1. Implementing NICE guidance
When to suspect child maltreatment
Implementing NICE guidance
ABOUT THIS PRESENTATION:
This presentation has been written to help you raise awareness of the NICE clinical guideline on when to suspect child maltreatment. This guideline has been written for all healthcare professionals working in the NHS.
This slide set presentation includes examples of the alerting features of child maltreatment, but it does not detail all the alerting features that are included in the guideline. Your audience will therefore need to refer to the NICE guideline or the quick reference guide when you get to this part of the presentation. The alerting features are listed on pages 8-17 of the quick reference guide, so you may want to just print these pages for your audience. The NICE pathway also lists the alerting features and you can link directly to this from slide 25 of this presentation.
You can add your own organisation’s logo alongside the NICE logo.
We have included notes for presenters, broken down into ‘key points to raise’, which you can highlight in your presentation, and ‘additional information’ that you may want to draw on, such as a rationale or an explanation of the evidence for a recommendation. Where necessary, the recommendation will be given in full.
DISCLAIMER
This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself.
PROMOTING EQUALITY
Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties.
2009
NICE clinical guideline 89

2. What this presentation covers
Scope
Definitions
How to use this guidance
Alerting features
Sharing information
Obstacles
Discussion
Find out more
NOTES FOR PRESENTERS:
In this presentation we will start by providing some background to the guideline and why it is important.
We will then describe the definitions of terms used and the framework that should be used to put this guidance into practice.
We will then present some examples of the alerting features of child maltreatment.
Next, we will summarise how information should be shared, before looking at the obstacles to identifying child maltreatment.
Then we will open the meeting up with a list of questions to help prompt a discussion on local issues for incorporating the guidance into practice.
Finally, we will end the presentation with further information about the support provided by NICE.

3. Scope
This guidance provides a summary of the alerting features associated with child maltreatment.
Its purpose is to:
raise awareness
help healthcare professionals who are not specialists in child maltreatment
It does not cover how to diagnose, confirm or disprove child maltreatment.
NOTES FOR PRESENTERS:
Key points to raise:
Its purpose is to raise awareness and help healthcare professionals who are not specialists in child protection to identify children who may be being maltreated.
All healthcare professionals have an important role to play in child protection.
The effects of child maltreatment can be severe and last into adulthood.
Obstacles to identifying child maltreatment exist (for example, concern about missing a treatable disorder, fear of losing a positive relationship with a family).
All agencies have a duty to be proactive, share information and cooperate at the earliest possible time to effectively protect children from maltreatment.
For details of the exclusions from the guidance invite your audience to refer to page 7 of the quick reference guide when presenting this slide.

4. Definitions
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.
NOTES FOR PRESENTERS:
Key points to raise:
The alerting features in this guidance have been divided into two categories, according to the level of concern, with recommendations to either ‘consider’ or ‘suspect’ maltreatment.
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).
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’, available from:
Additional information:
Supplementary guidance to Working Together 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 Heath, Home Office, Foreign and Commonwealth Office (2004) Young people and vulnerable adults facing forced marriage.

5. How to use this guidance
It is good practice to follow this process to help you decide whether to consider, suspect or exclude child maltreatment:
NOTES FOR PRESENTERS:
Key points to raise:
If you encounter an alerting feature described in the guidance it is good practice to follow the process outlined here.

6. Listen and observe
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
NOTES FOR PRESENTERS:
Recommendation in full from the quick reference guide:
Listen and observe Take into account the whole picture of the child or young person. Sources of information that help to do this include:
any history that is given
report of maltreatment, or disclosure from a child or young person or third party
child’s appearance, demeanour or behaviour
symptom
physical sign
result of an investigation
interaction between the parent or carer and child or young person.
It is standard practice to refer to children’s social services when a child or young person makes a disclosure of maltreatment (even though it may not be precise in every detail).

7. Seek an explanation
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.
NOTES FOR PRESENTERS:
Recommendation in full from the NICE version of the guidance:
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.
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.

8. An unsuitable explanation
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 to 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.
NOTES FOR PRESENTERS:

9. 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.
NOTES FOR PRESENTERS:
Key points to raise:
At this point the healthcare professional may consider, suspect or exclude child maltreatment from the differential diagnosis.
You may wish to consider discussing a local example at this point in the presentation.

10. Consider maltreatment
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.
NOTES FOR PRESENTERS:
Key points to raise:
If an alerting feature prompts you to consider child maltreatment:
Look for other alerting features of maltreatment in the child or young person’s history, presentation or parent – or carer – child interactions now or in the past.
Then do one or more of the following:
Discuss the case 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.
At any stage during the process of considering maltreatment the level of concern may change and lead to exclude or suspect maltreatment.

11. Suspect maltreatment
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.
NOTES FOR PRESENTERS:
Key points to raise:
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.

12. Exclude maltreatment
Exclude maltreatment when a suitable explanation is found for alerting features.
NOTES FOR PRESENTERS:
Key points to raise:
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.

13. Record Record all actions taken in previous stages and the outcome.
NOTES FOR PRESENTERS:
Key points to raise:
You may wish to consider discussing a local example at this point in the presentation.

14. Alerting features
Alerting features in the following categories may lead you to consider or suspect child maltreatment:
Physical features
Sexual abuse
Neglect
Emotional, behavioural, interpersonal and social functioning
Clinical presentations
Fabricated or induced illness
Parent– or carer–child interactions
NOTES FOR PRESENTERS:
Examples of alerting features in each of these categories are shown in the following slides. For further alerting features and detail refer to the NICE guideline or quick reference guide.

15. Physical features Consider:
Any serious or unusual injury with an absent or unsuitable explanation.
Suspect:
Bruising in the shape of a hand, ligature, stick, teeth mark, grip or an implement.
NOTES FOR PRESENTERS:
Key points to raise:
Invite your audience to refer to pages 8 and 9 of the quick reference guide when presenting this slide.
The slide provides one example of an alerting feature that should prompt healthcare professionals to consider maltreatment and one example of an alerting feature that should prompt healthcare professionals to suspect maltreatment.
Each alerting feature has particular characteristics or circumstances that are important in assessment, for full details on the alerting features please see the quick reference guide.
For further alerting features and detail refer to NICE guideline or quick reference guide

16. Sexual abuse Consider:
Persistent or recurrent dysuria or anogenital discomfort, or an anal or genital symptom in a girl or boy, without a medical explanation.
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.
NOTES FOR PRESENTERS:
Key points to raise:
Invite your audience to refer to pages 10 and 11 of the quick reference guide when presenting this slide.
The slide provides one example of an alerting feature that should prompt healthcare professionals to consider maltreatment and one example of an alerting feature that should prompt healthcare professionals to suspect maltreatment.
Each alerting feature has particular characteristics or circumstances that are important in assessment, for full details on the alerting features please see the quick reference guide.
Pregnancy in a child under 13 years (sex with a child under 13 years is unlawful, therefore pregnancy in a girl of this age means she has been maltreated).
For further alerting features and detail refer to NICE guideline or quick reference guide

17. Neglect
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 or dirty.
NOTES FOR PRESENTERS:
Key points to raise:
Invite your audience to refer to pages 12 and 13 of the quick reference guide when presenting this slide.
The slide provides one example of an alerting feature that should prompt healthcare professionals to consider maltreatment and one example of an alerting feature that should prompt healthcare professionals to suspect maltreatment.
Each alerting feature has particular characteristics or circumstances that are important in assessment, for full details on the alerting features please see the quick reference guide.
When highlighting the suspect example on the slide, it is important to note that children often become smelly or dirty 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 smelly or dirty (for example, an early morning visit)
if the dirtiness is ingrained.
If a child has been abandoned this is child maltreatment.
For further alerting features and detail refer to NICE guideline or quick reference guide

18. Emotional, behavioural, interpersonal and social functioning
Consider:
Unusual, unexpected or developmentally inappropriate response by a child to a health examination or assessment (for example, extreme passivity, resistance or refusal).
Suspect:
Repeated or coercive sexualised behaviours or preoccupation in a prepubertal child (for example, sexual talk associated with knowledge, drawing genitalia or emulating sexual activity with another child).
NOTES FOR PRESENTERS:
Key points to raise:
Invite your audience to refer to pages 14 and 15 of the quick reference guide when presenting this slide.
The slide provides one example of an alerting feature that should prompt healthcare professionals to consider maltreatment and one example of an alerting feature that should prompt healthcare professionals to suspect maltreatment.
Each alerting feature has particular characteristics or circumstances that are important in assessment, for full details on the alerting features please see the quick reference guide.
For further alerting features and detail refer to NICE guideline
or quick reference guide

19. Clinical presentations
Consider:
Poor school attendance that the child’s parents or carers know about that is not justified on health (including mental health) grounds, and 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.
NOTES FOR PRESENTERES:
Key points to raise:
Invite your audience to refer to page 16 of the quick reference guide when presenting this slide.
The slide provides one example of an alerting feature that should prompt healthcare professionals to consider maltreatment and one example of an alerting feature that should prompt healthcare professionals to suspect maltreatment.
Each alerting feature has particular characteristics or circumstances that are important in assessment, for full details on the alerting features please see the quick reference guide.
For further alerting features and detail refer to NICE guideline or quick reference guide

20. 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.
Suspect:
As above, 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
NOTES FOR PRESENTERS:
Key points to raise:
Invite your audience to refer to pages 16 and 17 of the quick reference guide when presenting this slide.
Recommendation in full from the quick reference guide:
Child maltreatment should be considered when the 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.
Child maltreatment should be suspected when the child’s history, physical or psychological presentation, or findings of assessments, examinations or investigations leads to a discrepancy with a recognised clinical picture plus one or more of the following, even if the child has a past or concurrent physical or psychological condition:
− reported symptoms and signs are only observed by, or appear in the presence of, the parent or carer
− an inexplicably poor response to prescribed medication or other 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 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
− child’s normal daily activities (for example, school attendance) are limited, or they are using aids to daily living (for example, wheelchairs) more than expected from any medical condition that the child has.
Each alerting feature has particular characteristics or circumstances that are important in assessment, for full details on the alerting features please see the quick reference guide.

21. Parent– or carer– child interactions
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.
NOTES FOR PRESENTERS:
Key points to raise:
Invite your audience to refer to page 17 of the quick reference guide when presenting this slide.
The slide provides one example of an alerting feature that should prompt healthcare professionals to consider maltreatment and one example of an alerting feature that should prompt healthcare professionals to suspect maltreatment.
Each alerting feature has particular characteristics or circumstances that are important in assessment, for full details on the alerting features please see the quick reference guide.
For further alerting features and detail refer to NICE guideline or quick reference guide

22. Sharing information about children and young people
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
NOTES FOR PRESENTERS:
Recommendation in full from the quick reference guide:
If you are worried about sharing information about a child or young person, seek advice from named or designated professionals for safeguarding children.
If your 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 and reassure the child that they will continue to be kept informed about who the information is being shared with and what action is being taken.
When gathering collateral information from other health disciplines and agencies, use judgement about whether to explain to the child or young person the need to gather this information for their overall assessment.
Additional information:
This slide may provide a useful focus for discussion at the end of your presentation and allow your audience to share their experiences of the issues covered here and how any problems could be resolved.

23. Obstacles Obstacles should not stop action to prevent harm.
They include:
concern about missing a treatable disorder
fear of losing a positive relationship with a family
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
NOTES FOR PRESENTERS:
Key points to raise:
Obstacles to identifying child maltreatment exist. These should not stop healthcare professionals from acting to prevent harm to the child.
Examples of possible obstacles include:
Concern about missing a treatable disorder.
Healthcare professionals are used to working with parents and carers in the care of children and fear losing a 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.
An understanding of the reasons why the maltreatment might have occurred, and that there was no intention to harm the child.
Losing control over the child protection process and doubts about its benefits.
Stress.
Personal safety.
Fear of complaints.
Additional information:
This slide may provide a useful focus for discussion at the end of your presentation and allow your audience to share their experiences of the issues covered here and how any problems could be resolved.

24. Discussion
How can we ensure that this guidance reaches all healthcare professionals working in the NHS locally who work with children?
How can we overcome the obstacles?
To what extent are people trained to be able to respond to the guidance?
How can we ensure that information is recorded so that patterns are recognised over time and place?
NOTES FOR PRESENTERS:
We have provided some general questions to help provide a prompt for a discussion at the end of your presentation – please edit and adapt these to suit your local situation.
There are a number of potential discussion areas that may be relevant to your audience. You may wish to create questions that will enable:
further interrogation of the alerting features described in the quick reference guide
discussion of the obstacles and the opportunity to find possible solutions
the airing of concerns about sharing information about children and young people.

25. Click here to go to the NICE Pathways website
The NICE pathway for when to suspect child maltreatment covers:
obstacles to identifying maltreatment
good practice if altering features are found
details of the alerting features of maltreatment.
NOTES FOR PRESENTERS:
NICE Pathways: guidance at your fingertips
Our new online tool provides quick and easy access, topic by topic, to the range of guidance from NICE, including quality standards, technology appraisals, clinical and public health guidance and NICE implementation tools. Simple to navigate, NICE Pathways allows you to explore in increasing detail NICE recommendations and advice, giving you confidence that you are up to date with everything we have recommended.
Click here to go to the NICE Pathways website

26. Click here to go to the NHS Evidence website
Visit NHS Evidence for the best available evidence on all aspects of child health and child maltreatment
Click here to go to the NHS Evidence website
NOTES FOR PRESENTERS:
If you are showing this presentation when connected to the internet, click on the blue button to go straight to the NHS Evidence website. For the home page go to

27. Find out more Visit www.nice.org.uk/CG89 for: the guideline
the quick reference guide
‘Understanding NICE guidance’
costing statement
audit support
education resource
NOTES FOR PRESENTERS:
You can download the guidance documents from the NICE website.
The NICE guideline – all the recommendations.
A quick reference guide – a summary of the recommendations for healthcare professionals.
‘Understanding NICE guidance’ – information for patients and carers.
The full guideline – all the recommendations, details of how they were developed, and reviews of the evidence they were based on.
NICE has developed tools to help organisations implement this guideline, which can be found on the NICE website.
Costing statement – details of the likely costs and savings when the cost impact of the guideline is not considered to be significant.
Audit support – for monitoring local practice.
Education resource – to help understanding of how to apply the guideline in practice.

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