2.28 Physical abuse

Physical abuse is:

      “A form of abuse which may involve hitting, shaking, throwing, poisoning, burning, or scalding, drowning, suffocating or otherwise causing physical harm to a child. Physical harm may also be caused when a parent or carer fabricates the symptoms of, or deliberately induces, illness in a child.”

Working Together 2018

There is a separate policy for Fabricated & Induced Illness

The Office for National Statistics reports “three-quarters of adults who experienced physical abuse before the age of 16 years, from someone aged 16 years or over, also experienced another type of abuse. This could be sexual abuse, emotional abuse, and/or witnessing domestic violence or abuse” which suggests that these procedures need to be considered concurrently with others.

A note on physical punishment;

In England and Northern Ireland, smacking remains legal when used by parents in accordance with the reasonable chastisement defence, however section 58 of the Children Act 2004 provides legal basis to consider that battery of a child cannot be justified on the grounds that it constituted reasonable punishment.

In 2020 a legislative ban on smacking came into effect in Scotland. The new law means that the so-called “justifiable assault” defence is no longer available, and children have the same legal protection from assault as adults. In 2022 legislation also came into force in Wales abolishing the defence of Reasonable Punishment. 

Equally Protected? A review of the evidence on physical punishment of children (NSPCC 2015) found:

• Physical punishment is associated with increased childhood aggression and anti-social behaviour
• Experiencing physical punishment is related to depressive symptoms and anxiety among children
• Physical punishment carries a serious risk of escalation into abuse

Physical abuse can happen in any family, but some parents/ carers might find it hard to give their children a safe and loving home if they are facing:

• Poverty
• Poor housing
• Issues with substance abuse (drugs or alcohol)
• Mental health issues
• Relationship problems
• Domestic abuse
• Isolation or a lack of support
• The effects of their own childhood abuse or neglect

Adults who physically abuse children may have:

• emotional or behavioural problems – such as difficulty controlling their anger
• health issues, including mental health needs, which make it difficult for them to cope
• family or relationship problems
• experienced abuse as a child (Miller-Perrin and Perrin, 2013).

Babies have a higher risk of suffering physical abuse as well as disabled children; especially those who are unable to tell someone what is happening or those who do not understand that what is happening to them is abuse.

Physical abuse may also occur as part of ‘honour’ based violence and is in evidence across countries, cultures, and religions. Circumstances which may lead to the honour-based abuse are wide ranging and not culturally specific. It is important to remember that, despite the use of this label, there can be no ‘honour’ in abuse, and where culture or tradition are used to exert power or control over others, this can only be a misuse of that culture, often associated with a label of perceived shame brought to a family or a community group. There are procedures for honour based abuse which may need to be considered. Particular attention should be paid to children who make a disclosure of physical abuse, and despite evidence, they subsequently withdraw their disclosure; professionals should remain vigilant and exercise curiosity about the reasons why this might happen and question whether it is due to pressure from their family and/or community. Consideration should also be given to abuse linked to faith or belief as a small minority of people who believe in witchcraft or spirit possession may use fear and physical abuse to make children comply or when an attempt is made to ‘exorcise’ the child.

FGM  “procedures for the partial or total removal of the external female genitalia or injury to female genital organs whether for cultural or other non-therapeutic reasons” (WHO, 1996)” is also a form of Physical abuse and there are separate multi-agency safeguarding procedures available for this.

The diagram below illustrates typical features of accidental injuries to be considered within the context of a child’s developmental stage:

Typical features of accidental injuries

Bruising which might be indicative of non-accidental injury:

• bruises on the head - but also on the ear or neck or soft tissue areas - the abdomen, back and buttocks, defensive wounds on the forearm, upper arm, back of the leg, hands, or feet
• clusters of bruises on the upper arm, outside of the thigh or on the body (grip marks)
• bruises with dots of blood under the skin (petechial bruises)
• a bruised scalp and swollen eyes from hair being pulled violently
• bruises in the shape of a hand or object

Bruising is the most common injury sustained by children who have been subject to physical abuse. Excessive bruising that occurs as a result of minimal or no trauma, may be caused by, or exacerbated by, an underlying bleeding disorder or medical condition. NICE guidance provides more information about this and advises that the presence of a bleeding disorder or other underlying medical condition does not rule out non-accidental injury as a cause of abnormal bruising, as the two may co-exist. 

More detailed guidance on bruising can be found here:  Child protection evidence systemic review on bruising

*Bruising in non-mobile babies and children is unusual and is highly suggestive of non-accidental injury. Learning from serious incidents and case reviews has evidenced that professionals can underestimate the significance of the presence of bruising or minor injuries in children who are not independently mobile, thus missing the fact that a minor injury can be an indicator or precursor to a more significant injury or even death of a child. Early recognition and action in such cases is key to preventing further, and potentially more serious, injuries.

There are separate procedures for responding to injuries in babies or children under 2 years

Burns and scalds can result from hot liquids, hot objects, flames, chemicals, or electricity and may be accidental or indicative of abuse:

Burns which might be indicative of non-accidental injury include:

• burns on the hands, back, shoulders or buttocks; scalds may be on lower limbs, both arms and/or both legs
• burns in areas of the body which are usually protected and therefore difficult to injure e.g. inner thigh or under arm
• a clear edge to the burn or scald suggests an immersion injury, which in the absence of a satisfactory history may suggest abuse
• sometimes in the shape of an implement, for example an iron or electric heater
• circular cigarette burns
• multiple burns or scalds

More detailed guidance can be found here:  Child protection evidence systematic review on Burns

Bite marks should always be considered within the context of physical abuse.  They are:

• usually oval or circular in shape
• visible wounds, indentations or bruising from individual teeth

The commonest bites children sustain are animal bites; these have different canine distributions and usually tear rather than compress flesh.

If necessary, the police can refer to a forensic odontologist who may be able to identify the perpetrator of a bite mark from the dental characteristics.   

Fractures or broken bones may be accidental or indicative of abuse, however fractures which might be indicative of abuse, especially in children under 18 months, include:

• fractures to the ribs or the leg bones in babies
• multiple fractures or breaks at different stages of healing

More detailed guidance can be found here: Child protection evidence systemic review on fractures

Other injuries and health problems which may be indicative of physical abuse include:

• scarring
• effects of poisoning such as vomiting, drowsiness or seizures
• respiratory problems from drowning, suffocation, or poisoning
• torn frenulum of the mouth – these are the small folds of tissue under the tongue, inside the upper lip, inside the lower lip, and connecting the cheeks to the gum.

Attention should also be paid to:

• Any delay in seeking treatment
• Recurrent injury
• Vague or inconsistent explanations of what happened
• Any disclosure from a child e.g. “daddy did that with a fag”, although the disclosure may not always be so obvious and will be dependent on the child’s communication style (including Makaton for example), and/or communication with behaviours, that will require professional curiosity to understand what a child is saying.

Babies are particularly vulnerable, and head injuries are possible, so it is important to be aware of these visible signs of abuse:

• Swelling
• Bruising
• Fractures
• Being extremely sleepy or unconscious
• Breathing problems
• Seizures
• Vomiting
• Unusual behaviour, such as being irritable or not feeding properly

This section should be read alongside the specific procedures for referrals, immediate protection, strategy meetings and child protection enquiries

Physical Abuse Pathway

The pathway below sets out the multi-agency response to concerns about physical abuse:

Physical abuse pathway

Making a Referral

When you are considering whether a child’s physical injuries might be the result of abuse:

• consider the injuries in the context of the child’s medical and social history
• think about whether the explanation for the injury is consistent with the child’s stage of development and the environment where it was said to have occurred
• check whether the severity of the injury fits with the description of the cause.
• think about any pattern of injuries which collated may be of concern;
• do act on any injury of concern as and when it presents

Bruising in young children is probably the most overlooked or underappreciated injury. This harm-causing oversight is likely driven by several factors:

• bruising in and of itself rarely needs an intervention or treatment, so can be overlooked, or does not register as important
• bruising is common, ubiquitous and, for the most part, an inconsequential finding on active toddlers and older children
• even if the bruise is noticed, professionals may not feel comfortable concluding whether a bruise is or is not likely to occur from any one stated cause, therefore professionals are more likely to give the family the ‘benefit of the doubt’ and not make judgements about the bruising and injury ‘plausibility’.

(Bruising characteristics from unintentional injuries in children: the ‘green flag’ study Mary Clyde Pierce 2017)

Appropriately trained medical professionals are more likely to be able to assess bruising characteristics in relation to specific injury events across different development stages than other professionals.  It is therefore important that professionals do not attempt to undertake this assessment themselves. 

Where there are concerns of physical abuse professionals should seek support from their agency safeguarding lead to ensure the matter is referred to Children's Services or the Emergency Duty Service out of hours team. In the absence of the safeguarding lead, professionals must report directly to Children's Services or the Emergency Duty Service out of hours team. If a child is at risk of immediate harm the police should be contacted by telephoning 999.

The detail of what has been observed and discussed should be recorded, dated, timed, and signed in the child's individual record held by the agency and followed up in writing as part of the referral to Children's Services.  The referral should include any pertinent information that helps to provide an understanding of what life is like for the child.

Child protection body map

A child protection body map can be used to record information about physical injuries to a child, particularly if it is felt that the injury is non-accidental or thought to be following a pattern. The body map provides a visual record of physical injuries which have been seen and a written record of what has been said about the injury.  It will help professionals to work together when deciding whether there is a safeguarding concern and will be used to inform decisions about what action should be taken.

The details that should be included on a child protection body map are:

• Information on who noticed the injury, when they noticed it and what their role is in relation to the child.
• Details of the injury – where it is on the child, what it looks like, its colour, shape, size, and condition.
• Details of all visible injuries, even small marks that may not seem of concern at the time.
• In regard to the condition of the injury, is it deteriorating or getting better?
• Is the child in distress or indifferent about the injury?
• Information on any explanations behind the injuries.
• Observations of the child – how are they feeling, what is their behaviour like?
• Information on anything that the child or parent says about the injury.
• Include both a drawing and a written description of the injury.

In a situation where there are no visible injuries, but wider family members are expressing concerns about possible physical abuse, always make a referral to Children’s Social Care.

In order for professionals to make good decisions about children in need of protection, they have to have a full picture of what is happening in a child’s life. Part of this is about having access to all the information known about the child. But just as important is seeking out missing information, considering disparate pieces of information, and asking what bigger picture is being painted about a child’s experience, who else is in their life, the household they are in, what is known about these people historically and now. The totality of all this information must be considered to avoid an episodic approach that puts too much weight on a single observation. This requires All staff to be aware and compliant with information sharing protocols

Good child protection practice around referrals requires professionals to consider a wide range of evidence from many sources, and to synthesise it into meaningful working hypotheses within a very short time frame. This relies on professionals engaging in critical thinking, both individually and as a collective. It is particularly important that due weight is given to information provided by wider family members or other significant adults who try to speak on behalf of the child, even when the child tries to dismiss any such concerns possibly due to fear of the consequences or coercive control.  Every opportunity should be taken for multi-agency collective consideration and challenge, avoiding reliance on a single perspective. 

Professionals should also consider the possible consequences for the child of the family withholding consent for an early help intervention; the question should always be asked whether this increases concerns for the child requiring a step-up to a referral to Children’s Social Care. 

Strategy Meeting/ Discussion – the strategy discussion/ meeting should be convened by children’s social care and will include the police, children’s social work services, relevant health professionals and other agencies who hold information about the child.  An appropriately qualified medical professional must be involved if there are significant medical issues or if a medical examination may be required.  The strategy discussion/meeting should decide whether S47 enquiries should be made and, if so, how these should be conducted.  A clear plan should be agreed including any immediate action that may be needed to protect the child and any other children. 

Wherever possible these should be face to face meetings (possibly video conferencing) rather than telephone discussions to allow better analysis of the available information.

If the child is in hospital, the meetings should take place either at the hospital or using video conferencing to enable the medical professional involved in the child’s diagnosis/treatment to participate.

If the referral has been made anonymously or by friends/family, and there is no report of an obvious injury at the time of making the referral, then it is particularly important to triangulate the referral as far as possible.  Even where there is no obvious injury evident, allegations of bruising should always be taken seriously and consultation with a paediatrician may be required to gain advice as to the action to be taken. 

Checks with partner agencies are especially important to ascertain whether there has been a history of injuries previously or concerns about other children in the household/family to inform the strategy discussion. Referrals from friends, family and members of the community should not be deemed as being malicious without a full and thorough multi-agency assessment, including talking with the referrer, and agreement with the appropriate manager. The use of words like malicious can have many risks that occur because of its use, so therefore should be discourage in being used in a professional conclusion. Effective child protection practice requires professionals to understand the significant relationships in that child’s life, including their extended family or peer network, and to build a picture of the child’s experiences that draws on their views and listens to their concerns.

If concerns of significant harm are not substantiated determine and agree ongoing help and support of the child and family and the best means of meeting these.   

If new information is provided which adds to the weight of evidence of possible physical abuse, then the strategy discussion should be reconvened.

Photographic images may have been taken by carers or others using mobile phones or other devices and given to statutory agencies some time later when the injuries may have healed. These images may be of poor quality and their validity may be in question. Moreover, images can be digitally altered. Carers and others may bring these photographic images to the attention of statutory agencies (police/ children’s services) as evidence to support their concerns regarding possible child abuse. If requesting a medical opinion on photographic images this must be done within the context of requesting a medical assessment for possible child abuse or neglect. Therefore any agency receiving these images should ensure they are expediently passed to MASH where an initial telephone contact with the clinician should be made to discuss the case and decide if referral for medical assessment is appropriate. The following guidance should be followed: Best Practice Guidance Management of requests from statutory agencies (police/social services) for medical opinion on photographic images of possible physical abuse in children. Any photographic images received directly with MASH should also be shared with the Child Abuse Investigation Unit of the Police.

If possible, photographs should be taken at the time of the child protection medical assessment. Photographs should be of a standard that is suitable to be used in court.

The child protection medical assessment must be planned, timely and conducted by an appropriately qualified medical professional. Child protection medical assessments can be stressful for all concerned, particularly for the children and families, but also for police officers, social workers, and doctors. Nothing will remove that stress, but it can be mitigated to some degree by making sure that the child is seen by the right people at the right time and with the right facilities and processes in place.

It is important that children are seen as soon as is reasonable when visible signs might be present as these can soon become less visible or disappear completely. An assumption should be made that a child protection medical examination will be required and the rationale for not arranging one must be carefully recorded.

The RCPCH Child Protection Companion recommends that children are seen for an assessment of possible physical abuse within 24 hours, though it may be clinically appropriate to be seen more urgently, depending on the context. This may include accessing an appropriately qualified medical professional through accident and emergency services at the hospital if a medical cannot be pre-booked.

Consent should always be sought to examine a child for any reason. Consent may be from the child or young person if they are deemed to have capacity. If consent is withheld by the child/ young person or person with parental responsibility for the child then a discussion needs to take place with the paediatrician and social care regarding further action which may be needed in order to proceed to examine the child.

(Consider a chaperone in line with your organisations chaperone policy.)

For information this document provides good practice service delivery standards for the management of children referred for child protection medical assessments:

Good practice service delivery standards – medical assessments

Parents and carers should be provided with this leaflet informing them about a child protection medical. Here is an example of one:

Parent/carer leaflet – child protection medical assessments

Children do not always verbally tell people when they are being physically abused, but they may try to express what is happening to them, through the way they behave, present or respond or don’t, but for various reasons they are not heard or understood. Practitioners should be mindful of the powerful impact of coercion or control by parents/carers on a child who is experiencing physical abuse, their siblings/ other children in the household, which can make disclosure to a professional feel impossible. 

To understand what a child is telling you (as opposed to the words they are saying) practitioners need to think about how well these things fit together:

- What the child says (do they change what they say or say different things to different people? Sometimes what they do not say is a powerful indicator that something is wrong)

- How the child behaves (do they say everything is ok but then behave as though it is not?)

- What you see (do your observations of the child interacting with his/her family match what the child or others are saying?)

- What other people who know the child are saying (does this match what the child is saying or what you are seeing?)

Consideration should be given to the words spoken by a child and listened to by the professional and volunteers, but voice of the child means much more than this. It means an active process of receiving, interpreting and responding to communications that include all the senses and emotions and is not limited just to the spoken word.  It is therefore important to give consideration to the child’s age and development stage, first language, disability, ethnicity and culture to understand and analyse the behaviours, expressions and emotions of the child and people around them.  It is also important to triangulate this with what other agencies, professionals and volunteers, family members, neighbours and members of the community have observed and report, to be able to develop an understanding of the child’s lived experience.

If it is determined following a S47 child protection enquiry that a child is at risk of or has experienced significant harm then an Initial Child Protection Conference (ICPC) will be convened.  Care should be taken to consider how the child / young person can be enabled to participate in the ICPC – either through attendance, advocacy or both.

In reconciling the difference between the standard of evidence required for child protection purposes and the standard required for criminal proceedings, emphasis must be given to the protection of the child as the prime consideration.

The investigation and enquiries must also address the religious, cultural, language, sexual orientation, and gender needs of the child, together with any special needs of the child arising from illness or disability.

A victim support strategy should be established at the outset. Support will be required, especially in pre-trial, trial, and post-trial periods if the case proceeds to court.

Physical abuse can have long lasting effects on children and young people. It can lead to poor physical or mental health in life, including;

• Anxiety
• Behaviour issues
• Criminal behaviour
• Depression
• Substance misuse
• Eating disorders
• Issues in education
• Obesity
• Unsafe sexual behaviour
• Suicidal thoughts and/ or attempts

If a baby or infant is shaken or thrown, they might suffer head or brain injuries, causing;

• Fractures
• Internal injuries
• Long -term disabilities
• Learning problems
• Seizures
• Hearing and speech problems
• Behaviour issues
• Brain damage
• Death

Support will need to be specifically tailored for each child and consideration given to what support parents/ carers will need, especially non-abusive parents. NICE provide a quick guide of interventions after physical abuse, emotional abuse and neglect for children and parents: Not all interventions will suit everyone, and the choice should be informed by a detailed assessment and form part of the child’s Plan.

• Childline information for children on Physical Abuse  #

• The following website provides evidence based resources to help inform child protection procedures and professionals: https://childprotection.rcpch.ac.uk/child-protection-evidence/  

• ICON https://iconcope.org/