This toolkit provides busy practitioners with an easily navigable resource to ensure excellence in safeguarding practice in Primary Care.
We are awaiting a review before updating this resource. Please use with caution.
Physical, emotional, sexual abuse and neglect
A form of abuse which may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating or otherwise causing physical harm to a child. Physical harm may also be caused when a parent or carer fabricates the symptoms of, or deliberately induces, illness in a child.
Injuries to non-independently mobile children *
(*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, or 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.
Bruising is the most common presentation in children who have been physically abused although other injuries can include burns, fractures or unexplained bleeding. This short video is a useful resource.
Any injury to a child who is 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, child or 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 (see Introduction section for further information).
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 maltreatment or neglect.
If physical abuse is suspected, a safeguarding referral must be made immediately to Children's Social Care. Processes will vary across the nations, but in many places it is the responsibility of Children’s Social Care to arrange an urgent medical assessment by a Consultant Paediatrician. However, if the child is in need of urgent medical attention, you should arrange immediate medical assessment either through the Emergency Department or Paediatrics as well as making the immediate safeguarding referral to Children's Social Care.
It's important to make yourself aware of your local pathways of referral.
For more information on bruising and patterns of bruising in child abuse, please visit the Forensic Medicine for Medical Students website.
Tool to aid practitioners when faced with a possible injury in a non-mobile baby:
ICON Abusive Head Trauma prevention programme – GP six-week postnatal check intervention
Coping with a crying baby can be very stressful for parents. Serious Case Reviews show that crying is the main trigger for babies being shaken. Research has shown that public health campaigns educating new parents and caregivers in coping with their baby's crying can reduce rates of abusive head trauma by up to 75%. This poster from the Hampshire CCGs provides advice that health professionals can give parents to help them cope with their baby crying and also a suggested template for the 6-week postnatal check.
The six week postnatal check is the ideal time to enquire with parents and carers about their babies crying as infant crying hits a peak at 6-8 weeks of age. The ICON webpage offers advice and support to both parents and carers and professionals. This includes leaflets, posters, coping with crying plans and information about the research behind the programme and can be accessed via this link: www.iconcope.org
Fabricated or induced illness
Fabricated or induced illness (FII) is when a parent or carer fakes, or creates, the symptoms of an illness in their child.
In fabricated illness the perpetrator does not directly harm the child but reports a clinical story to doctors which is eventually established to be fabricated.
In induced illness the perpetrator inflicts direct (hands-on) harm on the child.
FII is a spectrum of presentations rather than a single entity. At one end of the spectrum, less severe presentations may include a genuine belief that the child is ill or exaggeration by carers of the child's existing symptoms. At the other end of the spectrum, the behaviour of carers includes them deliberately inducing symptoms in the child.
A key professional task is to distinguish between the very anxious carer who may be responding in a reasonable way to a very sick child and those who exhibit abnormal behaviour.
The following behaviours by carers can be associated with fabricating or inducing illness in a child:
- deliberately inducing symptoms in children such as giving medication or other substances, intentionally causing transient obstruction of airways or by interfering with the child’s body so as to cause physical signs;
- interfering with treatments by over dosing with medication, not administering them or interfering with medical equipment such as infusion lines;
- claiming the child has symptoms which cannot be verified unless observed directly, such as pain, frequency of passing urine, vomiting or fits. These claims result in unnecessary investigations and treatments which may cause secondary physical problems;
- exaggerating symptoms which cannot be verified unless observed directly, causing professionals to undertake investigations and treatments which may be invasive, are unnecessary and therefore are harmful and possibly dangerous;
- obtaining specialist treatments or equipment for children who do not require them;
- alleging psychological illness in a child.
What is the impact of FII on the child?
In addition to the consequences noted above, the impact of FII on a child can be catastrophic – some of these children will die due to this abuse. Many will suffer long term consequences such as significant emotional problems in adulthood, post-traumatic stress and inappropriate health-seeking behaviours.
FII comes under the category of physical abuse but it can also be neglectful and cause significant emotional harm.
Warning Signs of FII
In cases of suspected FII, the GP is likely to have had a higher level of involvement and knowledge of the child and family than other health professionals. GPs involvement and contribution to the management of FII concerns is essential to ensure that all key information with regard to the child is shared. GPs will also be aware about parental health issues – including both physical and mental health – and these should be taken into consideration as part of any assessment and information sharing.
Working with adults
Concerns about the welfare of a child may arise from a practitioner's involvement with a parent or carer. These concerns may increase if a parent/carer is known to fabricate or induce illness in themselves.
Good practice points
- The child's needs are paramount in this situation.
- As with any other forms of abuse, GPs have a duty to share any relevant and proportionate information that may impact on the welfare of a child. This includes sharing relevant information about parents and carers as well as the child.
- Good documentation is essential. As the primary record keeper of all health records, primary care can play a key role in recognising patterns or worrying behaviour from multiple presentations at different settings. When recording concerns about FII, GPs should ensure that these concerns are recorded within the child's clinical record but that the entry is not visible on online access, as parental awareness of the concern may escalate the risk to the child.
- Good communication between health professionals is essential.
- If there are concerns about FII and the child is not known to a Consultant, they should be referred to a Paediatrician, Consultant Child Psychiatrist or Consultant Clinical Psychologist (dependent upon the presenting issues) with expertise in symptoms and signs that are being presented. Concerns about possible FII should be in the referral letter.
- Chronologies can be helpful in these situations.
If you are in a situation where you are starting to consider Fabricated or Induced Illness in a child, it is vital that you seek further advice and guidance from experienced safeguarding colleagues. These are complex situations which should not be managed by any practitioner alone.
Where there are sufficient concerns that a child may be suffering or is likely to suffer significant harm resulting from a parent or carer's persistent attempt to fabricate, induce or exaggerate an illness, a referral should be made to Children's Social Care as soon as possible in line with local multi-agency safeguarding procedures.
At the point of referral to Children's Social Care, advice should be sought from the organisational safeguarding lead regarding whether or not parents should be made aware of the referral, since doing so may increase the risk for the child/ children.
- Fabricated and Induced Illness Practice Guidance North Yorkshire and the City of York Safeguarding Children Boards 2017
- Safeguarding children in whom illness is fabricated or induced. HM Government 2008
- Serious Case Review of Michael who was the victim of fabricated or induced illness (FII)
Emotional abuse is the persistent emotional maltreatment of a child such as to cause severe and persistent adverse effects on the child's emotional development. It may involve conveying to a child that they are worthless or unloved, inadequate, or valued only insofar as they meet the needs of another person. It may include not giving the child opportunities to express their views, deliberately silencing them, or 'making fun' of what they say or how they communicate. It can include ignoring a child. It may feature age or developmentally inappropriate expectations being imposed on children. These may include interactions that are beyond a child's developmental capability, as well as over-protection and limitation of exploration and learning, or preventing the child participating in normal social interaction. It may involve seeing or hearing the ill-treatment of another. It may involve serious bullying (including cyber bullying), causing children to frequently feel frightened or in danger, or the exploitation or corruption of children. Some level of emotional abuse is involved in all types of maltreatment of a child, though it may occur alone.
Presentation of emotional abuse in general practice is dependent on the child's age and developmental stage and may be difficult to identify. Alerting features include failure to thrive at any age, physical, mental, emotional developmental delay and the following age-related concerns:
- Babies: feeding difficulties, irritability.
- Toddler: sleep refusal, food refusal, behavioural difficulties, communication delay.
- School age: low self-esteem, withdrawn or shy, difficulty making friends, secondary enuresis, encopresis, hiding or scavenging food, unexplained change in emotional or behavioural state, school refusal; precocious or coercive sexualised behaviour, self-harm, somatisation – aches, pains.
- Adolescent: self-harming/mutilation, extremes of emotion, aggression or passivity, drug and/or solvent abuse, risk taking, sexual experimentation, homelessness, for example due to family conflict, running away.
Emotional abuse is the second most common reason for children needing protection from abuse in the UK.
For further information on emotional abuse visit the NSPCC website.
Involves forcing or enticing a child or young person to take part in sexual activities, not necessarily involving a high level of violence, or whether or not the child is aware of what is happening. The activities may involve physical contact, including assault by penetration (for example, rape or oral sex) or non-penetrative acts such as masturbation, kissing, rubbing and touching outside of clothing. They may also include non-contact activities, such as involving children in looking at, or in the production of, sexual images, watching sexual activities, encouraging children to behave in sexually inappropriate ways, or grooming a child in preparation for abuse. Sexual abuse can take place online, and technology can be used to facilitate offline abuse. Sexual abuse is not solely perpetrated by adult males. Women can also commit acts of sexual abuse, as can other children.
Asking about sexual abuse
Asking about sexual abuse can be very difficult. There is very little practical guidance available on how to ask children about sexual abuse (there are plenty of resources for older children and young people in context of Child Sexual Exploitation – CSE – see this section for further details).
The following questions are examples provided by the authors and reviewers of this toolkit – these are phrases that they use in everyday practice.
- "I need to ask you about your privates. You won't get in trouble" (perhaps draw a line drawing of a child to help)
- "Has anyone done anything to you that makes you feel uncomfortable?"
- "Has anyone asked you to keep a secret?"
If a child discloses, listen to the child and let them explain what happened in his or her own words. Don't stop the child in the middle of the story to go and get someone or do something else. The following questions can be useful.
- What happened?
- When did it happen?
- Where did it happen?
- Who did it?
- How do you know them? (If the relationship of the abuser is unclear).
It is also really important to ask the parent or guardian about any concerns they might have about the child. Changes in behaviour can be an important indicator of sexual abuse. Questions to ask parents or guardian:
- Who looks after your child in the day and at night other than you/ who is involved in the looking after of your child on a daily basis?
- Do you have any concerns about the care your child has? Have you noticed any change in your child's behaviour?
- Does your child seem to be afraid of anyone or not wanting to spend time with a particular person?
- Is your child having any problems at school? Have the school noticed any changes in your child's behaviour?
- Are you worried about the behaviour of anyone in your child's life?
- Is there anything else that worries you?
This NHS website has excellent information on sexual abuse – what it is, how to spot a child who may be being sexually abused, which children are more at risk and what the effects are of sexual abuse.
The Children's Society proposed the RADAR code:
Respect. Value all young people – remember how hard it can be for them to disclose abuse or exploitation
Approach. Show warmth from the start - give young people a chance to build a relationship with you
Discover. Be pro-active – stay alert and on the lookout for potential signs of abuse
Ask. Be 'professionally curious' - ask questions and take young people's answers seriously
Respond. Follow safeguarding procedures - keep the young person informed and supported
For further information on Child Sexual Exploitation (CSE) see the separate section on this.
The persistent failure to meet a child's basic physical and/or psychological needs, is likely to result in the serious impairment of the child's health or development. Neglect may occur during pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer failing to:
- provide adequate food, clothing and shelter (including exclusion from home or abandonment)
- protect a child from physical and emotional harm or danger
- ensure adequate supervision (including the use of inadequate care-givers)
- ensure access to appropriate medical care or treatment
It may also include neglect of, or unresponsiveness to, a child's basic emotional needs.
'Was Not Brought'
Children not being brought to health appointments can be a sign of neglect or other abuse. There are, of course, many simple reasons why a child may not be brought to a health appointment e.g. parent forgot the appointment, the child is now better, parent got the wrong appointment time/date. Generally, in most cases, a one-off missed appointment would not be a concern. However, patterns and context are very important. For example, a child who is on a child protection plan for neglect who is not brought to one health appointment should raise the practitioner's level of concern and prompt action to ensure the welfare of the child. Practices should consider having a practice procedure or policy relating to children not being brought to appointments.
Children not brought to appointments should be coded 'was not brought' rather than 'did not attend'.
Every time a child is not brought to a health appointment, the practitioner should consider what the impact on the welfare of the child could be, whether there are any other concerns within the family and take action if necessary. A checklist of issues to consider when a child is not brought to an appointment: (practices may consider doing this with the admin/reception team to aid the clinician)
- What was the purpose of the appointment (may not be known)? If the purpose is known, what could the potential impact of the missed appointment be on the child's welfare?
- Does the child have any ongoing physical or mental health problems?
- Are there other health appointments that the child has not been brought to? Is there a pattern of missed appointments?
- Are there a high volume of Emergency Department and GP Out of Hours attendances?
- Is the child on a child protection plan or a Looked After Child?
- Are there any safeguarding concerns documented in the child's records?
- Are there any siblings and if so, is there a pattern of health appointments that the children have not been brought to?
- Are there any concerns about the parent/carer that could impact on their ability to bring the children to health appointments, for example physical or mental health problems, drug and alcohol issues, domestic abuse, safeguarding concerns.
If there is any concern about the child following the completion of the checklist, action needs to be taken proportionate to the level of concern. This could include:
- asking the reception staff to contact the parents to arrange another appointment.
- contacting the parent/child yourself to discuss why the child has not been brought and make a further assessment.
- contacting other health professionals such as a health visitor, to share information and concerns to aid further decisions.
- contacting Children's Social Care.
In all cases, it is important to document your actions and reasons for them.
Video: Rethinking Did Not Attend