Jane Black

Designated Nurse, Safeguarding Children

Norfolk Health

Anita Bagge
Named Nurse, Safeguarding Children
Norfolk PCT

Anne Pringle
Health Visitor
Norfolk PCT

Introduction

‘There is a common link between domestic

violence and child abuse. Among victims
of child abuse 40% report domestic
violence in the home’ (Unicef 2006/07)

• Children Act 1989 – amendment to

definition of significant harm

• Adoption & Children Act 2002 (including

for example impairment suffered from
seeing or hearing the ill treatment of
another)

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2 studies:

– Improving Safeguarding Practice; Study of

Serious Case Reviews 2001-2003
Rose & Barnes, Open University

– Analysing child deaths and serious injury

through abuse and neglect, what can be
learnt?; A biennial analysis of Serious Case
Reviews 2003-2005
Brandon et al, UEA

Rose & Barnes

Features:
• Numbers of children experiencing neglect
• Numbers of children living in
circumstances where domestic violence
prevailed
• Often co-existing with other problems such
as parental substance mis-use and mental
ill health

UEA
Preponderance of Domestic Violence
Parental characteristics
• Violence
• Mental Health issues
• Substance mis-use

Two thirds of children in intensive sample

(47) were living with extreme family
conflict including domestic violence

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Both Reviews

In many of the cases there was an overlap

of parental problems of domestic violence,
substance mis-use and mental health
difficulties

UEA

• Domestic violence recorded in 7 of 8

cases of head/shaking injuries to babies

• Volatility

Case Study:
Carly aged 8 weeks
Carly suffered a head injury (thought to be a
shaking injury) when she was 9 weeks old. At
the time of the injury the family had not been
receiving any services beyond universal health
care.

Carly lived with her mother, aged 19 and her

father, aged 20, in rented accommodation.

During pregnancy Carly’s mother presented 4

times to Accident & Emergency; twice reporting
assault to her abdomen.

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Case Study: Carly aged 8 weeks Continued …..

Carly’s mother was known to Children’s Social

Care and Child & Adolescent Mental Health
Services when younger. She had special
education needs and left school early. She was
reported to be self-contained and withdrawn at
school and aggressive at home.

Police had been called regularly to the family

home during Carly’s mother’s adolescence to
respond to reports of violence amongst family
members.

Case Study: Carly aged 8 weeks Continued …..

Carly’s father had a history of mental health

problems and behavioural problems throughout
childhood. He had taken a number of overdoses
and was reported to have poor anger
management and poor self control.

There was domestic violence in his household

when he was younger and his mother had long-
term depression.

Case Study: Carly aged 8 weeks Continued …..

There had been financial difficulties in the

household and the Police had been called to an
incident of violence between parents in the past.

Both parents had high level of contact with a

range of Health Professionals including Health
Visitor, GP, NHS Direct, Out of Hours Service
and A&E Dept in the early weeks of Carly’s life.

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Case Study: Carly aged 8 weeks Continued …..

No Health professionals were aware of the high

level of contact with different branches of the
service, nor of the pattern of contact, e.g.
repeated attendances at A&E.

Domestic violence had not been identified as an

issue either in the antenatal period or following
Carly’s birth.

• Domestic violence accounts for 15% of all

violent incidents

• One in four women and one in six men will

be a victim of domestic violence in their
lifetime with women at greater risk of
repeat victimisation and serious injury

• 89% of those suffering four or more

incidents are women

• One incident of domestic violence is

reported to the police every minute

• On average, two women a week are killed

by a current or former male partner

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• Have you ever felt frightened because of
the behaviour of a partner/someone at
home?

• Have you ever experienced violent

behaviour by a partner/someone at home

Westmarland et al Bristol University (Tyneside&Gateshead

• Trauma affecting infants and toddlers witnessing

domestic violence manifests as overwhelming
fear, helplessness, loss of control and fear of
annihilation

• This triggers a traumatic deregulation of

neurobiological, cognitive, social and emotional
processes. It can have an enduring impact on
developmental outcomes by adversely affecting
experience-dependent brain development

Observations in practice
Infant states (under 6 months) could
show distressed behaviours such as:
– prolonged crying
– feeding difficulties
– less easily soothed & consoled
– Watchfulness
– eye aversion
– agitated body movements

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Observations in practice Continued ……

Six months to a year may show:

– frozen watchfulness or dissociation

– sleep difficulties
– feeding difficulties
– emerging insecure attachment
behaviours

Observations in practice Continued ……

Toddler with little ability to self regulate

(emotional state):

frenetic ‘hyper aroused’ • language delay

behaviours • development delay
• avoidant behaviours • lack of concentration
• Watchfulness • aggressive
• placating behaviours behaviours
• sleep disturbance • clinginess and
• feeding difficulties emotional insecurity

Observations in practice Continued ……

Children:
– may use aggressive behaviours
– low self confidence
– difficulties in peer relationships
– learning difficulties
– depression and anxiety as seen in quiet,
withdrawn and compliant child
– sleep disturbance
– eating concerns

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Attachment & Domestic Violence
• A single risk factor may not distinguish
secure from insecure infants, a clearer
relationship between risk and attachment
emerges when multiple risk factors are
considered simultaneously
• As a stand alone factor, mothers who are
in an abusive relationship are more likely
to have infants with insecure attachments

The first environment actively shaping the

human brain is the womb. The womb is
host to an interactive biological and
neurobiological dance between the mother
and infant

Research on prenatal assaults during late

gestation hypothesized links between
domestic violence and childhood anti
social behaviour (with raised corticosteriod
levels) and aggression in adulthood
Kramer 1996

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 Example in ‘Ghosts from the
nursery’ (Robin Karr-Morse)
“Harris was born three months early after his
mother was brutally kicked in the abdomen by
her angry husband. This was the first of many
violent experiences……a violence he later
turned on animals and people. At age twenty five
he shot two teenagers point blank, laughed at
them after he pulled the trigger and calmly ate
the hamburgers they had just bought for lunch.
We could not find a more dramatic example of a
life that began and ended in violence”

Impact on children’s development may

stem from ‘behavioural scripts’ (general
strategy of behaviour derived from
observing the behaviour of others). Could
help explain high rate of co-occurrence of
partner and child abuse (Holden 1998) as
children respond to witnessing parental
violence with increased levels of
externalised maladaptive behaviours.

Some children however manifest

internalised symptoms such as anxiety
and depression. This may be explained by
the impact of domestic violence on
parenting capacity through a ‘spill over’ of
emotion from the couple’s relationship to
the parent-child relationship.

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 Children who are exposed to overt
parental conflict respond more negatively
than children who are absent during the
conflict. Recent research suggests that
children’s understanding of what is
happening around them is in fact a more
potent predictor of their adjustment than
exposure to domestic violence itself.
(Harold & Howarth 2004)

Gender differences show girls under threat

more likely to internalise experience
resulting in higher levels of anxiety and
depression, while boys more likely to
experience feelings of responsibility
resulting in externalising behaviours of
aggression

Tigers – real and imaginary

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 Practitioner’s feelings
as communication
The encounter that leaves you feeling

• Anxious may reflect something unsaid (as potentially

seen in women experiencing domestic abuse or with low
mood/anxiety) or you may have observed something
anxiety provoking in the mother-child interactions that
has later left you feeling concerned. The reflective
process is likely to give you important information about
the mother and child’s experience.

• Exhausted/ Irritated may reflect something awry in the

mother-child relationship or maternal sate of mind
affecting her interactions and communication with others
including her infant/child

Practitioner’s feelings
as communication Continued …..

• Helpless/ Disempowered, which may

reflect the maternal and / or child’s state of
mind and experience which, if left
unresolved, is likely to lead to increased
stress and mental health difficulties.

• Intimidated by parental behaviour, which

may mirror domestic abuse.

Supervision
• Encouraging analysis from observations
• Helping practitioners to think about the
child’s experience
• Understanding multiple/cumulative risk
• Looking at the whole picture – both risk
and resilience

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• Holding the infant in mind

• Since brain development is linked to

environmental factors, active early
intervention offers the greatest hope for
children’s future
Danya Glaser

All professionals, including

those working with offenders
and adults, need to be alert to
the effects of domestic
violence on children

UEA

The Police were the agency

which responded most often in
the many cases where there
was volatility and domestic
violence

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UEA

There was little evidence of

shared expertise between
specialist services like
Substance Mis-use Services
and Domestic Violence Units
with Children’s Social Care

UEA

Safer practice requires

professionals from different
agencies to look beyond their
individual specialism and to look
more broadly to acknowledge the
impact of parental behaviour of
children in the household

Even the most effective integrated

responses from Children Services will only
ever ameliorate the impacts of parent
based risk factors on a child. To reduce
the actual risk factor at source, joint
working with Adult Social Services is
required to tackle the parents problems
(Cabinet Office 2007, P29)

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All services aimed at adults not
children must make children a
priority in their services. This
presents a challenge to
service providers and
commissioners

The use of the Common

Assessment Framework and of
the Lead Professional roles
provide an opportunity for staff
from any agency, identifying a
child’s needs for additional
services so that early help can
be provided

What now?

• Assessment
• Understanding of impact
• Information sharing
• Sharing of expertise

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