National Institute for Health and Clinical Excellence (NICE)
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NICE issues guidance to help healthcare professionals identify child maltreatment

NICE has today (22 July 2009) issued guidance to help healthcare professionals to identify children who may have been maltreated. The guidance provides a summary of alerting features that should prompt a healthcare professional to consider, suspect or exclude child maltreatment. Child maltreatment includes neglect, physical, sexual and emotional abuse, and fabricated or induced illness.

In the 12 months to 31 March 2008 there were 538,500 referrals of children to social services departments (DCSF 2008). The number of referrals only represents those children identified as ‘at risk’ of maltreatment and as such is likely to underestimate the number of children being maltreated.

There is strong evidence of the harmful short- and long-term effects of child maltreatment. All aspects of the child’s health, development and wellbeing can be affected and these effects can last into adulthood and include anxiety, depression, substance misuse, and self-destructive, oppositional or antisocial behaviours. In adulthood, there may be difficulties in forming or sustaining close relationships, sustaining employment and parenting capacity. Physical abuse may result in lifelong disability or physical scarring and harmful psychological consequences, and may even be fatal. The National Service Framework (NSF) for Children, Young People and Maternity Services for England states ‘The high cost of abuse and neglect both to individuals (and to society) underpins the duty on all agencies to be proactive in safeguarding children.’

This guidance provides a comprehensive summary of physical and psychological symptoms, signs and interactions, that may alert healthcare professionals to suspect maltreatment. This includes bruises, cuts, ano-genital signs and symptoms, neglect and emotional abuse observed in parent– or carer–child interactions. The guidance is intended to encourage healthcare professionals to think holistically when a child presents so that they think about what they see, hear and any other information they receive to help them build up a picture. For example, if maltreatment is considered, they may need to look at the whole child, gather relevant information from other sources and discuss the case with a senior colleague and review the child. The guidance will ensure that children who need help get it early in order to prevent further or future harm, and to enable additional supportive services to be provided to families where needed.

Dr Sheila Shribman, National Clinical Director, Children, Young People and Maternity Services said: “Spotting the signs of child maltreatment and protecting vulnerable children is an important but often difficult challenge for healthcare professionals.  I welcome this guidance as an important means of helping frontline staff identify maltreatment and provide support for them in taking appropriate action."

Andrew Dillon, NICE Chief Executive said: “We want to give healthcare professionals the confidence to recognise the signs of maltreatment and to know when to refer on to a specialist. This guidance does not include recommendations on how to diagnose, confirm or disprove maltreatment; this should be done by specialists in social care, following Local Safeguarding Children Board procedures.”

Danya Glaser, Guideline Development Group Chair and Consultant Child and Adolescent Psychiatrist said: "Child maltreatment is a real problem but it may go unrecognised. It can include neglect and emotional abuse as well as sexual and physical abuse, and often has long lasting effects into adulthood.  Healthcare professionals can find it difficult to acknowledge and act on the signs of maltreatment and may be concerned that action may lead to more harm to the child or the relationship with the family.  However, this should not preclude them from following the appropriate course of action to prevent further harm to the child. This guidance provides healthcare professionals with a comprehensive list of alerting features which will help them recognise child maltreatment as it happens. Parenting is difficult, parents often do not intend to harm their children and this guidance is also about identifying the parents who need more help to look after their children."

Monica Lakhanpaul, Clinical Co-director, NCC for Women’s and Children’s Health said: “This guidance is a tool aimed to support front line health care professionals to take responsibility to ensure the safety of children and to ensure children and families receive help in a timely way. Health professionals need to be able to recognise clinical features that should alert them to gather further information about the child , discuss the child or share information with colleagues and decide whether a child may be being maltreated in any way or may have an alternative diagnoses. This guidance will help professionals to decide the urgency with which they need to involve other agencies or involve people with more expertise in the field.”

Christine Habgood, GP, Brighton and Hove said:  "This guideline provides welcome support for front-line healthcare professionals in their work with children. It gives them the information they need to identify those children who have been maltreated and need protection and help. Although most clinical encounters with children involve physical, behavioural or emotional issues, child maltreatment needs to be in the list of possible causes for many of these presentations. We are asking GPs and others to think really carefully about what they are seeing, to discuss their suspicions with other colleagues if necessary or refer children on to the appropriate agencies if they suspect them to be maltreated. Every child should feel safe and secure and we all need to make sure this happens."

Kathryn Gutteridge User representative and Consultant Midwife, Sandwell and West Birmingham NHS Trust said: “Child abuse is a wide reaching problem in society; particularly in the place they should feel safe – their own homes.  The very people that children should be able to trust and seek comfort, respect and unconditional love from are more often than not the abuser in their lives.  I am one of those adults who experienced the harm of sexual and emotional abuse – it made my life impossible at times and harder than it should ever have been.  I grew up with unimaginable stressors and harm; this certainly affected my physical and emotional wellbeing into adulthood.  Healthcare professionals could have helped me but they didn’t, this guidance is a start for front line healthcare workers to begin to identify the signs that children show when they are experiencing abuse.”

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