When to suspect child maltreatment

Implementing NICE guidance 2009

NICE clinical guideline 89

What this presentation covers

Scope Definitions How to use this guidance Alerting features Sharing information Obstacles Discussion Find out more

Scope

This guidance provides a summary of the

alerting features

associated with child maltreatment.

Its purpose is: • to raise awareness • help healthcare professionals who are not specialist in child maltreatment It does not how to diagnose, confirm or disprove child maltreatment.

Definitions

Child maltreatment

includes neglect, physical, sexual and emotional abuse, and fabricated or induced illness. To

consider

child maltreatment means maltreatment is one possible explanation for the alerting feature or is included in the differential diagnosis.

To

suspect

child maltreatment means a serious level of concern about the possibility of child maltreatment but is not proof of it.

How to use this guidance

It is good practice to follow this process to consider, suspect or exclude child maltreatment:

Listen and observe

Take into account the whole picture of the child or young person. Sources of information include: • history • report of maltreatment, or disclosure • child’s appearance, demeanour or behaviour • symptom • physical sign • result of an investigation • interaction between parent or carer and the child or young person

Seek an explanation

Seek an explanation in an open and non judgemental manner.

Seek appropriate expertise if you are concerned about a child or young person with a disability.

An unsuitable explanation

Is one that is implausible, inadequate or inconsistent: • with the child or young person’s presentation, normal activities, existing medical condition, age or developmental stage, or account compared to that given by parent and carers • between parents or carers or between accounts over time Cultural practice is an unsuitable explanation for hurting a child or young person.

Record in the child or young person’s clinical record exactly what is observed and heard from whom and when. Record why this is of concern.

Record

Consider maltreatment

When hearing about or observing an alerting feature, look for other alerting features of maltreatment, then do one or more of the following: • Discuss with a relevant child health specialist or designated professional for safeguarding children • Gather collateral information • Ensure review at a date appropriate to the concern • Look out for repeated presentations of this or any other alerting features At any stage during the process of considering maltreatment the level of concern may change and lead to exclude or suspect maltreatment.

Suspect maltreatment

If an alerting feature or consideration prompts you to suspect child maltreatment refer to children’s social care.

This may trigger a child protection investigation.

Supportive services may be offered to the family following an assessment or alternative explanations may be identified.

Exclude maltreatment

Exclude maltreatment when a suitable explanation is found for alerting features.

Record all actions taken in previous stages and the outcome.

Record

Alerting features

The following forms of alerting features that may lead you to consider or suspect child maltreatment are covered: • Physical features • Sexual abuse • Neglect • Emotional, behavioural, interpersonal and social functioning • Clinical presentations • Fabricated or induced illness • Parent– or carer–child interactions

Physical features

Consider:

Any serious or unusual injury with an absent or unsuitable explanation.

Suspect:

•Bruising in the shape of a hand, ligature, stick, teeth mark, grip or an implement.

For further alerting features and detail refer to NICE guideline or quick reference guide

Sexual abuse

Consider:

Persistent or recurrent dysuria or anogenital discomfort, or an anal or genital symptom in a girl or boy, without a medical explanation.

Suspect:

Persistent or recurrent genital or anal symptom in a girl or boy, without a medical explanation, that is associated with behavioural or emotional change.

For further alerting features and detail refer to NICE guideline or quick reference guide

Neglect

Consider:

Parents or carers who repeatedly fail to attend essential follow-up appointments that are necessary for the health and wellbeing of their child.

Suspect:

The child is persistently smelly or dirty.

For further alerting features and detail refer to NICE guideline or quick reference guide

Emotional, behavioural, interpersonal and social functioning

Consider:

Unusual, unexpected or developmentally inappropriate response by a child to a health examination or assessment (for example, extreme passivity, resistance or refusal).

Suspect:

Repeated or coercive sexualised behaviours or preoccupation in a prepubertal child (for example, sexual talk associated with knowledge, drawing genitalia or emulating sexual activity with another child).

For further alerting features and detail refer to NICE guideline or quick reference guide

Clinical presentations

Consider:

Poor school attendance that the child’s parents or carers know about that is not justified on health (including mental health) grounds, and formally approved home education is not being provided.

Suspect:

Repeated apparent life-threatening events in a child, if the onset is witnessed only by one parent or carer and a medical explanation has not been identified.

For further alerting features and detail refer to NICE guideline or quick reference guide

Fabricated or induced illness

Consider:

Child’s history, physical or psychological presentation, or findings of assessments, examinations or investigations, leads to a discrepancy with a recognised clinical picture, even if the child has a past or concurrent physical or psychological condition.

Suspect:

As above, plus one or more of the following: • reported symptoms and signs are only observed by, or appear in the presence of, the parent or carer • an inexplicably poor response to treatment • new symptoms are reported as soon as previous symptoms stop • biologically unlikely history of events • despite a definitive clinical opinion being reached, multiple opinions are sought and disputed by the parent or carer and the child continues to be presented with a range of signs and symptoms • child’s normal daily activities are limited, or they are using aids to daily living more than expected

Parent – or carer– child interactions

Consider:

• Potentially harmful parent– or carer–child interactions (emotional abuse), including: − negativity or hostility towards or rejection or scapegoating of a child or young person − developmentally inappropriate expectations of or interactions with a child, including inappropriate threats or methods of disciplining − exposure to frightening or traumatic experiences, including domestic abuse − using the child to fulfil the adult’s needs (for example, in marital disputes) − failure to promote the child’s appropriate socialisation (for example, not providing stimulation or education, isolation or involving them in unlawful activities)

Suspect:

Persistent harmful parent – or carer–child interactions.

For further alerting features and detail refer to NICE guideline or quick reference guide

Sharing information about children and young people

Good communication between all parties is essential.

If worried, seek advice from designated professionals for safeguarding children. If concerns are based on information given by a child, explain to the child: • that you may be unable to maintain confidentiality • explore the child’s concerns about sharing this information • reassure the child that they will continue to be kept informed

Obstacles

Obstacles should not stop acting to prevent harm. They include: • concern about missing a treatable disorder • fear of losing positive relationship with a family already under care • divided duties to adult and child patients and breaching confidentiality • an understanding of the reasons for the maltreatment, and no intention to harm the child • losing control over the child protection process and doubts about its benefits • stress, personal safety, fear of complaints

Discussion

• How can we ensure that this guidance reaches all healthcare professionals working in the NHS locally who work with children?

• How can we overcome the obstacles?

• To what extent are people trained to be able to respond to the guidance?

• How can we ensure that information is recorded so that patterns are recognised over time and place?

Find out more

Visit www.nice.org.uk/CG89 for: • the guideline • the quick reference guide • ‘Understanding NICE guidance’ • costing statement • audit support • A&E slide set