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When to suspect child maltreatment

About

What is covered

This pathway covers the alerting features in children and young people (under 18 years) of physical, sexual and emotional abuse, neglect and fabricated or induced illness.
The effects of child maltreatment can be severe and last into adulthood.
Children may present with both physical and psychological symptoms and signs that constitute alerting features of one or more types of maltreatment.
Maltreatment may be observed in parent– or carer–child interactions.

Updates

Updates to this pathway

9 January 2014 Footnote 1 in the Sexual abuse node has been further amended to ensure it accurately reflects Crown Prosecution Service guidance. A new footnote has also been added to this node reflecting Crown Prosecution Service guidance.

Topics outside the scope of this pathway

The following topics were outside the scope of this pathway and have therefore not been covered:
  • risk factors for child maltreatment, which are well recognised (for example, parental or carer drug or alcohol misuse, parental or carer mental health problems, intrafamilial 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 maltreatmentIt should be noted that there are special procedures that should be followed when a child dies unexpectedly.
  • 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.

Your responsibility

Guidelines

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this pathway is not mandatory and does 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.
Local commissioners and/or providers have a responsibility to enable the pathway to be applied when individual health professionals and their patients or service users 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 pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Technology appraisals

The recommendations in this pathway 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 pathway 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.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this pathway 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 pathway 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 pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

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.

Short Text

Everything NICE has said on when to suspect child maltreatment in the under 18s in an interactive flowchart.

What is covered

This pathway covers the alerting features in children and young people (under 18 years) of physical, sexual and emotional abuse, neglect and fabricated or induced illness.
The effects of child maltreatment can be severe and last into adulthood.
Children may present with both physical and psychological symptoms and signs that constitute alerting features of one or more types of maltreatment.
Maltreatment may be observed in parent– or carer–child interactions.

Updates

Updates to this pathway

9 January 2014 Footnote 1 in the Sexual abuse node has been further amended to ensure it accurately reflects Crown Prosecution Service guidance. A new footnote has also been added to this node reflecting Crown Prosecution Service guidance.

Sources

NICE guidance and other sources used to create this pathway.

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.
These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.
NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Topics outside the scope of this pathway

The following topics were outside the scope of this pathway and have therefore not been covered:
  • risk factors for child maltreatment, which are well recognised (for example, parental or carer drug or alcohol misuse, parental or carer mental health problems, intrafamilial 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 maltreatmentIt should be noted that there are special procedures that should be followed when a child dies unexpectedly.
  • 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.

Your responsibility

Guidelines

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this pathway is not mandatory and does 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.
Local commissioners and/or providers have a responsibility to enable the pathway to be applied when individual health professionals and their patients or service users 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 pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Technology appraisals

The recommendations in this pathway 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 pathway 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.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this pathway 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 pathway 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 pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

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.

Supporting information

Glossary

Under 13 years
Includes physical, emotional and sexual abuse, neglect, and fabricated or induced illness. The definitions of child maltreatment in Working together to safeguard children (2010) are used in this guidance.
Maltreatment is one possible explanation for the alerting feature or is included in the differential diagnosis.
Transient episodes of detachment that are outside the child's control and that are different from daydreaming, seizures or deliberate avoidance of interaction.
Repeatedly defecating a normal stool in an inappropriate place.
Under 1 year
Serious level of concern about the possibility of child maltreatment but not proof of it.
An unsuitable explanation is one that is:
  • implausible, inadequate or inconsistent:
    • with the child or young person's presentation, normal activities, medical condition (if one exists), age or developmental stage, or account compared with that given by parent and carers
    • between parents or carers
    • between accounts over time
  • based on cultural practice, because this should not justify hurting a child or young person.
13–17 years

Paths in this pathway

Pathway created: January 2012 Last updated: September 2016

© NICE 2016

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