1. When to suspect child maltreatment Implementing NICE guidance Workshop on implementing NICE guidance in an Accident and Emergency settings 2009 NICE clinical guideline 89

2. Pre-workshop test What is the definition of child maltreatment? What does it mean to consider child maltreatment? What does it mean to suspect child maltreatment? What is the five-step best practice process for considering, suspecting or excluding child maltreatment? What should you do if you are considering child maltreatment? What should you do if you suspect child maltreatment? Give three examples of potential alerting features which might cause you to consider child maltreatment? Give three examples of potential alerting features which might cause you to suspect child maltreatment?

3. Workshop structure Scope Definitions How to use this guidance and case studies Alerting features: case studies Sharing information and obstacles Action planning Find out more

4. Scope This guidance provides a summary of the alerting features associated with child maltreatment. Its purpose is: to raise awareness to help healthcare professionals to identify children who may be being maltreated. It does not give recommendations on how to diagnose, confirm or disprove child maltreatment.

5. Child maltreatment includes neglect, physical, sexual and emotional abuse, and fabricated or induced illness. To consider child maltreatment means maltreatment is one possible explanation for the alerting feature or is included in the differential diagnosis. To suspect child maltreatment means a serious level of concern about the possibility of child maltreatment but is not proof of it. Definitions

6. It is good practice to follow this process to consider, suspect or exclude child maltreatment: How to use this guidance

7. Take into account the whole picture of the child or young person. Sources of information include: history report of maltreatment, or disclosure child’s appearance, demeanour or behaviour symptom physical sign result of an investigation interaction between parent or carer and the child or young person. Listen and observe

8. Seek an explanation in an open and non-judgemental manner. Seek appropriate expertise if you are concerned about a child or young person with a disability. Seek an explanation

9. 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, or account compared with that given by parent and carers between parents or carers or between accounts over time. Cultural practice is an unsuitable explanation for hurting a child or young person. An unsuitable explanation

10. 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. Record

11. When hearing about or observing an alerting feature, look for other alerting features of maltreatment, then do one or more of the following: Discuss with a relevant child health specialist or designated professional for safeguarding children. Gather collateral information. Ensure review at a date appropriate to the concern. Look out for repeated presentations of this or any other alerting features. At any stage during the process of considering maltreatment the level of concern may change and lead to exclude or suspect maltreatment. Consider maltreatment

12. If an alerting feature or consideration prompts you to suspect child maltreatment refer to children’s social care. This may trigger a child protection investigation. Supportive services may be offered to the family following an assessment or alternative explanations may be identified. Suspect maltreatment

13. Exclude maltreatment when a suitable explanation is found for alerting features. Exclude maltreatment

14. Record all actions taken in previous stages and the outcome. Record

15. Best practice – case studies Break into groups (15 minutes) Child x presents with y – what do you do? Feedback at end (5 minutes)

16. Alerting features The following forms of alerting features that may lead you to consider or suspect child maltreatment are covered: Physical features Sexual abuse Neglect Emotional, behavioural, interpersonal and social functioning Clinical presentations Fabricated or induced illness Parent– or carer–child interactions

17. Physical features For further alerting features and detail refer to NICE guideline or quick reference guide Consider: Any serious or unusual injury with an absent or unsuitable explanation.

18. Bruises Suspect: Bruising in the shape of a hand, ligature, stick, teeth mark, grip or implement. Bruising or petechiae not caused by a medical condition, with an unsuitable explanation: –in a child who is not independently mobile –that are multiple, in clusters, of similar shape and size –on non-bony parts of the face or body, including the eyes, ears and buttocks –on the neck that look like attempted strangulation –on the ankles and wrists that look like ligature marks.

19. Bites  Consider: Animal bite on an inadequately supervised child. Suspect: Human bite mark thought unlikely to have been caused by a young child.

20. Lacerations, abrasions or scars Suspect lacerations, abrasions or scars, if there is an unsuitable explanation, including those: on a child who is not independently mobile that are multiple or have a symmetrical distribution on areas usually protected by clothing, or the eyes, ears and sides of face on the neck, ankles and wrists that look like ligature marks.

21. Thermal injuries Suspect burn or scald injuries: if there is an absent or unsuitable explanation the child is not independently mobile on soft tissue areas not expected to come into contact with a hot object (for example, backs of hands, soles of feet, buttocks, back) in the shape of an implement (for example, cigarette or iron) that indicate forced immersion (for example, scalds to buttocks, perineum and lower limbs, to limbs in a glove, stocking or symmetrical distribution or with sharply delineated borders).

22. Cold injuries Consider: If a child has cold injuries (for example, swollen, red hands or feet) with no obvious medical explanation. If a child presents with hypothermia, with an unsuitable explanation.

23. Fractures Suspect fractures if: there is no medical condition that predisposes to fragile bones or the explanation is absent or unsuitable, including: –fractures of different ages –X-ray evidence of occult fractures (for example, rib fractures in infants).

24. Intracranial injuries Suspect intracranial injury if there is no major confirmed accidental trauma or known medical cause in one or more of the following circumstances: the explanation is absent or unsuitable the child is aged under 3 years there are also other inflicted injuries, retinal haemorrhages, or rib or long bone fractures there are multiple subdural haemorrhages with or without subarachnoid haemorrhage with or without hypoxic ischaemic damage to the brain.

25. Other physical features Suspect, if there is no major confirmed accidental trauma or medical explanation: retinal haemorrhages or injury to the eye in a child signs of spinal injury in a child intra-abdominal or intrathoracic injury in a child with an absent or unsuitable explanation, or with a delay in presentation. There may be no external bruising or other injury.

26. Sexual abuse For further alerting features and detail refer to NICE guideline or quick reference guide Suspect: Persistent or recurrent genital or anal symptom in a girl or boy, without a medical explanation, that is associated with behavioural or emotional change. If a girl or boy has a genital, anal or perianal injury and the explanation is absent or unsuitable.

27. Neglect For further alerting features and detail refer to NICE guideline or quick reference guide Consider: Parents or carers who repeatedly fail to attend essential follow-up appointments that are necessary for the health and wellbeing of their child. Suspect: The child is persistently smelly and dirty.

28. Emotional, behavioural, interpersonal and social functioning For further alerting features and detail refer to NICE guideline or quick reference guide Consider: Unusual, unexpected or developmentally inappropriate response by a child to a health examination or assessment. Suspect: Repeated or coercive sexualised behaviours or preoccupation in a prepubertal child.

29. Clinical presentations For further alerting features and detail refer to NICE guideline or quick reference guide Consider: Poor school attendance that the child’s parents or carers know about that is not justified on health (including mental health) grounds, and formally approved home education is not being provided. Suspect: Repeated apparent life-threatening events in a child, if the onset is witnessed only by one parent or carer and a medical explanation has not been identified.

30. Fabricated or induced illness Consider: Child’s history, physical or psychological presentation, or findings of assessments, examinations or investigations, leads to a discrepancy with a recognised clinical picture, even if the child has a past or concurrent physical or psychological condition.

31. Fabricated or induced illness Suspect: As previous slide, plus one or more of the following: reported symptoms and signs are only observed by, or appear in the presence of, the parent or carer an inexplicably poor response to treatment new symptoms are reported as soon as previous symptoms stop biologically unlikely history of events despite a definitive clinical opinion being reached, multiple opinions are sought and disputed by the parent or carer and the child continues to be presented with a range of signs and symptoms child’s normal daily activities are limited, or they are using aids to daily living more than expected.

32. Parent– or carer– child interactions For further alerting features and detail refer to NICE guideline or quick reference guide Consider: Potentially harmful parent– or carer–child interactions (emotional abuse), including: − negativity or hostility towards or rejection or scapegoating of a child or young person − developmentally inappropriate expectations of or interactions with a child, including inappropriate threats or methods of disciplining − exposure to frightening or traumatic experiences, including domestic abuse − using the child to fulfil the adult’s needs (for example, in marital disputes) − failure to promote the child’s appropriate socialisation (for example, not providing stimulation or education, isolation or involving them in unlawful activities) Suspect: Persistent harmful parent– or carer–child interactions.

33. Alerting features: case studies Break into groups. Look at the following case studies and consider, suspect or exclude child maltreatment: 1.Multiple bruises on a child of a similar shape and size. The explanation offered is that the child fell over in the garden. 2.A child under the age of 5 presents with a thermal injury to the palm of their hand having come into contact with a hot baking tray. The child is distressed and in pain. The parent continues to blame the child throughout the examination process. 3.A child under the age of 1 presents as drowsy with no explanation offered. A CT scan reveals an intracranial injury. Upon further examination rib fractures are also found.

34. Good communication between all parties is essential. If worried, seek advice from designated professionals for safeguarding children. If concerns are based on information given by a child, explain to the child: that you may be unable to maintain confidentiality explore the child’s concerns about sharing this information reassure the child that they will continue to be kept informed. Sharing information about children and young people

35. Obstacles should not stop acting to prevent harm. They include: concern about missing a treatable disorder fear of losing positive relationship with a family already under care divided duties to adult and child patients and breaching confidentiality an understanding of the reasons for the maltreatment, and no intention to harm the child losing control over the child protection process and doubts about its benefits stress, personal safety, fear of complaints. Obstacles

36. Action planning What is your action as a result of today’s session?

37. Find out more Visit www.nice.org.uk/CG89 for:www.nice.org.uk/CG89 the guideline the quick reference guide ‘Understanding NICE guidance’ costing statement audit support slide sets