NICE clinical guidelines
Issued: July 2009 (last modified: March 2013)
CG89

When to suspect child maltreatment

This is an extract from the guidance. The complete guidance is available at guidance.nice.org.uk/cg89

Introduction

This guidance provides a summary of clinical features associated with child maltreatment (alerting features) that may be observed when a child presents to healthcare professionals. Its purpose is to raise awareness and help healthcare professionals who are not specialists in child protection to identify children who may be being maltreated. It does not give healthcare professionals recommendations on how to diagnose, confirm or disprove child maltreatment.

Children may present with both physical and psychological symptoms and signs that constitute alerting features of one or more types of maltreatment, and maltreatment may be observed in parent– or carer–child interactions.

There is strong evidence of the harmful short- and long-term effects of child maltreatment. All aspects of the child's health, development and wellbeing can be affected. The effects of child maltreatment can last throughout adulthood and include anxiety, depression, substance misuse, and self-destructive, oppositional or antisocial behaviours. In adulthood, there may be difficulties in forming or sustaining close relationships, sustaining employment and parenting capacity. Physical abuse may result in lifelong disability or physical scarring and harmful psychological consequences, and may even be fatal. The National Service Framework (NSF) for Children, Young People and Maternity Services for England states 'The high cost of abuse and neglect both to individuals (and to society) underpins the duty on all agencies to be proactive in safeguarding children.'


Definitions

Child maltreatment

Child maltreatment includes neglect, physical, sexual and emotional abuse, and fabricated or induced illness. This guidance uses the definitions of child maltreatment as set out in the document 'Working together to safeguard children'[1].

Age groups

This guidance uses the following terms to describe children of different ages:

  • infant (aged under 1 year)

  • child (aged under 13 years)

  • young person (aged 13–17 years).

Exclusions from the guideline

The following topics were outside the scope of this guideline and have therefore not been covered:

  • risk factors for child maltreatment, which are well recognised. Examples include

    • parental or carer drug or alcohol misuse

    • parental or carer mental health problems

    • intra-familial violence or history of violent offending

    • previous child maltreatment in members of the family

    • known maltreatment of animals by the parent or carer

    • vulnerable and unsupported parents or carers

    • pre-existing disability in the child

  • protection of the unborn child

  • children who have died as a result of child maltreatment[2]

  • diagnostic assessment and investigations (for example, X-rays)

  • treatment and care of the child if maltreatment is suspected

  • how healthcare professionals should proceed once they suspect maltreatment

  • healthcare professionals' competency, training and behaviour

  • service organisation

  • child protection procedures

  • communication of suspicions to parents or carers, or the child or young person

  • education and information for parents or carers, or the child or young person.

Communicating with and about the child or young person

Good communication between healthcare professionals and the child or young person, as well as with their families and carers, is essential. Communication should take into account additional needs such as physical, sensory or learning disabilities, or the inability to speak or read English. Consideration should be given to cultural needs of children or young people and their families and carers.


If healthcare professionals have concerns about sharing information with others, they should obtain advice from named or designated professionals for safeguarding children. If concerns are based on information given by a child, healthcare professionals should explain to the child when they are unable to maintain confidentiality, explore the child's concerns about sharing this information and reassure the child that they will continue to be kept informed about what is happening. When gathering collateral information from other health disciplines and other agencies, professionals need to use judgement about whether to explain to the family the need to gather this information for the overall assessment of the child.

Potential obstacles to recognising and responding to possible maltreatment

Healthcare professionals may come across many different obstacles in the process of identifying maltreatment but these should not prevent them from following the appropriate course of action to prevent further harm to the child or young person. Examples of potential obstacles include the following:

  • Concern about missing a treatable disorder.

  • Healthcare professionals are used to working with parents and carers in the care of children and fear losing a positive relationship with a family already under their care.

  • Discomfort of disbelieving, thinking ill of, suspecting or wrongly blaming a parent or carer.

  • Divided duties to adult and child patients and breaching confidentiality.

  • An understanding of the reasons why the maltreatment might have occurred, and that there was no intention to harm the child.

  • Losing control over the child protection process and doubts about its benefits.

  • Stress.

  • Personal safety.

  • Fear of complaints.



[1] Working together to safeguard children. Supplementary guidance to 'Working together' includes: Department of Health, Home Office (2000) Safeguarding children involved in prostitution; Department of Health, Home Office, Department for Education and Skills, Welsh Assembly Government (2002) Safeguarding children in whom illness is fabricated or induced; Home Office. Female Circumcision Act 1985, Female Genital Mutilation Act 2003, Home Office Circular 10/2004; Association of Directors of Social Services, Department of Education and Skills, Department of Heath, Home Office, Foreign and Commonwealth Office (2004) Young people and vulnerable adults facing forced marriage.

[2] It should be noted that there are special procedures that should be followed when a child dies unexpectedly.