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When to suspect child maltreatment

About

What is covered

This interactive flowchart 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 interactive flowchart

9 January 2014 Footnotes in sexual abuse have been amended to ensure they accurately reflect Crown Prosecution Service guidance.

Topics outside the scope of this interactive flowchart

The following topics were outside the scope of this interactive flowchart 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 maltreatment (it 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.

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 abuse, neglect and fabricated or induced illness in children and young people in an interactive flowchart

What is covered

This interactive flowchart 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 interactive flowchart

9 January 2014 Footnotes in sexual abuse have been amended to ensure they accurately reflect Crown Prosecution Service guidance.

Sources

NICE guidance and other sources used to create this interactive flowchart.

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

Topics outside the scope of this interactive flowchart

The following topics were outside the scope of this interactive flowchart 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 maltreatment (it 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.

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

Unsuitable explanation

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.

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
13–17 years

Paths in this pathway

Pathway created: January 2012 Last updated: June 2017

© NICE 2017

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