child neglect case study uk

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• Published: 11 September 2017

A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy

• Magdalena Romanowicz   ORCID: orcid.org/0000-0002-4916-0625 1 ,
• Alastair J. McKean 1 &
• Jennifer Vande Voort 1  

BMC Psychiatry volume  17 , Article number:  330 ( 2017 ) Cite this article

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Long-term effects of neglect in early life are still widely unknown. Diversity of outcomes can be explained by differences in genetic risk, epigenetics, prenatal factors, exposure to stress and/or substances, and parent-child interactions. Very common sub-threshold presentations of children with history of early trauma are challenging not only to diagnose but also in treatment.

Case presentation

A Caucasian 4-year-old, adopted at 8 months, male patient with early history of neglect presented to pediatrician with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. He was subsequently seen by two different child psychiatrists. Pharmacotherapy treatment attempted included guanfacine, fluoxetine and amphetamine salts as well as quetiapine, aripiprazole and thioridazine without much improvement. Risperidone initiated by primary care seemed to help with his symptoms of dyscontrol initially but later the dose had to be escalated to 6 mg total for the same result. After an episode of significant aggression, the patient was admitted to inpatient child psychiatric unit for stabilization and taper of the medicine.

Conclusions

The case illustrates difficulties in management of children with early history of neglect. A particular danger in this patient population is polypharmacy, which is often used to manage transdiagnostic symptoms that significantly impacts functioning with long term consequences.

Peer Review reports

There is a paucity of studies that address long-term effects of deprivation, trauma and neglect in early life, with what little data is available coming from institutionalized children [ 1 ]. Rutter [ 2 ], who studied formerly-institutionalized Romanian children adopted into UK families, found that this group exhibited prominent attachment disturbances, attention-deficit/hyperactivity disorder (ADHD), quasi-autistic features and cognitive delays. Interestingly, no other increases in psychopathology were noted [ 2 ].

Even more challenging to properly diagnose and treat are so called sub-threshold presentations of children with histories of early trauma [ 3 ]. Pincus, McQueen, & Elinson [ 4 ] described a group of children who presented with a combination of co-morbid symptoms of various diagnoses such as conduct disorder, ADHD, post-traumatic stress disorder (PTSD), depression and anxiety. As per Shankman et al. [ 5 ], these patients may escalate to fulfill the criteria for these disorders. The lack of proper diagnosis imposes significant challenges in terms of management [ 3 ].

J is a 4-year-old adopted Caucasian male who at the age of 2 years and 4 months was brought by his adoptive mother to primary care with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. J was given diagnoses of reactive attachment disorder (RAD) and ADHD. No medications were recommended at that time and a referral was made for behavioral therapy.

She subsequently took him to two different child psychiatrists who diagnosed disruptive mood dysregulation disorder (DMDD), PTSD, anxiety and a mood disorder. To help with mood and inattention symptoms, guanfacine, fluoxetine, methylphenidate and amphetamine salts were all prescribed without significant improvement. Later quetiapine, aripiprazole and thioridazine were tried consecutively without behavioral improvement (please see Table  1 for details).

No significant drug/substance interactions were noted (Table 1 ). There were no concerns regarding adherence and serum drug concentrations were not ordered. On review of patient’s history of medication trials guanfacine and methylphenidate seemed to have no effect on J’s hyperactive and impulsive behavior as well as his lack of focus. Amphetamine salts that were initiated during hospitalization were stopped by the patient’s mother due to significant increase in aggressive behaviors and irritability. Aripiprazole was tried for a brief period of time and seemed to have no effect. Quetiapine was initially helpful at 150 mg (50 mg three times a day), unfortunately its effects wore off quickly and increase in dose to 300 mg (100 mg three times a day) did not seem to make a difference. Fluoxetine that was tried for anxiety did not seem to improve the behaviors and was stopped after less than a month on mother’s request.

J’s condition continued to deteriorate and his primary care provider started risperidone. While initially helpful, escalating doses were required until he was on 6 mg daily. In spite of this treatment, J attempted to stab a girl at preschool with scissors necessitating emergent evaluation, whereupon he was admitted to inpatient care for safety and observation. Risperidone was discontinued and J was referred to outpatient psychiatry for continuing medical monitoring and therapy.

Little is known about J’s early history. There is suspicion that his mother was neglectful with feeding and frequently left him crying, unattended or with strangers. He was taken away from his mother’s care at 7 months due to neglect and placed with his aunt. After 1 month, his aunt declined to collect him from daycare, deciding she was unable to manage him. The owner of the daycare called Child Services and offered to care for J, eventually becoming his present adoptive parent.

J was a very needy baby who would wake screaming and was hard to console. More recently he wakes in the mornings anxious and agitated. He is often indiscriminate and inappropriate interpersonally, unable to play with other children. When in significant distress he regresses, and behaves as a cat, meowing and scratching the floor. Though J bonded with his adoptive mother well and was able to express affection towards her, his affection is frequently indiscriminate and he rarely shows any signs of separation anxiety.

At the age of 2 years and 8 months there was a suspicion for speech delay and J was evaluated by a speech pathologist who concluded that J was exhibiting speech and language skills that were solidly in the average range for age, with developmental speech errors that should be monitored over time. They did not think that issues with communication contributed significantly to his behavioral difficulties. Assessment of intellectual functioning was performed at the age of 2 years and 5 months by a special education teacher. Based on Bailey Infant and Toddler Development Scale, fine and gross motor, cognitive and social communication were all within normal range.

J’s adoptive mother and in-home therapist expressed significant concerns in regards to his appetite. She reports that J’s biological father would come and visit him infrequently, but always with food and sweets. J often eats to the point of throwing up and there have been occasions where he has eaten his own vomit and dog feces. Mother noticed there is an association between his mood and eating behaviors. J’s episodes of insatiable and indiscriminate hunger frequently co-occur with increased energy, diminished need for sleep, and increased speech. This typically lasts a few days to a week and is followed by a period of reduced appetite, low energy, hypersomnia, tearfulness, sadness, rocking behavior and slurred speech. Those episodes last for one to 3 days. Additionally, there are times when his symptomatology seems to be more manageable with fewer outbursts and less difficulty regarding food behaviors.

J’s family history is poorly understood, with his biological mother having a personality disorder and ADHD, and a biological father with substance abuse. Both maternally and paternally there is concern for bipolar disorder.

J has a clear history of disrupted attachment. He is somewhat indiscriminate in his relationship to strangers and struggles with impulsivity, aggression, sleep and feeding issues. In addition to early life neglect and possible trauma, J has a strong family history of psychiatric illness. His mood, anxiety and sleep issues might suggest underlying PTSD. His prominent hyperactivity could be due to trauma or related to ADHD. With his history of neglect, indiscrimination towards strangers, mood liability, attention difficulties, and heightened emotional state, the possibility of Disinhibited Social Engagement Disorder (DSED) is likely. J’s prominent mood lability, irritability and family history of bipolar disorder, are concerning for what future mood diagnosis this portends.

As evidenced above, J presents as a diagnostic conundrum suffering from a combination of transdiagnostic symptoms that broadly impact his functioning. Unfortunately, although various diagnoses such as ADHD, PTSD, Depression, DMDD or DSED may be entertained, the patient does not fall neatly into any of the categories.

This is a case report that describes a diagnostic conundrum in a young boy with prominent early life deprivation who presented with multidimensional symptoms managed with polypharmacy.

A sub-threshold presentation in this patient partially explains difficulties with diagnosis. There is no doubt that negative effects of early childhood deprivation had significant impact on developmental outcomes in this patient, but the mechanisms that could explain the associations are still widely unknown. Significant family history of mental illness also predisposes him to early challenges. The clinical picture is further complicated by the potential dynamic factors that could explain some of the patient’s behaviors. Careful examination of J’s early life history would suggest such a pattern of being able to engage with his biological caregivers, being given food, being tended to; followed by periods of neglect where he would withdraw, regress and engage in rocking as a self-soothing behavior. His adoptive mother observed that visitations with his biological father were accompanied by being given a lot of food. It is also possible that when he was under the care of his biological mother, he was either attended to with access to food or neglected, left hungry and screaming for hours.

The current healthcare model, being centered on obtaining accurate diagnosis, poses difficulties for treatment in these patients. Given the complicated transdiagnostic symptomatology, clear guidelines surrounding treatment are unavailable. To date, there have been no psychopharmacological intervention trials for attachment issues. In patients with disordered attachment, pharmacologic treatment is typically focused on co-morbid disorders, even with sub-threshold presentations, with the goal of symptom reduction [ 6 ]. A study by dosReis [ 7 ] found that psychotropic usage in community foster care patients ranged from 14% to 30%, going to 67% in therapeutic foster care and as high as 77% in group homes. Another study by Breland-Noble [ 8 ] showed that many children receive more than one psychotropic medication, with 22% using two medications from the same class.

It is important to note that our patient received four different neuroleptic medications (quetiapine, aripiprazole, risperidone and thioridazine) for disruptive behaviors and impulsivity at a very young age. Olfson et al. [ 9 ] noted that between 1999 and 2007 there has been a significant increase in the use of neuroleptics for very young children who present with difficult behaviors. A preliminary study by Ercan et al. [ 10 ] showed promising results with the use of risperidone in preschool children with behavioral dyscontrol. Review by Memarzia et al. [ 11 ] suggested that risperidone decreased behavioral problems and improved cognitive-motor functions in preschoolers. The study also raised concerns in regards to side effects from neuroleptic medications in such a vulnerable patient population. Younger children seemed to be much more susceptible to side effects in comparison to older children and adults with weight gain being the most common. Weight gain associated with risperidone was most pronounced in pre-adolescents (Safer) [ 12 ]. Quetiapine and aripiprazole were also associated with higher rates of weight gain (Correll et al.) [ 13 ].

Pharmacokinetics of medications is difficult to assess in very young children with ongoing development of the liver and the kidneys. It has been observed that psychotropic medications in children have shorter half-lives (Kearns et al.) [ 14 ], which would require use of higher doses for body weight in comparison to adults for same plasma level. Unfortunately, that in turn significantly increases the likelihood and severity of potential side effects.

There is also a question on effects of early exposure to antipsychotics on neurodevelopment. In particular in the first 3 years of life there are many changes in developing brains, such as increase in synaptic density, pruning and increase in neuronal myelination to list just a few [ 11 ]. Unfortunately at this point in time there is a significant paucity of data that would allow drawing any conclusions.

Our case report presents a preschool patient with history of adoption, early life abuse and neglect who exhibited significant behavioral challenges and was treated with various psychotropic medications with limited results. It is important to emphasize that subthreshold presentation and poor diagnostic clarity leads to dangerous and excessive medication regimens that, as evidenced above is fairly common in this patient population.

Neglect and/or abuse experienced early in life is a risk factor for mental health problems even after adoption. Differences in genetic risk, epigenetics, prenatal factors (e.g., malnutrition or poor nutrition), exposure to stress and/or substances, and parent-child interactions may explain the diversity of outcomes among these individuals, both in terms of mood and behavioral patterns [ 15 , 16 , 17 ]. Considering that these children often present with significant functional impairment and a wide variety of symptoms, further studies are needed regarding diagnosis and treatment.

Abbreviations

Attention-Deficit/Hyperactivity Disorder

Disruptive Mood Dysregulation Disorder

Disinhibited Social Engagement Disorder

Post-Traumatic Stress Disorder

Reactive Attachment disorder

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MR, AJM, JVV conceptualized and followed up the patient. MR, AJM, JVV did literature survey and wrote the report and took part in the scientific discussion and in finalizing the manuscript. All the authors read and approved the final document.

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Romanowicz, M., McKean, A.J. & Vande Voort, J. A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy. BMC Psychiatry 17 , 330 (2017). https://doi.org/10.1186/s12888-017-1492-y

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Serious Case Review (SCR) analysis 2020 for the education sector: Neglect

Neglect was found to be a feature in three-quarters of all SCRs considered. It is therefore important for education professionals to understand this learning and how to respond to protect children from the harmful effects of neglect.

Neglect is consistently the most common initial category of abuse for children on a child protection plan, and the number of children on such plans for neglect has been rising in recent years from 41.8 per cent in 2013 to 48 per cent in 2018.

What is notable throughout this analysis, is the complexity of family circumstances and cumulative nature of harm through neglect.

It is well understood that neglectful parenting is almost inevitably a sign of complex and longstanding problems, such as parental mental health and domestic abuse.

This presents a challenge for educational professionals to keep a wide view of the challenges a family may be facing and the impact on the child, asking questions to explore all of the factors.

There is evidence from a range of studies that suggests a strong link between the socio-economic circumstances of the family and the likelihood of a child experiencing abuse and neglect.

Focus on: Poverty blindness

Research has found that professionals who work with children and families sometimes normalise and become ‘blind’ to poverty in their assessment of risk and need for support. Poverty is often seen as an outcome or co-existing factor rather than a potential cause of a family’s difficulties.

Poverty blindness may occur where professionals are working in areas of high deprivation and so poverty becomes the norm and an associated desensitisation to warning signs of poor hygiene, dirty clothes and poor dental hygiene.

For those working in education, and particularly in areas of high deprivation, consideration should be given to how to ensure that lower standards of child care and living conditions are not accepted.

Case example: Poverty blindness

Cara was a two-year-old White British girl who died from ingesting 20ml of her mother’s methadone. She was born the youngest of five children to a mother struggling with long-term drug addiction and domestic abuse. On admittance to hospital she was found to be suffering from neonatal abstinence syndrome. The family had a long history of contact with adult and children’s services; all the children had some degree of developmental needs.

Concerns over poverty and the state of the home had been identified some five years prior to the birth of Cara. At one point the family were living with no furniture or carpets, all the children shared a single bed and there was very little food in the house. On other occasions the younger children failed to attend nursery because of unpaid fees. There were times when Cara’s mother borrowed money from relatives to buy food or depended on charities to supply food parcels.

The primary focus for agencies was to improve the physical conditions of the home and to ensure that the parents continued to attend their drug treatment programme. The parents sometimes struggled to manage their finances. The lack of assessment of the ways in which poverty affected the children, resulted in short-term bursts of activity to clean up the home or provide cash or food for the children. Signs of improvement resulted in the case being closed to children’s social care. The underlying causes of the family’s poverty and its relationship with parental drug addiction were not explored. Perhaps most significant was the lack of any exploration of the children’s experiences and how poverty impacted on their safety, health and overall development.

Early help assessment, intervention and monitoring

The use of early-help assessments by practitioners that work with children and families are a helpful tool for understanding risk and prompting early protective and supportive action. Schools and education professionals are well-positioned to initiate and coordinate this process.

As evidenced through several cases analysed in this review, early assessment and intervention is not always taken early enough.

This is compounded where incidents are seen in isolation and not considered or tracked effectively as part of a pattern of concern.

Lack of professional curiosity can also extend to adolescents showing challenging behaviour or involved in anti-social behaviour or crime, where their actions are not considered in the context of their experience of neglect.

A common feature in the cases of neglect analysed is a so-called ‘spiralling-risk’ – a period of low-level concerns followed by a sudden escalation of risk. A thorough chronology of all historic concerns and incidents, reviewed and monitored regularly, can help to identify cumulating risk and prompt early intervention.

Early help assessments also present an opportunity to create a shared chronology across agencies and thus prevent ‘fractured perspectives’ of different professionals holding information in isolation.

Case example: Spiralling risk

In one SCR of neglect, the reviewers concluded that:

• The use of a chronology identifying missed appointments and untruths should have formed part of the historical information available to professionals working with the family so they could triangulate such information and at least catalogue the extent and nature of the ‘non-compliance’. Whilst this historical information should not determine current thinking, it should have significant impact on decision-making.
• The overview reviewers found there was a tendency to focus on ‘the concern of the moment’ rather than seeing the whole picture. There was an inadequate use of chronologies which, had they been used, may have aided in an earlier identification of problems in this case.

Voice of the child

Empowering children to express their views and talk about their experiences is central to effective safeguarding practice, however, it is something that is all-too-often missing in cases that result in a SCR. Those in schools, both teachers and support staff, have daily contact with children and so are well placed to notice concerning changes and recognise the voice of the child.

Even when a child’s disclosure is responded to, triggering child protection action, their emotional and developmental needs can be overlooked in providing support.

Adolescents may be especially vulnerable to the effects of neglect on their mental health, behaviour and vulnerability to exploitation with a correlation seen in self-harm and suicide.

Whilst listening to the views of children and young people is essential, the child’s wishes must be balanced with the responsibility to ensure their welfare and safety.

Any assessment of a child’s competency to make decisions should be based on a full understanding of their life experiences and vulnerabilities.

Case example: Voice of the adolescent

One example of neglect and subsequent suicide included in the reviews is that of an adolescent who took a fatal dose of opiates aged 15 years. Born with serious narcotic withdrawal symptoms into a family with a long history of substance misuse, sex work, alcohol-fuelled violence and domestic abuse, the harmful influence of the family shaped this child’s life. Signs of distress and self-harm were first identified by a schoolteacher when the child was 12 years old. When asked about the cuts on her arms the teacher reported being told ‘when I am feeling this pain, I am not feeling anything else’.

Examples of self-harm escalated to the extent that prior to the fatal overdose, 32 episodes had been recorded. Although all the professionals working with this child were aware of her extreme vulnerability, there was little recorded of what life was like for her or her perspective, views and wishes, in the SCR.

In this particular case, if the incidents of self-harming had been managed as safeguarding concerns, there is greater likelihood that the police and children’s services along with other professionals would have engaged in a strategy meeting that focused on the nature of risk and supported a much clearer sharing of information.

Wider family and community support

A child’s wider family and community can be a valuable source of support and intervention, and perhaps especially so in cases of neglect where its longstanding nature may take greater resources to combat. Schools may be both a key resource themselves, and a point of expertise and coordination of support networks available in the community. However, all-too-often, these opportunities are ignored or downplayed by professionals.

The invisibility of men in parental roles and the issue of absent fathers persists in the sample of cases analysed here.

Professionals can overlook gaining an understanding of the risks (and potential strengths and protective factors) posed by men in a child’s life in their assessment and support plans.

The commitment of relatives was noted in a number of SCRs. However, their perspectives, voice and the significance of their relationship can be easily lost and should be actively sought out as part of establishing the context of a child’s life and experience.

A consideration should be made, when planning support, of not only the statutory agencies that should be involved, but also the voluntary or community resources that might be available and engaged for the benefit of the family.

Focus on: Role of the school nurse

Cases considered in this analysis showed how school-based assessments by the school nurse can be helpful in ensuring that the child’s voice is heard. School nurses are often well-placed to do this and trusted by the child. However, this does not always mean that this voice is used to initiate meaningful intervention. In one example:

‘A child was observed to be very tired and wearing a dirty ill-fitting school uniform; his face was unwashed and nose dirty. He reported the children were given biscuits or crisps with tea instead of an evening meal. He contrasted this with the proper cooked dinners (meat and pasta) whilst fostered. This led to a social worker being tasked with monitoring their evening meals.’

In this case, an assessment of concern did not lead to suitable protective action with a clear outcome. The child’s voice was lost in the reactive response that it generated, without taking a holistic approach.

Key learning for education

• Professional curiosity is all-too-often lost and seemingly small incidents or concerns not fully explored.
• Cumulative harm is often poorly recognised, with action being triggered only on a sudden escalation of risk.
• Early assessment, intervention and monitoring can help to track risk and provide timely support; however, it is often not done early enough.
• Schools need to understand how poverty may affect children and work to actively avoid the desensitisation that can result from working in areas of high deprivation.
• Whilst some interventions, such as providing food through breakfast clubs, can help to address the manifestations of poverty and a chaotic lifestyle, they do not assure safety.
• School staff are uniquely placed to capture the voice of the child and notice distress or behaviour changes through the development of trusting relationships.
• Whilst non-compliance of parents or caregivers should be noted, there is a danger in labelling individuals as resistant or hard to engage. Instead, professionals should explore the underlying issues that are limiting engagement and try to address them.
• The role of men in a child’s life, the wider family and community are often overlooked – both in terms of risk and as a protective or supportive resource.
• In cases of persisting self-harm or disturbing behaviour, a reactive approach is all-too-often taken, instead of proactively exploring underlying factors and issues.

Questions for education settings to consider

• How confident are you that your processes and recording system for child protection and safeguarding allows you to effectively record low-level concerns and track and monitor cumulative risk?
• How do you ensure that you both capture the voice of the child routinely in your contact with them, and keep it at the front of decision-making and support planning?
• How do you actively enable children with additional needs, such as learning and communication difficulties, to express their wishes and feelings?
• How can teachers, support staff and others working with children be trained on the signs and significance of poverty and neglect to ensure that they do not become desensitised to it?
• What is your approach to early assessment and intervention? Are resources effectively allocated to ensure that it can take place meaningfully?

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Star Hobson case raises more questions over burden on children’s services

Social work department had been struggling for years, was deluged with work and had huge staff turnover

Another week, yet another terrible case involving the murder of a child after months of abuse, by parents and carers whose casual violence, threats and neglect had led others to raise the alarm with social workers. Yet they slipped through the safeguarding net, with tragic consequences.

Less than a fortnight ago we learned of the appalling case of six-year-old Arthur Labinjo-Hughes, who was abused, tortured and beaten to death by his stepmother, Emma Tustin, during the first Covid lockdown. Tustin, 32, of Solihull, was jailed for 29 years; Arthur’s father, Thomas Hughes, received 21 years for manslaughter.

On Tuesday came the verdict on another shattering killing : 16-month-old Star Hobson, beaten to death in lockdown by her mother’s partner after months of cruelty and abuse. Savannah Brockhill, 28, of Bradford, was convicted of murder, while Star’s mother, Frankie Smith, 18, was found guilty of causing or allowing the death of a child.

After the shock at the inhumanity of the perpetrators – and their brutality, narcissism and sadistic determination to do harm – come inevitable questions about the authorities whose duty is to safeguard vulnerable children. Why were chances missed to intervene to potentially save Arthur and Star?

We know that between January 2020, when Star was first visited by a social worker, and her death on 22 September that year, six referrals were made to safeguarding staff by friends or family concerned about her safety. Social workers visited four times and closed the case on three occasions. The police visited once and arranged for Star to be medically examined at a hospital, with seemingly no follow-up.

Why were these opportunities missed? The inquiry into the circumstances surrounding Star’s death will consider in detail why officials who visited the family concluded there was no obvious risk. Human error and poor professional judgment is often a factor in these cases, as is the manipulative deceit of the abusers.

But it is also clear in the case of Star’s death that errors occurred in a specific context: not just lockdown, with all the confusion and restrictions that entailed, but a social work department that had been struggling for years, was deluged with work and had huge staff turnover.

Ofsted inspectors judged Bradford’s children’s services “inadequate” in 2018, two years before Star’s death. They uncovered chaotic child protection services, and social workers leaving in droves, at a time when referrals of children were soaring. There was poor practice, they found, “leaving children at risk of significant harm”.

Children at risk were often exposed to neglect for too long before action was taken to protect them, Ofsted found. Social workers were sometimes guilty of “over-optimism” and failed to take swift enough action in some cases where children were living in households where domestic abuse was taking place.

Ofsted visited on six subsequent occasions to monitor the department, including during the period in which Star was referred to social services. Improvement was slow. There was “drift” and delay in assessing children. Some individual social workers were overseeing as many as 50 children at a time.

The problem with high caseloads, said Ray Jones, an emeritus professor of social work at Kingston University, is that they can quickly overwhelm staff, forcing them to close cases just to keep on top of the constant flow of new ones coming in. “It is likely that if they could find a reason to close work down, they would do,” Jones said.

Was there pressure to close down cases? The high reliance on agency staff meant a high degree of organisational instability, Ofsted noted. Such volatility typically leads to the loss of local knowledge, Jones said. “These are workforces that are not getting to know their families.”

The detailed answers as to why safeguarding agencies did not do more to try to save Star and Arthur are subject to independent inquiries. The former review is expected to report in January, and the latter as part of a wider national review into “lessons learned”, no doubt triggering wider debate about how children’s social care should be run.

But Star’s death is unlikely to be the last of its kind to emerge from lockdown, and Bradford is not the only council struggling to keep its child protection department afloat and working effectively. There will be wider questions too about cuts, about the erosion of family support services, and the legacy of a decade of austerity.

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Safeguarding children in affluent families

Professor Claudia Bernard undertook the first piece of social work research in the UK to explore child abuse in affluent families.

Through investigating problems faced by social workers intervening with affluent parents, this research drew attention to an underexplored area of child social care.

Exploring child neglect in affluent families

Social work research and literature has tended to focus on child abuse in poor and working-class families.

Professor Bernard established a partnership with the City of London Corporation, a London borough, to explore the nature of child neglect in affluent families,

An initial review confirmed that most child protection social work is perceived to be focused on families in poverty. Training for social workers used case studies almost exclusively from poorer families, even in more affluent areas.

Commissioned by the City of London Corporation, Professor Bernard led a national study exploring how social workers engage with parents from affluent backgrounds in suspected child neglect cases.

The study focused on twelve of the wealthiest local authorities in England, including interviews and focus groups with frontline social workers and managers.

[Bernard’s findings] empower colleagues to be more confident in challenging affluent families.

Accredited Independent Safeguarding Consultant, Department for Education

The findings

Bernard’s research found that recognising and naming child neglect in affluent families can be difficult.

Children from these families who came to the attention of social workers had high-quality housing, diets and education opportunities, making it hard to evidence cases of emotional neglect – the most common type of abuse in affluent families.

The research also showed that affluent parents used their social and financial capital to manipulate the child protection system. Parents sometimes obstructed interventions, for example by threatening legal action or directly contacting senior managers and councillors.

These factors made it difficult for social workers to intervene in suspected child abuse cases, posing serious challenges for safeguarding children at risk.

Changing the social work field and beyond

Professor Bernard’s research led to policy changes on social work with affluent families in the City of London and five other London boroughs, affecting the work of over 4,800 social workers. The impacts of the policy changes were shared with all 343 local authorities in England.

The research has brought about change beyond the social work field, with several independent schools incorporated the findings into their safeguarding policies.

The regulatory body for independent schools uses the insights in their training of over 700 inspectors and the Council of International Schools uses the research to provide child protection and student well-being training in international schools across the globe.

Children from middle-class and affluent families suffer childhood neglect in less visible ways.

UK Adverse Childhood Experiences

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• Parenting, childcare and children's services
• Safeguarding and social care for children
• Safeguarding and child protection
• Preventing neglect, abuse and exploitation

Training resources on childhood neglect: exercises and guidance

Exercises and guidance documents for training multi-agency groups on identifying and preventing child neglect.

PDF , 41.5 KB , 1 page

PDF , 42.8 KB , 2 pages

E1: understanding neglect

PDF , 57.2 KB , 3 pages

G1: understanding neglect

PDF , 43.1 KB , 1 page

E2: noticing neglect

PDF , 40.4 KB , 1 page

G2: noticing neglect

E3: identifying concerns about parenting capacity.

PDF , 39.2 KB , 1 page

G3: identifying concerns about parenting capacity

PDF , 44.7 KB , 1 page

E4: assessing family and environmental factors

PDF , 29.6 KB , 1 page

G4: assessing family and environmental factors

PDF , 48 KB , 2 pages

E5: recognising the impact of neglect

PDF , 34.5 KB , 1 page

G5: recognising the impact of neglect

PDF , 46.1 KB , 2 pages

E6: neglect and attachment

PDF , 39.1 KB , 1 page

G6: neglect and attachment

PDF , 43.9 KB , 1 page

E7: neglect and unmet health needs

PDF , 28.5 KB , 1 page

G7: neglect and unmet health needs

PDF , 62.5 KB , 6 pages

E8: understanding factors affecting parental empathy

G8: understanding factors affecting parental empathy.

PDF , 42.7 KB , 1 page

E9: impact of substance misuse on parenting capacity

PDF , 44 KB , 1 page

G9: impact of substance misuse on parenting capacity

PDF , 49.9 KB , 2 pages

E10: impact of learning disabilities on parenting capacity

PDF , 46.4 KB , 2 pages

G10: impact of learning disabilities on parenting capacity

PDF , 43.9 KB , 2 pages

E11: impact of neglect on educational achievement

PDF , 127 KB , 1 page

G11: impact of neglect on educational achievement

PDF , 138 KB , 2 pages

E12: communicating with the child

G12: communicating with the child.

PDF , 47.1 KB , 2 pages

E13: communicating concerns to parents

PDF , 46.9 KB , 2 pages

G13: communicating concerns to parents

PDF , 56.2 KB , 3 pages

E14: understanding adult substance misuse and dependence

PDF , 37.5 KB , 1 page

G14: understanding adult substance misuse and dependence

PDF , 44 KB , 2 pages

E15: assessing the child in their community

PDF , 52.7 KB , 2 pages

G15: assessing the child in their community

E16: the child’s perspective.

PDF , 44.4 KB , 2 pages

G16: the child’s perspective

PDF , 165 KB , 2 pages

E17: assessing adolescent wellbeing

PDF , 37 KB , 1 page

G17: assessing adolescent wellbeing

PDF , 72.1 KB , 2 pages

E18: understanding attachment and separation

PDF , 40 KB , 1 page

G18: understanding attachment and separation

PDF , 45.6 KB , 1 page

E19: planning to meet a child or young person's needs

PDF , 33.1 KB , 2 pages

G19: planning to meet a child or young person's needs

PDF , 54.9 KB , 2 pages

E20: assessing impact of substance misuse

PDF , 33.7 KB , 1 page

G20: assessing impact of substance misuse

PDF , 61.5 KB , 4 pages

E21: engaging parents and carers

PDF , 29.8 KB , 1 page

G21: engaging parents and carers

PDF , 50.7 KB , 2 pages

E22: analysing the interaction between parents and communities

PDF , 37.8 KB , 1 page

G22: analysing the interaction between parents and communities

PDF , 47.9 KB , 1 page

E23: keeping the child at the centre

PDF , 47 KB , 2 pages

G23: keeping the child at the centre

PDF , 50.1 KB , 2 pages

E24: ensuring a child's needs are met

PDF , 32.5 KB , 1 page

G24: ensuring a child's needs are met

PDF , 46.3 KB , 1 page

E25: working directly with a child or young person

PDF , 38.4 KB , 1 page

G25: working directly with a child or young person

PDF , 60 KB , 4 pages

E26: reviewing and sustaining change

PDF , 39.5 KB , 1 page

G26: reviewing and sustaining change

PDF , 51.2 KB , 2 pages

E27: connecting the child and family with communities

PDF , 592 KB , 1 page

G27: connecting the child and family with communities

E28: outcomes or indicators.

PDF , 37.4 KB , 1 page

G28: outcomes or indicators?

PDF , 54.8 KB , 3 pages

E29: promoting resilience

PDF , 494 KB , 4 pages

G29: promoting resilience

PDF , 47.3 KB , 2 pages

E30: improving parenting capacity

PDF , 32.9 KB , 1 page

G30: improving parenting capacity

PDF , 45.8 KB , 1 page

E31: reviewing pace of change

PDF , 49.5 KB , 2 pages

G31: reviewing pace of change

E32: addressing housing needs.

PDF , 79.8 KB , 4 pages

G32: addressing housing needs

PDF , 72.5 KB , 2 pages

E33: considering your views of neglect

PDF , 29.3 KB , 1 page

G33: considering your views of neglect

E34: considering public perception.

PDF , 28.3 KB , 1 page

G34: considering public perception

PDF , 31.6 KB , 1 page

E35: taking concerns seriously

PDF , 35.8 KB , 1 page

G35: taking concerns seriously

PDF , 41.9 KB , 2 pages

E36: exploring your values

PDF , 107 KB , 1 page

G36: exploring your values

PDF , 74.5 KB , 3 pages

E37: thinking about whether you have been worried about a child

PDF , 38.2 KB , 1 page

G37: thinking about whether you have been worried about a child

PDF , 64.2 KB , 2 pages

E38: thinking about your perceptions

PDF , 38.9 KB , 1 page

G38: thinking about your perceptions

PDF , 47.9 KB , 2 pages

E39: guarding against bias

PDF , 38 KB , 1 page

G39: guarding against bias

PDF , 45 KB , 1 page

E40: taking account of historical information

PDF , 31 KB , 1 page

G40: taking account of historical information

PDF , 42.6 KB , 1 page

E41: the emotional impact of talking about children families

PDF , 36.6 KB , 1 page

G41: the emotional impact of talking about children families

E42: working with children, parents and families.

PDF , 53 KB , 1 page

G42: working with children, parents and families

PDF , 45.5 KB , 1 page

E43: planning to meet carers needs

PDF , 39 KB , 1 page

G43: planning to meet carers needs

PDF , 51.5 KB , 2 pages

E44: promoting and maintaining meaningful change

PDF , 230 KB , 3 pages

G44: promoting and maintaining meaningful change

PDF , 227 KB , 3 pages

E45: working together in a sustained way to help the young person

G45: working together in a sustained way to help the young person.

PDF , 61.3 KB , 3 pages

E46: the language of services

PDF , 42.8 KB , 1 page

G46: the language of services

PDF , 54 KB , 2 pages

All trainer guidance documents have the letter ‘G’ as the prefix and the accompanying exercise handouts have the letter ‘E’ as the prefix.

The presentations and notes , handouts and family case studies that complement these guidance and exercise documents are also available.

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Child abuse and neglect in the UK today

Research into the prevalence of child maltreatment in the united kingdom.

In 2000 we published the first ever UK-wide study of child maltreatment (Cawson et al, 2000). Ten years later we carried out a much larger study to give us a more up-to-date picture of what children were experiencing.

In 2009 we interviewed over 6,000 young adults, teenagers, children and parents of younger children. Our report looks at their experiences of abuse and neglect. It examines the impact of abuse and highlights that many children experiencing abuse by their parents or carers also experience other forms of abuse from other people.

Although these findings remain the most robust UK-wide research-based indication of the prevalence of child abuse and neglect available, they are increasingly dated. That's why we welcome the ONS’s current work, scoping the feasibility of a new survey to measure the current scale and nature of child abuse and neglect (ONS, 2019).

Authors: Lorraine Radford, Susana Corral, Christine Bradley, Helen Fisher, Claire Bassett, Nick Howat and Stephan Collishaw Published: 2011

Key findings

A substantial minority of children experience severe maltreatment and abuse at home, in school, in the community, from adults and from peers.

• 1 in 5 children have experienced severe maltreatment
• Children abused by parents or carers are almost 3 times more likely to also witness family violence
• 1 in 3 children sexually abused by an adult didn’t tell anyone at the time
• All types of abuse and neglect are associated with poorer mental health

Strong associations were found between maltreatment, sexual abuse, physical violence, and poorer emotional wellbeing, including self-harm and suicidal thoughts.

Please cite as: Radford, L. et al. (2011) Child abuse and neglect in the UK today. London: NSPCC.

Cawson, P. et al (2000) Child maltreatment in the United Kingdom: a study of the prevalence of child abuse and neglect . London: NSPCC.

Office for National Statistics (ONS) (2019) Improving crime statistics for England and Wales: progress update July 2019 . [Newport]: Office for National Statistics (ONS).

Related resources

Find out about the different types of child abuse, how to recognise the signs in children and young people and how you can work with children, parents and carers to prevent and respond to concerns.

Find out what data is available and what it can tell us about how many children and young people experience abuse and neglect in the UK.

The NSPCC Library and Information Service helps professionals access the latest child protection research, policy and practice resources and can answers your safeguarding questions and enquiries.

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• Case Studies

Hampshire Safeguarding children Partnership (HSCP) and its associated partners have developed several case studies to support the application of its toolkits.

Case studies are real-life stories highlighting how agencies have worked to safeguard, protect, and support children and their families. They are an effective learning tool, providing professionals with the ability to see services and tools in action, understand a situation from a different perspective and demonstrate areas of good practice.

The toolkit case studies listed below can be downloaded for training purposes, team meetings and staff briefing sessions.

Case study 1 –   Charlie

Case study 2-   Sarah

Case study 3 –   Amir

Case study 4 –  Logan

Case study 5 –  Family A

Case study 6 – Gracie

Case study 7 – Emily (obesity) – NEW

Case study 8 – Freya (educational neglect) – NEW

Additional case study examples can be found on pages 17-18 of the  HSCP and IOWSCP Neglect Strategy 2020-23.

Department for Education The Department for Education have published  case studies   for training multi-agency groups on identifying and preventing child neglect, in addition to associated  guidance documents   and   supporting handouts .

• Neglect Strategy and Action Plan
• Neglect Threshold and Indicator Chart
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• Tell us about your good practice

Up to 40pc of mental health conditions are linked to child abuse and neglect, study finds

In 1996, Ange McAuley was just 11 years old when ABC's Four Corners profiled her family living on Brisbane's outskirts.

At the time her mother was pregnant with her sixth child and her father had long ago moved back to Perth.

WARNING: This story contains details that may be distressing to some readers.

It was a story about child protection and the program was profiling the role of community volunteers helping her mother, who had been in and out of mental health wards.

Ange was the eldest and it fell to her to get her younger siblings ready for school.

By the time the new baby arrived, she would stay home and change nappies.

"It was pretty crazy back then — I wasn't going to school a lot," she said.

By that age she was already holding a secret — she'd been sexually abused at age six by her stepfather, who would later be convicted of the crime.

"Back in the nineties, a lot of people kept stuff hidden and it wasn't spoken about outside of the family," she said.

"I've carried all these big burdens that weren't even mine. Sexual abuse happened to me. I didn't ask for it."

She says the trauma triggered a lifetime of mental health problems from substance abuse and self-harm as a teen, right through to post-natal depression.

Hidden source of our mental health crisis

A new study from the University of Sydney's Matilda Centre has established just how much Australia's mental health crisis can be traced back to this kind of childhood abuse and neglect.

The research has found that childhood maltreatment is responsible for up to 41 per cent of common mental health conditions including anxiety, depression, substance abuse, self-harm and suicide attempts.

The research, which draws on a 2023 meta-analysis of 34 research studies covering 54,000 people, found maltreatment accounted for 41 per cent of suicide attempts in Australia, 35 per cent of self-harm cases and 21 per cent of depression episodes.

It defined childhood maltreatment as physical, sexual, emotional abuse, emotional or physical neglect and domestic violence before the age of 18.

Lead researcher Lucy Grummitt said it is the first piece of work to quantify the direct impact of child abuse on long-term mental health. 

It found if childhood maltreatment was eradicated it would avert more than 1.8 million cases of depression, anxiety and substance use disorders.

"It shows just how many people in Australia are suffering from mental health conditions that are potentially preventable," she said.

Dr Grummitt said they found in the year 2023 child maltreatment in Australia accounted for 66,143 years of life lost and 118,493 years lived with disability because of the associated mental health conditions.

"We know that when a child is exposed to this level of stress or trauma, it does trigger a lot of changes in the brain and body," Dr Grummitt said.

"Things like altering the body's stress response will make a child hyper-vigilant to threat. It can lead to difficulties with emotion regulation, being able to cope with difficult emotions."

While some areas of maltreatment are trending down, figures from the landmark Australian child maltreatment study last year show rising rates of sexual abuse by adolescents and emotional abuse.

That study found more than one in three females and one in seven males aged 16 to 24 had experienced childhood sexual abuse.

Dr Grummit says childhood trauma can affect how the brain processes emotions once children become teens.

"It could be teenagers struggling to really cope with difficult emotions and certainly trauma can play a huge role in causing those difficult emotions," she said.

Mental health scars emerge early

For Ange, the trauma of her early years first showed itself in adolescence when she started acting out — she remembers punching walls and cars, binge drinking and using drugs.

"I would get angry and just scream," she said.

"I used to talk back to the teachers. I didn't finish school. Mum kicked me out a lot as a teenager. I was back and forth between mum and dad's."

By the time she disclosed her abuse, she was self-harming and at one point tried to take her own life.

"I was just done," she said.

"I was sick of having to get up every day. I didn't want to do it anymore."

Later on, she would have inappropriate relationships with much older men and suffered from depression, including post-natal depression.

"It's definitely affected relationships, it's affected my friendships, it's affected my intimate relationships," she said.

"Flashbacks can come in at the most inappropriate times — you're back in that moment and you feel guilt and shame.

"I feel like it's held me back a lot."

Calls for mental health 'immunisation'

Dr Grummitt said childhood abuse and neglect should be treated as a national public health priority.

In Australia, suicide is the leading cause of death for young people. 

"It's critical that we are investing in prevention rather than putting all our investments into treatment of mental health problems," she said.

Her team has suggested child development and mental health check-ins become a regular feature across a person's lifetime and have proposed a mental health "immunisation schedule".

Chief executive of mental health charity Prevention United, Stephen Carbone, said they estimate that less than 1 per cent of mental health funding goes toward prevention.

"There's been a big steady increase in per capita funding for mental health over the last 30 years but that hasn't translated into reductions," Dr Carbone, a GP, said. 

"You're not going to be able to prevent mental health conditions unless you start to tackle some of these big causes, in particular child maltreatment."

He said most of Australia's child protection system was about reacting to problems rather than trying to prevent them.

"If you're not tackling the upstream risk factors or putting in place protective factors you just keep getting more and more young people experiencing problems and services being overwhelmed," he said.

Now a mother of two teens herself, Ange says she wants to break the cycle and has been going to therapy regularly to help identify and avoid destructive patterns that she's seen herself fall into.

"I love my girls so much and I want better for them."

• X (formerly Twitter)

Related Stories

Generation overwhelmed: these kids fought back against a national health crisis — and won.

There's a mental health crisis gripping kids today, but the way out is a job for all of us

'The air went out of the room': Shocking new statistics on the abuse and neglect of Australian children

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• About Adverse Childhood Experiences
• Risk and Protective Factors
• Program: Essentials for Childhood: Preventing Adverse Childhood Experiences through Data to Action
• Adverse childhood experiences can have long-term impacts on health, opportunity and well-being.
• Adverse childhood experiences are common and some groups experience them more than others.

What are adverse childhood experiences?

Adverse childhood experiences, or ACEs, are potentially traumatic events that occur in childhood (0-17 years). Examples include: 1

• Experiencing violence, abuse, or neglect.
• Witnessing violence in the home or community.
• Having a family member attempt or die by suicide.

Also included are aspects of the child’s environment that can undermine their sense of safety, stability, and bonding. Examples can include growing up in a household with: 1

• Substance use problems.
• Mental health problems.
• Instability due to parental separation.
• Instability due to household members being in jail or prison.

The examples above are not a complete list of adverse experiences. Many other traumatic experiences could impact health and well-being. This can include not having enough food to eat, experiencing homelessness or unstable housing, or experiencing discrimination. 2 3 4 5 6

Quick facts and stats

ACEs are common. About 64% of adults in the United States reported they had experienced at least one type of ACE before age 18. Nearly one in six (17.3%) adults reported they had experienced four or more types of ACEs. 7

Preventing ACEs could potentially reduce many health conditions. Estimates show up to 1.9 million heart disease cases and 21 million depression cases potentially could have been avoided by preventing ACEs. 1

Some people are at greater risk of experiencing one or more ACEs than others. While all children are at risk of ACEs, numerous studies show inequities in such experiences. These inequalities are linked to the historical, social, and economic environments in which some families live. 5 6 ACEs were highest among females, non-Hispanic American Indian or Alaska Native adults, and adults who are unemployed or unable to work. 7

ACEs are costly. ACEs-related health consequences cost an estimated economic burden of $748 billion annually in Bermuda, Canada, and the United States. 8

ACEs can have lasting effects on health and well-being in childhood and life opportunities well into adulthood. 9 Life opportunities include things like education and job potential. These experiences can increase the risks of injury, sexually transmitted infections, and involvement in sex trafficking. They can also increase risks for maternal and child health problems including teen pregnancy, pregnancy complications, and fetal death. Also included are a range of chronic diseases and leading causes of death, such as cancer, diabetes, heart disease, and suicide. 1 10 11 12 13 14 15 16 17

ACEs and associated social determinants of health, such as living in under-resourced or racially segregated neighborhoods, can cause toxic stress. Toxic stress, or extended or prolonged stress, from ACEs can negatively affect children’s brain development, immune systems, and stress-response systems. These changes can affect children’s attention, decision-making, and learning. 18

Children growing up with toxic stress may have difficulty forming healthy and stable relationships. They may also have unstable work histories as adults and struggle with finances, jobs, and depression throughout life. 18 These effects can also be passed on to their own children. 19 20 21 Some children may face further exposure to toxic stress from historical and ongoing traumas. These historical and ongoing traumas refer to experiences of racial discrimination or the impacts of poverty resulting from limited educational and economic opportunities. 1 6

Adverse childhood experiences can be prevented. Certain factors may increase or decrease the risk of experiencing adverse childhood experiences.

Preventing adverse childhood experiences requires understanding and addressing the factors that put people at risk for or protect them from violence.

Creating safe, stable, nurturing relationships and environments for all children can prevent ACEs and help all children reach their full potential. We all have a role to play.

• Merrick MT, Ford DC, Ports KA, et al. Vital Signs: Estimated Proportion of Adult Health Problems Attributable to Adverse Childhood Experiences and Implications for Prevention — 25 States, 2015–2017. MMWR Morb Mortal Wkly Rep 2019;68:999-1005. DOI: http://dx.doi.org/10.15585/mmwr.mm6844e1 .
• Cain KS, Meyer SC, Cummer E, Patel KK, Casacchia NJ, Montez K, Palakshappa D, Brown CL. Association of Food Insecurity with Mental Health Outcomes in Parents and Children. Science Direct. 2022; 22:7; 1105-1114. DOI: https://doi.org/10.1016/j.acap.2022.04.010 .
• Smith-Grant J, Kilmer G, Brener N, Robin L, Underwood M. Risk Behaviors and Experiences Among Youth Experiencing Homelessness—Youth Risk Behavior Survey, 23 U.S. States and 11 Local School Districts. Journal of Community Health. 2022; 47: 324-333.
• Experiencing discrimination: Early Childhood Adversity, Toxic Stress, and the Impacts of Racism on the Foundations of Health | Annual Review of Public Health ( annualreviews.org).
• Sedlak A, Mettenburg J, Basena M, et al. Fourth national incidence study of child abuse and neglect (NIS-4): Report to Congress. Executive Summary. Washington, DC: U.S. Department of Health an Human Services, Administration for Children and Families.; 2010.
• Font S, Maguire-Jack K. Pathways from childhood abuse and other adversities to adult health risks: The role of adult socioeconomic conditions. Child Abuse Negl. 2016;51:390-399.
• Swedo EA, Aslam MV, Dahlberg LL, et al. Prevalence of Adverse Childhood Experiences Among U.S. Adults — Behavioral Risk Factor Surveillance System, 2011–2020. MMWR Morb Mortal Wkly Rep 2023;72:707–715. DOI: http://dx.doi.org/10.15585/mmwr.mm7226a2 .
• Bellis, MA, et al. Life Course Health Consequences and Associated Annual Costs of Adverse Childhood Experiences Across Europe and North America: A Systematic Review and Meta-Analysis. Lancet Public Health 2019.
• Adverse Childhood Experiences During the COVID-19 Pandemic and Associations with Poor Mental Health and Suicidal Behaviors Among High School Students — Adolescent Behaviors and Experiences Survey, United States, January–June 2021 | MMWR
• Hillis SD, Anda RF, Dube SR, Felitti VJ, Marchbanks PA, Marks JS. The association between adverse childhood experiences and adolescent pregnancy, long-term psychosocial consequences, and fetal death. Pediatrics. 2004 Feb;113(2):320-7.
• Miller ES, Fleming O, Ekpe EE, Grobman WA, Heard-Garris N. Association Between Adverse Childhood Experiences and Adverse Pregnancy Outcomes. Obstetrics & Gynecology . 2021;138(5):770-776. https://doi.org/10.1097/AOG.0000000000004570 .
• Sulaiman S, Premji SS, Tavangar F, et al. Total Adverse Childhood Experiences and Preterm Birth: A Systematic Review. Matern Child Health J . 2021;25(10):1581-1594. https://doi.org/10.1007/s10995-021-03176-6 .
• Ciciolla L, Shreffler KM, Tiemeyer S. Maternal Childhood Adversity as a Risk for Perinatal Complications and NICU Hospitalization. Journal of Pediatric Psychology . 2021;46(7):801-813. https://doi.org/10.1093/jpepsy/jsab027 .
• Mersky JP, Lee CP. Adverse childhood experiences and poor birth outcomes in a diverse, low-income sample. BMC pregnancy and childbirth. 2019;19(1). https://doi.org/10.1186/s12884-019-2560-8.
• Reid JA, Baglivio MT, Piquero AR, Greenwald MA, Epps N. No youth left behind to human trafficking: Exploring profiles of risk. American journal of orthopsychiatry. 2019;89(6):704.
• Diamond-Welch B, Kosloski AE. Adverse childhood experiences and propensity to participate in the commercialized sex market. Child Abuse & Neglect. 2020 Jun 1;104:104468.
• Shonkoff, J. P., Garner, A. S., Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, & Section on Developmental and Behavioral Pediatrics (2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129(1), e232–e246. https://doi.org/10.1542/peds.2011-2663
• Narayan AJ, Kalstabakken AW, Labella MH, Nerenberg LS, Monn AR, Masten AS. Intergenerational continuity of adverse childhood experiences in homeless families: unpacking exposure to maltreatment versus family dysfunction. Am J Orthopsych. 2017;87(1):3. https://doi.org/10.1037/ort0000133.
• Schofield TJ, Donnellan MB, Merrick MT, Ports KA, Klevens J, Leeb R. Intergenerational continuity in adverse childhood experiences and rural community environments. Am J Public Health. 2018;108(9):1148-1152. https://doi.org/10.2105/AJPH.2018.304598.
• Schofield TJ, Lee RD, Merrick MT. Safe, stable, nurturing relationships as a moderator of intergenerational continuity of child maltreatment: a meta-analysis. J Adolesc Health. 2013;53(4 Suppl):S32-38. https://doi.org/10.1016/j.jadohealth.2013.05.004 .

Adverse Childhood Experiences (ACEs)

ACEs can have a tremendous impact on lifelong health and opportunity. CDC works to understand ACEs and prevent them.

Domestic abuse: ‘I was quite controlling, things needed to change’

• Published 7 May

Amy and Peter were referred to charity For Baby's Sake by social workers when they were expecting their first child

"I just thought it was normal," says Peter looking back at how volatile he used to be with his partner, Amy.

The 25-year-old admits he was "quite controlling", bombarding her with texts and phone calls demanding to know her movements.

And if Amy didn't keep up with his communications, he says he would get "quite angry". He now feels ashamed of his behaviour.

The couple, whose names have been changed and identities protected, have been helped by charity For Baby's Sake.

It's one of the organisations being evaluated for a project aiming to identify the best way to support children and families experiencing domestic abuse.

More than 800,000 children in England and Wales have spent the past 12 months living in an abusive home, according to new research estimates.

This is more than the number of children who will start primary school this year - says Foundations, a leading research centre examining family support services.

Overall, one child in every five has experienced some form of abuse at home, it says.

The research centre is leading the £2.6m study which aims to produce better evidence to ensure public money is spent on the most effective schemes.

"We're currently operating in the dark," says Dr Jo Casebourne, Foundations' chief executive.

"We just don't know what works to support children affected by domestic abuse, which feels completely unacceptable given the scale of children affected."

'It was really difficult'

Amy says their daughter, Rosie, is thriving

Amy and Peter were referred to For Baby's Sake by social workers when they were expecting their first child.

At first, Amy, 23, admits she struggled to accept they had a problem, but she says "looking back, it was really difficult".

"I would always be waiting by the phone," she explains. "And I'd be worried about doing certain things just in case I didn't answer the phone, in case it would upset him."

Pregnant mothers can be referred to the programme by GPs, midwives and other professionals when there are concerns about domestic abuse. For Baby's Sake will then work with both parents and support them for two years.

Amy and Peter saw separate counsellors each week, which they say allowed them to start working through their problems before their daughter, Rosie, was born.

Peter says it helped him understand the impact of witnessing domestic abuse and coercive control during his own childhood.

"I was thinking, 'there's no problems here,'" he says. "'This is how I've grown up, I've seen relationships handled. It's no one else's business'. But then upon some deeper reflection, I noticed the impact I was having on her, I realised things need to change."

Domestic violence is a major reason for referrals to children's social care. And the police recorded more than 1.4 million domestic abuse-related incidents and crimes in England and Wales , external in the year to March 2023.

It can include physical, sexual or emotional abuse, including controlling behaviour. The Home Office calculates the social and economic cost of the damage it causes in England and Wales at about £74bn a year.

But the impact on the lives of families and children is incalculable.

'Regulate my emotions'

Judith Rees, director of operations at For Baby's Sake, says the group's work has resulted in a reduction in domestic violence

Amy says the counselling made the couple realise the effect their relationship would have on their daughter, and that potentially it could "result in the same things happening to her when she grows up".

When Rosie arrived, the For Baby's Sake team also worked with them as a family.

Two years on, she is a chatty, happy toddler and the couple are expecting a second child.

Without the help, Amy doesn't think their daughter would be "thriving like she is now - and as happy as she is".

"Now I know what's expected of me," says Peter. "I know how to regulate my emotions. I know how to be the best dad and partner possible."

Judith Rees, director of operations at For Baby's Sake, says they start seeing families when the mother is pregnant because research shows stress levels can have an impact on babies in the womb.

They work with "the person causing harm and the person experiencing domestic abuse" in a non-judgmental way, she says.

Support to leave

Andrew says the project showed him "there was light at the end of the tunnel"

Another parent supported by For Baby's Sake is father-of-two Andrew. The charity helped him separate from his wife.

"I was getting abused mentally, not physically, and this is when I fled," he says.

As a man experiencing abuse, he says he found it particularly difficult to ask for help.

"You feel worthless," he says. "You try to disguise it and pretend that everything's fine and try to keep going. But it doesn't work that way. It destroys you."

For Baby's Sake says it recognises many couples don't stay together and it is important that they separate safely and in the best way for the children.

Its own results show most of the families involved have babies born at full-term and a good birth weight, which gives those children a healthy start.

Judith explains: "We've also seen that in 75% of babies that are reaching [the age of] one in the last six months, there has not been a police call out to that home. So, there is a reduction in domestic abuse within home as well."

Thorough research

Dr Jo Casebourne says there is a moral and financial case for evaluating which services are most effective

There are many small organisations providing support for families experiencing domestic abuse, but most can't provide this kind of clear information about their effectiveness, according to Foundations.

The project's five-year plan is called REACH (Researching Effective Approaches for Children) which it believes could transform domestic abuse services.

It will start with thorough academic research assessing the effectiveness of six projects.

In addition to For Baby's Sake, the projects are:

Bounce Back 4 Kids (BB4K): Mainly uses group sessions to support children and their non-abusive parent

WeMatter: A video-based programme to support 8-17 year olds

Restart: Combines early support from social workers, housing teams and domestic abuse workers for families

Breaking the cycle: A counselling service for 4-16 year olds

Fathers for Change: A US programme which will be adapted to work with fathers with a history of abusive behaviour in the UK

The initial cost of the research is £2.6m, but the aim is to examine 80 different programmes over five years.

Foundations is asking the government to contribute £50m to the overall costs, with another £25m coming from grants and donations.

At the end of the research the most effective half a dozen projects will be pinpointed. The recommendations can then help authorities decide where to spend public money.

Dr Casebourne says the long-term impact domestic violence has on children means there is a strong moral case for finding out what works best for them, but with public services under such financial pressure there is an economic case too.

"We can't afford not to do this," she says.

Andrew says his weekly meeting with his counsellor helped him realise, "there was a light at the end of the tunnel, and you can survive with your children".

His advice to others living with domestic abuse is clear.

"Seek help. Don't sit there thinking, this is your destiny. Your destiny doesn't have to be that way," he says. "And there's someone out there who will listen."

If you or someone you know has been affected by any of the issues raised in this article, help can be found at BBC Action Line.

Related Topics

• Domestic abuse
• Family & Education
• Home Office

Blog The Education Hub

https://educationhub.blog.gov.uk/2024/05/16/new-rshe-guidance-what-it-means-for-sex-education-lessons-in-schools/

New RSHE guidance: What it means for sex education lessons in schools

R elationships, Sex and Health Education (RSHE) is a subject taught at both primary and secondary school.  

In 2020, Relationships and Sex Education was made compulsory for all secondary school pupils in England and Health Education compulsory for all pupils in state-funded schools.  

Last year, the Prime Minister and Education Secretary brought forward the first review of the curriculum following reports of pupils being taught inappropriate content in RSHE in some schools.  

The review was informed by the advice of an independent panel of experts. The results of the review and updated guidance for consultation has now been published.   

We are now asking for views from parents, schools and others before the guidance is finalised. You can find the consultation here .   

What is new in the updated curriculum?  

Following the panel’s advice, w e’re introducing age limits, to ensure children aren’t being taught about sensitive and complex subjects before they are ready to fully understand them.    

We are also making clear that the concept of gender identity – the sense a person may have of their own gender, whether male, female or a number of other categories   – is highly contested and should not be taught. This is in line with the cautious approach taken in our gu idance on gender questioning children.  

Along with other factors, teaching this theory in the classroom could prompt some children to start to question their gender when they may not have done so otherwise, and is a complex theory for children to understand.   

The facts about biological sex and gender reassignment will still be taught.  

The guidance for schools also contains a new section on transparency with parents, making it absolutely clear that parents have a legal right to know what their children are being taught in RSHE and can request to see teaching materials.   

In addition, we’re seeking views on adding several new subjects to the curriculum, and more detail on others. These include:   

• Suicide prevention  
• Sexual harassment and sexual violence  
• L oneliness  
• The prevalence of 'deepfakes’  
• Healthy behaviours during pregnancy, as well as miscarriage  
• Illegal online behaviours including drug and knife supply  
• The dangers of vaping   
• Menstrual and gynaecological health including endometriosis, polycystic ovary syndrome (PCOS) and heavy menstrual bleeding.  

What are the age limits?   

In primary school, we’ve set out that subjects such as the risks about online gaming, social media and scams should not be taught before year 3.   

Puberty shouldn’t be taught before year 4, whilst sex education shouldn’t be taught before year 5, in line with what pupils learn about conception and birth as part of the national curriculum for science.  

In secondary school, issues regarding sexual harassment shouldn’t be taught before year 7, direct references to suicide before year 8 and any explicit discussion of sexual activity before year 9.  

Do schools have to follow the guidance?  

Following the consultation, the guidance will be statutory, which means schools must follow it unless there are exceptional circumstances.   

There is some flexibility w ithin the age ratings, as schools will sometimes need to respond to questions from pupils about age-restricted content, if they come up earlier within their school community.   

In these circumstances, schools are instructed to make sure that teaching is limited to the essential facts without going into unnecessary details, and parents should be informed.  

When will schools start teaching this?  

School s will be able to use the guidance as soon as we publish the final version later this year.   

However, schools will need time to make changes to their curriculum, so we will allow an implementation period before the guidance comes into force.     

What can parents do with these resources once they have been shared?

This guidance has openness with parents at its heart. Parents are not able to veto curriculum content, but they should be able to see what their children are being taught, which gives them the opportunity to raise issues or concerns through the school’s own processes, if they want to.

Parents can also share copyrighted materials they have received from their school more widely under certain circumstances.

If they are not able to understand materials without assistance, parents can share the materials with translators to help them understand the content, on the basis that the material is not shared further.

Copyrighted material can also be shared under the law for so-called ‘fair dealing’ - for the purposes of quotation, criticism or review, which could include sharing for the purpose of making a complaint about the material.

This could consist of sharing with friends, families, faith leaders, lawyers, school organisations, governing bodies and trustees, local authorities, Ofsted and the media.  In each case, the sharing of the material must be proportionate and accompanied by an acknowledgment of the author and its ownership.

Under the same principle, parents can also share relevant extracts of materials with the general public, but except in cases where the material is very small, it is unlikely that it would be lawful to share the entirety of the material.

These principles would apply to any material which is being made available for teaching in schools, even if that material was provided subject to confidentiality restrictions.

Do all children have to learn RSHE?  

Parents still have the right to withdraw their child from sex education, but not from the essential content covered in relationships educatio n.  

You may also be interested in:

• Education Secretary's letter to parents: You have the right to see RSHE lesson material
• Sex education: What is RSHE and can parents access curriculum materials?
• What do children and young people learn in relationship, sex and health education

Tags: age ratings , Gender , Relationships and Sex Education , RSHE , sex ed , Sex education

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