J Thoburn

Each country represented at the conference, whether "rich" or "poor" or somewhere in between, has committed its government and its citizens to providing protection from what UK legislation describes as "significant harm". The UN Convention on the Rights of the Child talks of the need to protect child victims of "any form of neglect, exploitation or abuse", and lists possible causes of maltreatment as having their origins in social and legal systems as well as resulting from the acts or inaction of parents.

The commitment unites us, but beyond that, each country has to work out for itself the reasons why its children suffer significant harm, and decide, in the light of available resources, which strategies it will develop to protect them. Will it emphasise prevention and family support or will it rely on rescue? Will it rely heavily on professionals or on building protective communities, using the ideas behind the new discourse of "civil society" and "capacity building"?

In this paper I shall consider the following themes:

• Which children may need protection?

• The centrality of needs assessment

  • including the need for protection services

• Multi-level responses to childhood adversity

• From assessment to choice of service options

• When to use formal protection systems?

• The importance of preventative strategies

Assessment of Need: the First Imperative

Put simply, assessment comprises two tasks:

• Understanding what it is in any society, local community or family, which leads to children's health or development being significantly impaired;

• Deciding how to make best use of whatever resources are available.

Assessment at Community Level

Who are the children in adversity in your country - those who may, to use UNICEF's phrase, be in need of special protective measures? Recently a television programme made up entirely of the voices of children shocked UK viewers. Three sisters aged 6, 7 and 9, who bore on their faces all the signs of serious neglect said, when asked how life was for them: ''All right. The heroin is worse than the beer''. ''No'', said the younger one ''the beer is the worst''. When asked 'if you could ask the Prime Minister to do something to make you life better, what would it be? The seven year old replied: ''A nice house and a quiet place and them [parents and visitors to the house] not doing drugs. Ask him to change things that happen that are bad. Ask him to change the whole thing. Ask him to make everybody forget what they have done in their whole life that's bad.'' A ten year old boy, who it was all too easy to envisage beating his own children in the not-too-distant future said: ''When you get smacked all the time you get used to it - not bothered whether they hit you or not.'' And then, with pride, ''I'm not saying I'm tough, but I can take a good beating''.

In Britain, perhaps more than most countries, we responded to the problem of child maltreatment by putting our trust in formal procedures to identify cases of child abuse. The Department of Health commissioned research (summarised under the title: Child Abuse: Messages from Research) which told us that we were spending ever more resources in detecting abuse but less and less on helping those who had been abused, or preventing it happening in the first place. The identification of risk was almost exclusively confined to risk of acts of physical or sexual maltreatment by parents or parental figures.

Other causes of significant impairment to children's health or development were left unattended. Bullying or racist taunts in school, for example, have lead to the deaths through suicide of children whose caring parents were turned away when they sought help because, they are told, ''we only work with child abuse cases''. Children who had been sexually assaulted by the mother's boyfriend were "investigated" and "conferenced" but offered no further help when it became clear that the abuser was no longer in the home. Cases of neglect and emotional maltreatment were identified but rarely received a longer term service, despite the clear evidence that long term impairment is highly likely to result from persistent physical or emotional neglect. Worst of all, despite unassailable evidence that the children whose health or development was most likely to be most significantly impaired were those who came into the care of the local authorities when older, these children were often not allocated to a social worker's caseload. They were "safe" (that is, apparently safe from further parental maltreatment) and the harm to which they continued to be exposed, in most cases as a result of system inadequacy or their own risk-taking behaviour rather than deliberate abusive acts, received too little attention.

Unlike the situation in many parts of the world where the major reason for child prostitution is family poverty, in the UK it is largely explained by family dysfunction and the failure of our child welfare system to pick up early enough on serious family problems and provide appropriate help. (I shall return to this point later.) It took the recent Utting Report People Like Us, to draw to the attention of Government the fact that a large proportion of runaways and children living on the streets were running away from state "care". "People like us", the report pointed out, do not turn our children out at the age of 16. We continue to be there for them for as long as they need us.

Before I go on to look more closely at the UK response to this research, I will answer my earlier question in respect of UK children. Who are the children in adversity for whom we must build a caring community? This list will resemble your lists in some respects but be different in others. The point is, we can not use our resources effectively to build caring communities until we first identify who are the children in need of protective measures and the possible causes for this.

Table 1 shows the reasons why UK children come to the attention of social services departments, either because their parents seek help or because a neighbour or a professional believed they may be at risk of suffering significant harm.

In support of this, Table 2 is taken from two cohort studies, respectively of children newly identified as suffering or likely to suffer significant harm, and of children referred for family support or because of concerns about emotional maltreatment or neglect.

The response of the UK government to this research-led agenda has been to "refocus" its child welfare and child protection services. At the community level, it is important for professional agencies, NGOs, and representatives of vulnerable groups and service users to get together to understand the nature of the risks in their own communities. In the light of these consultations, each local authority must produce annually a Children's Services Plan. In the light of this plan, the health, education and social services departments must prioritise needs in the light of available resources and jointly commission services to meet the identified needs. Vulnerable communities may be geographical areas with high levels of deprivation and social exclusion, or they may be "communities of interest" such as parents of children with disabilities or who are HIV positive, or homeless young people or care leavers. A set of performance indicators (the Quality Protects indicators) inform these plans and are used to measure their effectiveness. At least, that is the rhetoric, but to date, most plans are dominated by professionals and it is rare for service users to be involved. However, small steps are being taken, encouraged by the government guidance on family participation, The Challenge of Partnership (DH, 1996). For example, in the area in which I live parents of children on the child protection register have been invited to be members of a working party designing leaflets to inform parents about child protection investigation and conference processes.

Assessments of Children in Need

In individual cases, the Children Act 1989, inspired by the principles in the UN Convention on the Rights of the Child, provided the framework for a shift in emphasis from "risk assessment" to "needs assessment". This is not that we are to turn our backs on child maltreatment, but rather that children's needs for protection should be firmly located within their other needs and those of their parents and siblings.

Figure 1 illustrates the framework which will be used for assessing the needs of all children referred for a service, including a child protection service. The preliminary assessment may take an hour or it may take a week. But it must go beyond the narrow assessment of risk of abuse to cover all these areas, without being any more intrusive into family privacy than is necessary to get a full enough picture on which to base a decision about appropriate intervention in each particular case. Amongst the basic principles for assessment is the statement that help should start immediately and be revised in the light of further assessment. This is in response to the research which found that families requesting a very specific practical service were often told that nothing could be done to help them until lengthy assessments had been completed.

Figure 1 Framework for assessment. (From Department of Health, 1999)

Your response to this assessment framework may well be - but what is new about that? It is the "ecological model" of the early 1980s or the "unitary model" or systems approach; person in environment or psycho-social casework. Maybe in your countries it is not necessary to restate the basic principles of assessment. But in the UK, for several years the emphasis on the investigation of risk of parental assault had squeezed out the more careful assessment of other family needs. I welcome it because it gets us away from over-reliance on "quick fixes", whether through procedures or magic cures - the latest therapy or the dream of "rescue" represented by the ''permanence'' approach of terminating parental rights and contact and placing for adoption.

Central to the assessment framework is an appraisal of the strengths as well as the weakness in the family and also in the community. What family, community and professional resources are there, and how can they be harnessed to ensure that this particular child's welfare is not further impaired and any damage already done is repaired?

As part of the assessment, the professional resources previously available to family members have to be appraised. If the family is well known to the welfare and mental health agencies, a careful social work history needs to be compiled, from the records and the family members. It is essential to know about the services provided and the therapeutic methods used in the past, noting those which have been found useful and those which were seen to be unhelpful. (Evidence-based practice is essential if best use is to be made of scarce resources.) A singular weakness of social work recording identified by researchers is the lack of evaluative summaries and case closure summaries. A new worker picking up a re-referred case can not benefit from the assessment of the previous worker as to ''what worked'' amongst the different intervention methods tried.

Voluntary Action or Coercion?

We have learned from the research that our formal processes and the negative impact on self-esteem which often results when children's names are placed on the child protection register, are themselves damaging to parents. Sometimes it is necessary to inflict this further damage in order to ensure that parents realise that they are damaging their children and that society, in the shape of the protective agencies, cannot stand by and let them continue to do so. But our UK research showed that we were alienating parents by these procedures, especially registration and the use of court orders, in cases where combinations of parenting education, negotiation, support, practical help, casework and therapy would have had the same or a better result. The emphasis in the new draft of Working Together (DH, 1999) is on using negotiation rather than coercion to arrive at a support and protection plan whenever possible. At each stage in the assessment and protection process, the question is to be asked, is the formal child protection process necessary or could the same result be achieved by voluntary agreement? Is it necessary to undertake a child protection inquiry or can a voluntary agreement be reached about the appropriate child protection plan? Is a child protection conference necessary? Is registration necessary? Is court action and supervision necessary? Is it necessary for the child to be placed away from home, and if so is it necessary to seek a care order or can the same results be achieved by voluntary arrangements? (As an aside, it is important to note, for those interested in international comparisons of child abuse statistics, that the UK Child Abuse Registration figures do not give information on all the children believed to have been abused or maltreated. They can only tell you about those who have been or are likely to be maltreated and for whom a formally sanctioned protection plan is considered by a multi-disciplinary conference to be necessary.)

From Assessment to the Provision of Services: Making Best Use of Scarce Resources

At the community level and the level of the individual child and family, an appropriately full assessment leads on to a service plan. I shall first look at a community level plan for two groups of vulnerable children: child prostitutes and children who are at risk of harm because of exposure to extreme or persistent parental conflict or violence.

The research I have cited has shown that the second of these is a more substantial problem in the UK, whereas in some countries of South East Asia the "child sex trade" is numerically a much bigger problem. Both should feature in any Children's Services Plan (or whatever the equivalent is in your countries). The plan should provide an analysis of the main reasons why these problems exists, and the response at the following levels:

Child Prostitution

Looking first at child prostitution, the analysis in UK, as I have indicated earlier, suggests that the majority of children drawn into the sex trade are from families who could broadly be described as "dysfunctional". Using economic language, it is the "push factors" which have to be tackled. Children leave environments (their family homes or children's homes) because they find them intolerable. Once on the streets, "pull factors" come into play. The UK government no longer provides financial support, other than in exceptional circumstances, to young people aged 16 and 17 living away from their families. If unable to find employment, the young person has to chose between asking to go into local authority care (which many have already run away from) or finding some more dubious source of housing and food. They become exposed to the "pull" of the pimp or of the adult willing to pay for casual sex. Poverty, therefore is only a secondary cause of child prostitution in the UK. In South East Asia the position is reversed. Poverty is the major cause, though the pull factor of "easy money" and the sex trade is also very strong. Sale of children by parents or relatives (sometimes linked to poverty, sometimes to cultural norms, sometimes to dysfunctional relationships) is a bigger cause of child prostitution in South East Asia than in the UK. But it does exist amongst some families where a culture of inter-generational use of children for the sexual gratification of adults has become accepted. Some of our most high profile child abuse scandals have included the introduction of children into sexual activity by parents and other adults who are well-known to them.

The point I am making is that creating a caring and safe community will differ depending on the reasons which underlie the particular risks. In the East a major response to child prostitution will be at the primary, societal level. Both the push factor of poverty and the pull factor of a thriving sex trade with a ready supply of "customers" has to be a major plank in any policy. Civil society has a crucial role to play in persuading governments that the earnings from "sex tourism" can have no place in their plans to improve the health of their economies. The physical and mental health of a nation's children are infinitely more important.

In the UK, our approach has emphasised services at the secondary, tertiary and "quaternary" levels of intervention, with halfway houses and casework and education services. Because the major problem is dysfunctional families and problems with our care system, the response to child prostitution at the secondary and tertiary levels is the same as our response to other forms of child maltreatment. A range of models of family support and family casework, direct work with the children themselves, together with attempts to improve quality of services in children in care, are appropriate preventive services for all forms of child maltreatment, including child prostitution. But we have been slow to take up the challenge of adapting our child abuse services to tackle the "pull" factor of pimps and "customers" looking for sex with children. We are moving in that direction, but we have still not yet persuaded our government and police service to totally stop prosecuting the young women as criminals, and to treat them as abused children and their "customers" as sexual abusers.

Parental Conflict and Violence

In the UK I might go so far as to say that ''exposure to parental conflict and violence'' is the latest category of parental behaviour recognised at ''child abuse''. In the new version of Working Together there is a separate paragraph of guidance, and it is beginning to appear as a heading in Children's Services Plans. So what might be a multi-level approach to children whose development has been impaired, or is at risk of being impaired, because of marital violence. I think that, unlike child prostitution there would be many similarities to the broad approach in different countries, though different cultural approaches to marriage and male/female relationships would lead to differences in the detail.

At the primary level, public education has an important part to play. How about a television commercial ?''Do you want to know how to scar your child for life? Just go on taking out your temper and bad moods on his mother and you will succeed.'' An advertising consultant would make a better job, but I think you know what I mean. Whilst many parents don't stop to think whether they are emotionally damaging their parent by psychological or physical assaults, most do not want to harm their children. It just doesn't occur to them in the heat of the marital row, that that is what they are doing. In our study of emotional maltreatment we asked parents what they thought was meant by "significant harm". These three responses (Thoburn et al, 1999) indicate that parents who emotionally neglect their children because of their own preoccupations understand that it is harmful. To them, emotional abuse meant:

Being put down or upset by your parents' attitude to each other if they row a lot - emotional blackmail from parent to parent;

If parents are rowing all the time...if they are seeing violence;

I suppose that is like emotional blackmail if a child was being torn between mother and father - being made to choose.

A publicity campaign might get to them before the children have already been harmed, and perhaps push them into seeking help or leaving a violent relationship.

With conflict and violence a protection plan would include intervention at all levels. At the tertiary level, when it becomes clear that children are being harmed by parental conflict, it is unlikely to be helpful in most cases for the formal child protection system to be used. The new Working Together does not have it as a separate category for registration but includes it under emotional abuse ?though I think in most cases it would fit better under emotional neglect. There is also some risk of physical harm if a child gets caught in the cross-fire.

Intervention at the Family Level: What Works?

Moving on to intervention at the individual level, after the assessment of the problems and strengths of the family and the resources available to them a view will need to be taken about the sort of services which may be helpful. This means going beyond the reasons for referral and specific identified needs to make a professional judgement about the sort of family under consideration. Some risk and need questions to be answered are:

• What is the extent of impairment to health or development of each child?
• Is harm or impairment actual, suspected, or likely?
• Is it impairment to physical, emotional, behavioural, intellectual or sexual development?
• Is there a danger to ''life or limb''?
• How imminent and how likely is that danger?
• Who is or is suspected to be culpable/responsible for any maltreatment or neglect?

Cleaver and Freeman (1995) developed a typology of families referred to the child protection services upon which a decision might be based about the likely intensity and duration of and the casework methods which might be most effective. Table 4 gives the proportions in the different groups for all the families referred to four social services departments.

At this stage some important questions are:

• Is there any evidence that these services are likely to be effective in these circumstances?

• Can they be afforded?

• Are the short or long-term costs of doing nothing, measured in terms of serious injury or death; children's wasted lives or long term criminal careers, so heavy that they have to be afforded?

• Are these services acceptable to the parents and children?

• If not are the risks to the child so great that we have to use coercive measures?

• Even if the risks are high, do we have sufficient confidence in the efficacy of what we are proposing in these circumstances that we consider it ethically right to overrule the parents or child?

• Is there evidence that, by going against the wishes of parents or children our coercive measures could do more harm than good? (This is sadly often the case with those older children whose problems are already severe.)

The cost of a service will be important when we decide whether the threshold to a service should be ''guarded'' by a parent or child, who will ask themselves the question: do I think it is worth my while attending this holiday club, this class on how to separate from my husband without harming my child? etc.

At the other end of the continuum, placing a child in long term care is both costly and possibly harmful and the professional will have a major say in whether it should be provided. In the middle, when children have not yet been seriously harmed, early intervention which makes use of short-term methods, such as solution focused therapy or a period of cognitive behavioural therapy or counselling, should be decided upon jointly by the family members and professionals. Here, careful thought is needed about prioritisation. Therapeutic services of this nature are expensive, but leaving the situation to get worse can be even more expensive. In our emotional abuse study, some families were turned away eight times in the course of the year, at which stage the situation was so bad that a care order had to be sought.

In Conclusion

In conclusion, I return to the question: what do we know from research about "what works?" in broad terms there is an overarching message: the older the child, the longer we delay intervention, the more difficult will it be to reverse the harm the child has suffered; the less effective will be our interventions and the more costly.

Which brings us back to the importance of each community, each culture, getting together to decide about the sources of potential harm to children and the societal and cultural factors which give rise to them. The proper resourcing of early intervention strategies is essential if we are to do more than provide an ambulance service for the child casualties of our ever more complex world. And that means people as well as finance, which is why civil society is so important. It also means learning from our own part successes and failures and those of others who have faced similar problems in similar circumstances.

References

Brandon M, Thoburn J, Lewis A, Way A (1999). Safeguarding Children with the Children Act 1989, London: The Stationery Office.

Cleaver H, Freeman P (1995). Parental Perspectives in Cases of Child Abuse, London: HMSO.

Dartington Social Research Unit (1995). Child Protection: Messages from Research, London: HMSO.

Department of Health (1999). Framework for the Assessment of Children in Need and their Families, London: Social Services Inspectorate.

Department of Health (1999). Working Together to Safeguard Children: New Government Guidance on Inter-agency Cooperation, London: Social Services Inspectorate.

Utting W (1997). People Like Us? The Report of the Review of the Safeguards for Children Living Away From Home, London: The Stationery Office.