Disability

Alerting features of maltreatment in children with disabilities may also be features of the disability, making identification of maltreatment more difficult.

Healthcare professionals may need to seek appropriate expertise if they are concerned about a child or young person with a disability.

Consider

At any stage during the process of considering maltreatment the level of concern may change and lead to exclude or suspect maltreatment.

When hearing about or observing an alerting feature in the guidance:

look for other alerting features of maltreatment in the child or young person's history, presentation or parent- or carer-interaction with the child or young person now or in the past.

Then do one or more of the following:

• Discuss your concerns with a more experienced colleague, a community paediatrician, child and adolescent mental health service colleague, or a named or designated professional for safeguarding children.
• Gather collateral information from other agencies and health disciplines, having used professional judgement about whether to explain the need to gather this information for an overall assessment of the child.
• Ensure review of the child or young person at a date appropriate to the concern, looking out for repeated presentations of this or any other alerting features.

Suspect

If an alerting feature or considering child maltreatment prompts a healthcare professional to suspect child maltreatment they should refer the child or young person to children's social care, following Local Safeguarding Children Board procedures.

This may trigger a child protection investigation, supportive services may be offered to the family following an assessment or alternative explanations may be identified.

Exclude

Exclude maltreatment when a suitable explanation is found for alerting features. This may be the decision following discussion of the case with a more experienced colleague or after gathering collateral information as part of considering child maltreatment.

Bruises

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

Suspect^c 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.^c 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

Suspect^c 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.

Consider^c 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

Suspect^c child maltreatment if a child has lacerations, abrasions or scars and the explanation is unsuitable.^c 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

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

• if the explanation for the injury is absent or unsuitable^c 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

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

Consider^c child maltreatment if a child presents with hypothermia and the explanation is unsuitable.^c

Fractures

Suspect^c 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.^c 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

Suspect^c 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^c
• 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

Suspect^c 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

Suspect^c 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

Suspect^c 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,^c or a delay in presentation. There may be no external bruising or other injury.

Oral injury

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

General injuries

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

Anogenital symptoms and signs

Suspect^c 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.^c

Suspect^c 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.

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

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

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

Consider^c sexual abuse if a girl or boy has dysuria (discomfort on passing urine) or anogenital 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).

Consider^c 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

Consider^c 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.

Consider^c 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.

Suspect^c 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.

Consider^c 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.

Consider^c 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.

Consider^c 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.^d

Consider^c 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.

Consider^c 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.

Consider^c 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.

Provision within the home

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

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

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) would not be alerting features for possible neglect.

Suspect^c neglect if a child is persistently smelly and dirty.

Children often become dirty and smelly during the course of the day. However, the nature of the child's smell may be so overwhelming that the possibility of persistent lack of provision or care should be taken into account. 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.

Suspect^c neglect if you repeatedly observe or hear reports of the following home environment 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.

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.

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

Malnutrition

Consider^c neglect if a child displays faltering growth (failure to thrive) because of lack of provision of an adequate or appropriate diet.

Self-harm

Consider^c past or current child maltreatment, particularly sexual, physical or emotional abuse, if a child or young person is deliberately self-harming. Self-harm includes cutting, scratching, picking, biting or tearing skin to cause injury, pulling out hair or eyelashes and deliberately taking prescribed or non-prescribed drugs at higher than therapeutic doses.

Disturbances in eating and feeding behaviour

Suspect^c child maltreatment if a child repeatedly scavenges, steals, hoards or hides food with no medical explanation.

Wetting and soiling

Consider^c child maltreatment if a child has secondary day- or night-time wetting that persists despite adequate assessment and management unless there is a medical explanation (for example, urinary tract infection) or clearly identified stressful situation that is not part of maltreatment (for example, bereavement, parental separation).

Consider^c child maltreatment if a child is reported to be deliberately wetting.

Consider^c child maltreatment if a child shows encopresis (repeatedly defecating a normal stool in an inappropriate place) or repeated, deliberate smearing of faeces.

Sexualised behaviour

Suspect^c child maltreatment, and in particular sexual abuse, if a prepubertal child displays or is reported to display repeated or coercive sexualised behaviours or preoccupation (for example, sexual talk associated with knowledge, drawing genitalia, emulating sexual activity with another child).

Suspect^c past or current child maltreatment if a child or young person's sexual behaviour is indiscriminate, precocious or coercive.

Suspect^c sexual abuse if a prepubertal child displays or is reported to display unusual sexualised behaviours. Examples include:

• oral–genital contact with another child or a doll
• requesting to be touched in the genital area
• inserting or attempting to insert an object, finger or penis into another child's vagina or anus.

Runaway behaviour

Consider^c child maltreatment if a child or young person has run away from home or care, or is living in alternative accommodation without the full agreement of their parents or carers.

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.

Why this is important

A well-conducted prospective study is needed in this area to address problems of reporting bias in the existing literature, particularly in relation to non-abused children.