BMJ 2011;342:d3040 doi: 10.1136/bmj.
d3040
Head to Head
Has child protection become a form of madness? Yes
Alain Gregoire and Simonetta Agnello Hornby argue that child protection fails to detect many
children in need of help while becoming ever more bureaucratic and unhelpful, while Margaret
Spinelli and Louise Howard (doi:10.1136/bmj.d3063) believe that child protection interventions
are essential to prevent child abuse
Alain Gregoire clinical director for mental health and learning disability, Simonetta Agnello Hornby
family law solicitor
1
South Central Strategic Health Authority, Southampton, UK; 2London, UK
“Madness,” in both popular usage and in its now outmoded
professional sense, is characterised by beliefs that are out of
touch with reality or contrary to evidence, that are associated
with negative emotions and unhelpful behaviours, and that
impair functioning. The term is an apt descriptor for our
society’s efforts in child protection.
Apart from the dramatic failures that result in inquiries and
accusatory headlines, child protection processes fail to detect
90% of the cruelty experienced by children[1] and let down
high risk groups such as disabled children.[2] The surprise at
the failings and the blind eye turned to the inadequacies reflect
an almost delusional belief in the potential of ever more
bureaucratic processes to protect our children from harm by
detecting maltreatment and stopping it.[3]
We have lost touch with the reality of what matters for children’s
wellbeing, well defined by Unicef: “The true measure of a
nation’s standing is how well it attends to its children—their
health and safety, their material security, their education and
socialization, and their sense of being loved, valued, and
included in the families and societies into which they are
born.”[4] Most children identified as being in need in relation
to such issues do not become subject to child protection plans,[5]
and they often receive little or no support. Our growing emphasis
on child protection for those already neglected or abused has
distracted us from taking action on the underlying causes, which
are well known. Even worse, we are spending more and more
on responding to the social consequences, largely through the
criminal justice system, which will do nothing to stem the tide
of social problems. Sweden and Finland spend 50% more of
their gross domestic product on children and families than we
do; we spend 200% more than they do on social problems.[6]
Our emotional responses swing dysfunctionaly between
disinterested complacency at child poverty to indignant, punitive
outrage when social workers fail to prevent severe abuse. Our
society’s behaviour towards children is absurdly paradoxical:
pious statements by politicians to stamp out child maltreatment
are coupled with the youngest age of criminal responsibility in
the developed world (apart from some US states), 10 year olds
facing trial in adult courts, and more children in prison than any
other western European country.[7] We also imprison the parents
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HEAD TO HEAD
of over 160 000 children without providing specific support
services or parenting interventions. At an individual level, the
preoccupation with child protection may now be driving
dysfunctional attitudes and behaviours between the generations,
including fear, suspicion, and avoidance.[8]
Failure of system
The impact of this loss of touch with reality on our functioning
is severe. On multiple measures the UK has the worst child
wellbeing of all the 21 richest nations in the world (for example,
poverty concentrated in families with children, high proportion
of low birthweight babies, fifth from bottom in educational
wellbeing), and, not surprisingly, our children are the
unhappiest.[4] Perhaps the underpinning factor to all the others
is that our children have by far the worst family and peer
relationships of all the world’s richest nations.
Even if we select only the extreme indicators of wellbeing we
are failing to protect our children from risks: our children carry,
by a large margin, the worst levels of risks among the world’s
21 richest nations. This includes measures such as involvement
in violence; experience of bullying; use of alcohol, tobacco, and
illicit drugs; underage and unprotected sex; and teenage
pregnancy. Worst of all are the outcomes for the children we
claim to have protected by removal into state care. Both
objective measures of outcome and children’s experiences reveal
that we continue to fail these children to a degree that would
justify their removal from our care.[9] [10]
We live in one of the most unequal and divisively class ridden
societies in the developed world. Far from breaking
intergenerational cycles of disadvantage, we have low and
falling levels of social mobility coupled with inequitable
education and health. Our poorest, most vulnerable, and most
disadvantaged children are the first to become parents
themselves.
Despite the current poor prognosis, effective treatment is
possible. Firstly we must cease our dependency on the
symptomatic relief apparently offered by child protection: those
countries with the strongest emphasis on this have the highest
death rates from child maltreatment. The lowest rates are found
in those countries that invest in families and prevention.[11]
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BMJ 2011;342:d3040 doi: 10.1136/bmj.d3040
We must shift from child to family focused policies and invest
in cost effective early (pre-birth) interventions targeted at the
most vulnerable families, attending to the emotional and social
wellbeing of parents and children.
Competing interests: All authors have completed the Unified Competing
Interest form at www.icmje.org/coi_disclosure.pdf (available on request
from the corresponding author) and declare no support from any
organisation for the submitted work; no financial relationships with any
organisation that might have an interest in the submitted work in the
previous three years; and no other relationships or activities that could
appear to have influenced the submitted work.
“Child protection has become a form of madness” will be debated in a
Maudsley debate at the Institute of Psychiatry, King’s College London
(www.iop.kcl.ac.uk/events/?id=1209) on 19 May.
Provenance and peer review: Commissioned; not externally peer
reviewed.
1 Sidebotham P, ALSPAC Study Team. Patterns of child abuse in early childhood, a cohort
study of the children of the nineties. Child Abuse Rev 2000;9:311–32.
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HEAD TO HEAD
2 NSPCC. It doesn’t happen to disabled children. Child protection and disabled children.
2003. www.nspcc.org.uk/Inform/publications/Downloads/itdoesnthappentodisabledchildren_
wdf48044.pdf.
3 Munro E. The Munro review of child protection. Part one: a systems analysis. 2010. www.
education.gov.uk/munroreview/downloads/TheMunroReviewofChildProtection-Part%
20one.pdf.
4 Unicef. Child poverty in perspective. An overview of child well being in rich countries.
2007. www.unicef-irc.org/publications/pdf/rc7_eng.pdf.
5 Department for Education. Children in need census 2009-2010. http://data.gov.uk/dataset/
children-in-needin-england-including-characteristics-2009-10.
6 New Economics Foundation. Backing the future. Why investing in children is good for us
all. 2009. www.neweconomics.org/sites/neweconomics.org/files/Backing_the_Future_1.
pdf.
7 Barnardos. Locking up or giving up: why custody thresholds for teenagers aged 12, 13
and 14 need to be raised. 2009. www.barnardos.org.uk/locking_up_or_giving_up_august_
2009.pdf.
8 Furedi F, Bristow J. Licensed to hug: how child protection policies are poisoning the
relationship between the generations, and damaging the voluntary sector. 2nd ed. Civitas,
2010
9 Department for Children, Schools and Families. Outcome indicators for children looked
after: twelve months to 30 September 2009, England. 2010. www.education.gov.uk/
rsgateway/DB/SFR/s000930/sfr08-2010.pdf .
10 Ofsted. Children’s care monitor. 2010. www.ofsted.gov.uk/Ofsted-home/Publications-and-
research/Browse-all-by/Care/Children-s-rights/Children-s-care-monitor-2010.
11 Action for Children. Deprivation and risk: the case for early intervention. 2009 www.
actionforchildren.org.uk/uploads/media/36/9432.pdf.
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