224 Chapter 27
controlled trials suggest they help reduce symptoms and distress. Groups
may help children achieve cognitive understanding, put their experience
in perspective, and receive support from others who have had similar
experiences. Meeting the child’s longer-term needs may include fostering
a sense of self-worth and an ability to communicate about emotions and be
assertive in threatening situations. An understanding of their own sexual
responses and of the boundaries between appropriate and inappropriate
sexual behaviour will need to be developed. Family work will need
to address whether the mother has resolved the issue of split loyalties
between the victim and the perpetrator. Severely affected children with
profound mood disturbance, severe self-mutilation, anorexia or other
symptoms may need an extensive programme of therapeutic work, often
best undertaken in a therapeutic community or residential setting.
When maltreatment was first widely recognised, there was often strong
pressure to remove the child from the family, frequently influenced by
people’s sense of outrage. Subsequent research showed that many of these
children did badly, often because the substitute care was deficient. This
was particularly the case in some children’s homes, where there was a
high turnover of poorly trained staff, and where the child was at risk of
being abused by care workers or co-residents. Currently, the emphasis is
on rehabilitating the child within the family wherever possible. Therefore,
it is important to be able to predict when this will be successful. In clinical
studies where treatment is given and children stay within their families
of origin, the overall established rate of re-abuse is 20–70%. Factors
predicting outcome are set out in Table 27.1. Parental acknowledgement
that abuse has occurred, and a willingness on their part to stay in a treat-
ment programme are two of the most important predictors of successful
rehabilitation.
Where the chances of improvement are slight, the court may order
that alternative care be provided for the child, such as foster or adoptive
parents, or in the case of older children, placement in a residential home.
In England and Wales, the Children Act (1989) states that:
The primary justification for the State to initiate proceedings seeking compulsory
powers is actual or likely harm to the child, where harm includes both ill-treatment
(which includes sexual abuse and non-physical ill-treatment such as emotional
abuse) and the impairment of health or development, health meaning physical or
mental health, and development meaning physical, intellectual, emotional, social,
or behavioural development.The Act puts great emphasis on working with parents voluntarily to
maintain the child within the family wherever possible.
Primary prevention of child abuse through intensive home visiting
programmes for high risk mothers contacted antenatally has been shown
to work, for example, in a programme called the Nurse–Family Partnership
(named Family Nurse Partnership in England) but is not widely deployed.