2.1. Child maltreatment
In 2008 there were 29 200 children in England and 2320 in Wales (including 420 and five unborn children, respectively) who were the subject of a child protection plan.2 This translates into rates of 26 per 10 000 children younger than 18 years (excluding unborn children) in England for any type of abuse, 12 per 10 000 for neglect, three for physical abuse, two for sexual abuse, seven for emotional abuse and two for multiple types of abuse. There were 538 500 referrals concerning child maltreatment to social services departments in England3 and 43 411 in Wales4 during the year ending 31 March 2008. These figures represent those seen by children's social care services as ‘at risk’ of maltreatment and are likely to be an underestimation of the true scale of the problem, with surveys of the general public suggesting that around 20% of people have suffered some form of maltreatment as a child. This underestimation is in part due to lack of recognition or reporting by professionals, including healthcare professionals, of suspected child maltreatment.
Social advantage is not necessarily protective of child maltreatment, which also affects children in higher socio-economic groups. There is compelling evidence, including that reported in the National Service Framework (NSF) for England, of the harmful short- and long-term effects of various forms of child maltreatment, affecting all aspects of the child's health, development and wellbeing and which can last into and throughout adulthood. These effects can include anxiety, depression, substance misuse and self-destructive behaviours. In adulthood, there may be difficulties in forming or sustaining close relationships, in sustaining work, and future parenting capacity can be affected. The NSF for England states that: ‘The high cost of abuse and neglect both to individuals (and to society) underpins the duty on all agencies to be proactive in safeguarding children.’ There is some evidence from a number of randomised control trials suggesting that interventions to prevent abuse or recurrence of abuse have some effect on the short- and long-term wellbeing of the child.
It was anticipated that this guidance would support and update the implementation of relevant recommendations from the NSFs for Children, Young People and Maternity Services in England and Wales.
This guidance is predicated on an acceptance of the paramountcy of the needs of children as articulated in the United Nations Convention on the Rights of the Child, specifically Article 19. This guidance applies to all children and young people younger than 18 years.
At the outset, the remit of the guidance was discussed at length with the Department of Health. Following this, workshops were held with key stakeholders and the National Institute for Health and Clinical Excellence (NICE) to discuss the purpose of the guidance, its remit and its main outcomes. Information gathered from these meetings formed the basis of the content of the scope outlined below. It was decided that the guidance provided would integrate published literature with consensus opinion. Formal Delphi consensus methods would be adopted for part of this process.
In this guidance, the definitions of various forms of child maltreatment set out in Working Together to Safeguard Children1 are used, based on the concept of significant harm as the threshold for protective intervention, which was introduced in the Children Act 1989.
In order for effective child protection to occur, all agencies must cooperate and do so at the earliest point possible. This guidance addresses the crucial contribution of healthcare professionals to this endeavour, by setting out the indicators which will alert healthcare professionals to the recognition of possible child maltreatment.
2.2. Aim of the guidance
This guidance provides a summary of clinical features associated with child maltreatment (alerting features) that may be observed when a child presents to healthcare professionals. When used in routine practice, the guidance should prompt all healthcare professionals to think about the possibility of maltreatment. The guidance is not intended to be a definitive assessment tool nor does it define diagnostic criteria or tests. The guidance is about child protection issues rather than the wider context of safeguarding.
2.3. Understanding the obstacles to recognising maltreatment
There are obstacles among healthcare professionals to recognising child maltreatment and to accepting that child maltreatment commonly occurs. Some of these obstacles relate to the healthcare practitioners' professional and personal experiences (including maltreatment) or lack of training. Other obstacles include the following:
concern about missing a treatable disorder
healthcare professionals are used to working with parents and carers in the care of children and fear losing the positive relationship with a family already under their care
discomfort of disbelieving, thinking ill of, suspecting or wrongly blaming a parent or carer
divided duties to adult and child patients and breaching confidentiality
understanding the background and reasons why the maltreatment might have occurred, especially when there is no perceived intention to harm the child
difficulty in saying that a presentation is unclear and there is uncertainty about whether the presentation really indicates significant harm
uncertainty about when to mention suspicion, what to say to parent(s) or carer(s) and what to write in the clinical file
losing control over the child protection process and doubts about its benefits
child protection processes can be stressful for professionals and time-consuming
personal safety
fear of complaints, litigation and dealings with professional bodies
fear of seeking support from colleagues.
2.4. Areas outside the scope of the guidance
The following topics were outside the scope of this guidance and have therefore not been covered:
risk factors for child maltreatment, which are well recognised. Examples include:
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parental or carer drug or alcohol abuse
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parental or carer mental health
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intra-familial violence or history of violent offending
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previous child maltreatment in members of the family
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known maltreatment of animals by the parent or carer
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vulnerable and unsupported parents or carers
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pre-existing disability in the child
protection of the unborn child
children who have died as a result of child maltreatment
*diagnostic assessment and investigations, for example X-rays
treatment and care of the child if maltreatment is suspected
how healthcare professionals should proceed once they have come to suspect maltreatment
healthcare professionals' competency, training and behaviour, including behavioural change and the type of healthcare professional who should think about maltreatment
service organisation
child protection procedures
communication of suspicions to parents, carers or the child
education and information for parents, carers and the child.
2.5. Terms used to describe age groups
Definition: This guidance uses the following terms and definitions to describe children of different ages:
infant (aged under 1 year)
child (aged under 13 years)
young person (aged 13–17 years).
2.6. Definitions of child maltreatment
For the purposes of this document, child maltreatment includes physical abuse, sexual abuse, emotional abuse, neglect, and fabricated or induced illness (FII). The following definitions of child maltreatment are adopted in this document and correspond to those in Working Together to Safeguard Children.1
Physical abuse
Physical abuse 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.
Emotional abuse
Emotional abuse is the persistent emotional maltreatment of a child such as to cause severe and persistent adverse effects on the child's emotional development. It may involve conveying to children that they are worthless or unloved, inadequate, or valued only insofar as they meet the needs of another person. It may feature age- or developmentally inappropriate expectations being imposed on children. These may include interactions that are beyond the child's developmental capability, as well as overprotection and limitation of exploration and learning, or preventing the child participating in normal social interaction. It may involve seeing or hearing the ill-treatment of another. It may involve serious bullying, causing children frequently to feel frightened or in danger, or the exploitation or corruption of children. Some level of emotional abuse is involved in all types of maltreatment of a child, though it may occur alone.
Sexual abuse
Sexual abuse involves forcing or enticing a child or young person to take part in sexual activities, including prostitution, whether or not the child is aware of what is happening. The activities may involve physical contact, including penetrative (for example, rape, buggery or oral sex) or non-penetrative acts. They may include non-contact activities, such as involving children in looking at, or in the production of, sexual online images, watching sexual activities, or encouraging children to behave in sexually inappropriate ways.
Neglect
Neglect is 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 caregivers)
ensure access to appropriate medical care or treatment.
It may also include neglect of, or unresponsiveness to, a child's basic emotional needs.
The supplementary guidance to Working Together to Safeguard Children1 includes:
Department of Health, Home Office (2000) Safeguarding Children Involved in Prostitution
Department of Health, Home Office, Department for Education and Skills, Welsh Assembly Government (2002) Safeguarding Children in whom Illness is Fabricated or Induced
Home Office. Female Circumcision Act 1985, Female Genital Mutilation Act 2003, Home Office Circular 10/2004
Association of Directors of Social Services, Department of Education and Skills, Department of Health, Home Office, Foreign and Commonwealth Office (2004) Young People and Vulnerable Adults Facing Forced Marriage.
2.7. For whom is the guidance intended?
This guidance is of relevance to those who work in or use the National Health Service (NHS) in England and Wales and in the independent health sector, in particular:
GPs, primary care and child health teams
professional groups who are routinely involved in the care of children and families
professionals who may encounter children in the course of their professional duties, for example radiographers, adult mental health professionals, surgeons
those responsible for commissioning and planning healthcare services, including primary care trust commissioners, Health Commission Wales commissioners, and public health and trust managers.
In addition, this guidance may be of interest to professionals working in social services and education/childcare settings.
2.9. Who has developed the guidance?
The guidance was developed by a multi-professional and lay working group (the Guideline Development Group or GDG) convened by the National Collaborating Centre for Women's and Children's Health (NCC-WCH). Membership included:
one child and adolescent psychiatrist
two GPs
two nurses/health visitors
one child psychologist
one accident and emergency consultant
three consultant community paediatricians
one consultant hospital paediatrician
one social worker
four patient/consumer members.
All committee members were recruited because of their expertise in child protection.
Staff from the NCC-WCH provided methodological support for the guidance development process, undertook systematic searches, retrieved and appraised the evidence and wrote successive drafts of the guidance. A clinical adviser with expertise in child protection and the related evidence base was recruited to support the technical team.
All GDG members' interests were recorded on declaration forms provided by NICE. The form covered consultancies, fee-paid work, shareholdings, fellowships and support from the healthcare industry. GDG members' interests are listed in Appendix A. No material conflicts of interest were identified.
2.10. Other relevant documents
This guidance is intended to complement other existing and proposed works of relevance, including related NICE guidance:
Eating Disorders: Core Interventions in the Treatment and Management of Anorexia Nervosa, Bulimia Nervosa and Related Eating Disorders (NICE clinical guideline 9), available from
www.nice.org.uk/Guidance/CG9 Self-harm: The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care (NICE clinical guideline 16), available from
www.nice.org.uk/Guidance/CG16 Constipation in Children: the Diagnosis and Management of Idiopathic Childhood Constipation in Primary and Secondary Care (NICE clinical guideline; publication expected March 2010, details available from
www.nice.org.uk)
Nocturnal Enuresis in Children (Bedwetting): the Management of Bedwetting in Children (NICE clinical guideline; publication expected August 2010, details available from
www.nice.org.uk)
What to do if You're Worried a Child is Being Abused, available from
www.dh.gov.uk Working Together to Safeguard Children, 2006, available from www.everychildmatters.gov.uk/socialcare/safeguarding/workingtogether
Safeguarding Children: Working Together under the Children Act 2004, available from new.wales.gov.uk/topics/childrenyoungpeople/publications/safeguardingunder2004act?lang=en
Safeguarding Children in Whom Illness is Fabricated or Induced, 2008, available from www.everychildmatters.gov.uk/socialcare/safeguarding
Safeguarding Children in Whom Illness is Fabricated or Induced, 2008, available from new.wales.gov.uk/topics/childrenyoungpeople/publications/illnessfabricated/?lang=en
Information Sharing Pocket Guide, available from www.everychildmatters.gov.uk/_files/983B14537FB904C95CA470DAB6928F19.pdf
Fabricated and Induced Illness by Carers, available from www.rcpch.ac.uk/Policy/Child-Protection/Child-Protection-Publications
Child Protection Companion, available from www.rcpch.ac.uk/Policy/Child-Protection/Child-Protection-Publications
Standards for Radiological Investigations of Suspected Non-accidental Injury, available from www.rcpch.ac.uk/Policy/Child-Protection/Child-Protection-Publications
The Physical Signs of Child Sexual Abuse, 2008, available to order from www.rcpch.ac.uk/Research/Research-Activity/Completed-Projects/CSA-Handbook.
2.11. Guideline development methodology
This guidance was commissioned by NICE and developed in accordance with the guideline development process outlined in the NICE Guidelines Manual.5 The general approach is outlined below. Where deviations to this approach occurred, this is addressed in the relevant section.
In accordance with NICE's Equality Scheme, ethnic and cultural considerations and factors relating to disabilities have been considered by the GDG throughout the development process and specifically addressed in individual recommendations where relevant. Further information is available from: www.nice.org.uk/aboutnice/howwework/NICEEqualityScheme.jsp.
Forming clinical questions
The GDG identified a list of features that were thought to be signs or symptoms of maltreatment. The list was refined based on relevance to the healthcare setting (see Appendix B). The standard clinical question was ‘when is feature X a reason to suspect child maltreatment?’ It should be noted that clinical features that do not appear in this guidance may be indicators of maltreatment nonetheless.
Literature search strategy
Initial scoping searches were executed to identify relevant guidelines (local, national and international) produced by other development groups. The RCPCH document The Physical Signs of Child Sexual Abuse,6 the Health Technology Assessment (HTA) ‘Performance of screening tests for child physical abuse in accident and emergency departments’7 and systematic reviews by the Welsh Child Protection Systematic Review Group were referred to, with permission.
Relevant published evidence to inform the guideline development process and answer the clinical questions was identified by systematic search strategies, unless recent high-quality systematic reviews had been identified. Additionally, stakeholder organisations were invited to submit evidence for consideration by the GDG provided it was relevant to the clinical questions and of equivalent or better quality than evidence identified by the search strategies.
Systematic searches to answer the clinical questions formulated and agreed by the GDG were executed using the following databases via the OVID platform: Medline (1950 onwards), Embase (1980 onwards), Cumulative Index to Nursing and Allied Health Literature (1982 onwards), PsycINFO (1967 onwards), Cochrane Central Register of Controlled Trials (3rd Quarter 2007), Cochrane Database of Systematic Reviews (3rd Quarter 2007), and Database of Abstracts of Reviews of Effects (3rd Quarter 2007).
Search strategies combined relevant controlled vocabulary and natural language in an effort to balance sensitivity and specificity. Unless advised by the GDG, searches were not date-specific. Language restrictions were applied to searches and searches were limited to English language results. Both generic and specially developed methodological search filters were used appropriately.
There was no systematic attempt to search grey literature (conferences, abstracts, theses and unpublished trials). Hand searching of journals not indexed on the databases was not undertaken.
At the end of the guideline development process, searches were updated and re-executed, thereby including evidence published and included in the databases up to 5 September 2008. Any literature published after this date was not included. This date should be considered the starting point for searching for new literature for future updates to this guidance.
Further details of the search strategies, including the methodological filters employed, are provided in separate files on the NICE website.
Synthesis of clinical evidence
Clinical evidence was reviewed using established guides8–11 and classified using the established hierarchical system shown in .11 This system reflects the susceptibility to bias that is inherent in particular study designs.
Levels of evidence for intervention studies.
The type of clinical question dictates the highest level of evidence that may be sought. In assessing the quality of the evidence, each study receives a quality rating coded as ‘++’, ‘+’ or ‘−’. For issues of therapy or treatment, the highest possible evidence level (EL) is a well-conducted systematic review or meta-analysis of randomised controlled trials (RCTs; EL = 1++) or an individual RCT (EL = 1+). As therapeutic interventions were not part of the scope, no randomised controlled trials were reviewed. Studies of poor quality are rated as ‘−’. Usually, studies rated as ‘−’ should not be used as a basis for making a recommendation, but they can be used to inform recommendations.
For each clinical question, the highest available level of evidence was selected. Where appropriate, for example if a systematic review or meta-analysis existed in relation to a question, studies of a weaker design were not included. Where systematic reviews or meta-analyses did not exist, comparative studies and large case series (comprising data on more than 50 children) were sought.
Evidence was synthesised qualitatively by summarising the content of identified papers in evidence tables and agreeing brief statements that accurately reflected the evidence.
Summary results and data are presented in the text. More detailed results and data are presented in the evidence tables provided on the NICE website. Where possible, dichotomous outcomes are presented as relative risks (RRs) with 95% confidence intervals (CIs), and continuous outcomes are presented as mean differences with 95% CIs or standard deviations (SDs).
Delphi consensus
A two-round modified Delphi consensus process12,13 was used to derive recommendations in some areas (see Appendix C). These areas were defined by:
there being a lack of relevant literature on a clinical feature's importance in child maltreatment, or
the GDG being unable to reach a congruent opinion, or
the GDG requiring external validation from a wider group of experts (the Delphi panel) for their opinion.
There were some areas where the evidence base was sparse but the GDG was able to reach internal consensus.
The Delphi panel comprised child protection experts (clinicians with significant experience in child protection). There were 95 respondents to Round 1 of the survey and their affiliations are as follows (see Appendix C for information on the recruitment processes):
30 paediatricians (including 13 named/designated doctors for child protection/safeguarding children)
15 nurses (including 14 named/designated nurses for child protection/safeguarding children)
three GPs (one child protection adviser for GPs)
one genito-urinary medicine physician
seven health visitors
four dentists (including one named dentist from a safeguarding children board)
three psychotherapists
three forensic physicians
11 psychiatrists
13 psychologists (including two clinical leads for Child and Adolescent Mental Health Services (CAMHS))
one gastroenterologist
one social services representative
two academics
one other.
Participants were asked to rate their level of agreement with and comment on a series of statements via an online survey. Agreement was measured using a Likert-like scale taking values between 1 and 9 where 1 represented ‘strongly disagree’ and 9 represented ‘strongly agree’. Consensus was said to have been reached if more than 75% of respondents answered 7, 8 or 9. Statements which did not meet the threshold for agreement in the first round were either excluded or modified according to the comments and sent out for a second round. After the second round, the GDG reviewed the responses using the same threshold for agreement. The GDG accepted statements that met the threshold. The GDG was allowed to amend statements in the light of the Delphi panel's comments after the second validation phase.
Forming recommendations
For each clinical question, recommendations were derived using, and explicitly linked to, the evidence that supported them. In the first instance, informal consensus methods were used by the GDG to agree evidence statements and recommendations. Additionally, in some areas formal consensus methods were used to identify current best practice as described above. A number of recommendations that underpin the suspicion of child maltreatment were formed through GDG consensus. These are based on principles of good clinical practice and form the basis upon which the clinical features section of the guidance rests. Shortly before the consultation period, the GDG members independently assessed all recommendations and group consensus was sought. The agreed draft recommendations were sent to two user reviewers for comment before the consultation phase.
The GDG also identified some areas where information that corresponded to the remit of this guidance was lacking and formulated recommendations for future research. From these recommendations, five key priorities for research were identified based on clinical need.
External review
This guidance has been developed in accordance with the NICE guideline development process. This has included giving registered stakeholder organisations the opportunity to comment on the scope of the guidance at the initial stage of development and on the evidence and recommendations at the concluding stage. The developers have carefully considered all of the comments during the consultations by registered stakeholders and the validation by NICE.
Health economics
NICE clinical guidelines ordinarily have economic input to inform the GDG of potential economic issues and to help ensure that recommendations represent a cost-effective use of healthcare resources.
However, for this guidance, it was decided that such an approach is not appropriate. Economic evaluation involves a comparison of two or more alternatives in terms of their costs and benefits. As such, it is a tool to aid decision-making in selecting between these different alternatives. This guidance does not explicitly address clinical decision-making between different courses of action on economic grounds but rather seeks to promote awareness of features that could indicate child maltreatment. Therefore, without any economic decision-making component to recommendations, it was felt that health economics was not relevant to this guidance.
2.12. Schedule for updating the guidance
Clinical guidelines commissioned by NICE are published with a review date 4 years from date of publication. Reviewing may begin earlier than 4 years if significant evidence that affects guideline recommendations is identified sooner. The updated guidance will be available within 2 years of the start of the review process.
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It should be noted that there are special procedures that should be followed when a child dies unexpectedly.
