and
• The adequacy of parental care.

A child centred approach is fundamental to safeguarding and promoting the welfare of every child. A child centred approach means keeping the child in focus when making decisions about their lives and working in partnership with them and their families.

All practitioners should follow the principles of the Children Acts 1989 and 2004 - which state that the welfare of children is paramount and that they are best looked after within their families, with their parents playing a full part in their lives, unless compulsory intervention in family life is necessary.

2. Categories of Abuse and Neglect

The following definitions are taken from Working Together to Safeguard Children.

Abuse

A form of maltreatment of a child. Somebody may abuse or 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 others. Abuse can take place wholly online, or technology may be used to facilitate offline abuse. Children may be abused by an adult or adults or another child or children.

2.1 Physical Abuse

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. Further information, see the Perplexing Presentations (PP) and Fabricated or Induced Illness (FII) in Children Procedure.

2.2 Emotional Abuse

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 a child 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 a 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 cyber bullying), causing children frequently to feel frightened or in danger, or the exploitation or corruption of children.

2.3 Sexual Abuse and Sexual Exploitation

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. Sexual abuse 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. Sexual abuse can take place online, and technology can be used to facilitate offline abuse.

Sexual abuse is not solely perpetrated by adult males. Women can also commit acts of sexual abuse, as can other children.

In addition, sexual abuse includes abuse of children through sexual exploitation which occurs where an individual or group takes advantage of an imbalance of power to coerce, manipulate or deceive a child or young person under the age of 18 into sexual activity (a) in exchange for something the victim needs or wants, and/or (b) for the financial advantage or increased status of the perpetrator or facilitator. The victim may have been sexually exploited even if the sexual activity appears consensual. Child sexual exploitation does not always involve physical contact; it can also occur through the use of technology.

2.4 Neglect

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 and development.

Neglect may occur during pregnancy as a result of maternal substance misuse, maternal mental ill health or learning difficulties or a cluster of such issues.

Once a child is born, neglect may involve a parent or carer failing to:

• Provide adequate food and clothing, 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 unresponsiveness to, a child's basic emotional needs.

3. Indicators of Significant Harm

4. Recognising Physical Abuse

Children can sustain minor injuries for a variety of reasons; explanations given by themselves and by their parents and carers should always be sought even where there is no obvious concern about the injury sustained. Professionals should be alert to any pattern in explanations or discrepancies in the explanations given by a parent and child, between parents or given to different professionals.

Whilst some injuries may appear insignificant in themselves, repeated minor injuries, or an accumulation of minor injuries, especially in very young and non mobile children can indicate physical abuse. Where such concerns are identified, professionals should document these, and consider whether this amounts to a likelihood of significant harm which requires contact with social work services in line with their local procedures. For babies in particular, a single injury can be catastrophic and even fatal.

It can sometimes be difficult to recognise whether an injury has been caused accidentally or non-accidentally, but it is vital that all concerned with children are alert to the possibility that an injury may not be accidental, and seek appropriate expert advice. Medical opinion will be required to determine whether an injury has been caused accidentally or not.

The Royal College of Paediatrics and Child Health have developed an evidence-based resource for clinicians in to help inform clinical practice, child protection procedures and professional and expert opinion in the legal system. The resource comprises 15 systematic reviews covering a range of issues including bites, bruising, fractures, burns, dental neglect, oral injuries and spinal injuries.

Female Genital Mutilation (FGM) and breast ironing / breast flattening are also forms of physical abuse.

4.1 Bruising

See also:

Bradford, Calderdale, Kirklees and Wakefield District Safeguarding Children Partnerships - Multi-Agency Protocol for the Assessment of Bruising, Burns and Scalds in Non Mobile Babies

Leeds Multi-agency Protocol for Bruising in Non-independently Mobile Children

Bruising is the most common injury in physical child abuse. However, it is also common in non abused children - except pre mobile babies. The main diagnostic dilemma is distinguishing abusive from non-abusive bruises. It may be necessary to undertake a variety of medical investigations to determine if there is an underlying medical reason for the skin changes. The possibility of non-accidental injury or inflicted injury must be considered where there is a lack of adequate explanation; this would include the following:

• All actual or suspected bruising, burns or scalds to babies who are not yet self-mobile;
• Disabled children may bruise due to knocks during transfers or ill fitting equipment. However, the pattern of bruising and the developmental assessment of the child should be considered to ascertain whether those bruises are concerning for physical abuse;
• The head is the most common site of bruising in child abuse. Other commonly bruised sites in abuse include the ear, neck, trunk, buttocks, thighs and arms. Bruises on soft parts of the body such as the cheeks, ears, neck, genitalia and buttocks are rarely seen in non-abused children, in contrast to abused children;
• Abusive bruises can carry the imprint of the implement used. These include single or multiple linear bruising due to being struck with a rod-like instrument, banding where the hand has been tied or an imprint of the implement such as an electrical cord, studded belt or dog collar;
• The present of petechiae (pin point non blanching spots) with bruising occurs more commonly in abuse than accidental injuries. However, the absence of petchiae is not helpful in excluding abuse. Petichiae in the absence of bruising may occur as a consequence of suffocation. Petechiae was located on the skin of the face and throat, the upper thorax, the shoulders and the mucous membranes of the mouth;
• Clusters of bruises are a common feature in abused children. These are often defensive injuries as the child tries to protect their head; on the upper arm, side of chest, outside of the thigh or bruises on the trunk and adjacent;
• Bruising in or around the mouth, particularly in small babies, for example 3 to 4 small round or oval bruises on one side of the face and one on the other, which may indicate force feeding.

4.2 Fractures

Fractures may cause pain, swelling and discolouration over a bone or joint. It is unlikely that a child will have had a fracture without the carers being aware of the child's distress.

If the child is not using a limb, has pain on movement and/or swelling of the limb, there may be a fracture. 

There are grounds for concern if:

• The history provided is vague, non-existent or inconsistent with the fracture type;
• There are associated old fractures;
• Medical attention is sought after a period of delay when the fracture has caused symptoms such as swelling, pain or loss of movement;
• There is an unexplained fracture in the first year of life.

4.3 Abusive head trauma (AHT)

Abusive head trauma  is the commonest cause of death in physical child abuse. It is predominantly seen in children under the age of two; most commonly in those under six months of age. The mortality from AHT is up to 30%. Half of the survivors have residual disability of variable severity.

Infants with AHT present to hospital with a variety of symptoms. These range from poor feeding, lethargy, fits and respiratory difficulty to sudden death. In some cases, the absence of either a history or external signs of injury may delay diagnosis. Not all infants are acutely ill; others present for example with an increasing head circumference. Children with chronic subdural haemorrhage or effusions present a diagnostic problem because many lack a clear history of symptom-onset and corroborative findings are usually absent.

The diagnosis of AHT must be considered in any infant or young child who has an unexplained ALTE (Apparent Life-Threatening Event) or apnoeic episode.

Important features of AHT

It is widely accepted that AHT arises from severe repetitive rotational, acceleration - deceleration injury (from shaking) with or without additional impact, or impact alone.

Features associated with AHT include:

• Extra axial bleeding: subdural and subarachnoid haemorrhages (extradural haemorrhages are rarely seen in AHT and far more commonly seen in unintentional injury);
• Subdural collections are often multiple, and common sites are over the convexity of the cerebral hemisphere, inter-hemispheric or in the posterior fossa. In the acute stage they are typically small and do not cause mass effect;
• Brain injury – includes hypoxic ischaemic injury, cerebral oedema and parenchymal injury; which are likely to be responsible for the poor outcome in these children;
• Retinal haemorrhages (RH) in one or more usually both eyes are reported in 70-80% of cases of AHT;
• Bruising/abrasions, lacerations or swelling to the head; including scalp or face;
• Skull fracture(s), usually with overlying haematoma if injury is recent;
• Skeletal injury: rib or long bone fractures. There is a recognised association with cervical spinal injury;
• Bruising;
• Apnoea and seizures;
• Neck and cervical spinal cord injury.

4.4 Mouth Injuries

Tears to the frenulum (tissue attaching upper lip to gum) often indicates force feeding of a baby. There is often finger bruising to the cheeks and around the mouth. Rarely, there may also be grazing on the palate. Blunt trauma to the mouth causes swelling and damage to the inner aspect of the lips.

4.5 Internal Injuries

There may be internal injury e.g. perforation to the gut or intra abdominal organ with no apparent external signs of bruising to the abdomen wall.

4.6 Poisoning

Ingestion of tablets or domestic poisoning in children under 5 is usually due to the lack of appropriate supervision from a parent or carer, but it may be self harm even in young children.

See also Perplexing Presentations (PP) and Fabricated or Induced Illness (FII) in Children Procedure.

4.7 Bite Marks

Human bites are always inflicted injuries. They are currently the only physically abusive injury where there is the potential to identify the perpetrator. This may be from dental characteristics or from salivary DNA. Therefore, it is essential that paediatricians recognise a potential bite and refer to a forensic odontologist where available.

Many human bites are not recognised as such and are dismissed as bruises. Any bruise with the shape of opposing curves should be treated as suspicious and the services of a forensic odontologist sought early in the investigation. The forensic odontologist will take dental impressions of any suspected perpetrators and make a comparison with the bite mark on the skin (this may also apply to children who are accused of causing the bite) and, if necessary, will present the evidence in court as an expert witness.

So-called 'love bites' are suction marks caused by the mouth with or without teeth marks and can appear as petechial haemorrhages.

Bite marks can leave clear impressions of the teeth when seen shortly after the injury has been inflicted. The shape then becomes a more defused ring bruise or oval or crescent shaped. Those over 3cm in diameter are more likely to have been caused by an adult or older child.

A medical/dental opinion, preferably within the first 24 hours, should be sought where there is any doubt over the origin of the bite (for example it may be a dog bite).

4.8 Burns and Scalds

Please also refer to:

Bradford, Calderdale, Kirklees and Wakefield District Safeguarding Children Partnerships Multi-Agency Protocol for the Assessment of Non Mobile Babies with Injuries Including Bruising, Burns and Scalds in Non Mobile Babies

Leeds Multi Agency for the Assessment of Suspected Neglectful or Inflicted Burn or Scald Injury

It can be difficult to distinguish between accidental and non-accidental burns and scalds, and will always require experienced medical opinion. Any burn with a clear outline may be suspicious e.g.:

• Circular burns from cigarettes (but may be friction burns if along the bony protuberance of the spine or impetigo in which case they will quickly heal with treatment);
• Linear burns from hot metal rods or electrical fire elements;
• Burns of uniform depth over a large area;
• Scalds that have a line indicating immersion (glove and sock burns) or poured liquid (a child getting into hot water of its own accord will struggle to get out and cause splash marks);
• Old scars indicating previous burns/scalds which did not have appropriate treatment or adequate explanation.

Scalds to the buttocks of a small child, particularly in the absence of burns to the feet, are indicative of dipping into a hot liquid or bath.

The following points are also worth remembering:

• A responsible adult checks the temperature of the bath before the child gets in;
• A child is unlikely to sit down voluntarily in a hot bath and cannot accidentally scald its bottom without also scalding their feet;
• A child getting into too hot water of their own accord will struggle to get out and there will be splash marks.

See also: Bathtime Duck (Leeds Safeguarding Children Partnership).

4.9 Scars

A large number of scars or scars of different sizes or ages, or on different parts of the body, or unusually shaped, may suggest abuse.

5. Recognising Emotional Abuse

Emotional abuse may be difficult to recognise, as the signs are usually behavioural rather than physical. The manifestations of emotional abuse might also indicate the presence of other kinds of abuse.

The indicators of emotional abuse are often also associated with other forms of abuse.

The following may be indicators of emotional abuse:

• Developmental delay;
• Inappropriate emotional responses (e.g. overly affectionate to strangers);
• Abnormal attachment between a child and parent/carer e.g. anxious, indiscriminate or no attachment;
• Indiscriminate attachment or failure to attach;
• Aggressive behaviour towards others;
• A child scapegoated within the family;
• Frozen watchfulness, particularly in pre-school children;
• Low self esteem and lack of confidence;
• Withdrawn or seen as a 'loner' difficulty relating to others;
• A child who is sad, tearful, or unhappy looking;
• A child living in a household with domestic abuse.

Domestic Abuse

Children can be affected by seeing, hearing and living with domestic abuse as well as being caught up in any incidents directly, whether to protect someone or as a target. It should also be noted that young people aged 16 and 17 have been found in recent studies to be increasingly affected by domestic abuse in their peer relationships.

Domestic abuse can encompass a wide range of behaviours and may be a single incident or a pattern of incidents. Domestic abuse is not limited to physical acts of violence or threatening behaviour, and can include emotional, psychological, controlling or coercive behaviour, sexual and/or economic abuse. Types of domestic abuse include intimate partner violence, abuse by family members, teenage relationship abuse and adolescent to parent violence. Anyone can be a victim of domestic abuse, regardless of gender, age, ethnicity, socio-economic status, sexuality or background and domestic abuse can take place inside or outside of the home.

. Domestic abuse has a significant impact on children and young people. Children may experience domestic abuse directly, as victims in their own right, or indirectly due to the impact the abuse has on others such as the non-abusive parent.

6. Recognising Sexual Abuse

A child under the age of 13 is not legally capable of consenting to sex (it is statutory rape) or any other type of sexual touching:

• Sexual activity with a child over 15 but under 16 is also an offence;
• It is an offence for a person to have a sexual relationship with a 16 or 17 year old if they hold a position of trust or authority in relation to them;
• Although sexual activity with a 16 or 17 year old does not result in an offence being committed, it may still result in harm, or the likelihood of harm being suffered;
• Non-consensual sex is rape whatever the age of the victim; and
• If the victim is incapacitated through drink or drugs, or the victim or their family has been subject to violence or the threat of it, they cannot be considered to have given true consent; therefore offences may have been committed.

Child sexual exploitation is therefore potentially a child protection issue for all children under the age of 18 years, and for boys as well as girls.

Boys and girls of all ages may be sexually abused. Children are unlikely to tell someone that they are being sexually abused, particularly when the perpetrator is known to them. Therefore, parents, professionals and the public must understand and know how to respond to the signs and symptoms of child sexual abuse. This includes recognising the signs of abusive relationships between an adult and a child, or between two children, and relationships that lack boundaries. Everyone in society needs to know how to recognise the signs of abuse of a child and how best to respond when they suspect a child is being abused.

Verbal disclosure by children is rare, so professionals and other responsible adults need to be able to spot the signs of possible abuse and take appropriate action. The nature of disclosure as a process means that some disclosures are partial, and more detail may emerge over time. The details of the abuse will largely be missing when disclosure is communicated through behaviours or other signals.

Disclosures, when they do occur, are often not recognised or are misunderstood, dismissed or ignored. Some groups of children, such as boys, disabled children and children from some ethnic minority groups face greater barriers to disclosure.

Girls in some communities find it very difficult to raise the subject of sexual abuse because of religious and cultural beliefs and attitudes towards women, so they do not disclose for fear of reprisal or rejection from the family or wider community. When they do disclose, they can feel responsible for the sexual violence and for the potential perceived loss of theirs and their family's honour.

Disabled children may be less likely to disclose at all, and more likely to delay disclosure, compared with other children. There are also barriers for disabled children in child protection processes, including:

• Failure to recognise abuse or apply appropriate thresholds;
• Lack of holistic assessment;
• Lack of communication with the child and maintaining a focus on their needs;
• Despite improvements, a continuing lack of effective multi-agency working.

Children abused by a female family member can face higher levels of disbelief from professionals, who may also view the abuse as less serious and less harmful than male-perpetrated abuse.

To enable children to disclose, they need access to safe adults with the skills to listen and the opportunity to obtain information and confidentially explore the consequences of disclosure.

Just because children have not verbally disclosed the abuse does not mean they have not disclosed. Many children do not 'tell' in a straightforward way; rather, their behaviour and demeanour or the characteristics or behaviour of caregivers indicates that something is wrong. In the same way in which a child might not disclose any other form of abuse, such as neglect or emotional abuse, professionals can still work to uncover or protect the child from sexual abuse without a verbal disclosure from the child themselves.

Some behavioural indicators associated with this form of abuse are:

• Sexualised behaviour which is not age appropriate;
• Sexual knowledge which is not age appropriate;
• Sexually explicit behaviour, play or conversation, which is not age appropriate;
• Continual and inappropriate or excessive masturbation;
• Self-harm (including eating disorder), self mutilation and suicide attempts;
• Wetting and soiling (especially in older children or those who have previously been 'dry');
• Running away from home;
• Poor concentration and learning problems;
• Loss of self-esteem;
• Involvement in sexual exploitation;
• An anxious unwillingness to remove clothes for - e.g. sports events (but this may be related to cultural norms or physical difficulties).

Some physical indicators associated with this form of abuse are:

• Pain or itching of genital area;
• Urine infections or STIs;
• Recurrent pain on passing urine or faeces / secondary incontinence;
• Blood on underclothes;
• Pregnancy in a child or young person who is unable to consent (including learning disabilities);
• Pregnancy in a younger girl where the identity of the father is not disclosed and/or there is secrecy or vagueness about the identity of the father;
• Physical symptoms such as injuries to the genital or anal area, bruising to buttocks, abdomen and thighs, 'love bites' sexually transmitted infection, presence of semen on vagina, anus, external genitalia or clothing.

See also: Child Sexual Abuse in the Family Environment Procedure for further guidance of what constitutes sexual abuse.

7. Recognising Neglect

Please also refer to:

• Bradford Neglect Strategy;
• Bradford Neglect Toolkit;
• Calderdale Neglect Strategy;
• Kirklees Neglect Strategy;
• Leeds Local Protocol: Recognising, Assessing and Responding to Neglect;
• Wakefield Neglect Toolkit.

The growth and development of a child may suffer when the child receives insufficient or inappropriate food, love, warmth, care and concern, praise, encouragement and stimulation. Apart from the child's neglected appearance, other signs may include:

• Short stature and underweight / failure to thrive;
• Medical neglect – Lack of parental response where a child is identified as seriously at risk from any medical disorder including severe obesity with medical risk;
• Poor compliance with medication or treatment
• Persistent Red/purple mottled skin, particularly on the hands and feet, seen in the winter due to cold whereby there is no known / suspected medical explanation;
• Swollen limbs with sores that are slow to heal, usually associated with cold injury whereby there is no known / suspected medical explanation;
• Abnormal voracious appetite at school or nursery / stealing food in an underweight child;
• Dry, sparse hair / greasy hair,
• persistent head lice;
• Dirty or smelly skin, dirty nails,
• Persisting dental caries, despite input from dental and other professionals (see dental neglect guidance)
• Persistent worms;
• Inappropriate or ill-fitting clothing/shoes;
• A child seen to be listless, apathetic and unresponsive or watchful / frozen awareness with no apparent medical cause;
• Unresponsiveness;
• Tired, fatigued, bags under eyes, sleeping in school time;
• Indiscrimination in relationships with adults (may be attention seeking);
• Frequent "was not brought" episodes to important appointments / vaccination / reviews.

A clear distinction needs to be made between organic and non-organic failure to thrive. This may require a medical diagnosis or it may be possible to see the pattern of neglect leading to poor growth. Non-organic failure to thrive or faltering growth are the terms used when a child does not put on weight and grow as expected and there is no underlying medical cause for this. For additional guidance, see Faltering Growth Policy.

Obesity is not about how a child looks it’s about the damage this is doing to the body. Childhood obesity or failure to reduce weight alone is not a child protection concern. However, neglect or abuse may be factors in development (cause) of the obesity and / or failure to act when a child is identified as at risk (maintenance). Only a very small number of children will reach the safeguarding threshold in relation to obesity linked to neglect. Further information is available within the article by R Viner in the British Medical Journal.

8. Impact of Abuse and Neglect

The sustained abuse or neglect of children physically, emotionally, or sexually can have long-term effects on the child's health, development and well-being. It can impact significantly on a child's self esteem, self image and on their perception of self and of others. The effects can extend into adult life and lead to difficulties in forming and sustaining positive and close relationships. In some situations it can affect parenting ability and lead to the perpetration of abuse on others.

In particular, physical abuse can lead directly to neurological damage, as well as physical injuries, disability or at the extreme, death. Harm may be caused to children, both by the abuse itself, and by the abuse taking place in a wider family or institutional context of conflict and aggression. Physical abuse has been linked to aggressive behaviour in children, emotional and behavioural problems and educational difficulties.

Severe neglect of young children is associated with major impairment of growth and intellectual development. Persistent neglect can lead to serious impairment of health and development, and long term difficulties with social functioning, relationship and educational progress. Neglect can also result in extreme cases in death.

Sexual abuse can lead to behavioural concerns including self-harm, anxiety and inappropriate sexual behaviour. The adverse effects may last into adulthood. The severity of impact is believed to increase the longer the abuse continues, the more extensive the abuse and the older the child. A child's ability to cope with the experience of sexual abuse, once recognised or disclosed, will be strengthened by the support of a non-abusive adult or carer who believes the child, helps the child to understand the abuse and is able to offer help and protection.

There is increasing evidence of the adverse long-term consequences for children's development where they have been subject to sustained emotional abuse. Emotional abuse has an important impact on a developing child's mental health, attachment and self-esteem. It can be especially damaging in infancy. Underlying emotional abuse may be as important, if not more so, than other more visible forms of abuse in terms of its impact on the child. Domestic abuse, adult mental health problems and parental substance misuse may be features in families where children are exposed to such abuse.

The context in which the abuse takes place may also be significant. The interaction between a number of different factors can serve to minimise or increase the likelihood or level of significant harm. Relevant factors will include the individual child's coping and adapting strategies, support from family or social network, the impact and quality of professional interventions and subsequent life events.