EXPLANATORY MEMORANDUM

to Recommendation No. R (93) 2

of the Committee of Ministers to member states

The medico-social aspects of child abuse

 

(adopted by the Committee of Ministers on 8 January 1993
at the 484th meeting of the Ministers' Deputies)

 

 

 

Preamble and commentary

 

General considerations

 

Child abuse is not a new phenomenon. However, in recent years, it has given rise to a great deal of concern. Member states of the Council of Europe have, in varying ways and to different degrees, taken steps to respond to the emergence of child abuse as a significant social problem in recent decades. The policy responses depend, inter alia, upon political and social choices; on socio-economic factors; on the legal framework; on the nature, scope and structure of health, welfare and other services and on societal and professional conceptions of, and attitudes towards, childhood and child abuse in particular. Experience suggests that close co-operation between professionals from varied disciplines is required for the sensitive and appropriate management of cases of child abuse. In practice, however, a suitable organisational framework for identifying and notifying cases of abuse and for offering appropriate intervention to help abused children and their families is often lacking. The Select Committee of Experts on the medico-social aspects of child abuse was asked to focus its work principally upon these organisational aspects.

 

Child abuse is not a disease. It is the label attached to several specific harms suffered by children, caused by the actions (or omissions) of their parents, relatives, friends, siblings, strangers or others. The forms of abuse most commonly subsumed for operational purposes under the label child abuse are neglect, physical abuse, emotional abuse and sexual abuse. Certain harms to children are, therefore, customarily excluded by the term child abuse; for example, the disproportionately high incidence of infant mortality and morbidity among certain groups of children in the population, the limitations on life chances and life experiences consequent upon material deprivation or environmental conditions, or the economic exploitation of children through child labour.

The committee adopted the following definitions of child abuse:

 

Physical abuse

 

Physical injury to a child or failure to prevent injury or suffering, including deliberate poisoning or suffocation, where there is definite knowledge, or a reasonable suspicion, that the injury was knowingly inflicted or not prevented.

 

Sexual abuse

 

Sexual abuse is the improper exposure of a child to sexual contact, activity or behaviour. It includes any sexual touching, intercourse or exploitation by anyone in whose care the child has been left, or an individual who takes advantage of a child. Such a person could be a parent, a relative, a friend, a professional or voluntary worker, or a stranger.

 

Sexual abuse may be divided into non-contact abuse and contact abuse. Non-contact abuse includes, for example, encounters with exhibitionists and engagement in sexual activity (exposure to pornographic videos, for example) where no physical contact occurs. Contact abuse applies to behaviour involving sexual contact including fondling of breasts and genitals, intercourse and oral or anal sex.

 

Emotional abuse

 

Emotional abuse includes behaviour that causes a severe adverse effect on the emotional and behavioural development of a child. Emotional abuse may take the form of verbal attacks on a child's sense of self, repeated humiliation or rejection. Exposure to violence or severe conflict in the home, forced isolation, restraint or causing the child to be afraid much of the time may also cause emotional harm.

 

Neglect

 

Neglect is any lack of care, which causes serious harm to a child's development and/or endangers the child.

 

Physical neglect is the failure to meet the child's physical needs. This includes failing to provide adequate nutrition, clothing, shelter, health care and protection from harm.

 

Emotional neglect is the failure to meet the child's emotional needs for affection and a sense of belonging.

 

Educational neglect is the failure to allow the child to achieve his/her full educational potential, for example, through persistent school absenteeism or child labour in or out of the domestic environment.

 

Systems abuse (secondary victimisation)

 

Systems abuse is the further abuse or neglect of children, and avoidable harm to their families, caused by the very system set up to help and protect children and their families. Examples include denial of the child's right to information and of his/her views to be heard; unwarranted separation of children from their parents; neglect and/or abusive treatment in day care, schools, foster or residential care or other settings; trauma for children caused by insensitive or unwarranted medical examinations; distress for children resulting from their dealings with the judicial system (for example, delays in hearing cases or damaging experiences as child witnesses); denial of parents' rights to information and to participate in decisions, wherever consistent with the child's welfare; insufficient services or resources to help abused children remain with their families wherever possible.

 

The committee's terms of reference explicitly precluded consideration of foetal abuse. None the less, the committee noted the serious consequences arising from harmful actions (for example, drug or alcohol abuse in pregnancy) which would directly affect the foetus' physical development and/or its future intellectual and emotional development.

 

In its work, the committee defined a child as a person under the age of 16. However, for the purposes of implementing the recommendation in member states, the term child is defined in accordance with the age-limits laid down in national legislation.

 

General measures

 

Article 1 – Prevention

 

Although the committee's terms of reference and, therefore, its primary focus were on policies and a framework of services for the protection of children from abuse in all its forms, certain key principles underpinned consideration of the issues. These included an acknowledgement of the right of children to live in conditions which promote their proper development and to grow up free from all forms of child maltreatment, as well as further effects such as late development, psychosomatic illness, drug addiction, suicide and crime. In consequence, the committee considered the need for policies designed to prevent child abuse.

 

Prevention

 

Child abuse is a complex phenomenon, with multiple causation and many manifestations in neglect and in sexual, physical, emotional and other forms of abuse. To prevent child abuse is, therefore, a difficult issue which requires a multi-faceted approach. None the less, the committee's recommendations concerning the multidisciplinary arrangements for handling cases of child abuse need to be accompanied by a serious and sustained commitment to preventive policies. It will not, of course, be possible to prevent all child abuse but there is a pressing need to develop and implement preventive strategies at a number of levels. Some require large-scale social, economic and cultural change, for example in minimising violence within society and its use as a means of resolving interpersonal and intrafamilial disputes or, in the sphere of sexual child abuse, in altering patterns of socialisation which lead some people, particularly men and youths, to exert power through the sexual abuse of children. Measures are required to improve general socio-economic conditions and to support families, particularly those which are economically and socially disadvantaged, to help them to parent effectively by reducing levels of personal and environmental stress. Also at the societal level, public information and awareness campaigns are necessary to emphasise the harmful consequences of abuse, and how to avoid it in interaction with children.

 

At the secondary and tertiary levels, there is a broad range of possible approaches. Details of such measures are contained in Recommendation No. R (79) 17 concerning the protection of children against ill-treatment, and Recommendation No. R (90) 2 on social measures concerning violence within the family and some are specified in this recommendation. Measures need to be tailored to suit the particular infrastructure of health and social welfare provision in each member state. All member states, however, need to develop a preventive strategy and to strengthen their preventive policies in respect of child abuse. Prevention of somatic illnesses, which is efficient in most countries, is ineffective if not completed by other coherent preventive measures at other levels (at psychological and social levels, for example).

 

Child protection services

 

The committee's central recommendation is for all member states to establish, where they do not exist, policies and services for the protection of children from abuse, based on appropriate legislation, training and resources. The system should include a lead agency with designated powers and duties and the promulgation of clear guidelines outlining the roles and responsibilities of the various professionals and agencies involved. Services should be established for the detection, notification, investigation, assessment, management and prevention of child abuse. In many instances, the system is intended to build upon the existing infrastructure of health, social services, police and judicial authorities. However, existing services will need to be developed, strengthened and consolidated (and in some cases, created) and resources, training and skills increased in order to improve and co-ordinate service provision to provide effective help to abused children and their families.

 

The primary objective is to ensure that effective services are made available to protect children from abuse and to help them recover, physically and psychologically. To achieve this, services for abused children need to be based on clear principles including the rights of children to be heard and to have their views taken into account; rights to information, to representation and to appeal against decisions; rights to help which is sensitive to the child's gender and to his/her ethnic, religious, cultural and linguistic background and to any special needs, such as disability; services which work in partnership with parents and which strive, wherever possible and so far as is consistent with the child's welfare, to allow the child to remain with or return to the family home.

 

Article 2 – Detection and notification

 

The protection of children from abuse is aided by the early detection and notification of suspected cases. A prerequisite is the designation in each locality of an agency (or agencies) to receive such notifications, undertake and co-ordinate initial investigations and take any necessary emergency action to protect the child. The lead agency will vary depending on local structures of service delivery. However, the essence of a notification system is that it should be clear, well-publicised and in operation in all localities on a twenty-four-hour basis. It should be user-friendly both for the general public and for children. Those with concerns need to know to whom they should refer and what actions will be taken in consequence. Notification should be seen as a means of alerting the relevant authorities of the possibility of child abuse and not viewed as synonymous with the institution of legal proceedings.

 

The committee noted the variations in respect of policies and practices concerning notification in the member states, with mandatory reporting systems existing in some and voluntary systems in others. Bearing this in mind, the recommendation is for the establishment of systems of notification, whether by legislation or administrative mandate, encouraging professionals in contact with children to report cases where they have reason to believe that abuse has taken place.  If children are to be effectively protected from abuse, professional staff from a variety of disciplines need to share and exchange relevant information. Ethical codes concerned with confidentiality should not be used to prevent the responsible exchange of information. The interests and safety of the child are the paramount consideration and they should take precedence over professional secrecy. It is important to emphasise that, if any person, including a doctor, has reason to believe that a child is being abused or is at serious risk of abuse, it is permissible and, indeed, her/his duty to disclose the information to a third party who can act to protect the child. If this cannot be achieved without the imposition of a legislative mandate to report, such legislation should be passed.

 

Besides staff in statutory and voluntary agencies, members of the community also have an important part to play in the early detection of child abuse. For this reason, public awareness and information campaigns should be run, highlighting the problem of child abuse, alerting people to the signs and to the appropriate agencies to contact in such circumstances. Information about services available and sources of help (such as children's helplines) should be widely disseminated through the media and local services to reach all children and families in order to encourage early referral.

 

Article 3 – Investigation and assessment

 

The investigation of child abuse requires a multidisciplinary assessment incorporating a medical, psychological and social assessment and, where appropriate, police investigation. The aim of investigation and initial assessment is to establish whether child abuse has occurred, to assess the degree of risk to the child, to take measures for the emergency protection of the child (if required) and, where appropriate, to gather evidence for legal intervention for the protection of the child and, in some cases, for the prosecution of the abuser(s).

 

Clear procedures for the involvement of the various professionals and agencies need to be formulated and circulated to all concerned with child abuse. A reasonable time limit should be set for the completion of the initial investigation and assessment.

 

A multidisciplinary assessment can only take place if professionals from various disciplines share and exchange responsibly the information they have about abused children and their families. Those in receipt of such information must treat it as having been given in confidence in order to protect the child, and should not divulge it to a third party without the originator's permission. Wherever possible, and consistent with the protection of the child, children and parents should be informed by professional staff of the information about them which they propose to share with workers from other agencies.

 

It is vital that children and, unless there are exceptional circumstances, parents are fully informed at an early stage of the investigation about the nature of the concerns about them and of their rights to be heard and involved in decision-making and of appeal. If the child or parent has communication difficulties, help (for example, a sign language interpreter, the use of large print or braille or a spoken language interpreter) must be given so that they can understand what is happening and the decisions which have to be made. Throughout investigation and assessment and subsequently, children's views should be sought, having regard to their age and understanding and any special needs they may have, such as disability, and their wishes taken into account.

 

Medical assessment

 

The purpose of medical assessment is to establish whether a child has been abused, to ensure the provision of any necessary medical treatment and, if appropriate, to gather evidence in connection with legal proceedings for the protection of the child or the prosecution of the abuser(s). The specialities of the doctors involved vary within and between member states. Paediatricians, police surgeons, forensic pathologists and general practitioners are among those often used, as are child psychiatrists in cases of trouble in mental development and emotional disturbance. The designation of the doctor is, perhaps, less important than ensuring that, where required, the minimum number of medical examinations are carried out, are conducted with sensitivity and in the least intrusive way consistent with achieving their purposes. The doctor(s) should have the requisite training, skill and experience in the identification of child abuse in all its manifestations and an aptitude for working with children. Wherever possible, girls and young women should be offered the option of examination by a female doctor.

 

A full written report of the clinical findings should be provided to the lead agency and the doctor(s) involved should, wherever appropriate, participate in any multidisciplinary meetings held to discuss the case.

 

It should be noted that, in some forms of abuse, particularly non-penetrative sexual abuse or where the abuse is alleged to have occurred some time previously, there may be no physical signs. The purpose of medical examination in such circumstances should be carefully considered. In other cases, for example, of physical injury the physical signs may be ambiguous or equivocal. The absence of clear, diagnostic signs of abuse with or without medical examination should not necessarily be taken to imply that abuse has not occurred. A full assessment of the circumstances surrounding the allegation of abuse and of the child and family functioning is also required.

 

The involvement of the police and the judicial system

 

The appropriate role for the police and the prosecution of perpetrators is a matter of considerable current controversy. Nowhere in the member states is the case being pressed strongly for the removal from the statute book of offences such as the physical and sexual abuse of children. However, there is a trend in some localities for a de facto decriminalisation, in which therapeutic services are provided to children and families on a confidential basis without, in most cases, disclosure of the abuse to the police or the legal authorities. Proponents of this approach argue, inter alia, that its voluntary and non-punitive character encourages the early referral of families with problems and facilitates work with the child and family, including the perpetrators. By contrast, others argue that absence of police investigations and of prosecutions for criminal offences implies that this particular crime is not as serious as others, thus giving covert messages about its social acceptability; that it enables abusers to avoid facing the implications and consequences of their actions and that it forfeits the opportunity to demonstrate to those who have been abused that what has occurred is not their fault, but it is in violation of the law; and can lead to relapses. This matter should be analysed in depth, to compare the effects of systems applying legal measures with those that do not.

 

This recommendation recognises the necessity of developing policies and practices in this matter in accordance with varying national circumstances and traditions. It is, however, important to elaborate some principles upon which such involvement of the police and the legal system as is requisite in child abuse should be based, namely, that the interests of the child should be paramount; that the processes of interviewing children and of their giving evidence in prosecutions should be sensitive to their needs; that any delays caused by the legal process should not prejudice the child's right to receive help and that legal officers involved in criminal proceedings are appropriately trained.

 

Article 4 – Intervention

 

Following multidisciplinary initial investigation and assessment, the on-going protection of abused children also requires a co-ordinated approach from various disciplines and agencies which may include medicine, social work, psychology, education, the judicial system and others.

 

In all cases of child abuse, the child's welfare should be paramount. It should always be emphasised that the services exist primarily for the benefit and protection of abused children. The aim should be for children to be brought up by their parents wherever possible and consistent with the child's welfare. However, in some circumstances, state intervention will be required. This may be on a temporary, or more rarely, a permanent basis. The objective should be to work, wherever possible, on a voluntary basis in partnership with parents, acknowledging that parents (or legal guardians) bear the primary responsibility for the upbringing of their children.

 

A corollary of the state's right to intervene to protect children is that the state has a duty to ensure that intervention is sensitive, effective and does not further avoidably damage or traumatise the child and the family. Effective intervention requires skill, commitment, training and resources. Intervention may take many forms: the provision of counselling, social work services and psychological or psychiatric help on an individual or group basis to the child and the family; substitute or respite care, for example, in foster homes, crisis centres, child refuges or residential care; rehabilitation of children with their families, if at all possible, if separation has occurred; and work with abusers to minimise the likelihood of recurrence of abuse. Material, financial or other support should be made available where necessary to enable parents to provide adequate care for their children. This may include the provision of day care, play space, housing, financial aid or other resources. Every effort should be made to foster, enhance and sustain the capacity of parents to care for their children.

 

Article 5 – Training

 

The effective protection of children from abuse in the member states requires a sufficient supply of adequately trained personnel. These basic prerequisites have not yet been met. The need for training for all aspects of work related to child abuse, prevention, identification, assessment, intervention and follow-up for children, their families and abusers, is well-documented. The committee noted the wide variation in the member states between countries, between professions and between specific training courses and institutions which cover the topic of child abuse and child protection in basic, in-service or post-qualifying training, and in the priority accorded to multidisciplinary training. Specific current training priorities include training in the identification of abuse for certain medical personnel, in increasing skill and knowledge in those members of the legal services involved with cases of child abuse and in the skills of communicating with children and intervening sensitively and successfully for all personnel who work with abused children. The quality of service offered to abused children and their families depends, in no small measure, upon the competence and skill which the requisite training can engender.

 

Article 6 – Research

 

Despite the considerable increase in research on child abuse in recent decades, important gaps in knowledge remain. Particularly significant from the committee's point of view is the absence of comparative cross-national studies of systems for the management of child abuse and of their impact upon children and their parents. There is much variation within and between the member states in handling child abuse, for example in matters such as mandatory notification, the involvement of the police and in the role, powers and structure of the relevant health, social welfare, judicial and other services. However, there is little analytic or evaluative research on these different systems and their efficacy on a national level, and even less on a cross-national comparative basis. There is an urgent need to research the main features of the various systems of notification, investigation, assessment and intervention and to compare and contrast their consequences for abused children and their families. Other current research priorities include the evaluation of different treatment approaches in direct work with abused children, their families and abusers and research on the effectiveness of programmes for the prevention of child abuse.

 

Article 7 – Resources

 

The establishment of policies and programmes to enable children to live in conditions which promote their proper development and to grow up free from neglect, emotional abuse, physical abuse, sexual abuse and other forms of child maltreatment requires commitment and resources at international, national and local levels. The nature and size of the specific task to establish policies to prevent child abuse, services for the welfare and protection of abused children and help for their families in accordance with the recommendation varies between the member states. All, however, need to ensure that financial and other resources are made available to implement speedily the measures outlined in the recommendation for the effective prevention and protection of children from abuse.