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RCGP Safeguarding toolkit

Part 2A: Identification of abuse and neglect

Physical abuse

Physical abuse is when someone hurts or harms a child or young person on purpose. It includes:

  • hitting with hands or objects
  • slapping and punching
  • kicking
  • shaking
  • throwing
  • poisoning
  • burning and scalding
  • biting and scratching
  • breaking bones
  • drowning.

It's important to remember that physical abuse is any way of intentionally causing physical harm to a child or young person. It also includes making up the symptoms of an illness or causing a child to become unwell.

Bruising

There are a number of possible clinical findings suggestive of abuse. These including bruising in pre-mobile children, bruises that are seen away from bony prominences and bruises that carry the imprint of an implement used or a ligature. Bruising is the most common injury in children who have been abused. It is also a common injury in non-abused children. However, the exception to this is pre-mobile infants in whom accidental bruising is rare (0-1.3%).

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Smacking

Smacking is now illegal in Wales and Scotland.

Wales – All physical punishment of children is illegal in Wales, including by parents, carers and anyone acting in loco parentis in any setting in Wales. In March 2022, the law changed to remove the use of the defence of ‘reasonable punishment’.

Scotland – All forms of physical punishment of children are against the law in Scotland. In November 2020, the law changed to remove the use of the defence of ‘reasonable chastisement’.

The RCPCH published a policy report in April 2024 calling for the same legal changes in England and Northern Ireland: Equal protection from assault in England and Northern Ireland.

References
Injuries to non-independently mobile children *

(*The term ’non-independently mobile children’ includes not only babies, but older children with physical disabilities who are not independently mobile.)

The likelihood of children sustaining accidental injuries increases with increasing mobility. However, Serious Case Reviews (SCR) have identified that professionals sometimes fail to recognise the highly predictive value, for child abuse, of the presence of injuries to non-independently mobile children.

Infants under 12 months are at increased risk of non-accidental injury (NAI). When examining a child who is non-independently mobile, it is important to remember 'those who can't cruise rarely bruise'. A small apparently insignificant bruise in a baby might be a marker for a serious life-threatening injury. Children under 12 months are consistently over-represented in Serious Case Reviews (SCR), almost exclusively because of severe injury or death as a result of physical abuse. This short video developed by Nottinghamshire Safeguarding Children Partnership is a useful resource.

Bruising is the most common presentation in children who have been physically abused although other injuries can include burns, fractures or unexplained bleeding.

Any injury to a child who is not independently mobile should be treated with concern. Physical abuse must be considered.

When faced with an injury or potential injury in a non-independently mobile child, practitioners should:

  • Seek an explanation from the parent or carer.
  • Consider if the injury is feasible given the child's age and developmental stage (bearing in mind that developmental age is not always related to chronological age).
  • Consider if there has been a delay in presentation.
  • Consider whether there are any other safeguarding concerns regarding the child's presentation, for example, indicators of neglect.
  • Consider adult behaviours which may affect the safety of their child such as domestic abuse, mental health issues, learning disability or substance misuse.
  • Consider if there is any information available regarding the child or family history which would raise concerns, for example, children subject to previous child protection plans.
  • Seek further information about who is in the child's life, for example, new partner of the parent or the hidden male.
  • Children should, where possible, be asked to contribute to the history taking and have an opportunity to be seen alone during a consultation if age-appropriate. Young or pre-verbal children presenting with physical indicators of harm should be fully examined.

It is important to note that even in the absence of other known safeguarding concerns such as those listed above, an injury to a non-independently mobile child must still be taken seriously – this may be the first indication that a child is suffering abuse or neglect.

Each area may have different local multi-agency safeguarding protocols regarding bruising in non-mobile babies and children. It is important that each practitioner is aware of their local pathways.

For more information on bruising and patterns of bruising in child abuse, please visit the Forensic Medicine for Medical Students website.

References
Abusive head trauma and persistently crying babies

Abusive head trauma, previously known as Shaken Baby Syndrome, is a devastating form of abuse which can result in catastrophic injuries and death. It affects 1 in 4000 – 5000 infants every year. Males represent 70% of perpetrators. Fathers and male surrogates are nearly five times as likely as mothers to shake an infant.

Stress is an especially prominent factor in violence towards children. Stressors include background or environmental factors such as noisy environments and in particular, uncontrollable noise. A crying baby can be described as uncontrollable and its effects on parents and caregivers can be very powerful. A baby’s excessive crying can promote feelings of ‘living on the edge’, social isolation and ‘gradual introversion’ for families. Parents fear losing control.

Persistently crying babies is a common presentation in general practice with multiple possible causes. Evidence suggests that those parents and carers who complain to professionals that their baby cries excessively, actually do have a baby who cries more frequently and for longer than most. In addition, babies who cry excessively will do so despite the quality and level of parenting provided. Parents do not necessarily have an innate ability to parent effectively and most parents need support at some point.

Infant crying, along with poor sleep patterns and difficulties sleeping can have a significant impact on parents:

  • Reduction in coping ability.
  • Poor parent/child interaction.
  • Reduction in self-esteem.
  • Exhaustion.
  • Frustration.
  • Anger.

All of these can potentially be the trigger which, in some people, will manifest as frustration then aggression. Inconsolable crying can trigger a series of events that may lead to some parents shaking their baby with sometimes fatal consequences.

When faced with a consultation about a persistently crying baby, there are some useful steps you can take:

  1. CONSIDER CAUSES OF PERSISTENT CRYING
    • Acutely unwell baby - follow usual procedures for management.
    • Abusive head trauma suspected - arrange immediate specialist medical assessment and follow multiagency safeguarding procedures.
    • Non-accidental injury suspected - follow multiagency safeguarding procedures.
    • Feeding issues.
    • Physical illness causes but baby is not acutely unwell.
    • Cause unknown - under investigation.
    • No obvious cause.
  2. CONSIDER IMPACT ON PARENTS/CARERS
    • Exhaustion.
    • Reduction in coping ability.
    • Reduction in self-esteem.
    • Poor parent/child interaction.
    • Unsafe sleeping practices as parents may resort to this to stop the baby crying.
    • Anger and frustration which could lead to some parents/carers shaking their baby.
  3. CONSIDER VULNERABILITIES
    • Social isolation.
    • Parents/carers with neurodiversity - consider impact of noise.
    • Parental/carer mental health difficulties.
    • Parental/carer substance misuse.
    • Known safeguarding concerns e.g. domestic abuse.
    • Other life stresses.
  4. ACTIONS
    • Advise on strategies that may help to soothe a crying infant.
    • Encourage parents/carers to look after their own wellbeing.
    • Deliver the ICON message (a programme developed from the study of effective interventions and research into the prevention of Abusive Head Trauma (AHT).
    • Deliver Safe sleeping advice.
    • Consider use of the PAMIC tool (Potentiality for the Adult’s Mental Health to Impact on the Child) – see below.
    • Act on any safeguarding concerns.
    • Consider if a separate appointment is needed for parents/carers and their own health.
    • Arrange follow-up.

ADDITIONAL PRACTICE POINT - When adults present with mental health difficulties and/or substance misuse difficulties, consider whether they are a current or prospective parent/carer, and ask if there is new baby in the household. Consider the impact of a new baby on parental mental health and wellbeing.

The PAMIC tool (Potentiality for the Adult’s Mental Health to Impact on the Child)

The PAMIC tool was developed by the Safeguarding Children Boards for Teeside. PAMIC stands for: Potentiality for the Adult’s Mental Ill Health to Impact on the Child. It can be used when considering how likely, and with what severity, an adult’s mental health will impact on a child. It involves the practitioner thinking about the nature of risk and also the protective factors for the child so it includes the practitioner’s professional judgement. When undertaking an assessment, consideration should always be given to any other current or previous safeguarding concerns. A summary of the tool is below:

Risk of significant harm – If any of the following factors are present they are highly likely to have a direct impact on the safety and well-being of the child. Immediate referral to Children’s Social Care in line with local safeguarding children procedures
  • Delusional beliefs/ideas involving the child.
  • Risk that child will be harmed as part of a suicide plan.
  • The child is a target for parental aggression or rejection.
  • Co-existing domestic abuse, drug or alcohol abuse.
  • There is no other adult that can be depended upon to meet the needs of the child. (Children of lone parents or isolated parents are at greater risk as they are less likely to have an alternative caregiver when a parent is in crisis.)
  • The child is the parent’s carer and this is impacting on the child’s welfare.
Moderate risk of harm – Where factors such as the following are present, although not of the same severity as above, they can potentially impact on parenting and result in concern for the child’s care. Seek consent* for a referral to children’s social care for an assessment.
  • The presenting mental ill health (including the effect of medication/treatment) is impacting on the parent/s’ capability to consistently meet the needs of the child.
  • The parental mental health disorder is designated ‘untreatable’, either totally or within time-scales compatible with the child’s best interests.
Low risk of harm – Where factors such as the following are present, they require an assessment of the child’s needs to support planning for the child’s care. Seek consent for Early Help assessment.
  • Parental learning disability rendering the child more vulnerable.
  • Non-compliance or inconsistent compliance with treatment, reluctance or difficulty in engaging with necessary services, lack of insight into illness or its impact on the child.
  • The child is vulnerable due to, for example, age, illness, disability or behavioural/emotional issues.
  • Changes in the child’s behaviour since the onset of the parent/carer’s mental ill health.
Not considered at risk – No obvious impact on the child’s health and well-being are evident. Liaise with key others where appropriate and consent to do so is obtained.
  • As events may change keep under review.

*Whilst the PAMIC tool’s original wording is ‘seek consent’, practitioners should be aware that consent is not required for a child safeguarding referral if there is a risk of significant harm to the child.

References