Safeguarding children

Safeguarding children: definitions⁴

Note: in this article, the word 'carers' refers to parents and/or others caring for a child. A 'child' refers to someone who has not reached their 18th birthday.

'Child abuse' and 'child maltreatment' are used interchangeably although some experts in the field consider that child maltreatment has a wider implication, encompassing all forms of inappropriate care or lack of care. In this article, the term 'child abuse' is used.

Categories of child abuse

Four categories of child abuse are generally recognised - a child may suffer more than one type at a time:

• Physical abuse: involves physical harm such as hitting, shaking, burning, throwing, poisoning or causing suffocation. Includes fabricated or induced illness by carers (factitious illness by proxy - formerly referred to as Münchhausen's syndrome by proxy). Female genital mutilation (FGM) is a type of child abuse and is illegal in the UK.

• Emotional abuse: persistent emotional ill-treatment or neglect causing adverse effects on the child's emotional development. For example: making the child feel worthless or unloved, unrealistic expectations, preventing normal social activity, serious bullying, seeing the ill-treatment of another person, making a child often frightened, exploitation or corruption.

• Sexual abuse: forcing or enticing a child into sexual activity (this includes both penetrative and non-penetrative acts). It also includes 'non-contact' activities - eg, involvement in pornography, the child looking at sexual activities or pornographic material, or encouraging inappropriate sexual behaviour in a child.

• Neglect: the persistent failure to meet a child's basic physical or psychological needs, in a way likely to impair the child's health or development seriously. For example: not providing food or shelter, inadequate protection from danger or supervision, not enabling adequate medical care, emotional neglect.

Emotional abuse and neglect in particular may reflect the carer's own health or social needs.

Concepts of safeguarding

National Institute for Health and Care Excellence (NICE) guidance suggests the concepts of 'alerting features', which should induce one to 'consider' or 'suspect' child maltreatment:

• 'Alerting features' are symptoms, signs and patterns of injury or behaviour, which may indicate child abuse.

• 'Consider' means that abuse is one possible explanation for an alerting feature (but there are other differential diagnoses).

• 'Suspect' means there is a serious level of concern about abuse but it is not proof. It may trigger a child protection investigation. This may lead to child protection procedures, to offering the family more support; or it may lead to alternative explanations being found.

• 'Exclude' maltreatment when an alternative explanation is found.

NICE guidance encourages thorough documentation of all actions taken in the process of investigating concerns. GMC guidance reassures us that: "Taking action will be justified, even if it turns out that the child or young person is not at risk of, or suffering, abuse or neglect, as long as the concerns are honestly held and reasonable, and the doctor takes action through appropriate channels. Doctors who make decisions based on the principles in the GMC guidance will be able to justify their decisions and actions if we receive a complaint about their practice⁵ ."

Epidemiology¹

Exact figures of abuse are not known but a 2018 report by the National Society for the Prevention of Cruelty to Children (NSPCC) shows in the year 2017-2018 in the UK:

• There were 98 child homicides.

• 58 children died as a consequence of assault or undetermined intent.

• There were 52,339 sexual offences committed against children that were recorded by police. These included rape, sexual assault, grooming and offences relating to indecent images of children.

• There were 15,204 recorded cases of cruelty or neglect.

• Childline referred 4,604 children to external agencies.

• The NSPCC calculated from self-reporting sources that:

  • One in twenty children have been sexually abused.

  • Nearly one in five children have experienced high levels of abuse or neglect.

It is thought that a large proportion of children who are being maltreated are not known to child protection services. The NSPCC has estimated that for every child on a child protection plan there are another eight who are being maltreated.

Government statistics show that in 2018-19 in England there were 650,900 referrals, a decrease of 1% from the previous year which reversed the upward trend seen between 2016 and 2018. The number of re-referrals continued to increase however and is at the highest level since 2015. There were 147,200 re-referrals in 2018-19, an increase of 2% from 2017-18, and represented 23% of all referrals in 2018-19⁶ .

Child abuse risk factors ¹

• Previous history of child maltreatment in the family (health visitors and social workers may have useful information).

• Domestic violence. Also domestic/marital conflict, and history of violent offending in the family.

• Mental health disorders, learning disability, physical illness or disability in the carers.

• Drug or alcohol misuse in the carers - especially if unstable or chaotic drug misuse.

• Housing or financial problems.

• Disability or long-term chronic illness in the child.

• Single parents, especially if immature or unsupported.

• History of animal/pet maltreatment.

• Children in the care system.

• Some children are vulnerable to being 'lost' by the system - for example, where the families are homeless or asylum seekers, or where children are carers or young offenders.

Safeguarding assessment

General principles⁴

If you encounter a feature which alerts you to possible child abuse, follow these steps:

• Listen and observe: take into account the history, symptoms and signs, any other information or disclosure from third parties, the child's appearance, behaviour and interaction of the child and carers.

• Seek an explanation: enquire in an open and non-judgemental way, as to the explanation for injuries or other features. An unsuitable explanation is:
  

  • Inconsistent with child's age, development, medical condition, history of the injury.

  • Inconsistent between carers, differs from child's account or changes over time.

  • Cultural practices are not an acceptable excuse for hurting a child.

• Record: what is said and observed, by whom, and why you are concerned.

• If at this point you are considering or suspecting child abuse: think about your level of concern and whether there is immediate danger to the child. Then discuss with colleagues, refer and/or seek more information. See the separate Safeguarding Children (Referral and Management of an Abused or At-risk Child) article. If child maltreatment cannot be excluded, ensure the child is reviewed.

History

• Listen; use open and non-judgemental questions ("What happened?") rather than leading questions ("Were you hit?").

• Where possible, have separate communication with the child, in a way which helps develop trust. Consider taking a history directly from the child, if it is in their best interests. If necessary, this may be done without the carer's consent - but document your reasons.

• Listen to the child. Ask yourself "What is a day like in the life of this child?⁷ "

• If using interpreters, you may need one from outside the family.

• NB: the child may show no outward signs of abuse and hide what is happening.

Examination

• Document all findings. Record signs on a body map - examples are available^{8 9} .

• Consent should be obtained for a physical examination which is specifically for the purpose of child protection. Consent may be given by the child if competent, by a person with parental responsibility, or by the court. However, in an emergency, it may be in the child's best interest to have this examination without explicit consent. If so, document the reasons.

• Assess the whole child and all the injuries present.

Recognising child maltreatment: general safeguarding principles

Child maltreatment may come to the attention of doctors in any of the following ways :

• Communication from other agencies/departments - eg, police notifications, social services, A&E departments, drug and alcohol services, mental health services.

• Findings on history or examination during a consultation, including patterns of injuries or unsuitable explanations.

• Disclosure by child or carer.

• Behaviour towards practice staff.

• Observation of interaction in waiting room or consultation room.

• Presence of risk factors.

The following indicators should prompt an awareness of the possibility of child maltreatment:

• Frequent attendance or unusual patterns of attendance to healthcare services, including frequent injury.

• Change to the child's behaviour or emotional state. Examples which may be indicative of maltreatment are listed in the emotional abuse section below.

• Injury with features of maltreatment (see 'Physical abuse' section below for specifics).

• Evidence of sexual activity.

• Harmful interactions between child and carer.

• Appearance of neglect.

• Failure to access medical care appropriately (including non-attendance for routine immunisations, delay in presentation).

• Unsuitable explanations. Explanations which are inconsistent over time or between people, or which are not consistent with the presenting features.

Neglect - symptoms and signs^{4 1}

Failure of provision to supply basic needs

Consider neglect if:

• There are frequent and/or severe infestations: scabies or head lice.

• The child regularly has inappropriate clothing or footwear.

• There is evidence of failure to thrive.

Suspect neglect if:

• The child is persistently smelly or dirty.

• There are reports of home hygiene which is poor enough to affect health, inadequate provision of food, an unsafe living environment.

• There is evidence of child abandonment.

Failure to provide adequate supervision

• Consider neglect if injuries are suggestive of inadequate supervision (eg, sunburn, ingestion of harmful substance, near drowning, animal bite).

• Consider neglect if there is evidence that the child is being cared for by a person who is not able to provide adequate care.

Failure to provide access to appropriate medical care or education

Consider neglect if:

• Parents or carers do not administer prescribed medication.

• There is repeated failure to attend appointments.

• There is persistent failure to engage with immunisations, regular development reviews or screening.

• There is failure to seek treatment for dental caries.

Suspect neglect if:

• There is failure to seek medical care to the extent that the child's health or well-being is compromised.

• Unjustified poor attendance at school.

Physical abuse - symptoms and signs⁴

The following should prompt you to suspect physical abuse (to suspect rather than consider unless specified):

Bruises

• Bruising in the shape of an object - fingertips, hand, ligature, stick, teeth mark or implement such as belt buckle.

• Any bruising on a non-mobile baby (especially facial bruising).

• Bruising or petechiae in the absence of a medical condition which do not have a suitable explanation:

  • Multiple bruises.

  • Bruises of similar size and shape

  • Bruises at sites where accidental bruising is unusual: face, eyes, ears (bruising around the pinna may be subtle), the 'safe triangle' of the neck (the neck and top of the shoulder), inner arms, buttocks, abdomen, groins.

  • Bruising suggestive of strangulation on the neck.

  • Bruising on a child who is not independently mobile, due to age or disability.

Bites

• Human bites (other than those thought to be caused by another young child).

• Animal bites (consider neglect).

Lacerations, abrasions and scars

As for bruises, suspect physical abuse where a child has lacerations, abrasions or scars and the explanation is unsuitable. For example:

• On a baby or child who is not independently mobile.

• Multiple lesions.

• Symmetrical lesions.

• On areas usually covered by clothing.

• On the eyes, ears or side of the face.

• Lesions which look like ligature marks on wrists, ankles or neck.

Burns and scalds (thermal injuries)

• Where the explanation is not consistent with the injury.

• If the child is not independently mobile.

• On areas of skin which would not be expected to come into contact with the hot object.

• Where the affected area is shaped like a recognisable object (iron, cigarette end).

• Pattern suggestive of forced immersion in boiling water.

• Consider neglect (lack of supervision) where the history does fit with the injury.

Cold injuries

Consider maltreatment where a child presents with hypothermia (and no explanation) or cold swollen hands or feet.

Fractures

In the absence of a medical condition such as osteogenesis imperfecta, suspect child maltreatment if a child presents with one or more fractures.

Particular suspicion should arise if:

• There are fractures of different ages.

• The explanation is not consistent with the injury.

• There are occult fractures on X-ray.

• The child is not independently mobile.

Intracranial injuries

In the absence of major accidental trauma, suspect child maltreatment if:

• There is an inconsistent explanation.

• The child is less than 3 years old.

• There are associated retinal haemorrhages, rib or limb fractures, or other associated injuries.

• There are multiple subdural haemorrhages.

Eye injuries

Suspect maltreatment if there are retinal haemorrhages or eye injuries in the absence of major accidental trauma or medical cause.

Spinal injuries

Suspect maltreatment in any spinal injury in the absence of confirmed major accidental trauma.

Other injuries

• Suspect maltreatment in any visceral injury in the absence of confirmed major accidental trauma.

• Consider maltreatment in any oral injury without adequate explanation.

• Consider maltreatment in any unusual or serious injury.

• Consider maltreatment where there has been a delay in presentation.

Fabricated or induced illness

There may be:

• Symptoms or signs occur only in the presence of one person.

• Multiple specialists or opinions sought or involved.

• Inexplicably poor response to treatment.

• Unlikely history of events.

• Discrepancy in the clinical picture.

• Reporting of new symptoms as soon as previous ones resolve.

• Compromise of normal daily activities of the child.

Female genital mutilation (FGM)

From 31st October 2015, health professionals have a statutory duty to report cases of FGM in girls under the age of 18 to the police. FGM is illegal in the UK and considered child abuse¹⁰ .

Emotional abuse - symptoms and signs^{4 1}

Behaviour of the child

Consider emotional abuse if:

• There are reported changes in behaviour or emotional state without other cause, such as:

  • Recurring nightmares with similar themes.

  • Extreme distress.

  • Withdrawal of communication.

  • Becoming withdrawn.

  • Aggressive behaviour.

• Behaviour or emotional state is not consistent with age and which has no other cause such as medical condition:

  • Being fearful, withdrawn or having low self-esteem.

  • Aggressive behaviour.

  • Body rocking.

  • Affection-seeking behaviour or attention-seeking behaviour.

  • Over-friendliness to professionals and strangers.

  • Excessive clinginess.

  • Inappropriate interpersonal interactions with carer.

  • Over-obedience.

• There are extreme or inappropriate emotional responses not due to age or medical conditions:

  • Temper tantrums in school-aged children.

  • Frequent rages with little provocation.

  • Inconsolable crying.

• The child shows dissociative behaviour.

• The child has responsibilities which interfere with normal daily activity.

• The child responds to medical examination in an unusual or inappropriate way.

• There is self-harming behaviour.

• There is inappropriate bedwetting or soiling (secondary or deliberate).

• The child has run away.

• There is disturbance in eating behaviour. (Suspect maltreatment if a child repeatedly hoards, scavenges, hides or steals food.)

• There is delayed development (physical, mental or emotional; speech disorders).

Behaviour of the parent or carer

Consider emotional abuse when there is:

• Reporting of bedwetting (or punishment for bedwetting) despite being told by professionals that this is involuntary.

• Rejecting or scapegoating of a child or young person.

• Inappropriate expectations.

• Inappropriate threats or disciplining.

• Using the child to fulfil an adult's needs.

• Refusal to allow a child to speak to a health professional on their own.

• Unresponsiveness towards a child.

• Negativity or hostility towards a child.

• Exposure of a child to frightening events such as domestic abuse.

• Failure to promote appropriate socialisation of a child.

Suspect emotional abuse when there is persistent evidence of the behaviours listed above.

Sexual abuse - symptoms and signs^{4 1}

Consider sexual abuse if:

• There are genital or anal symptoms (bleeding or discharge) or recurrent dysuria without a suitable explanation or medical cause.

• There are foreign bodies in the vagina or anus.

• A gaping anus is observed during an examination (without a medical explanation - eg, a neurological disorder or severe constipation).

• Hepatitis B or anogenital warts occur in a child aged less than 13 (unless there is clear evidence of transmission during birth or blood transmission, or non-sexual transmission).

• Hepatitis B or anogenital warts occur in a child aged 13-15 (other than in the circumstances above or where acquired from consensual sex with a peer).

• A child aged 13-15 is pregnant.

• Sexually transmitted infection (STI) or pregnancy occurs in a young person aged 16-17 if any evidence that sex was non-consensual or that the young person was being exploited, or that there is a clear difference in power/mental capacity between the two people.

• There are behaviours such as self-harm, running away or secondary bedwetting.

Suspect sexual abuse if:

• A child presents with a genital, anal or perianal injury in the absence of a suitable explanation.

• There are persistent or recurrent genital or anal symptoms (bleeding or discharge) associated with behavioural or emotional change.

• A child presents with an anal fissure (unless there is a medical reason such as constipation or Crohn's disease).

• A child aged less than 13 years is pregnant.

• A child aged less than 13 years presents with an STI (other than proven vertical transmission during pregnancy or birth, or blood contamination).

• A child aged 13-15 years presents with an STI other than where the circumstances above are proven, or where there has been consensual sex with a peer.

• There is evidence of sexualised behaviour in a prepubertal child.

Other notes:

• Examination of the genitalia should only be performed by an expert. See the separate Safeguarding Children (Referral and Management of an Abused or At-risk Child) article.

• Sexual activity with a child aged <13 years, by law is sexual abuse; the child's 'consent' is irrelevant at this age.

Differential diagnosis

• Medical causes of failure to thrive.

• Other causes of falls and accidental fractures - eg, epilepsy.

• Conditions causing increased bruising - eg, thrombocytopenia, leukaemia.

• Mongolian blue spot (a congenital mark), which can resemble a bruise.

• Medical conditions predisposing to fractures - eg, osteogenesis imperfecta, metabolic bone disease in neonates, rickets, copper deficiency, osteomyelitis, leukaemia and disseminated neuroblastoma.

• Glutaric acidaemia, which may be a rare cause of subdural haematoma.

Investigations¹¹

Depending on the presentation, investigations may be required. Investigations which may be of relevance include:

• Blood tests: FBC, clotting screen.

• Skeletal survey or bone scan: where physical abuse is suspected in children aged <2 years, a skeletal survey or radionuclide bone scan is indicated. This may also be needed in some older children.

• Brain imaging:

  • This is needed if head injury is suspected clinically. Also, infants aged <1 year with any physical abuse injuries should have neuro-imaging for possible non-accidental brain injury. A child with abusive injuries and any signs or symptoms of brain injury should have neuro-imaging performed.

• Retinal examination: if there is head injury, also arrange a retinal examination by an ophthalmologist and a skeletal survey with oblique views of the ribs.

• Spinal imaging:

  • A full skeletal survey (if indicated, as above) must include plain X-rays of the spine, including lateral views.

  • If any fracture is seen or spinal cord injury is suspected, do an MRI scan of the spine.

  • Consider the possibility of co-existing spinal injury in children with non-accidental brain injury - in such cases, arrange MRI scan of the spine if there are concerns about co-existing spinal injury.

• Sexual health tests: If sexual abuse is suspected, the child may need screening for STIs, carried out by an appropriately trained clinician. See the separate Safeguarding Children (Referral and Management of an Abused or At-risk Child) article.

• Forensic dentistry: forensic dentists can interpret bite marks, differentiating animal from human ones, and sometimes identifying the abuser.

• Other specific investigations may be required to exclude the various differential diagnoses (above).

Management

See the separate Safeguarding Children (Referral and Management of an Abused or At-risk Child) article. The child's welfare is paramount.

Sources of help in child protection

Prognosis and complications⁴

• Without appropriate intervention, child abuse can be a recurrent or escalating problem. It may be fatal.

• A child's health, well-being and development can be adversely affected.

• The physical, emotional and social effects of abuse can be lifelong.

• Adverse effects extending into adulthood include:

  • Anxiety and depression.

  • Post-traumatic stress disorder.

  • Substance misuse.

  • Self-destructive, aggressive or antisocial behaviour.

  • Poor parenting.

  • Relationship difficulties.

  • Difficulties in employment.

  • Disability or physical scarring.

  • Effects of STIs, including HIV.

  • Association with an increased risk of involvement in crime.

Prevention

• Early identification and support of vulnerable children and families. Providing targeted early help.

• Share information between agencies - eg, incidents of domestic violence are notified to the GP and health visitor.

• Education and training of all professionals.

• When a parent or carer is ill, find out how the family and children are affected; enlist extra support if needed.

• For children with additional needs, the Early Assessment Framework (EAF) is now used (in England) to assess the child's needs.