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Child abuse and neglect

About

What is covered

This interactive flowchart covers recognising and responding to child abuse and neglect in under 18s. It covers physical, sexual and emotional abuse, and neglect. It also has recommendations on child sexual exploitation, child trafficking, female genital mutilation and forced marriage.
It aims to help anyone whose work brings them into contact with children and young people to spot signs of abuse and neglect, including helping healthcare professionals to spot clinical features, and to know how to respond. It also supports practitioners who carry out assessments and provide early help and interventions to children, young people, parents and carers.

Updates

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on child abuse and neglect in an interactive flowchart

What is covered

This interactive flowchart covers recognising and responding to child abuse and neglect in under 18s. It covers physical, sexual and emotional abuse, and neglect. It also has recommendations on child sexual exploitation, child trafficking, female genital mutilation and forced marriage.
It aims to help anyone whose work brings them into contact with children and young people to spot signs of abuse and neglect, including helping healthcare professionals to spot clinical features, and to know how to respond. It also supports practitioners who carry out assessments and provide early help and interventions to children, young people, parents and carers.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Child abuse and neglect (2017) NICE guideline NG76

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

NICE has produced resources to help implement its guidance on:

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Child sexual exploitation is a form of child sexual abuse. It occurs where an individual or group takes advantage of an imbalance of power to coerce, manipulate or deceive a child or young person under the age of 18 into sexual activity (a) in exchange for something the victim needs or wants, and/or (b) for the financial advantage or increased status of the perpetrator or facilitator. The victim may have been sexually exploited even if the sexual activity appears consensual. Child sexual exploitation does not always involve physical contact; it can also occur through the use of technology.
For recommendations starting with 'consider':
  • Look for other alerting features in the child or young person's history, presentation or interactions with their parents or carers, now or in the past.
  • Gather information from other agencies and explain to the family that this information is needed to make an overall assessment of the child or young person. If this is likely to place the child or young person at risk, seek advice from children's social care.
  • Make sure a review of the child or young person takes place, with the timing depending on your level of concern. Continue to look out for the alerting feature being repeated, or for any other alerting features.
After taking these steps, if your level of concern increases to 'suspect', discuss the need for a referral with children's social care. If you conclude that a referral to children's social care is not required, you may wish to undertake or make a referral for early help assessment in line with local procedures.
Foster carers care for children and young people who are 'looked after' in the public care system. They must go through a process of assessment and approval, before providing care for the child or young person as a member of their household. Some are 'kinship foster carers', which means they are relatives or friends who are fostering a child or young person who has entered the public care system.
Honour-based abuse includes forced marriage and FGM. It can be described as a collection of practices used to control behaviour within families or other social groups to protect perceived cultural and religious beliefs and/or honour. Such abuse can occur when perpetrators perceive that a relative has shamed the family or community by breaking their honour code.
The persistent failure to meet a child's basic physical and/or psychological needs, likely to result in the serious impairment of the child's health or development. Neglect may occur during pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer failing to:
  • provide adequate food, clothing and shelter (including exclusion from home or abandonment)
  • protect a child from physical and emotional harm or danger
  • ensure adequate supervision (including the use of inadequate care-givers)
  • ensure access to appropriate medical care or treatment.
It may also include neglect of, or unresponsiveness to, a child's basic emotional needs.
Used in this guidance to acknowledge that people other than a child or young person's parent may be caring for them. We have defined 'parent' as the person with parental responsibility for a child, including an adoptive parent, and 'carer' as someone other than a parent who is caring for a child. This could include family members, such as the partner of a parent. Where we are referring specifically to paid carers we use the term 'foster carer'.
Used in this guidance to acknowledge that people other than a child or young person's parent may be caring for them. We have defined 'parent' as the person with parental responsibility for a child, including an adoptive parent, and 'carer' as someone other than a parent who is caring for a child. This could include family members, such as the partner of a parent. Where we are referring specifically to paid carers we use the term 'foster carer'.
Involves forcing or enticing a child or young person to take part in sexual activities, not necessarily involving a high level of violence, whether or not the child is aware of what is happening. The activities may involve physical contact, including assault by penetration (for example, rape or oral sex) or non-penetrative acts such as masturbation, kissing, rubbing and touching outside of clothing. They may also include non-contact activities, such as involving children in looking at, or in the production of, sexual images, watching sexual activities, encouraging children to behave in sexually inappropriate ways, or grooming a child in preparation for abuse (including via the internet). Sexual abuse is not solely perpetrated by adult males. Women can also commit acts of sexual abuse, as can other children.
A person who has been granted an SGO, a private law order which grants parental responsibility for a named child or young person. While parents do not lose parental responsibility when an SGO is granted, the special guardian has the exclusive right to exercise it, and make important decisions about the child or young person. Special guardians may also in some circumstances be provided with local authority financial and other support.
For recommendations starting with 'suspect':
  • Discuss the need for a referral with children's social care using local multi-agency safeguarding procedures.
For the purposes of this guidance, an unsuitable explanation for an injury or presentation 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
    • account compared to that given by parent and carers
  • between parents or carers
  • between accounts over time.
An explanation based on cultural practice is also unsuitable because this should not justify hurting a child or young person.

Glossary

attention deficit hyperactivity disorder
female genital mutilation
sexually transmitted infection
special guardianship order
(analysis involves organising the information collected during assessment, judging its significance and exploring different perspectives, to identify themes and reach conclusions on what these mean for the child or young person and their family; it should draw on knowledge from research and practice combined with an understanding of the child's needs)
(interventions which are based on attachment theory; attachment-based interventions focus on improving the relationships between children and young people and their key attachment figures (often, parents or carers), for example by helping the parent or carer to respond more sensitively to the child or young person)
(persistent behaviour by a person or group of people that intentionally hurts a child or young person either physically or emotionally)
(in this guidance child abuse and neglect includes inflicting harm on a child or young person and also failing to protect them from harm: children and young people may be abused by someone they know in a family or in an institutional or community setting or, more rarely, by someone they don't know (for example through the internet); some indicators of abuse and neglect may be indicators of current or past abuse and neglect )
(in this guidance child abuse and neglect includes inflicting harm on a child or young person and also failing to protect them from harm: children and young people may be abused by someone they know in a family or in an institutional or community setting or, more rarely, by someone they don't know (for example through the internet); some indicators of abuse and neglect may be indicators of current or past abuse and neglect)
(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 Department for Education's Working together to safeguard children)
(recruiting and transporting children and young people for the purposes of exploitation, for example, sexual exploitation, forced labour or services, benefit fraud, domestic servitude or the removal of organs)
(children and young people who meet the Equality Act 2010 definition of disability, namely those who have a physical or mental impairment that has a substantial and long-term negative effect on their ability to do normal daily activities)
(any incident or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse between those aged 16 or over who are, or have been, intimate partners or family members regardless of gender or sexuality)
(support provided early as soon as a problem emerges; early help can prevent a problem from worsening or further problems from arising)
(persistently treating a child or young person in a way that can cause severe adverse effects on their emotional development: for example, conveying to them that they are worthless or unloved; not giving them opportunities to express their views; deliberately silencing them or making fun of them; imposing inappropriate expectations on them for their age or developmental stage; and serious bullying (including cyber bullying))
(used in relation to infants and young children whose weight gain occurs more slowly than expected for their age and sex; in the past this was often described as a 'failure to thrive' but this is no longer the preferred term)
(a practice involving removal of or injury to any part of a girl's external genitalia for non-medical purposes; female genital mutilation is illegal in England and Wales according to the Female Genital Mutilation 2003 Act)
a marriage in which one or both partners have not consented (or cannot consent because of a learning disability) to be married and pressure or abuse has been used
(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 Department for Education's Working together to safeguard children)
(a psycho-educational intervention focusing on improving parenting skills)
(abuse or neglect that a child or young person may have experienced but which is no longer occurring; for example, abuse which occurred in a previous family environment before the child or young person was placed in care or with an adoptive family)
(a form of abuse which may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating or otherwise causing physical harm to a child; physical harm may also be caused when a parent or carer fabricates the symptoms of, or deliberately induces, illness in a child)
(person working with children and young people who may have a role in safeguarding them)
(people working with children and young people who may have a role in safeguarding them)
a genetic condition leading to a range of symptoms, including over-eating, restricted growth, reduced muscle tone, and learning and behavioural difficulties
(regulated professions as defined in section 5B(2)(a), (11) and (12) of the Female Genital Mutilation Act 2003; a person works in a regulated profession if they are a healthcare professional, a teacher, or (in Wales) if they are a social care worker)
(situations, behaviours or underlying characteristics of children, young people and their parents or carers and their social environment that increase the child or young person's vulnerability to child abuse or neglect)

Paths in this pathway

Pathway created: October 2017 Last updated: October 2017

© NICE 2017. All rights reserved. Subject to Notice of rights.

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