RCGP Safeguarding toolkit

Presentations of child abuse and neglect in general practice are seldom clear-cut and well-defined, and different types of abuse can overlap in the same child. The context for concerns is often more important than the identification of an 'incident'. Child protection work has been likened to a patchwork or jigsaw puzzle. Often, it is only when individuals and agencies share information together that the picture is complete. This involves effective record keeping, information-sharing and communication, both internally and between agencies.

Professional curiosity is fundamental to how we work with children and their families. Professional curiosity is a practice mindset and communication skill that involves exploring and understanding what is happening by asking questions and maintaining an open mind. It is about understanding one’s own responsibility in managing risk and safety and knowing when to act, rather than making assumptions and taking things at face value.

Liaising with other universal health services providers (for example, midwives, health visitors and school nurses) is invaluable as they may be the first health professionals to recognise when a child, young person or family member is in difficulty and can help to build a more complete picture. The value of universal service provision is that GPs and their staff see a multitude of presentations and behaviours in children and young people, the majority of whom will not require action to be taken to ensure their welfare. Thus, when there is a situation that 'does not feel quite right' practitioners' intuition and clinical acumen are, in our experience, usually well-founded.

Below are some examples of how child abuse and neglect may present in general practice. This list is not exhaustive. Children and young people may disclose abuse and neglect, although disclosure to professionals is rarely a sudden or one-off event. They may tell a relative or friend and then be brought to a GP to explore next steps.

• The child gives signs or indicators (verbal or non-verbal) that raises suspicion of abuse.
• The child shares what is happening to them.
• Physical signs, e.g. bruises, injuries.
• Behaviour changes, e.g. more withdrawn, more angry, challenging behaviour, missing school, running away from home.
• Mental health concerns, e.g. anxiety, depression, self-harm, suicidal thoughts/attempts.
• Parents/carers/family members sharing concerns.
• Child displays harmful behaviour towards others, e.g. harmful sexual behaviour.
• Parent/child interactions that give rise to concerns.
• Parental mental health/substance misuse.
• Behaviour of an adult that raises concerns about the safety of children in their care.
• Disclosures from a parent/carer about abuse in their own life, e.g. domestic abuse, that also indicates abuse to children.
• Information shared from other health colleagues or other agencies/professionals.
• ‘Was not brought’ – repeated patterns of children not being brought to health appointments.
• Behaviour of a colleague or a Person in Position of Trust that gives concerns they may be a risk to children.
• Proactive questioning, for example, assessing for risk of child sexual exploitation in a contraception review.

It is worth noting that the signs of lots of different types of abuse can be similar. For example, a child who is more withdrawn could be experiencing any type of abuse. It is therefore important for practitioners to be able to recognise signs of trauma to be able to safeguard and protect children. If practitioners are concerned about abuse and neglect, they should provide children with opportunities for disclosure (if possible dependent on age, communication needs, situation) but should not rely on disclosure before taking action to protect children from harm.

Children and young people can find it difficult to tell someone or even understand that they are being abused or neglected. However, they may communicate an emotional reaction to their experiences indirectly through their behaviour. Marked changes to a child’s behaviour, emotional state or attitude should prompt practitioners to explore concerns through a sensitive enquiry about their wellbeing, giving them space and opportunity to talk.

Marked changes in behaviour or emotional state

A change in a child's behaviour or emotional state which is not fully explained by a stressful situation that is not part of child abuse and neglect such as bereavement, parental separation or a medical cause. Examples of marked changes may include:

• recurrent nightmares containing similar themes
• extreme distress
• markedly oppositional behaviour
• withdrawal of communication
• becoming withdrawn.

Practitioners should continue to consider the possibility of child abuse or neglect as a cause for behavioural and emotional changes, even if they are seemingly explained by another cause.

Children may not tell anyone about the abuse and neglect they are experiencing for numerous reasons, including:

• they are not aware they are being abused or neglected
• they are too scared to say anything for fear of reprisals or adverse repercussions to them or their family
• they told someone before and nothing happened or the abuse got worse
• they have specific communication needs.

Creating a supportive environment for the conversation, being sensitive and asking open questions may encourage children and young people to disclose abuse or neglect when they feel ready. If practitioners are concerned about abuse and neglect, whilst providing children with opportunities for disclosure (if possible dependent on age, communication needs, situation) they should also not rely on disclosure before taking action to protect children from harm.

References

• NICE Quality standard. QS179. Child abuse and neglect. 2019. 
• North Yorkshire Safeguarding Children Partnership. Professional curiosity – Practice Guidance. 2024.