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Child health - Putting children first

Despite increased public awareness of child abuse in recent decades the problem persists in Ireland, write Ciara Ryan and Maria O’Shea

“Child abuse and neglect includes all forms of physical and emotional ill-treatment, sexual abuse, neglect, and exploitation that results in actual or potential harm to the child’s health, development or dignity”.1 Globally, 40 million children between 0-14 years are subjected to abuse each year.2 In Ireland, child welfare and protection reports to the HSE increased by almost 36% between 2007 and 2011.3

The HSE policy on ‘Staff Responsibility for the Protection and Welfare of Children’ applies to all employees of the HSE. Therefore, it is of great importance that nurses and midwives take on this responsibility also. As healthcare professionals, it is important to note that “child abuse is not restricted to any socio-economic group, gender or culture”.4 Any child that comes into our care could be a victim of some form of abuse and it is essential that we have a reasonable ground for concern and report any suspicious findings in relation to that child/family.4

In 2010, some 29,277 reports of suspected abuse were made to the HSE, a rise of 26% since 2007. In this report, concerns about child welfare (56%) were followed by neglect (16%), sexual abuse (10%) and physical abuse (9%).5 These figures are interesting to note as reports of abuse are still prevalent in our society. It is important that nurses and midwives understand what constitutes child abuse, including neglect, physical, sexual and emotional abuse so it can be identified in nursing practice.

According to the Irish Child Protection and Welfare Practice Handbook 2011,6 neglect is the most common form of child abuse. “Neglect can be defined… where the child suffers significant harm or impairment of development by being deprived of food, clothing, warmth, hygiene, intellectual stimulation, supervision and safety, attachment to and affection from adults, and/or medical care”.4 In extreme cases of neglect, attachment issues can arise when an infant or young child is left alone in long periods of distress.7 Neglected children’s development can be impaired physically, emotionally and educationally.8

Many cases of neglect have been reported over recent years in Ireland, including the Roscommon case, where six children were put into care following the sentencing of their mother for severe neglect. The offences took place over a six-year period at the family home, where they had the right to feel safe.9 The court heard that the children were not fed properly, had headlice, and were beaten and abused on regular occasions.10 The six children at the centre of this case were denied their voice on many occasions. No request to protect them under the Child Care Act 1991 was heard in the District Court until 2004 when finally “these children in effect rescued themselves when they could no longer be silenced”.9

Many cases of physical abuse have been reported in Ireland. “Physical abuse of a child… results in actual or potential physical harm from an interaction, or lack of interaction, which is reasonably within the control of a parent or person in a position of responsibility, power or trust”.4

The phenomenon of physical abuse was brought to public attention by Kempe et al,11 who described it as ‘battered baby syndrome’.

Any child who isn’t moving should not have bruises, burns, scalds or fractures. Physical abuse accounts for almost half of all deaths caused by child maltreatment resulting from one extremely violent attack or an accumulation of assaults and beatings. Not surprisingly, it is the children under five years old who are most likely to die after such an assault, with about one third of babies under 12 months old.8

The Ferns, Ryan, Murphy and Cloyne reports contain evidence of horrendous physical abuse in residential institutions, some of which were implemented with leather belts, belt buckles, canes, rulers, crucifixes for small issues such as bed-wetting, stammering, left-handedness or for ‘looking the wrong way’ at a staff member.12,13,14,15,16

Corporate punishment was widely used in schools until it was banned by John Boland, Minister for Education, in 1982 and became a criminal offence in 1996. In recent years, cases of sexual abuse have been exposed in Ireland by the publications of the Ferns, Ryan, Murphy and Cloyne reports, which were the results of inquiries into the abuse of children who lived in residential institutions.12,13,14,15

“Sexual abuse occurs when a child is used by another person for his or her gratification or sexual arousal, or for that of others”.4 Signs that a child has been sexually abused include: pain on micturition, swollen labia, scratches and bites on buttocks, foreign bodies or semen on skin and clothes. The most common form of sexual abuse is incest, most frequently being father-daughter relationships. The father figure is gratifying his sexual needs at the expense of his child’s needs for security and self-esteem.17 The child, as a result, develops confusion about his/her self-worth and this also affects his/her relationships with other people.

Another form of sexual abuse is molestation, which refers to acts by people outside of the family. The perpetrators are often strangers but may be known to the child. In 2010, there were 1,557 child abuse cases confirmed by the HSE.18 Self-reports by survivors of child sexual violence revealed that almost 80% were abused by someone who was known to them.19 For example, immediate family members, relatives or family friends. Some 12% of survivors were abused by those in authority (ie. a teacher, coach or priest), while 3% were abused by strangers and 5% by others.20

The findings from the SAVI Report 19 show that most reported sexual abuse in childhood occurred in the prepubescent period, with 67% of girls and 62% of boys experiencing abuse before the age of 12. One in five girls and one in six boys had experienced sexual abuse as a child. This report also showed that those who had been sexually abused as children were eight times more likely to have been inpatients in a psychiatric hospital than those who were not abused.

Social media is also an area where children can be victims of sexual abuse. Vulnerable teenagers using the internet can become victims of paedophiles and can easily become exposed to pornographic sites.

Emotional abuse is very commonly associated with other forms of abuse including physical, sexual and neglect. Such abuse can lead to serious psychological damage to children, which can greatly inhibit development.

“Emotional abuse… occurs when a child’s developmental need for affection, approval, consistency and security are not met”.4 Emotional abuse includes children ignored and left alone, teasing, prevented from going to school, retarded mental development and delayed milestones. Young children, who are left alone in times of distress and in need of comfort, can’t turn to their caregiver and have nowhere else to go other than inwards with their hurt and anxiety. Severe consequences can arise as a result of rejection, affecting self-esteem and damaging emotional intelligence.8

We in the healthcare profession, are in the ideal position to identify signs of neglect or abuse when the child is in our care. Many parents are slow to seek medical help, especially when their child is experiencing obvious pain following deliberate physical harm. When parents do present their child to a healthcare setting their explanation for the child’s injuries may be inconsistent, vague and implausible.8

According to the Criminal Law (Sexual Offences) Act 2006,21 the legal age of sexual consent is 17 years. Some cases may not be regarded as child sexual abuse but we should be aware of the legal age of consent and be mindful of our teenage patients.

“Parties should take all appropriate measures to protect the child from all forms of physical or mental violence, injury or abuse, neglect or negligent treatment, maltreatment or exploitation, including sexual abuse”.22 Until recently, the invisibility of children in law, policy and public debate was directly related to the fact that children did not have express constitutional rights.16 It is paramount that vulnerable children are protected against such neglect and abuse in our society.

As nurses, particularly as children’s and public health/community nurses, we need to advocate for the children/adolescents we come in contact with. We must recognise the vulnerable child or teenager and offer support to families who find it hard to cope.

Despite the public’s awareness of child abuse over the past decades, the problem continues to occur in Irish society. Therefore, it is imperative that nurses and midwives be mindful of this, be knowledgeable about the Children’s First Guidelines and be even observant of the children we care for.

When in doubt, we should ask appropriate questions to ensure a child’s opportunity for help is not wasted.

Ciara Ryan is a final-year student, and Maria O’Shea is a lecturer, at the School of Nursing and Midwifery at UCC


  1. World Health Organisation Child Maltreatment, 2013. Available from: http://www.euro.who.int/en/publications/abstracts/european-report-on-preventing-child-maltreatment-2013
  2. Child sexual abuse: a silent health emergency: report of the Regional Director; 2004. Available from: http://apps. who.int/iris/bitstream/10665/1878/1/AFR.RC54.15%20 Rev.1.pdf?ua=1
  3. Department of Children and Youth Affairs. State of the Nation’s Children; Ireland. Dublin: Government Publications, Stationary Office, 2012. http://www.dcya.gov.ie/documents/research/StateoftheNationsChildren2012.pdf
  4. Department of Children and Youth Affairs. Children First: National Guidance for the Protection and Welfare of Children. Dublin: Government Publications, Stationary Office, 2011
  5. HSE Review of Adequacy of Child and Family Services 2009 and 2010. Health Service Executive Publication, 2012
  6. Child Protection and Welfare Practice Handbook. Health Service Executive. HSE Publications, 2011
  7. Stevenson O. Neglected children and their families. 2nd Ed. Blackwell Publishing Ltd; 2007
  8. Howe D. Child abuse and neglect: Attachment, development and intervention. Palgrave Macmillan; 2005
  9. Gibbons N. Chairperson of Roscommon Child Care Inquiry. Roscommon Child Care Case: Report of the Inquiry Team to the Health Service Executive, HSE Publication, 2010
  10. RTÉ “Mother gets seven years in incest case”, 22nd January 2009. Available from: http://www.rte.ie/news/2009/0122/113023-roscommon/
  11. Kempe CH, Silverman F, Steal B, Droegmuller W. & Silver H. The ‘Battered Child’ Syndrome. Journal of the American Medical Association. 1962; 181:17-24
  12. The Ferns Report: Presented to the Minister for Health and Children, Government Publications, Dublin: Stationary Office, 2005
  13. Ryan Report: Commission to Inquire into Child Abuse Report, Vols. I-V, Government Publications, Dublin: Stationary Office, 2009
  14. Murphy (Dublin) Report: Commission of Investigation, Report into the Catholic Archdiocese of Dublin, Government Publications, Dublin: Stationary Office, 2009
  15. Cloyne Report: Commission of Investigation, Report into the Catholic Diocese of Cloyne, Government Publication, Dublin: Stationary Office, 2010
  16. Holohan C. In Plain Sight: Responding to the Ferns, Ryan, Murphy and Cloyne Reports [Internet]. Amnesty International Ireland; 2011. Available from: http://www.amnesty.ie/sites/default/files/INPLAINSIGHT%20(WEB_VERSION).pdf
  17. Empson J. & Nabuzoka D. Atypical Child Development in Context. Palgrave MacMillan, New York; 2004
  18. HSE Review of Adequacy of Child and Family Services 2009 and 2010. Health Service Executive Publication, 2012
  19. The SAVI Report Sexual Abuse and Violence in Ireland, 2002. The Liffey Press, Dublin in association with Dublin Rape Crisis Centre
  20. National Rape Crisis Statistics and Annual Report. Rape Crisis Network Ireland; 2010. Available from: http://www.rcni.ie/uploads/RCNINationalRapeCrisisStatisticsAndAnnualReport2010.pdf,
  21. Government of Ireland Criminal Law (Sexual Offences) Act, Dublin: Stationary Office, 2006. Available from: http://www.hse.ie/eng/services/Publications/services/Children/RoscommonChildCareCase.pdf
  22. Children’s Rights Alliance: The United Nations Convention on the Rights of a Child, Article 19: Protection from abuse and neglect, 2010. Available from: http://www.childrensrights.ie/sites/default/files/submissions_reports/files/UNCRCEnglish_0.pdf
Child health - Putting children first


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