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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

Updates to this interactive flowchart

11 February 2019 Child abuse and neglect (NICE quality standard 179) added.

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.

Updates

Updates to this interactive flowchart

11 February 2019 Child abuse and neglect (NICE quality standard 179) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Child abuse and neglect (2017) NICE guideline NG76
Child abuse and neglect (2019) NICE quality standard 179

Quality standards

Child abuse and neglect

These quality statements are taken from the child abuse and neglect quality standard. The quality standard defines clinical best practice for child abuse and neglect and should be read in full.

Quality statements

Noticing changes

This quality statement is taken from the child abuse and neglect quality standard. The quality standard defines clinical best practice for child abuse and neglect and should be read in full.

Quality statement

Children and young people who display marked changes in behaviour or emotional state are encouraged to talk about their wellbeing.

Rationale

Children and young people can find it difficult to tell someone or even understand that they are being abused or neglected. However, they may communicate an emotional reaction to their experiences indirectly through their behaviour. Practitioners who work with the same group of children or young people for an extended period are in a position to notice changes in the child or young person’s behaviour, emotional state or attitude. These changes should be a prompt to explore concerns through a sensitive enquiry about their wellbeing, giving them space and opportunity to talk. Creating a supportive environment for the conversation, being sensitive and asking open questions may encourage children and young people to disclose abuse or neglect when they feel ready.

Quality measures

Structure
a) Evidence of local arrangements to ensure that people whose work brings them into contact with children or young people are trained to recognise alerting features for abuse and neglect.
Data source: Local data collection, for example, audit of organisational safeguarding policies and training records.
b) Evidence of local arrangements to ensure that people whose work brings them into contact with children or young people are trained to respond to child abuse and neglect in line with local safeguarding procedures.
Data source: Local data collection, for example, audit of organisational safeguarding policies and training records.
c) Evidence of local arrangements to ensure that there is a clear referral pathway to local authority children’s social care, to be followed by anyone who has concerns about child abuse and neglect.
Data source: Local data collection, for example, audit of organisational safeguarding policies, local authority referral pathways.
Outcome
a) Number of children in need because of abuse or neglect.
Data source: Characteristics of children in need: 2017 to 2018, Department for Education.
b) Number of children who were the subject of a child protection plan.
Data source: Children in need census 2010 to 2011 (provisional), Department for Education.

What the quality statement means for different audiences

Organisations providing services and activities for children and young people (such as nurseries, schools, after-school clubs, community centres, sports clubs and health settings) have clear safeguarding policies, systems, protocols and staff training in place to ensure that staff have the awareness and skills to recognise alerting features for abuse and neglect and take appropriate action as soon as concerns arise.
Practitioners whose work brings them into contact with children and young people (such as those who work in early years, social care, health, education settings, police, the voluntary and community sector, youth justice services and adult services) understand their responsibilities in safeguarding children and young people and ensure that they take action as soon as they recognise risk factors or spot signs of abuse or neglect. They stay alert to changes in behaviour or emotional state in children and young people they work with and ask them about their wellbeing as soon as they have concerns.
Commissioners (such as national and regional schools commissioners, local authorities and clinical commissioning groups) commission services in which all practitioners can recognise and respond to child abuse and neglect and in which agencies work together and share information to ensure that effective actions are taken. They also ensure that clear referral pathways are in place and services work together to safeguard children and young people.
Children and young people who show a change in their behaviour are asked about how they are, their feelings, friends, family and home life. Children and young people are given space and opportunity to talk to someone they trust about their wellbeing.

Source guidance

Child abuse and neglect (2017) NICE guideline NG76, recommendations 1.3.5 and 1.3.12

Definitions of terms used in this quality statement

Marked changes in behaviour or emotional state
A change in a child’s behaviour or emotional state which is not fully explained by a stressful situation that is not part of child abuse and neglect such as bereavement, parental separation or a medical cause. Examples of marked changes may include:
  • recurrent nightmares containing similar themes
  • extreme distress
  • markedly oppositional behaviour
  • withdrawal of communication
  • becoming withdrawn.
Practitioners should continue to consider the possibility of child abuse or neglect as a cause for behavioural and emotional changes, even if they are seemingly explained by another cause.
[NICE’s guideline on child abuse and neglect, recommendation 1.3.12 and expert opinion]

Equality and diversity considerations

Children and young people who are displaying marked changes in behaviour or emotional state may have problems with communication, for example because they are very young (pre-verbal stage) or because of disability or speech or language problems.
Practitioners who work regularly with these children and young people and notice the change should actively look for alternative ways of finding out what may be causing the changes. For example, they can discuss their observations with family members or carers if that is appropriate or use play, art or other activities to explore their concerns and gather more information.

Consistent support

This quality statement is taken from the child abuse and neglect quality standard. The quality standard defines clinical best practice for child abuse and neglect and should be read in full.

Quality statement

Children and young people who have experienced abuse or neglect receive support from a consistent group of practitioners.

Rationale

Working with the same practitioners over time enables children and young people who have experienced abuse or neglect to gain trust and build better relationships. It also protects them from being re-traumatised by having to re-tell their experiences. Consistency equally helps the practitioners to get to know the child and the broader family context that they live in. It also helps them to work more effectively with other agencies involved with that family to protect children and young people from further harm.

Quality measures

Structure
a) Evidence of local arrangements to ensure that children and young people who have experienced abuse or neglect receive support from a consistent group of practitioners.
Data source: Local data collection, for example, audit of service specification, protocols or practice.
b) Evidence of local arrangements to ensure that practitioners supporting children and young people who have experienced abuse or neglect work closely with other agencies involved in supporting the children and young people and their families.
Data source: Local data collection, for example, audit of service specification, protocols or communication between agencies.
Process
a) Proportion of children and young people supported by social workers because of their experience of abuse or neglect who had a change of social worker in the past 12 months.
Numerator – the number in the denominator who had a change of social worker in the past 12 months.
Denominator – the number of children and young people supported by a social worker because of their experience of abuse or neglect.
Data source: Local data collection, for example, audit of children’s social care records. The National Audit Office is currently piloting Stability index for children in care which requires data submission by the local authorities on changes to a social worker.
b) Proportion of children and young people supported by mental health practitioners because of their experience of abuse or neglect who had a change of practitioner in the past 12 months.
Numerator – the number in the denominator who had a change of practitioner in the past 12 months.
Denominator – the number of children and young people supported by a mental health practitioner because of their experience of abuse or neglect.
Data source: Local data collection, for example, audit of child and adolescent mental health services records.
Outcome
Experience of care and support received by children and young people who have experienced abuse or neglect.
Data source: Local data collection, for example, feedback from children and young people supported by children’s services.

What the quality statement means for different audiences

Service providers (such as schools, social services, sexual health services, drug and alcohol services, child and adolescent mental health services, youth offending services and primary and secondary care services) ensure that staff turnover and use of agency workers is minimised and that staff have an opportunity to build meaningful relationships by working with the same children and young people over time. They also ensure they have arrangements with other agencies involved with the children, young people and their families so that they can provide holistic support. This may include appointing a lead practitioner who can take responsibility for coordinating the services and interventions needed to support the child.
Practitioners (such as teachers, social workers, mental health professionals, specialist drug services professionals, health visitors, GPs, community nurses, youth workers, police and probation officers) ensure that they build meaningful relationships with children and young people. They also ensure they share information and build relationships with other practitioners working with that family and organise handovers if new staff members from their agency become involved.
Commissioners (such as local authorities, clinical commissioning groups and NHS England) commission services in which children, young people and practitioners experience stability in the services and relationships that are offered to them. They also ensure that they make arrangements to work with partners locally, to safeguard and promote the welfare of all children and young people in their area. This may be achieved by ensuring the role of a lead practitioner who can take responsibility for coordinating the services and interventions needed to support the child is part of the service.
Children and young people who have experienced abuse or neglect have opportunities to build stable, trusting relationships with practitioners who get to know them and their needs well.

Source guidance

Child abuse and neglect (2017) NICE guideline NG76, recommendations 1.6.1 and 1.8.1

Definitions of terms used in this quality statement

Children and young people who have experienced abuse or neglect
Includes those assessed as 'in need', likely to suffer significant harm or suffering significant harm.
[NICE’s guideline on child abuse and neglect, section 1.6]

Equality and diversity considerations

Children and young people who have experienced abuse or neglect may find building relationships with practitioners difficult as a result of communication difficulties. This could be because they are very young (pre-verbal stage) or because of disability or speech or language problems. Practitioners who work with these children should identify the support they need to engage with them in a meaningful way. This may include involving interpreters, or asking nursery staff or speech and language therapists for support with interactions.
Children and young people who are in temporary accommodation and move between placements are likely to experience more instability. Therefore, it is important to ensure that the transfer of records and follow-up appointments are timely. Commissioners and service providers should prioritise continuity among practitioners supporting children and young people with additional needs.

Voice of the child or young person

This quality statement is taken from the child abuse and neglect quality standard. The quality standard defines clinical best practice for child abuse and neglect and should be read in full.

Quality statement

Children and young people who have experienced abuse or neglect have their words accurately represented in notes summarising their conversations with practitioners.

Rationale

When children and young people share their experiences of abuse or neglect, they need to be confident that their voices are heard and that their words are captured accurately by the practitioners. The conversations they have with practitioners need to be appropriate to their age, developmental stage, and cognitive and language abilities. Summaries of these conversations should be written up immediately and reflect only the facts as the children and young people presented them. Where possible, the children and young people should also have an opportunity to reflect on what they said and review the record of the conversation.

Quality measures

Structure
a) Evidence of local arrangements to ensure that children and young people who have experienced abuse or neglect have their words accurately represented in notes summarising their conversations with the practitioners.
Data source: Local data collection, for example, audit of service specification or protocols.
b) Evidence of local arrangements to ensure that, when appropriate, children and young people have an opportunity to review what the practitioner noted.
Data source: Local data collection, for example, audit of service specification or protocols.
Outcome
a) Children and young people’s experience of working with health and social care practitioners.
Data source: Local data collection, for example, feedback from children and young people supported by children’s services.
b) Engagement with services among children and young people who have experienced abuse or neglect.
Data source: Local data collection, for example, feedback from children and young people supported by children’s services.
c) Health and wellbeing of children and young people who have experienced abuse or neglect.
Data source: Local data collection, for example, feedback from children and young people supported by children’s services.

What the quality statement means for different audiences

Organisations providing services and activities for children and young people (such as nurseries, schools, after-school clubs, community centres, sports clubs and health settings) ensure that their safeguarding policies and local protocols include writing up summaries of conversations about abuse or neglect that children and young people have with practitioners. They also ensure that the notes are written up immediately after the conversations and reflect only the facts as the children or young people presented them. When appropriate, children and young people have an opportunity to review what the practitioner noted.
Practitioners whose work brings them into contact with children and young people (such as those who work in early years, social care, health, education settings, the police, the voluntary and community sector, youth justice services and adult services) ensure that they do not ask leading questions and that all conversations with children and young people who experienced abuse or neglect are appropriate to their age, developmental stage and language abilities. They also ensure that they write up summaries of these conversations immediately after they took place and that the notes reflect only the facts as the children and young people presented them using the child’s words where possible. When appropriate, they give children and young people an opportunity to reflect on what they said and review the record of the conversation.
Commissioners (such as national and regional schools commissioners, local authorities and clinical commissioning groups) commission services in which practitioners accurately write up any conversations they had with children and young people who experienced abuse or neglect. They also ensure that this is done immediately after the conversation took place and only reflects the facts as the children and young people presented them.
Children and young people who talk to people such as social workers or healthcare staff about their experiences of abuse or neglect can feel confident that any notes from their conversations will accurately reflect what they said. They are also able to review what has been noted if they wish to do so.

Source guidance

Child abuse and neglect (2017) NICE guideline NG76, recommendation 1.1.6

Definitions of terms used in this quality statement

Children and young people who have experienced abuse or neglect
Includes those assessed as 'in need', likely to suffer significant harm or suffering significant harm.
[NICE’s guideline on child abuse and neglect, section 1.6]

Equality and diversity considerations

Children and young people who have experienced abuse or neglect may have problems with communication, for example because they are very young (pre-verbal stage) or because of disability or speech or language problems.
Practitioners should use creative resources, such as toys and play, to help gather information and make sure that they capture their observations and communication with children and young people as accurately as possible. If appropriate, they may need to be supported by interpreters, specialist practitioners, family members or carers (where they are not implicated in the abuse or neglect) who can also review what was noted.  

Communication

This quality statement is taken from the child abuse and neglect quality standard. The quality standard defines clinical best practice for child abuse and neglect and should be read in full.

Quality statement

Children and young people who have experienced abuse or neglect agree with practitioners how they will communicate with each other.

Rationale

Children and young people may be living in circumstances in which someone who may be abusing or neglecting them has access to their phone or email. This could pose a safety risk and mean they would not be able to respond when practitioners try to contact them. Also, they may want to contact the practitioner when they want to talk or need support. This may sometimes be urgent, outside the usual working hours or more frequent than initially agreed. Putting safe and effective arrangements in place to stay in touch is essential to ensure that children and young people are not put at additional risk and can access support when they need it.

Quality measures

Structure
Evidence of local arrangements to ensure that practitioners agree with children and young people who have experienced abuse or neglect how they will communicate with each other.
Data source: Local data collection, for example, audit of service specification or protocols.
Process
Proportion of children and young people who have experienced abuse or neglect whose case file contains a record of agreed methods of communication with practitioners.
Numerator – the number in the denominator whose case file contains a record of agreed methods of communication with practitioners.
Denominator – the number of children and young people who have experienced abuse or neglect.
Data source: Local data collection, for example, audit of individual case records.
Outcome
a) Engagement with services among children and young people who have experienced abuse or neglect.
Data source: Local data collection, for example, feedback from children and young people supported by children’s services.
b) Satisfaction with services among children and young people who have experienced abuse or neglect.
Data source: Local data collection, for example, feedback from children and young people supported by children’s services.
c) Health and wellbeing of children and young people who have experienced abuse or neglect.
Data source: Local data collection, for example, feedback from children and young people supported by children’s services.

What the quality statement means for different audiences

Service providers (such as schools, social services, sexual health services, drug and alcohol services, child and adolescent mental health services, youth offending services and primary and secondary care services) ensure that their safeguarding policies and local protocols include agreeing with children and young people who have experienced abuse or neglect, safe and effective ways of communicating. This may include children and young people naming a secure email address or a phone number or the time in the day when the practitioner can safely contact them. Also, the children and young people receive contact details that they can use to get help on any day and at any time of the day.
Practitioners (such as teachers, social workers, mental health professionals, specialist drug services professionals, health visitors, GPs, community nurses, youth workers, police and probation officers) ensure that they agree with children and young people who have experienced abuse or neglect, safe and effective ways of communicating. This may include children and young people naming a secure email address or a phone number or the time in the day when the practitioner can safely contact them. Also, the children and young people receive contact details that they can use to get help on any day and at any time of the day.
Commissioners (such as local authorities, clinical commissioning groups and NHS England) commission services in which children and young people who have experienced abuse or neglect agree with those practitioners safe and effective ways of communicating. This may include children and young people naming the secure email address or a phone number or the time in the day when the practitioner can safely contact them. Also, the children and young people receive contact details that they can use to get help on any day and at any time of the day.
Children and young people who have experienced abuse or neglect have contact details for their practitioners, including out-of-hours contact, so that they can get help and support whenever they need it. They also agree with the practitioner times and ways of communicating that they think is safe for them. This may mean creating a secure email address or having a phone number that other people have no access to.

Source guidance

Child abuse and neglect (2017) NICE guideline NG76, recommendation 1.1.9

Definitions of terms used in this quality statement

Children and young people who have experienced abuse or neglect
Includes including those assessed as 'in need', likely to suffer significant harm or suffering significant harm.
[NICE’s guideline on child abuse and neglect, section 1.6]

Equality and diversity considerations

Children and young people who need to communicate with practitioners about abuse or neglect may have problems with communication, for example because they are very young (pre-verbal) or because of disability or speech or language problems. The support may be in form of more frequent visits, involving family members who know the child or young person well (where they are not implicated in the abuse or neglect) and any specialists who can help with the communication such as speech and language therapists or interpreters.

Therapeutic interventions

This quality statement is taken from the child abuse and neglect quality standard. The quality standard defines clinical best practice for child abuse and neglect and should be read in full.

Quality statement

Children and young people who have experienced abuse or neglect are offered therapeutic interventions based on a detailed assessment of therapeutic needs.

Rationale

There are many ways in which children and young people can be affected by abuse and neglect. In order to offer effective therapeutic interventions, practitioners need to identify each child or young person’s therapeutic needs using a detailed assessment. They can then discuss the options with them and their parents and carers (if appropriate) and make a joint decision about the therapy. Some children and young people may not be ready or may not want the therapy at that point. This should be their choice.

Quality measures

Structure
a) Evidence of local arrangements to ensure that children and young people who have experienced abuse or neglect have a detailed assessment of therapeutic needs.
Data source: Local data collection, for example, audit of service specification or protocols.
b) Evidence of local arrangements to ensure that children and young people who have experienced abuse or neglect are offered therapeutic interventions based on a detailed assessment of therapeutic need.
Data source: Local data collection, for example, audit of service specification or protocols.
Process
a) Proportion of children and young people who have experienced abuse or neglect who had a detailed assessment of therapeutic needs.
Numerator – the number in the denominator who had a detailed assessment of therapeutic needs.
Denominator – the number of children and young people who have experienced abuse or neglect.
Data source: Statistics: children in need and child protection, Department for Education and local data collection, for example, audit of individual case records.
b) Proportion of children and young people who have experienced abuse or neglect who were offered therapeutic interventions based on a detailed assessment of therapeutic needs.
Numerator – the number in the denominator offered therapeutic interventions based on identified therapeutic needs.
Denominator – the number of children and young people who have experienced abuse or neglect and had a detailed assessment of therapeutic needs.
Data source: Statistics: children in need and child protection, Department for Education and local data collection, for example, audit of individual case records.
c) Proportion of children and young people who received a therapeutic intervention after experiencing abuse or neglect who had a review of how effective the therapeutic intervention was.
Numerator – the number in the denominator who had a review of how effective the therapeutic intervention was.
Denominator – the number of children and young people who received a therapeutic intervention after experiencing abuse or neglect.
Data source: Statistics: children in need and child protection, Department for Education and local data collection, for example, audit of individual case records.
Outcome
a) Acceptability of therapeutic interventions offered to children and young people who experienced abuse and neglect.
Data source: Local data collection, for example, feedback from children and young people supported by children’s services.
b) Health and wellbeing of children and young people who experienced abuse or neglect.
Data source: Local data collection, for example, feedback from children and young people supported by children’s services.

What the quality statement means for different audiences

Service providers (such social services, sexual health services, drug and alcohol services, child and adolescent mental health services, youth offending services and primary and secondary care services) ensure that members of staff who support children and young people who have experienced abuse or neglect are trained to carry out an effective detailed assessment of therapeutic needs. This is to establish the most appropriate therapeutic interventions, make referrals or to deliver these interventions, and to evaluate their effectiveness. They are also trained to discuss the interventions with children and young people in a way that helps shared decision making.
Practitioners (such as social workers, mental health professionals, specialist drug services professionals, health visitors, GPs, community nurses, youth workers and probation officers) ensure that they offer the most appropriate therapeutic interventions to children and young people who have experienced abuse or neglect based on a detailed assessment of their therapeutic needs. They also ensure that children and young people understand their choices and that if they decide to start the therapeutic intervention, they discuss throughout how effective it is.
Commissioners (such as local authorities, clinical commissioning groups and NHS England) commission services in which children and young people who have experienced abuse or neglect have access to the most suitable and effective therapeutic interventions.
Children and young people who have experienced abuse or neglect are offered therapeutic interventions that are seen as the most suitable for their circumstances. They have an opportunity to discuss their options, and get an explanation from their practitioner about what the interventions are and what they involve. They have a choice to participate in the interventions or not if they do not feel ready at that point.

Source guidance

Child abuse and neglect (2017) NICE guideline NG76, recommendations 1.7.1, 1.7.2 and 1.7.3

Definitions of terms used in this quality statement

Children and young people who have experienced abuse or neglect
Includes those assessed as 'in need', likely to suffer significant harm or suffering significant harm.
[NICE’s guideline on child abuse and neglect, section 1.6]

Equality and diversity considerations

Children and young people who need to communicate with practitioners about abuse or neglect may have problems with communication, for example because they are very young (pre-verbal) or because of disability or speech or language problems. The support may be in the form of more frequent visits, involving family members who know the child or young person well (where they are not implicated in the abuse or neglect) and any specialists who can help with the communication such as speech and language therapists or interpreters.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

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: February 2019

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