1.1 Recognition of Significant Harm and Types of Abuse and Neglect

1. Introduction

Working Together to Safeguard Children provides that all agencies and practitioners should:

Have an applied understanding of what constitutes a child suffering actual or likely significant harm;
Be alert to potential indicators of abuse, neglect and exploitation, and listen carefully to what a child says, how they behave, and observes how they communicate if non-verbal (due to age, special needs and/or disabilities, or if unwilling to communicate);
Consider the severity, duration and frequency of any abuse, degree of threat, coercion, or cruelty, the significance of others in the child’s world, including all adults and children in contact with the child (this can include those within the immediate and wider family and those in contexts beyond the family, including online), and the cumulative impact of adverse events;
Try to understand the child’s personal experiences and observe and record any concerns;
Communicate in a way that is appropriate to the child’s age and level of understanding and use evidence-based practice tools for engaging with children, including those with special educational needs and disabilities;
When practitioners have concerns or information about a child that may indicate a child is suffering or likely to suffer significant harm, share them with relevant practitioners and escalate them if necessary, and update colleagues when they receive relevant new information;
Never assume that information has already been shared by another professional or family member and always remain open to changing their views about the likelihood of significant harm.

Working Together to Safeguard Children defines Safeguarding as:

• Protecting children from maltreatment, whether the risk of harm comes from within the child’s family and/or outside (from the wider community), including online;
Preventing impairment of children's mental and physical health or development;
Ensuring that children are growing up in circumstances consistent with the provision of safe and effective care; and
Taking action to enable all children to have the best outcomes.

Protecting children from maltreatment is important in preventing the impairment of health or development though that in itself may be insufficient to ensure that children are growing up in circumstances consistent with the provision of safe and effective care. These aspects of safeguarding and promoting welfare are cumulative, and all contribute to the outcomes set out in Introduction, Working Together to Safeguard Children.

Child protection is a part of safeguarding and promoting welfare. This refers to the activity that is undertaken to protect specific children who are suffering, or are likely to suffer, Significant Harm.

Effective child protection is essential as part of wider work to safeguard and promote the welfare of children. However, all agencies and individuals should aim to proactively safeguard and promote the welfare of children so that the need for action to protect children from harm is reduced.

Referrals should not be deemed malicious without a full and thorough multi-agency assessment, including talking with the referrer and agreement with the appropriate manager. Referrals should also not be described as malicious in professional conclusions, due to the risks associated with this language.

There are additional duties for schools to safeguard and promote the welfare of children and young people (Keeping children safe in education: Statutory guidance for schools and colleges). In essence these require all school staff to have knowledge of the signs and symptoms of abuse and an understanding of the local early help and child protection arrangements.

Schools also have additional responsibilities in cases of suspected FGM, Child on Child abuse and children at risk of sexual exploitation.

All staff should be aware that children can abuse other children (often referred to as child-on-child abuse), and that it can happen both inside and outside of school or college and online. All staff should be clear as to the school's or college's policy and procedures with regard to child-on-child abuse and the important role they have to play in preventing it and responding where they believe a child may be at risk from it.

Schools and colleges should be aware of the importance of:

Making clear that there is a zero-tolerance approach to sexual violence and sexual harassment, that it is never acceptable, and it will not be tolerated. It should never be passed off as 'banter, 'just having a laugh', 'a part of growing up' or 'boys being boys'. Failure to do so can lead to a culture of unacceptable behaviour, an unsafe environment and in worst-case scenarios a culture that normalises abuse, leading to children accepting it as normal and not coming forward to report it;
Recognising, acknowledging, and understanding the scale of harassment and abuse and that even if there are no reports it does not mean it is not happening, it may be the case that it is just not being reported;
Challenging physical behaviour (potentially criminal in nature) such as grabbing bottoms, breasts and genitalia, pulling down trousers, flicking bras and lifting up skirts. Dismissing or tolerating such behaviours risks normalising them.

2. Children in Need

Children who are defined as being In Need, under Section 17 of the Children Act 1989, are those whose vulnerability is such that they are unlikely to reach or maintain a satisfactory level of health or development, or their health and development will be significantly impaired, without the provision of services (Section 17(10) of the Children Act 1989), plus those who are disabled. The critical factors to be taken into account in deciding whether a child is in need under the Children Act 1989 are:

What will happen to a child's health or development without services being provided; and
The likely effect the services will have on the child's standard of health and development;
Local authorities have a duty to safeguard and promote the welfare of children in need.

3. The Concept of Significant Harm

Harm may occur intentionally or unintentionally. The definitions of harm outlined below, taken from Working Together to Safeguard Children are used to determine whether a child needs a child protection plan.

Some children are in need because they are suffering, or likely to suffer, Significant Harm. The Children Act 1989 introduced the concept of Significant Harm as the threshold that justifies compulsory intervention in family life in the best interests of children, and gives local authorities a duty to make enquiries to decide whether they should take action to safeguard or promote the welfare of a child who is suffering, or likely to suffer, Significant Harm.

A court may make a care order (committing the child to the care of the local authority) or supervision order (putting the child under the supervision of a social worker or a probation officer) in respect of a child if it is satisfied that:

The child is suffering, or is likely to suffer, Significant Harm; and
The harm, or likelihood of harm, is attributable to a lack of adequate parental care or control (Section 31).

There are no absolute criteria on which to rely when judging what constitutes Significant Harm. Consideration of the severity of ill-treatment may include the degree and the extent of physical harm, the duration and frequency of abuse and Neglect, the extent of premeditation, and the presence or degree of threat, coercion, sadism and bizarre or unusual elements. Each of these elements has been associated with more severe effects on the child, and/or relatively greater difficulty in helping the child overcome the adverse impact of the maltreatment. Sometimes, a single traumatic event may constitute Significant Harm, for example, a violent assault, suffocation or poisoning. More often, Significant Harm is a compilation of significant events, both acute and long-standing, which interrupt, change or damage the child's physical and psychological development. Some children live in family and social circumstances where their health and development are neglected. For them, it is the corrosiveness of long-term emotional, physical or Sexual Abuse that causes impairment to the extent of constituting Significant Harm.

In each case, it is necessary to consider any maltreatment alongside the child's own assessment of his or her safety and welfare, the family's strengths and supports (For more details see Adcock, M. and White, R. (1998). Significant Harm: its management and outcome. Surrey: Significant Publications), as well as an assessment of the likelihood and capacity for change and improvements in parenting and the care of children and young people.

To understand and identify Significant Harm, it is necessary to consider:

The nature of harm, in terms of maltreatment or failure to provide adequate care;
The impact on the child's health and development;
The child's development within the context of their family and wider environment;
Any special needs, such as a medical condition, communication impairment or disability, that may affect the child's development and care within the family;
The capacity of parents to meet adequately the child's needs;
The wider and environmental family context.

The child's reactions, his or her perceptions, and wishes and feelings should be ascertained and the local authority should give them due consideration, so far as is reasonably practicable and consistent with the child's welfare and having regard to the child's age and understanding. (Section 53 of the Children Act 2004 amended Section 17 and Section 47 of the Children Act 1989, so that before determining what, if any, services to provide to a child in need under Section 17, or action to take with respect to a child under Section 47, the wishes and feelings of the child should be ascertained as far as is reasonable and given due consideration).

Young people at serious risk of harm from community based violence such as gang, group and knife crime are likely to have significant needs. Agencies and practitioners need to ensure that the safeguarding process responds effectively to the needs of children at risk of suffering violence within the community. This may involve both the perpetrators and victims of violent activity.

Sometimes 'significant harm' refers to harm caused by one child to another (which may be a single event or a range of ill treatment), which is generally referred to as 'child on child abuse.'

4. Communicating with Children

Safeguarding children and young people depends on communicating effectively with them, including those who find it difficult to do so because of their age, impairment, or their particular psychological or social situation. See also: Recognition of Communication Difficulties, Underlying Principles and Values.

This may involve:

Using interpreters and drawing upon the expertise of early years workers or those working with disabled children;
Creating the right atmosphere when meeting and communicating with children, to help them feel at ease and reduce any pressure from parents, carers or others;
Reassuring children that they will not be victimised for sharing information or asking for help or protection; this applies to children living in families as well as those in institutional settings, including custody;
Ensuring that any accounts of adverse experiences coming from children are as accurate and complete as possible. Accuracy is key, for without it effective decisions cannot be made and, equally, inaccurate accounts can lead to children remaining unsafe, or to the possibility of wrongful actions being taken that affect children and adults.

(Jones, D. P. H. (2003). Communicating with Vulnerable Children: a Guide for Practitioners, pp.1-2. London: Gaskell.)

5. Early Help

Working Together to Safeguard Children Chapter 3, Section 1 sets out national guidance on early help. Early help means providing support as soon as a problem emerges at any point in a child's life that improves a family’s resilience and outcomes or reduces the chance of a problem getting worse. It is not an individual service, but a system of support delivered by local authorities and their partners working together and taking collective responsibility to provide the right provision in their area. Some early help is provided through ‘universal services’, such as education and health services. They are universal services because they are available to all families, regardless of their needs. Other early help services are coordinated by a local authority and/or their partners to address specific concerns within a family and can be described as targeted early help. Examples of these include parenting support, mental health support, youth services, youth offending teams and housing and employment services. Early help may be appropriate for children and families who have several needs, or whose circumstances might make them more vulnerable. It is a voluntary approach, requiring the family’s consent to receive support and services offered. These may be provided before and/or after statutory intervention.

The Early Help System Guide provides a toolkit to assist local strategic partnerships responsible for their early help system in their area. Effective provision relies upon local organisations and agencies working together to:

Identify children and families who would benefit from early help;
Undertake an assessment of the need for early help which considers the needs of all members of the family;
Ensure good ongoing communication, for example, through regular meetings between practitioners who are working with the family;
Co-ordinate and/or provide support as part of a plan to improve outcomes. This plan will be designed together with the child and family, and updated as and when the child and family needs change;
Engage effectively with families and their family network, making use of family group decision-making, such as family group conferences, to help meet the needs of the child.

Any child may benefit from early help, but practitioners should, in particular, be alert to the potential need for early help for a child who:

Is disabled and has specific additional needs;
Has special educational needs (whether or not they have a statutory Education, Health and Care Plan);
Is a young carer;
Is bereaved;
Is showing signs of being drawn in to anti-social or criminal behaviour, including being affected by gangs and county lines and organised crime groups and/or serious violence, including knife crime;
Is frequently missing/goes missing from care or from home;
Is persistently absent from education, including persistent absences for part of the school day;
Is at risk of modern slavery, trafficking, sexual and/or criminal exploitation;
Is at risk of being radicalised;
Is viewing problematic and/or inappropriate online content (for example, linked to violence), or developing inappropriate relationships online;
Is at risk of so called 'honour'-based abuse or Forced Marriage;
At risk of Female Genital Mutilation (FGM);
Is in a family circumstance presenting challenges for the child, such as drug and alcohol misuse, adult mental health issues and domestic abuse;
Is misusing drugs or alcohol themselves;
Is suffering from mental ill health;
Has returned home to their family from care;
Is a privately fostered child;
Has a parent/carer in custody;
Is missing education, or persistently absent from school, or not in receipt of fulltime education;
Has experienced multiple suspensions and is at risk of, or has been permanently excluded.

A lead practitioner should co-ordinate the activity around the family, ensure the assessment and the family plan responds to all needs identified, and lead on ensuring the family co-produce the plan. The plan might include the family network. The time commitment to deliver this role will vary family by family depending on the complexity of their needs. Where appropriate, local authorities should engage families, including children, to have a say in who their lead practitioner is, and have a process in place to collate feedback on their relationship with them. The lead practitioner role could be held by a range of people. More details about which practitioners may act as a lead practitioner, their roles and responsibilities along with additional guidance, are provided in the Early Help System Guide.

The practitioners in Sheffield are supported through training and supervision to understand their role in identifying emerging problems, so that they:

Know when to share information with other practitioners and what action to take to support early identification and assessment;
Are able to identify and recognise all forms of abuse, neglect, and exploitation;
Have an understanding of domestic and sexual abuse, including controlling and coercive behaviour as well as parental conflict that is frequent, intense, and unresolved;
Are aware of new and emerging threats, including online harm, grooming, sexual exploitation, criminal exploitation, radicalisation, and the role of technology and social media in presenting harm;
Are aware that a child and their family may be experiencing multiple needs at the same time.

The agencies in Sheffield have agreements in place such as the Threshold document which provide effective ways to identify emerging problems and potential unmet needs for individual children and families as well as clear guidance and procedures for all practitioners, including those in universal services and those providing services to adults with children. The provision of early help services should form part of a continuum of support to respond to the different levels of need of individual children and families.
The local Threshold document includes information as follows:

The process for early help assessments and the type and level of early help and targeted early help services to be provided;
The criteria, including the level of need, for when a child should be referred to children's social care for assessment and for statutory services under:

Section 17 of the Children Act 1989 (children in need, including how this applies for disabled children);
Section 47 of the Children Act 1989 (reasonable cause to suspect a child is suffering or likely to suffer significant harm);
Section 31 of the Children Act 1989 (care and supervision orders);
Section 20 of the Children Act 1989 (duty to accommodate a child); and

Clear procedures and processes for cases relating to:

The abuse, neglect and exploitation of children;
Children managed within the youth secure estate;
Disabled children.

6. What is Abuse and Neglect?

Abuse is a form of maltreatment of a child. Somebody may abuse or neglect a child by inflicting harm or by failing to act to prevent harm. Harm can include ill treatment that is not physical as well as the impact of witnessing ill treatment of others. This can be particularly relevant, for example, in relation to the impact on children of all forms of domestic abuse, including where they see, hear, or experience its effects. Children may be abused in a family or in an institutional or extra-familial contexts by those known to them or, more rarely, by others. Abuse can take place wholly online, or technology may be used to facilitate offline abuse. Children may be abused by an adult or adults or another child or children.

7. Impact of Abuse and Neglect

Neglect or abuse, physically, emotionally or sexually, can have major long-term effects on all aspects of a child's health, development and wellbeing. Sustained abuse is likely to have a deep impact on the child's self-image and self-esteem, and on his or her future life. Difficulties may extend into adulthood. The experience of long-term abuse may lead to difficulties in forming or sustaining close relationships, establishing oneself in the work force, and to extra difficulties in developing the attitudes and skills needed to be an effective parent.

It is not only the stressful events of abuse that have an impact, but also the context in which they take place. Any potentially abusive incident has to be seen in context to assess the extent of harm to a child and appropriate intervention. Often, it is the interaction between a number of factors that serve to increase the likelihood or level of actual Significant Harm.

For every child and family, there may be factors that aggravate the harm caused to the child, for example racial harassment or bullying as a result of a disability, and those that protect against harm, such as supportive extended family. Relevant factors include the individual child's means of coping and adapting, support from a family and social network, and the impact of any interventions. The effects of harm on a child are also influenced by the quality of the family environment at the time of the abuse, and subsequent life events. An important point, sometimes overlooked, is the manner in which practitioners intervene may have a significant influence on subsequent outcomes.

8. Physical Abuse

Physical abuse 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.

Physical abuse can lead directly to neurological damage, physical injuries, pain and disability or, at the extreme, death. Harm may be caused to a child both by the abuse itself, and by the abuse taking place in a wider family or institutional context, of conflict and aggression. Physical abuse has been linked to aggressive behaviour, emotional and behavioural problems, and educational difficulties. Where a child is disabled, injuries or behavioural symptoms may mistakenly be attributed to his or her disability rather than the abuse.

8.1 Indicators of Physical Abuse

'Physical abuse varies from fatal to severe or moderate. All abuse is serious, and soft tissue injuries such as bruising involve considerable force in their production. This in turn inflicts pain and is invariably associated with some degree of emotional abuse, including harsh words, threats and rejection. The degree of danger of an injury relates especially to the age of the child. A small bruise in a baby may be a predictor of later serious or fatal abuse whereas a beating in an older child may denote no threat to life'.

The degree of risk to the child relates to the situation in the family rather than to the severity of the injury. The following offers a guide to the more common injuries found in cases of child abuse.

There are certain inconsistencies that are known by research and experience to suggest a cause for concern in relation to physical abuse. These include:

Unexplained delay in seeking treatment that is obviously needed, or treatment is sought at an inappropriate time;
Unawareness or denial of any injury;
Incompatible, vague or inadequate, discrepant explanations for the injury;
Inappropriate to the child's development e.g. non-mobile child;
Inappropriate care response e.g. unconcerned, aggressive;
Inappropriate child response e.g. did not cry/felt no pain;
Reluctance to give information or failure to mention previous injuries known to have occurred;
Consent for further medical investigation is refused.

Repeated presentation of minor injuries or illnesses, often to the GP or Accident and Emergency, which may represent a 'cry for help' and which, if not taken seriously, may lead to more serious injury.

N.B. Minor injuries in babies may be an indication that more serious injuries, like fractures, have already been sustained.

8.1.1 Bruises

Bruising occurs when blood is released from blood vessels into the surrounding tissues and is usually the result of trauma, accidental or non-accidental. Accidental bruising has a correlation to the developmental stage and mobility of a child under 5 years old. Non-mobile children should not have bruises without a clear, usually observed, incident consistent with the injury. In rare cases of severe bleeding disorder the force required to cause the injury may be minimal. If parents/main carers suspect that the child suffers from a bleeding disorder, and indicate that the child 'bruises very easily', this can be checked by the paediatrician.

Recent reviews of research literature by the Department of Child Health, Cardiff University have been used in these guidelines:

Accidental bruising

Occurs from everyday play activities and accidents;
Patterns do not differ by socio-economic group;
Patterns do not differ between boys and girls;
Increase in number in summer months and with increasing family size;
Increase in number with age and mobility;
Very uncommon in infants who are not yet crawling;
In walking children are commonest on shins and knees;
Most occur over bony prominences and at the front of the body, including the forehead;
Uncommon on back, buttocks, forearm, face, ears, abdomen, upper arm, posterior leg, foot or hands.

N.B. Bruising to the forehead, however, is commonly accidental.

Non-accidental bruises

No gender difference;
On average more numerous than in accidental bruising;
On average significantly bigger than accidental bruising;
Commonest sites are head, ear, face, neck, trunk, buttocks and arms;
Common on soft parts of the body away from bony prominences;
Multiple bruises in clusters;
May carry the impression of the implement used;
Patterned bruising can be accompanied by petechiae (pinpoint bruising) e.g. slap marks or compression injuries.

N.B. Fatal non-accidental head injury and fractures can occur without bruising.

Patterns of bruising

Some patterns of bruising suggest the cause of the injury, e.g.

Bruising in or around the mouth, or torn frenulum in non-mobile children (flap of tissue between gum and lip). In small babies this can indicate force-feeding. It may be associated with injuries to other parts of the mouth such as the teeth, tongue, palate and inner cheeks;
Grasp marks: On the arms, or chest of a child, caused often by forcibly holding the child;
Finger-tip bruises: These are small, round or oval and may occur on the face or the body. Often there will be a single mark (thumb) on one surface, with several reciprocal marks (fingers) on an opposite surface. If seen on cheeks, these marks are suggestive of gripping or squeezing the face;
Linear bruising: This may occur for example on the cheeks or ears (including behind the ears), caused by hand slaps; or on the bottom or back, caused by a hand, belt, or stick;
Bite marks: These are always inflicted injuries. They are usually round or oval marks often with a gap at each side or two crescent-shaped bruises. They can be made by an adult or a child, and it is sometimes possible for a forensic dentist to identify the perpetrator if the mark is recent and clear. Animal bites result in a different type of injury, with puncturing of the skin, although these too may be considered abusive if the dog's owner encouraged the attack.

We cannot age bruises accurately by colour

There is inter-observer variation in the perception of the colour of a bruise. Different colours appear in the same bruise at the same time and not all colours occur in every bruise. Bruises which occur at different times may display different colours. Research has shown that yellow discolouration does not occur within 24 hours of a bruise being sustained.

Bruising and black children

It is sometimes more difficult to see bruising in black children. Tenderness or minor swelling over the area of injury is an important clinical finding.

Eye injuries

Should always be seen by a doctor, even when they are thought to be accidental, as all the damage may not be visible without a proper examination, and treatment may be needed.

Some medical conditions can masquerade as bruising

A medical opinion is usually required to make the diagnosis.

8.1.2 Fractures and joint injuries

The following should be noted:

It takes considerable force to fracture a bone in an infant or child. All fractures require a consistent history and should be consistent with the developmental age of the child;
Any fracture that does not have a clearly accidental history should cause concern;
Fractures should be suspected if there is pain, swelling or occasionally discolouration over a limb or a joint, or a young child stops using a limb;
It is very rare for a child under one year to sustain a fracture accidentally and toddlers rarely sustain more than a greenstick, spiral tibia, or supracondylar fracture accidentally. Fractures normally cause pain and it is difficult for a parent to be unaware that the child has been hurt apart from where the fracture is greenstick, torous, or scaphoid;
Non-accidental fractures can be asymptomatic, particularly in infants where a skeletal survey may be required even in the absence of signs and symptoms. The need for a skeletal survey will be decided by the paediatrician;
The medical assessment of fractures and other bony injury often requires the involvement of several medical specialties including paediatrician, orthopaedic surgeon, and radiologist amongst others.

Fractures that may cause concern

Any fracture can be non-accidental and most can be caused accidentally. However, in the absence of underlying bone disease, certain fractures cause more concern than others. These include:

Any fracture in a young non-mobile child without consistent history;
Spiral fracture, particularly of the humerus;
Fractured femur in a child who is not yet walking;
Multiple fractures;
Multiple fractures in various stages of healing;
Injuries to the growing ends of the long bones (metaphyseal fractures);
Rib fractures;
Some skull fractures particularly complex ones or those which cross suture lines;
Spinal fractures.

A tender swollen limb with a normal X-ray may require a further X-ray 11-14 days later to reveal a fracture or bleeding under the lining of the bone.

A skeletal survey may be recommended by the paediatrician particularly in infants and toddlers who present with bruising or other injuries. It may need to be repeated, in total or partially, 2-3 weeks after the first survey.

Some medical conditions masquerade as non-accidental bony injury. The paediatrician will consider these when giving an opinion on the injury.

8.1.3 Brain and eye injuries

Death and permanent damage amongst abused infants and children are most frequently caused by head trauma, particularly in infants less than 6 months of age. Shaking injuries account for a significant proportion of these. The infants can present to hospital with a variety of signs and symptoms, including:

Sub-conjunctival haemorrhages;
Bruising or other injuries to the head;
Skull fractures with overlying swelling;
Enlarged head;
Irritability;
Vomiting, drowsiness;
Failure to thrive;
Collapse and unconsciousness;
Fits.

The infants are often found to have other injuries when examined, such as a torn frenulum, retinal haemorrhages, fractures on skeletal survey and subdural haematomas and hypoxic changes on brain scan. A skeletal survey is recommended on any infant in whom non-accidental head injury is suspected. Repeat brain scans are also required.

8.1.4 Internal injuries

Intra-abdominal injuries occur rarely either from accidental or non-accidental injury but do occasionally occur particularly in infants and young children. They have a high mortality rate. Diagnosis is difficult particularly in the absence of any history. If they do occur:

They are most common in the small bowel, but any solid organ can be involved;
They can be present without any sign of external bruising or bruising may be delayed;
Indicators can be unexplained collapse/severe abdominal pain/sepsis vomiting, restlessness, fever, pain, pallor and shock.

Management needs to be undertaken by paediatric surgeons.

8.1.5 Burns and scalds

Burns and scalds are common accidental injuries, resulting from varying degrees of parental inattention, so neglect may have to be considered at presentation. A number involve deliberate abuse. 1-29% have been reported as deliberately inflicted. Features causing concern about non-accidental injury include:

The same features in the history and presentation as for non-accidental bruising;
Burns or scalds with clear outlines of glove and stocking effect;
Small round marks which look as if they have been 'punched out' and have a dark, thick base, may be deliberate cigarette burns: brushing accidentally against a cigarette causes a flame-shaped mark. However, impetigo looks very similar and a paediatric opinion should be sought;
Contact burns with the outline of the hot object;
Friction burns;
Bilateral burns;
Burns on backs of hands and on feet.

N.B. A full thickness scald can occur in one second from liquids at a temperature of 60ºC.

8.1.6 Scars

Most children have some scars particularly on the areas most commonly injured accidentally such as knees and elbows, but an exceptionally large number should cause concern, particularly if of different ages and if accompanied by current bruising. Unusually shaped scars, (e.g. old cigarette burns) or large scars (e.g. burns that did not receive treatment) are also of concern.

8.1.7 Intentional poisoning

A child's ingestion of tablets, medicines, laxatives, domestic products, alcohol, drugs, and dangerous amounts of salt, may not always be due to accidental carelessness. A carer may administer substances like sedatives to a child to keep them quiet at night, or may wish to harm the child.

Symptoms may be extremely variable but may include drowsiness, vomiting, or seizures. Multiple attendances of children in a family with 'accidental ingestions' at an Emergency Department may signify intentional poisoning or at least lack of appropriate parental supervision when neglect may be a factor. 'Double' ingestions are of particular concern.

8.1.8 Suffocation

It may be impossible to differentiate intentional airways obstruction from other causes of unexplained death in infancy. It may present in young infants as:

Sudden death;
A well baby with a history of recurrent episodes of apnoea (cessation or suspension of breathing), cyanotic (blue) episodes, recurrent seizures, unexplained or unusual collapse, bleeding from the mouth and nose;
May be associated with petechiae (pinpoint bruising) around upper body, other injuries such as fractured ribs on skeletal survey or intra-cranial injury.

All infants should be admitted and investigated.

8.1.9 Fabricated or Induced Illness

This is the induction of an appearance of illness, or an actual state of physical ill health, most often by a parent/carer and may include some cases of suffocation, non-accidental poisoning and sudden infant death. The child is presented to health practitioners for investigation/treatment. It may be done in three ways:

Fabrication of symptoms of illness or injury, (inventing a story about illness);
Alteration of laboratory specimens like urine or blood;
Direct production by the perpetrator of the physical signs or the disease itself in the child e.g. causing scabbed lesions or poisoning.

In the first two of these, the harm to the child is indirect and caused by medical investigation/treatment; in the third, the harm is caused directly by the perpetrator, and then possibly compounded by medical investigation/treatment.

The acute signs and symptoms of the illness cease when the child is separated from the perpetrator.

It is important not to confuse this form of abuse with the actions of an over-anxious parent/carer who frequently seeks advice from health practitioners.

There are many and varied presentations of this condition but it should be considered if:

The signs and symptoms are unexplained and/or inconsistent;
New symptoms appear on resolution of the previous ones;
Bizarre symptoms;
Child's activities inappropriately restricted;
Incongruity between story and actions of parents/carers.

The doctor is usually the practitioner who first suspects Fabricated or Induced Illness. Its management requires involvement of other agencies, as outlined in the Fabricated or Induced Illness / Perplexing Presentations Procedure.

9. Emotional Abuse

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 children 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 may feature age or developmentally inappropriate expectations being imposed on children. These may include interactions that are beyond the child's developmental capability, as well as overprotection 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 cyberbullying), causing children frequently to 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.

There is increasing evidence of the adverse long-term consequences for children's development where they have been subject to sustained emotional abuse. Emotional abuse has an important impact on a developing child's mental health, behaviour and self-esteem. It can be especially damaging in infancy. Underlying emotional abuse may be as important, if not more so, than other more visible forms of abuse in terms of its impact on the child. In families where the child experiences a low level of emotional warmth and a high level of criticism, negative incidents may have a more damaging impact on the child. Domestic abuse, adult mental ill health problems, substance misuse, learning difficulties, may feature in families where children are exposed to emotional abuse, and in extreme cases can lead to suicide.

9.1 Indicators of Emotional Abuse

It is necessary to have further information about the context in which some of the following factors are seen, as they may have a number of different causes, some not related to abuse.

Physical, mental and emotional developmental delay or disturbance;
Punishment which appears excessive;
Domestic abuse between carers or others;
Over-reaction to mistakes;
Sudden speech disorders;
Fear of new situations;
Inappropriate emotional responses to stressful situations;
Self-mutilation;
Fear of parents being contacted;
Extremes of passivity or aggression;
Wetting/soiling;
Substance misuse;
Chronic running away;
Inability to play;
Compulsive stealing.

Parents/main caregivers' responses to the child may give cause for concern:

Scapegoating;
Ostracizing from normal family contact or activities;
Not allowing the child to receive gifts, play with toys, go on outings, when other family members are allowed to;
Indifference to the child's needs;
Hostility towards the child;
Ridicule, sarcasm, deliberate frightening, threatening;
Deliberately withholding, or forcing a child to 'earn', basic necessities like food, clothes, drink and warmth;
Cruelty, like being locked up in cold, dark surroundings;
Encouraging other members of the family to respond to the child in any of these ways.

Where emotional abuse is suspected, it will be most helpful to request expert assessment by the relevant Child and Family Therapy team (Children and Young People’s Mental Health Services (CYPMHS)).

Sometimes children may exhibit signs of emotional abuse when the cause is outside the family. Experience of bullying or racism may be the cause.

10. Sexual Abuse

Sexual abuse involves forcing or enticing a child or young person to take part in sexual activities, not necessarily involving a high level of violence, 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.

Sexual abuse 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.

In addition, sexual abuse includes abuse of children through sexual exploitation which occurs where an individual or group takes advantage of an imbalance of power to coerce, manipulate or deceive a child or young person under the age of 18 into sexual activity (a) in exchange for something the victim needs or wants, and/or (b) for the financial advantage or increased status of the perpetrator or facilitator. The victim may have been sexually exploited even if the sexual activity appears consensual. Child sexual exploitation does not always involve physical contact; it can also occur through the use of technology.

A child under the age of 13 is not legally capable of consenting to sex (it is statutory rape) or any other type of sexual touching:

Sexual activity with a child under 16 is also an offence;
It is an offence for a person to have a sexual relationship with a 16 or 17 year old if they hold a position of trust or authority in relation to them;
Where sexual activity with a 16 or 17 year old does not result in an offence being committed, it may still result in harm, or the likelihood of harm being suffered;
Non-consensual sex is rape whatever the age of the victim; and
If the victim is incapacitated through drink or drugs, or the victim or their family has been subject to violence or the threat of it, they cannot be considered to have given true consent; therefore offences may have been committed;
Child sexual exploitation is therefore potentially a child protection issue for all children under the age of 18 years and not just those in a specific age group.

10.1 Indicators of Sexual Abuse

Sexual abuse often occurs in association with other types of abuse. Its presentation can be varied and include:

Disclosure: this should be taken seriously and assessed by experienced practitioners. Bear in mind that the child may at first disclose only a minor part of any abuse and practitioners should have a low threshold for requesting a medical examination;
Specific physical findings e.g. genital signs of a sexual assault after an allegation of rape;
Behavioural changes e.g. sexualised behaviour inconsistent with the child's age and development, e.g. new onset of bowel or bladder disturbance in a child who was previously clean and dry, self harm in older children and young people;
Physical findings presenting as a medical problem e.g. rectal bleeding presenting as diarrhoea, vulvovaginitis;
Physical findings such as love bites/bruising around breasts, thighs or genitalia;
Specific signs or symptoms e.g. pregnancy, sexually transmitted diseases.

Medical examination is important in these children to look for medical and forensic evidence, to check on the physical and psychological wellbeing of the child, and to assess for further investigation and treatment and support.

11. Neglect

11.1 Indicators of Neglect

Neglect occurs when the standard of care falls below acceptable standards. It is important to keep the same expected standard of care for all children and not lower it in areas of high deprivation. Disabled children are at particular risk. Neglect covers the whole of the child's life and includes:

Neglect of the child's physical needs, e.g. nutrition/hygiene/clothing with presentation outside acceptable norms, failure to thrive, occasionally obesity;
Neglect of the child's medical needs, including routine needs such as immunisation as well as more urgent medical care;
Poor supervision and lack of awareness of safety, e.g. leading to increased 'accidental' injury and increased Accident and Emergency Department attendances;
Failure to ensure adequate stimulation and education;
Neglect of social needs;
Lack of appropriate affection.

These children may present with:

The physical signs of neglect: failure to thrive, poor hygiene and personal presentation;
Behavioural problems such as scavenging for food, voracious appetite, chronic running away, low self esteem, poor social functioning, indiscriminately seeking affection or attention from adults;
Developmental problems such as not reaching developmental milestones, poor language development, poor intellectual and social development.

Failure to thrive may be recognised in primary health care using standard techniques of growth measurement in a programme of health surveillance. The reason for the failure to thrive can only be discovered through a more detailed assessment, including an appropriate medical assessment.

12. Domestic Abuse

The Domestic Abuse Act 2021 says that behaviour is 'abusive' if it consists of any of the following:

Physical or sexual abuse;
Violent or threatening behaviour;
Controlling or coercive behaviour;
Economic abuse;
Psychological, emotional or other abuse;

and it does not matter whether the behaviour consists of a single incident or a course of conduct. The perpetrator of the abuse and the victim of the abuse have to be aged 16 or over and are 'personally connected' as intimate partners, ex-partners, family members or individuals who share parental responsibility for a child. There is no requirement for the victim and perpetrator to live in the same household.

Types of domestic abuse include intimate partner violence, abuse by family members, teenage relationship abuse and child to parent abuse. Anyone can be a victim of domestic abuse, regardless of sexual identity, age, ethnicity, socio-economic status, sexuality or background and domestic abuse can take place inside or outside of the home.

Domestic abuse has a significant impact on children and young people. Children may experience domestic abuse directly, as victims in their own right, or indirectly due to the impact the abuse has on others such as the non-abusive parent.

Domestic abuse in teenage relationships is just as severe and has the potential to be as life threatening as abuse in adult relationships.

13. Factors that may Impact on Parenting Capacity

Children may suffer directly and indirectly if they live in households where any of the following factors may be present. The risk to children may be heightened where a number of these factors co-exist. See also the procedures relating to:

Disabled Children Procedure

Domestic Abuse Procedure

Safeguarding Children Living in Families with Drug and / or Alcohol Misuse Protocol

Parents, Carers or family Members with Mental Ill Health Procedure

Children of Parents with Learning Difficulties Procedure

Fabricated or Induced Illness / Perplexing Presentations Procedure

14. Non-Recent (Historical) Abuse

Allegations of child abuse are sometimes made by adults and children many years after the abuse has occurred. There are many reasons for an allegation not being made at the time including fear of reprisals, the degree of control exercised by the abuser, shame or fear that the allegation may not be believed. The person becoming aware that the abuser is being investigated for a similar matter or their suspicions that the abuse is continuing against other children may trigger the allegation.

Reports of historical allegations may be complex as the alleged victims may no longer be living in the situations where the incidents occurred, or where the alleged perpetrators are also no longer linked to the setting or employment role. Such cases should be responded to in the same way as any other concerns. It is important to ascertain as a matter of urgency if the alleged perpetrator is still working with, or caring for, children.

Organisational responses to allegations by an adult of abuse experienced as a child must be of as high a standard as a response to current abuse because:

There is a significant likelihood that a person who abused a child/ren in the past will have continued and may still be doing so;
Criminal prosecutions can still take place despite the fact that the allegations are historical in nature and may have taken place many years ago.

If it comes to light that the historical abuse is part of a wider setting of institutional or organised abuse, the case will be dealt with according to the Organised and Complex Abuse Procedure.

15. Extra-familial Harm

Children may be at risk of or experiencing physical, sexual, or emotional abuse and exploitation in contexts outside their families.

Extra-familial contexts include a range of environments outside the family home in which harm can occur. These can include peer groups, school, and community/public spaces, including known places in the community where there are concerns about risks to children (for example, parks, housing estates, shopping centres, takeaway restaurants, or transport hubs), as well as online, including social media or gaming platforms.

Working Together to Safeguard Children recognises that, whilst there is no legal definition for the term extra-familial harm, it is widely used to describe different forms of harm that occur outside the home. Children can be vulnerable to multiple forms of extra-familial harm from both adults and/or other children. Examples of extra-familial harm may include (but are not limited to): criminal exploitation (such as county lines and financial exploitation), serious violence, modern slavery and trafficking, online harm, sexual exploitation, child-on-child (nonfamilial) sexual abuse and other forms of harmful sexual behaviour displayed by children towards their peers, abuse, and/or coercive control, children may experience in their own intimate relationships (sometimes called teenage relationship abuse), and the influences of extremism which could lead to radicalisation.

16. Technology Assisted Abuse

Technology is a significant component in many safeguarding and wellbeing issues. Children are at risk of abuse and other risks online as well as face to face. In many cases abuse and other risks will take place concurrently both online and offline.

Children can also abuse other children online, this can take the form of abusive, harassing, and misogynistic/misandrist messages, the non-consensual sharing of indecent images, especially around chat groups, and the sharing of abusive images and pornography, to those who do not want to receive such content. Children can also be groomed online and through social media by people coercing or manipulating them to sexually or criminally exploit them or seeking to radicalise them.

See Online Safety Procedure.

17. Child on Child Sexual Violence and Sexual Harassment

Keeping Children Safe in Education Part five: Child on Child Sexual Violence and Sexual Harassment sets out how schools and colleges should respond to all signs, reports and concerns of child-on-child sexual violence and sexual harassment, including those that have happened outside of the school or college premises, and/or online.

Sexual violence and sexual harassment can occur between two or more children of any age and sex, from primary through to secondary stage and into college. It can occur also through a group of children sexually assaulting or sexually harassing a single child or group of children. Sexual violence and sexual harassment exist on a continuum and may overlap; they can occur online and face-to-face (both physically and verbally) and are never acceptable.

Sexual Violence

Child on child sexual violence refers to sexual offences under the Sexual Offences Act 2003 as described below:

Rape: A person (A) commits an offence of rape if: he intentionally penetrates the vagina, anus or mouth of another person (B) with his penis, B does not consent to the penetration and A does not reasonably believe that B consents.

Assault by Penetration: A person (A) commits an offence if: s/he intentionally penetrates the vagina or anus of another person (B) with a part of her/his body or anything else, the penetration is sexual, B does not consent to the penetration and A does not reasonably believe that B consents.

Sexual Assault: A person (A) commits an offence of sexual assault if: they intentionally touches another person (B), the touching is sexual, B does not consent to the touching and A does not reasonably believe that B consents.

NOTE: Schools and colleges should be aware that sexual assault covers a very wide range of behaviour so a single act of kissing someone without consent, or touching someone's bottom/breasts/genitalia without consent, can still constitute sexual assault.

Sexual Harassment

Child on child sexual harassment means 'unwanted conduct of a sexual nature' that can occur online and offline and both inside and outside of school/college. Sexual harassment is likely to: violate a child's dignity, and/or make them feel intimidated, degraded or humiliated and/or create a hostile, offensive or sexualised environment.

Sexual harassment can include:

Sexual comments, such as: telling sexual stories, making lewd comments, making sexual remarks about clothes and appearance and calling someone sexualised names;
Sexual 'jokes' or taunting;
Physical behaviour, such as: deliberately brushing against someone, interfering with someone's clothes. Schools and colleges should be considering when any of this crosses a line into sexual violence – it is important to talk to and consider the experience of the victim;
Displaying pictures, photos or drawings of a sexual nature;
Upskirting (this is a criminal offence); and

Online sexual harassment. This may be standalone, or part of a wider pattern of sexual harassment and/or sexual violence. It may include:

Consensual and non-consensual sharing of nude and semi-nude images and/or videos. Taking and sharing nude photographs of under 18s is a criminal offence. UKCIS Sharing nudes and semi-nudes: advice for education settings working with children and young people provides detailed advice for schools and colleges;
Sharing of unwanted explicit content;
Sexualised online bullying;
Unwanted sexual comments and messages, including, on social media;
Sexual exploitation; coercion and threats; and
Coercing others into sharing images of themselves or performing acts they're not comfortable with online.

It is essential that all victims are reassured that they are being taken seriously and that they will be supported and kept safe. A victim should never be given the impression that they are creating a problem by reporting sexual violence or sexual harassment. Nor should a victim ever be made to feel ashamed for making a report.

See also: Addressing Child-on-child Abuse: a Resource for Schools and Colleges (Farrer and Co.) which is intended to be used as a resource and reference document for practitioners.

See Sheffield's Multi-Agency Response to the Assessment and Intervention of Children and Young People with Harmful Sexual Behaviour Procedure.