Child maltreatment

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 document ‘Working together to safeguard children’^[1].

Age groups

This guidance uses the following terms to describe children of different ages:

• infant (aged under 1 year)
• child (aged under 13 years)
• young person (aged 13–17 years).

Consider

For the purposes of this guidance, to consider child maltreatment means that maltreatment is one possible explanation for the alerting feature or is included in the differential diagnosis.

Multi-agency safeguarding arrangements

The responsibility for these arrangements is with 3 safeguarding partners: the local authority, clinical commissioning group for an area, and the chief officer of police for a police area. They have a shared and equal duty to work together to safeguard and promote the welfare of all children in a local area.

Suspect

For the purposes of this guidance, to suspect child maltreatment means a serious level of concern about the possibility of child maltreatment but is not proof of it.

Unsuitable explanation

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.

1. Listen and observe

Identifying or excluding child maltreatment involves piecing together information from many sources so that the whole picture of the child or young person is taken into account. This information may come from different sources and agencies and includes:

• any history that is given
• report of maltreatment, or disclosure from a child or young person or third party^[3]
• child’s appearance
• child’s behaviour or demeanour
• symptom
• physical sign
• result of an investigation
• interaction between the parent or carer and child or young person.

2. Seek an explanation

Seek an explanation for any injury or presentation from both the parent or carer and the child or young person in an open and non-judgemental manner.

3. Record

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

At this point the healthcare professional may consider, suspect or exclude child maltreatment from the differential diagnosis.

4. Consider, suspect or exclude maltreatment

5. Record

Record all actions taken in 4 and the outcome.

Bruises

1.1.1.

Suspect child maltreatment if a child or young person has bruising in the shape of a hand, ligature, stick, teeth mark, grip or implement.

1.1.2.

Suspect child maltreatment if there is bruising or petechiae (tiny red or purple spots) that are not caused by a medical condition (for example, a causative coagulation disorder) and if the explanation for the bruising is unsuitable^[4]. Examples include:

• bruising in a child who is not independently mobile
• multiple bruises or bruises in clusters
• bruises of a similar shape and size
• bruises on any non-bony part of the body or face including the eyes, ears and buttocks
• bruises on the neck that look like attempted strangulation
• bruises on the ankles and wrists that look like ligature marks.

Bites

1.1.3.

Suspect child maltreatment if there is a report or appearance of a human bite mark that is thought unlikely to have been caused by a young child.

1.1.4.

Consider neglect if there is a report or appearance of an animal bite on a child who has been inadequately supervised.

Lacerations (cuts), abrasions and scars

1.1.5.

Suspect child maltreatment if a child has lacerations, abrasions or scars and the explanation is unsuitable^[4]. Examples include lacerations, abrasions or scars:

• on a child who is not independently mobile
• that are multiple
• with a symmetrical distribution
• on areas usually protected by clothing (for example, back, chest, abdomen, axilla, genital area)
• on the eyes, ears and sides of face
• on the neck, ankles and wrists that look like ligature marks.

Thermal injuries

1.1.6.

Suspect child maltreatment if a child has burn or scald injuries:

• if the explanation for the injury is absent or unsuitable^[4] or
• if the child is not independently mobile or
• on any soft tissue area that would not be expected to come into contact with a hot object in an accident (for example, the backs of hands, soles of feet, buttocks, back) or
• in the shape of an implement (for example, cigarette, iron) or
• that indicate forced immersion, for example:

  –

  scalds to buttocks, perineum and lower limbs

  –

  scalds to limbs in a glove or stocking distribution

  –

  scalds to limbs with symmetrical distribution

  –

  scalds with sharply delineated borders.

Cold injury

1.1.7.

Consider child maltreatment if a child has cold injuries (for example, swollen, red hands or feet) with no obvious medical explanation.

1.1.8.

Consider child maltreatment if a child presents with hypothermia and the explanation is unsuitable^[4].

Fractures

1.1.9.

Suspect child maltreatment if a child has one or more fractures in the absence of a medical condition that predisposes to fragile bones (for example, osteogenesis imperfecta, osteopenia of prematurity) or if the explanation is absent or unsuitable^[4]. Presentations include:

• fractures of different ages
• X-ray evidence of occult fractures (fractures identified on X-rays that were not clinically evident). For example, rib fractures in infants.

Intracranial injuries

1.1.10.

Suspect child maltreatment if a child has an intracranial injury in the absence of major confirmed accidental trauma or known medical cause, in one or more of the following circumstances:

• the explanation is absent or unsuitable^[4]
• the child is aged under 3 years
• there are also:

  –

  retinal haemorrhages or

  –

  rib or long bone fractures or

  –

  other associated inflicted injuries

• there are multiple subdural haemorrhages with or without subarachnoid haemorrhage with or without hypoxic ischaemic damage (damage due to lack of blood and oxygen supply) to the brain.

Eye trauma

1.1.11.

Suspect child maltreatment if a child has retinal haemorrhages or injury to the eye in the absence of major confirmed accidental trauma or a known medical explanation, including birth-related causes.

Spinal injuries

1.1.12.

Suspect physical abuse if a child presents with signs of a spinal injury (injury to vertebrae or within the spinal canal) in the absence of major confirmed accidental trauma. Spinal injury may present as:

• a finding on skeletal survey or magnetic resonance imaging
• cervical injury in association with inflicted head injury
• thoracolumbar injury in association with focal neurology or unexplained kyphosis (curvature or deformity of the spine).

Visceral injuries

1.1.13.

Suspect child maltreatment if a child has an intra-abdominal or intrathoracic injury in the absence of major confirmed accidental trauma and there is an absent or unsuitable explanation^[4], or a delay in presentation. There may be no external bruising or other injury.

Oral injury

1.1.14.

Consider child maltreatment if a child has an oral injury and the explanation is absent or unsuitable^[4].

General injuries

1.1.15.

Consider child maltreatment if there is no suitable explanation for a serious or unusual injury.

Ano-genital signs and symptoms

1.1.16.

Suspect sexual abuse if a girl or boy has a genital, anal or perianal injury (as evidenced by bruising, laceration, swelling or abrasion) and the explanation is absent or unsuitable^[4].

1.1.17.

Suspect sexual abuse if a girl or boy has a persistent or recurrent genital or anal symptom (for example, bleeding or discharge) that is associated with behavioural or emotional change and that has no medical explanation.

1.1.18.

Suspect sexual abuse if a girl or boy has an anal laceration, and constipation, Crohn’s disease and passing hard stools have been excluded as the cause.

1.1.19.

Consider sexual abuse if an anus exhibiting dynamic anal dilation in a girl or boy is observed during an examination and there is no medical explanation (for example, a neurological disorder or severe constipation).

1.1.20.

Consider sexual abuse if a girl or boy has a genital or anal symptom (for example, bleeding or discharge) without a medical explanation.

1.1.21.

Consider sexual abuse if a girl or boy has dysuria (discomfort on passing urine) or ano-genital discomfort that is persistent or recurrent and does not have a medical explanation (for example, worms, urinary infection, skin conditions, poor hygiene or known allergies).

1.1.22.

Consider sexual abuse if there is evidence of one or more foreign bodies in the vagina or anus. Foreign bodies in the vagina may be indicated by offensive vaginal discharge.

Sexually transmitted infections

1.1.23.

Consider sexual abuse if a child younger than 13 years has hepatitis B unless there is clear evidence of mother-to-child transmission during birth, non-sexual transmission from a member of the household or blood contamination.

1.1.24.

Consider sexual abuse if a child younger than 13 years has anogenital warts unless there is clear evidence of mother-to-child transmission during birth or non-sexual transmission from a member of the household.

1.1.25.

Suspect sexual abuse if a child younger than 13 years has gonorrhoea, chlamydia, syphilis, genital herpes, hepatitis C, HIV or trichomonas infection unless there is clear evidence of mother-to-child transmission during birth or blood contamination.

1.1.26.

Consider sexual abuse if a young person aged 13 to 15 years has hepatitis B unless there is clear evidence of mother-to-child transmission during birth, non-sexual transmission from a member of the household, blood contamination or that the infection was acquired from consensual sexual activity with a peer.

1.1.27.

Consider sexual abuse if a young person aged 13 to 15 years has anogenital warts unless there is clear evidence of mother-to-child transmission during birth, non-sexual transmission from a member of the household, or that the infection was acquired from consensual sexual activity with a peer.

1.1.28.

Consider sexual abuse if a young person aged 13 to 15 years has gonorrhoea, chlamydia, syphilis, genital herpes, hepatitis C, HIV or trichomonas infection unless there is clear evidence of mother-to-child transmission during birth, blood contamination, or that the sexually transmitted infection (STI) was acquired from consensual sexual activity with a peer^[5].

1.1.29.

Consider sexual abuse if a young person aged 16 or 17 years has hepatitis B and there is:

• no clear evidence of mother-to-child transmission during birth, non-sexual transmission from a member of the household, blood contamination or that the infection was acquired from consensual sexual activity and
• a clear difference in power or mental capacity between the young person and their sexual partner, in particular when the relationship is incestuous or is with a person in a position of trust (for example, teacher, sports coach, minister of religion) or
• concern that the young person is being exploited.

1.1.30.

Consider sexual abuse if a young person aged 16 or 17 years has anogenital warts and there is:

• no clear evidence of non-sexual transmission from a member of the household or that the infection was acquired from consensual sexual activity and
• a clear difference in power or mental capacity between the young person and their sexual partner, in particular when the relationship is incestuous or is with a person in a position of trust (for example, teacher, sports coach, minister of religion) or
• concern that the young person is being exploited.

1.1.31.

Consider sexual abuse if a young person aged 16 or 17 years has gonorrhoea, chlamydia, syphilis, genital herpes, hepatitis C, HIV or trichomonas infection and there is:

• no clear evidence of blood contamination or that the STI was acquired from consensual sexual activity and
• a clear difference in power or mental capacity between the young person and their sexual partner, in particular when the relationship is incestuous or is with a person in a position of trust (for example, teacher, sports coach, minister of religion) or
• concern that the young person is being exploited.

Pregnancy

1.2.1.

Be aware that sexual intercourse with a child younger than 13 years is unlawful and therefore pregnancy in such a child means the child has been maltreated^[6].

1.2.2.

Consider sexual abuse if a young woman aged 13 to 15 years is pregnant^[7].

1.2.3.

Consider sexual abuse if a young woman aged 16 or 17 years is pregnant and there is:

• a clear difference in power or mental capacity between the young woman and the putative father, in particular when the relationship is incestuous or is with a person in a position of trust (for example, teacher, sports coach, minister of religion) or
• concern that the young woman is being exploited or
• concern that the sexual activity was not consensual.

Apparent life-threatening event

1.2.4.

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

1.2.5.

Consider child maltreatment if an infant has an apparent life-threatening event with bleeding from the nose or mouth and a medical explanation has not been identified.

Poisoning

1.2.6.

Suspect child maltreatment in cases of poisoning in children if:

• there is a report of deliberate administration of inappropriate substances, including prescribed and non-prescribed drugs or
• there are unexpected blood levels of drugs not prescribed for the child or
• there is reported or biochemical evidence of ingestions of one or more toxic substances or
• the child was unable to access the substance independently or
• the explanation for the poisoning or how the substance came to be in the child is absent or unsuitable^[4]or
• there have been repeated presentations of ingestions in the child or other children in the household.

1.2.7.

Consider child maltreatment in cases of hypernatraemia (abnormally high levels of sodium in the blood) and a medical explanation has not been identified.

Non-fatal submersion injury

1.2.8.

Suspect child maltreatment if a child has a non-fatal submersion incident (near-drowning) and the explanation is absent or unsuitable^[4] or if the child’s presentation is inconsistent with the account.

1.2.9.

Consider child maltreatment if a non-fatal submersion incident suggests a lack of supervision.

Attendance at medical services

1.2.10.

Consider child maltreatment if there is an unusual pattern of presentation to and contact with healthcare providers, or there are frequent presentations or reports of injuries.

Fabricated or induced illness

1.2.11.

Consider fabricated or induced illness if a child’s history, physical or psychological presentations or findings of assessments, examinations or investigations leads to a discrepancy with a recognised clinical picture. Fabricated or induced illness is a possible explanation even if the child has a past or concurrent physical or psychological condition.

1.2.12.

Suspect fabricated or induced illness if a child’s history, physical or psychological presentations or findings of assessments, examinations or investigations leads to a discrepancy with a recognised clinical picture and one or more of the following is present:

• Reported symptoms and signs only appear or reappear when the parent or carer is present.
• Reported symptoms are only observed by the parent or carer.
• An inexplicably poor response to prescribed medication or other treatment.
• New symptoms are reported as soon as previous ones have resolved.
• There is a history of events that is biologically unlikely (for example, infants with a history of very large blood losses who do not become unwell or anaemic).
• Despite a definitive clinical opinion being reached, multiple opinions from both primary and secondary care are sought and disputed by the parent or carer and the child continues to be presented for investigation and treatment with a range of signs and symptoms.
• The child’s normal daily activities (for example, school attendance) are being compromised, or the child is using aids to daily living (for example, wheelchairs) more than would be expected for any medical condition that the child has.

Fabricated or induced illness is a likely explanation even if the child has a past or concurrent physical or psychological condition.

Inappropriately explained poor school attendance

1.2.13.

Consider child maltreatment if a child has poor school attendance that the parents or carers know about that has no justification on health, including mental health, grounds and home education is not being provided.

Provision of basic needs

1.3.1.

Consider neglect if a child has severe and persistent infestations, such as scabies or head lice.

1.3.2.

Consider neglect if a child’s clothing or footwear is consistently inappropriate (for example, for the weather or the child’s size).

Take into account that instances of inadequate clothing that have a suitable explanation (for example, a sudden change in the weather, slippers worn because they were closest to hand when leaving the house in a rush) or resulting from behaviour associated with neurodevelopmental disorders such as autism would not be alerting features for possible neglect.

1.3.3.

Suspect neglect if a child is persistently smelly and dirty.

Take into account that children often become dirty and smelly during the course of the day. Use judgement to determine if persistent lack of provision or care is a possibility. Examples include:

• child seen at times of the day when it is unlikely that they would have had an opportunity to become dirty or smelly (for example, an early morning visit)
• if the dirtiness is ingrained.

1.3.4.

Suspect neglect if you repeatedly observe or hear reports of any of the following in the home that is in the parents’ or carers’ control:

• a poor standard of hygiene that affects a child’s health
• inadequate provision of food
• a living environment that is unsafe for the child’s developmental stage.

Be aware that it may be difficult to distinguish between neglect and material poverty. However, care should be taken to balance recognition of the constraints on the parents’ or carers’ ability to meet their children’s needs for food, clothing and shelter with an appreciation of how people in similar circumstances have been able to meet those needs.

1.3.5.

Be aware that abandoning a child is a form of maltreatment.

Malnutrition

1.3.6.

Consider neglect if a child displays faltering growth because of lack of provision of an adequate or appropriate diet. NICE has produced a guideline on faltering growth.

Supervision

Achieving a balance between an awareness of risk and allowing children freedom to learn by experience can be difficult. However, if parents or carers persistently fail to anticipate dangers and to take precautions to protect their child from harm it may constitute neglect.

1.3.7.

Consider neglect if the explanation for an injury (for example, a burn, sunburn or an ingestion of a harmful substance) suggests a lack of appropriate supervision.

1.3.8.

Consider neglect if a child or young person is not being cared for by a person who is able to provide adequate care.

Ensuring access to appropriate medical care or treatment

1.3.9.

Consider neglect if parents or carers fail to administer essential prescribed treatment for their child.

1.3.10.

Consider neglect if parents or carers repeatedly fail to bring their child to follow-up appointments that are essential for their child’s health and wellbeing.

1.3.11.

Consider neglect if parents or carers persistently fail to engage with relevant child health promotion programmes, which include:

• immunisation
• health and development reviews
• screening.

1.3.12.

Consider neglect if parents or carers have access to but persistently fail to obtain treatment for their child’s dental caries (tooth decay).

1.3.13.

Suspect neglect if parents or carers fail to seek medical advice for their child to the extent that the child’s health and wellbeing is compromised, including if the child is in ongoing pain.

Emotional and behavioural states

1.4.1.

Consider child maltreatment if a child or young person displays or is reported to display a marked change in behaviour or emotional state (see examples below) that is a departure from what would be expected for their age and developmental stage and is not fully explained by a known stressful situation that is not part of child maltreatment (for example, bereavement or parental separation) or medical cause. Examples include:

• recurrent nightmares containing similar themes
• extreme distress
• markedly oppositional behaviour
• withdrawal of communication
• becoming withdrawn.

1.4.2.

Consider child maltreatment if a child’s behaviour or emotional state is not consistent with their age and developmental stage or cannot be fully explained by medical causes, neurodevelopmental disorders (for example, attention deficit hyperactivity disorder [ADHD], autism spectrum disorders) or other stressful situation that is not part of child maltreatment (for example, bereavement or parental separation). Examples of behaviour or emotional states that may fit this description include:

• Emotional states:

  –

  fearful, withdrawn, low self-esteem

• Behaviour:

  –

  aggressive, oppositional

  –

  habitual body rocking

• Interpersonal behaviours:

  –

  indiscriminate contact or affection seeking

  –

  over-friendliness to strangers including healthcare professionals

  –

  excessive clinginess

  –

  persistently resorting to gaining attention

  –

  demonstrating excessively ‘good’ behaviour to prevent parental or carer disapproval

  –

  failing to seek or accept appropriate comfort or affection from an appropriate person when significantly distressed

  –

  coercive controlling behaviour towards parents or carers

  –

  lack of ability to understand and recognise emotions

  –

  very young children showing excessive comforting behaviours when witnessing parental or carer distress.

1.4.3.

Consider child maltreatment if a child shows repeated, extreme or sustained emotional responses that are out of proportion to a situation and are not expected for the child’s age or developmental stage or fully explained by a medical cause, neurodevelopmental disorder (for example, ADHD, autism spectrum disorders) or bipolar disorder and the effects of any known past maltreatment have been explored. Examples of these emotional responses include:

• anger or frustration expressed as a temper tantrum in a school-aged child
• frequent rages at minor provocation
• distress expressed as inconsolable crying.

1.4.4.

Consider child maltreatment if a child shows dissociation (transient episodes of detachment that are outside the child’s control and that are distinguished from daydreaming, seizures or deliberate avoidance of interaction) that is not fully explained by a known traumatic event unrelated to maltreatment.

1.4.5.

Consider child maltreatment if a child or young person regularly has responsibilities that interfere with the child’s essential normal daily activities (for example, school attendance).

1.4.6.

Consider child maltreatment if a child responds to a health examination or assessment in an unusual, unexpected or developmentally inappropriate way (for example, extreme passivity, resistance or refusal).

Behavioural disorders or abnormalities either seen or heard about

Why this is important

The existing evidence base does not fully account for the features that differentiate fractures from different causes in infants and pre-school age children. A prospective comparative study of fractures in physical abuse, those resulting from conditions that lead to bone fragility and those resulting from accidental trauma would help address this question. Any such study should encompass a study of metaphyseal fractures.

Why this is important

Anogenital warts can be acquired by vertical transmission, sexual contact and by non-sexual transmission within households. A thorough prospective study is needed to investigate the differential causes of anogenital warts in children. Such a study should include full viral typing of the warts in the index case and contacts where possible.

Why this is important

Although the alerting signs have been developed based on clinical experience and are considered clinically useful in detecting fabricated or induced illness, there is a need to establish their discriminant validity. This could be achieved by a prospective longitudinal study.

Why this is important

Much of the research in this area uses composite scores from instruments or scenarios to discriminate maltreated from non-maltreated children. To translate these scores into items that are usable for healthcare professionals who are meeting children for the first time, it is necessary to know whether particular behavioural and emotional states can be used to identify maltreated children. A prospective comparative study in the healthcare setting is required.

Why this is important

Recurrent abdominal pain is a common presentation in primary care and is often unexplained. A large observational study on the association between unexplained recurrent abdominal pain and child maltreatment is needed.