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Child maltreatment: when to suspect maltreatment in under 18s
Clinical guideline [CG89]Published: 22 July 2009 Last updated: 09 October 2017
This guidance provides a summary of clinical features associated with child maltreatment (alerting features) that may be observed when a child presents to healthcare professionals.
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. It does not give healthcare professionals recommendations on how to diagnose, confirm or disprove child maltreatment.
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 Department for Education’s statutory guidance on inter-agency working to safeguard and promote the welfare of children. This also includes an appendix of further relevant guidance from the Department for Education, other government departments and agencies, and external organisations.
Suspect child maltreatment if a child or young person has bruising in the shape of a hand, ligature, stick, teeth mark, grip or implement.
Suspect child maltreatment if there is bruising or petechiae (tiny red or purple spots) that are not caused by a medical condition (for example, a causative coagulation disorder) and if the explanation for the bruising is unsuitable. Examples include:
bruising in a child who is not independently mobile
multiple bruises or bruises in clusters
bruises of a similar shape and size
bruises on any non-bony part of the body or face including the eyes, ears and buttocks
bruises on the neck that look like attempted strangulation
bruises on the ankles and wrists that look like ligature marks.
Suspect child maltreatment if there is a report or appearance of a human bite mark that is thought unlikely to have been caused by a young child.
Consider neglect if there is a report or appearance of an animal bite on a child who has been inadequately supervised.
Suspect child maltreatment if a child has lacerations, abrasions or scars and the explanation is unsuitable. Examples include lacerations, abrasions or scars:
on a child who is not independently mobile
that are multiple
with a symmetrical distribution
on areas usually protected by clothing (for example, back, chest, abdomen, axilla, genital area)
on the eyes, ears and sides of face
on the neck, ankles and wrists that look like ligature marks.
Suspect child maltreatment if a child has burn or scald injuries:
if the explanation for the injury is absent or unsuitable or
if the child is not independently mobile or
on any soft tissue area that would not be expected to come into contact with a hot object in an accident (for example, the backs of hands, soles of feet, buttocks, back) or
in the shape of an implement (for example, cigarette, iron) or
that indicate forced immersion, for example:
scalds to buttocks, perineum and lower limbs
scalds to limbs in a glove or stocking distribution
scalds to limbs with symmetrical distribution
scalds with sharply delineated borders.
Consider child maltreatment if a child has cold injuries (for example, swollen, red hands or feet) with no obvious medical explanation.
Consider child maltreatment if a child presents with hypothermia and the explanation is unsuitable.
Suspect child maltreatment if a child has one or more fractures in the absence of a medical condition that predisposes to fragile bones (for example, osteogenesis imperfecta, osteopenia of prematurity) or if the explanation is absent or unsuitable. Presentations include:
fractures of different ages
X-ray evidence of occult fractures (fractures identified on X-rays that were not clinically evident). For example, rib fractures in infants.
Suspect child maltreatment if a child has an intracranial injury in the absence of major confirmed accidental trauma or known medical cause, in one or more of the following circumstances:
the explanation is absent or unsuitable
the child is aged under 3 years
there are also:
retinal haemorrhages or
rib or long bone fractures or
other associated inflicted injuries
there are multiple subdural haemorrhages with or without subarachnoid haemorrhage with or without hypoxic ischaemic damage (damage due to lack of blood and oxygen supply) to the brain.
Suspect child maltreatment if a child has retinal haemorrhages or injury to the eye in the absence of major confirmed accidental trauma or a known medical explanation, including birth-related causes.
Suspect physical abuse if a child presents with signs of a spinal injury (injury to vertebrae or within the spinal canal) in the absence of major confirmed accidental trauma. Spinal injury may present as:
a finding on skeletal survey or magnetic resonance imaging
cervical injury in association with inflicted head injury
thoracolumbar injury in association with focal neurology or unexplained kyphosis (curvature or deformity of the spine).
Suspect child maltreatment if a child has an intra-abdominal or intrathoracic injury in the absence of major confirmed accidental trauma and there is an absent or unsuitable explanation, or a delay in presentation. There may be no external bruising or other injury.
Consider child maltreatment if a child has an oral injury and the explanation is absent or unsuitable.
Consider child maltreatment if there is no suitable explanation for a serious or unusual injury.
Suspect sexual abuse if a girl or boy has a genital, anal or perianal injury (as evidenced by bruising, laceration, swelling or abrasion) and the explanation is absent or unsuitable.
Suspect sexual abuse if a girl or boy has a persistent or recurrent genital or anal symptom (for example, bleeding or discharge) that is associated with behavioural or emotional change and that has no medical explanation.
Suspect sexual abuse if a girl or boy has an anal laceration, and constipation, Crohn’s disease and passing hard stools have been excluded as the cause.
Consider sexual abuse if an anus exhibiting dynamic anal dilation in a girl or boy is observed during an examination and there is no medical explanation (for example, a neurological disorder or severe constipation).
Consider sexual abuse if a girl or boy has a genital or anal symptom (for example, bleeding or discharge) without a medical explanation.
Consider sexual abuse if a girl or boy has dysuria (discomfort on passing urine) or ano-genital discomfort that is persistent or recurrent and does not have a medical explanation (for example, worms, urinary infection, skin conditions, poor hygiene or known allergies).
Consider sexual abuse if there is evidence of one or more foreign bodies in the vagina or anus. Foreign bodies in the vagina may be indicated by offensive vaginal discharge.
Consider sexual abuse if a child younger than 13 years has hepatitis B unless there is clear evidence of mother-to-child transmission during birth, non-sexual transmission from a member of the household or blood contamination.
Consider sexual abuse if a child younger than 13 years has anogenital warts unless there is clear evidence of mother-to-child transmission during birth or non-sexual transmission from a member of the household.
Suspect sexual abuse if a child younger than 13 years has gonorrhoea, chlamydia, syphilis, genital herpes, hepatitis C, HIV or trichomonas infection unless there is clear evidence of mother-to-child transmission during birth or blood contamination.
Consider sexual abuse if a young person aged 13 to 15 years has hepatitis B unless there is clear evidence of mother-to-child transmission during birth, non-sexual transmission from a member of the household, blood contamination or that the infection was acquired from consensual sexual activity with a peer.
Consider sexual abuse if a young person aged 13 to 15 years has anogenital warts unless there is clear evidence of mother-to-child transmission during birth, non-sexual transmission from a member of the household, or that the infection was acquired from consensual sexual activity with a peer.
Consider sexual abuse if a young person aged 13 to 15 years has gonorrhoea, chlamydia, syphilis, genital herpes, hepatitis C, HIV or trichomonas infection unless there is clear evidence of mother-to-child transmission during birth, blood contamination, or that the sexually transmitted infection (STI) was acquired from consensual sexual activity with a peer. In these circumstances, consider should include discussion of your concerns with a named or designated professional for safeguarding children.
Consider sexual abuse if a young person aged 16 or 17 years has hepatitis B and there is:
no clear evidence of mother-to-child transmission during birth, non-sexual transmission from a member of the household, blood contamination or that the infection was acquired from consensual sexual activity and
a clear difference in power or mental capacity between the young person and their sexual partner, in particular when the relationship is incestuous or is with a person in a position of trust (for example, teacher, sports coach, minister of religion) or
concern that the young person is being exploited.
Consider sexual abuse if a young person aged 16 or 17 years has anogenital warts and there is:
no clear evidence of non-sexual transmission from a member of the household or that the infection was acquired from consensual sexual activity and
a clear difference in power or mental capacity between the young person and their sexual partner, in particular when the relationship is incestuous or is with a person in a position of trust (for example, teacher, sports coach, minister of religion) or
concern that the young person is being exploited.
Consider sexual abuse if a young person aged 16 or 17 years has gonorrhoea, chlamydia, syphilis, genital herpes, hepatitis C, HIV or trichomonas infection and there is:
no clear evidence of blood contamination or that the STI was acquired from consensual sexual activity and
a clear difference in power or mental capacity between the young person and their sexual partner, in particular when the relationship is incestuous or is with a person in a position of trust (for example, teacher, sports coach, minister of religion) or
concern that the young person is being exploited.
Be aware that sexual intercourse with a child younger than 13 years is unlawful and therefore pregnancy in such a child means the child has been maltreated. Under the Sexual Offences Act 2003, any sexual intercourse with a child younger than 13 years is unlawful. See the Crown Prosecution Service guidance about the act for further information about consent to sexual intercourse in people under 18.
Consider sexual abuse if a young woman aged 13 to 15 years is pregnant. Under the Sexual Offences Act 2003, any sexual intercourse with a child aged 13 to 15 years is unlawful. See the Crown Prosecution Service guidance about the act for further information about consent to sexual intercourse in people under 18.
Consider sexual abuse if a young woman aged 16 or 17 years is pregnant and there is:
a clear difference in power or mental capacity between the young woman and the putative father, in particular when the relationship is incestuous or is with a person in a position of trust (for example, teacher, sports coach, minister of religion) or
concern that the young woman is being exploited or
concern that the sexual activity was not consensual.
Suspect child maltreatment if a child has repeated apparent life-threatening events, the onset is witnessed only by one parent or carer and a medical explanation has not been identified.
Consider child maltreatment if an infant has an apparent life-threatening event with bleeding from the nose or mouth and a medical explanation has not been identified.
Suspect child maltreatment in cases of poisoning in children if:
there is a report of deliberate administration of inappropriate substances, including prescribed and non-prescribed drugs or
there are unexpected blood levels of drugs not prescribed for the child or
there is reported or biochemical evidence of ingestions of one or more toxic substances or
the child was unable to access the substance independently or
the explanation for the poisoning or how the substance came to be in the child is absent or unsuitable or
there have been repeated presentations of ingestions in the child or other children in the household.
Consider child maltreatment in cases of hypernatraemia (abnormally high levels of sodium in the blood) and a medical explanation has not been identified.
Suspect child maltreatment if a child has a non-fatal submersion incident (near-drowning) and the explanation is absent or unsuitable or if the child’s presentation is inconsistent with the account.
Consider child maltreatment if a non-fatal submersion incident suggests a lack of supervision.
Consider child maltreatment if there is an unusual pattern of presentation to and contact with healthcare providers, or there are frequent presentations or reports of injuries.
Consider fabricated or induced illness if a child’s history, physical or psychological presentations or findings of assessments, examinations or investigations leads to a discrepancy with a recognised clinical picture. Fabricated or induced illness is a possible explanation even if the child has a past or concurrent physical or psychological condition.
Suspect fabricated or induced illness if a child’s history, physical or psychological presentations or findings of assessments, examinations or investigations leads to a discrepancy with a recognised clinical picture and one or more of the following is present:
Reported symptoms and signs only appear or reappear when the parent or carer is present.
Reported symptoms are only observed by the parent or carer.
An inexplicably poor response to prescribed medication or other treatment.
New symptoms are reported as soon as previous ones have resolved.
There is a history of events that is biologically unlikely (for example, infants with a history of very large blood losses who do not become unwell or anaemic).
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.
The child’s normal daily activities (for example, school attendance) are being compromised, or the child is using aids to daily living (for example, wheelchairs) more than would be expected for any medical condition that the child has.
Fabricated or induced illness is a likely explanation even if the child has a past or concurrent physical or psychological condition.
Consider child maltreatment if a child has poor school attendance that the parents or carers know about that has no justification on health, including mental health, grounds and home education is not being provided.
Consider neglect if a child has severe and persistent infestations, such as scabies or head lice.
Consider neglect if a child’s clothing or footwear is consistently inappropriate (for example, for the weather or the child’s size).
Take into account that instances of inadequate clothing that have a suitable explanation (for example, a sudden change in the weather, slippers worn because they were closest to hand when leaving the house in a rush) or resulting from behaviour associated with neurodevelopmental disorders such as autism would not be alerting features for possible neglect.
Suspect neglect if a child is persistently smelly and dirty.
Take into account that children often become dirty and smelly during the course of the day. Use judgement to determine if persistent lack of provision or care is a possibility. Examples include:
child seen at times of the day when it is unlikely that they would have had an opportunity to become dirty or smelly (for example, an early morning visit)
if the dirtiness is ingrained.
Suspect neglect if you repeatedly observe or hear reports of any of the following in the home that is in the parents’ or carers’ control:
a poor standard of hygiene that affects a child’s health
inadequate provision of food
a living environment that is unsafe for the child’s developmental stage.
Be aware that it may be difficult to distinguish between neglect and material poverty. However, care should be taken to balance recognition of the constraints on the parents’ or carers’ ability to meet their children’s needs for food, clothing and shelter with an appreciation of how people in similar circumstances have been able to meet those needs.
Be aware that abandoning a child is a form of maltreatment.
Consider neglect if a child displays faltering growth because of lack of provision of an adequate or appropriate diet. See NICE’s guideline on faltering growth.
Achieving a balance between an awareness of risk and allowing children freedom to learn by experience can be difficult. However, if parents or carers persistently fail to anticipate dangers and to take precautions to protect their child from harm it may constitute neglect.
Consider neglect if the explanation for an injury (for example, a burn, sunburn or an ingestion of a harmful substance) suggests a lack of appropriate supervision.
Consider neglect if a child or young person is not being cared for by a person who is able to provide adequate care.
Consider neglect if parents or carers fail to administer essential prescribed treatment for their child.
Consider neglect if parents or carers repeatedly fail to bring their child to follow-up appointments that are essential for their child’s health and wellbeing.
Consider neglect if parents or carers persistently fail to engage with relevant child health promotion programmes, which include:
immunisation
health and development reviews
screening.
Consider neglect if parents or carers have access to but persistently fail to obtain treatment for their child’s dental caries (tooth decay).
Suspect neglect if parents or carers fail to seek medical advice for their child to the extent that the child’s health and wellbeing is compromised, including if the child is in ongoing pain.
Consider child maltreatment if a child or young person displays or is reported to display a marked change in behaviour or emotional state (see examples below) that is a departure from what would be expected for their age and developmental stage and is not fully explained by a known stressful situation that is not part of child maltreatment (for example, bereavement or parental separation) or medical cause. Examples include:
recurrent nightmares containing similar themes
extreme distress
markedly oppositional behaviour
withdrawal of communication
becoming withdrawn.
Consider child maltreatment if a child’s behaviour or emotional state is not consistent with their age and developmental stage or cannot be fully explained by medical causes, neurodevelopmental disorders (for example, attention deficit hyperactivity disorder [ADHD], autism spectrum disorders) or other stressful situation that is not part of child maltreatment (for example, bereavement or parental separation). Examples of behaviour or emotional states that may fit this description include:
Emotional states:
fearful, withdrawn, low self-esteem
Behaviour:
aggressive, oppositional
habitual body rocking
Interpersonal behaviours:
indiscriminate contact or affection seeking
over-friendliness to strangers including healthcare professionals
excessive clinginess
persistently resorting to gaining attention
demonstrating excessively ‘good’ behaviour to prevent parental or carer disapproval
failing to seek or accept appropriate comfort or affection from an appropriate person when significantly distressed
coercive controlling behaviour towards parents or carers
lack of ability to understand and recognise emotions
very young children showing excessive comforting behaviours when witnessing parental or carer distress.
Consider child maltreatment if a child shows repeated, extreme or sustained emotional responses that are out of proportion to a situation and are not expected for the child’s age or developmental stage or fully explained by a medical cause, neurodevelopmental disorder (for example, ADHD, autism spectrum disorders) or bipolar disorder and the effects of any known past maltreatment have been explored. Examples of these emotional responses include:
anger or frustration expressed as a temper tantrum in a school-aged child
frequent rages at minor provocation
distress expressed as inconsolable crying.
Consider child maltreatment if a child shows dissociation (transient episodes of detachment that are outside the child’s control and that are distinguished from daydreaming, seizures or deliberate avoidance of interaction) that is not fully explained by a known traumatic event unrelated to maltreatment.
Consider child maltreatment if a child or young person regularly has responsibilities that interfere with the child’s essential normal daily activities (for example, school attendance).
Consider child maltreatment if a child responds to a health examination or assessment in an unusual, unexpected or developmentally inappropriate way (for example, extreme passivity, resistance or refusal).
Consider emotional abuse if there is concern that parent– or carer–child interactions may be harmful. Examples include:
Negativity or hostility towards a child or young person.
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 for the fulfilment of the adult’s needs (for example, in marital disputes).
Failure to promote the child’s appropriate socialisation (for example, involving children in unlawful activities, isolation, not providing stimulation or education).
Suspect emotional abuse if the interactions observed in recommendation 1.5.1 are persistent.
Consider child maltreatment if parents or carers are seen or reported to punish a child for wetting or soiling despite professional advice that the symptom is involuntary.
Consider emotional neglect if there is emotional unavailability and unresponsiveness from the parent or carer towards a child or young person and in particular towards an infant.
Suspect emotional neglect if the interaction observed in recommendation 1.5.4 is persistent.
Consider child maltreatment if a parent or carer refuses to allow a child or young person to speak to a healthcare professional on their own when it is necessary for the assessment of the child or young person.