Dr Christine Habgood explains how NICE guidance directs professionals to obtain further information and take appropriate steps if child maltreatment is a possibility
  • Child maltreatment needs to be included as a possible cause of many clinical features
  • There are a range of obstacles that can prevent healthcare professionals from recognising and responding to child maltreatment, including concern about missing a treatable disorder, fear of wrongly blaming a parent/carer, and stress
  • Professionals should follow a process of:
    • listen and observe
    • seek an explanation
    • record
    • considering maltreatment
    • suspecting maltreatment
    • excluding maltreatment

Child maltreatment encompasses a range of harms to children including physical, sexual, and emotional abuse, neglect, and fabricated or induced illness.1 It is difficult to be certain of prevalence but research by Cawson for the NSPCC (2002) suggests that as many as 16% (1 in 6) of children experience serious maltreatment by their parents, with more than one form of maltreatment often co-existing.2 The effects of maltreatment persist into adulthood, and a child who has been maltreated is at an increased risk of later problems including:2

  • drug and alcohol misuse
  • juvenile or adult criminal behaviour
  • imprisonment
  • mental illness
  • homelessness.

It is hoped that early recognition of maltreatment and provision of appropriate services to the family, while incurring a cost in the short term, would reduce these significant consequences.3

Need for the guideline

Recognition of child maltreatment can sometimes be problematic for healthcare professionals as they will see symptoms, signs, and behaviours that can result from both medical and other conditions. Therefore, for many of these presentations, child maltreatment should be included in the list of possible causes.
This involves considering maltreatment and then looking further to either exclude it as a cause, or seeking further information and evidence to confirm or exclude a suspicion. However, there are a number of obstacles that can prevent healthcare professionals from recognising maltreatment and acting on their concerns:1

  • Concern about missing a treatable disorder
  • Fear of losing a positive relationship with a family already under their care
  • Discomfort of disbelieving, thinking ill of, suspecting, or wrongly blaming a parent or carer
  • Divided duties to adult and child patients and breaching confidentiality
  • An understanding of the reasons why the maltreatment might have occurred, and that there was no intention to harm the child
  • Losing control over the child protection process and doubts about its benefits
  • Stress
  • Personal safety
  • Fear of complaints.

The NICE guideline When to suspect child maltreatment is aimed primarily at front-line health workers who may come into contact with children during their work.1 This includes GPs, health visitors, school nurses, and staff working in accident and emergency departments, and others such as those working in adult mental health services where they may see children or be aware of risk factors. It may also be useful for those working for agencies outside health.

Application of the guidance

The NICE guideline contains a list of symptoms, signs, and presentations that may be indicative of child maltreatment, including:

  • physical features
  • clinical presentations
  • neglect
  • emotional, behavioural, interpersonal, and social functioning
  • parent–child interactions.

The guideline divides alerting features into those where the professional should consider or suspect maltreatment. Very specific understandings of these two terms have been used throughout the guidance:

  • Consider: maltreatment is one possible explanation of the alerting feature or is included in the differential diagnosis
  • Suspect: serious level of concern about the possibility of child maltreatment but not proof of it.

Pragmatic statements such as: ‘It may be difficult to distinguish between neglect and material poverty’, and ‘Children often become smelly or dirty during the course of the day’, will be helpful in emphasising the distinction that maltreatment involves harm to a child.1

The full version of the guideline is only available online via the NICE website.4 Within the document is a summary of the research evidence used to formulate some of the recommendations. For other indicators of maltreatment there was insufficient high-quality published evidence to make recommendations; in these cases, the multidisciplinary Guideline Development Group (GDG) based recommendations for these indicators on careful consideration, advice from other experts, and review by Delphi consensus survey. Professionals needing information to support their management of a case may find it very useful to review the evidence and recommendations relating to a particular symptom or sign.

The quick reference guide is available on the NICE website and in hard copy for regular use by professionals.5 It contains a summary of the main recommendations of the clinical guideline. This accessible summary aims to raise awareness of child maltreatment as a possible cause of common presentations; the flow chart, which forms the first page, provides professionals with a best practice step-by-step guide on when to consider or suspect child maltreatment when encountering an alerting feature (see Figure 1).

The Understanding NICE guidance document is an information leaflet for people who use NHS services.6 It explains to service users what the guideline says about child maltreatment. Professionals and others may find it helpful to provide a copy of the leaflet to those they are working with. The section about confidentiality and professional responsibilities in safeguarding children may be particularly useful.

Figure 1: Guide on when to consider or suspect child maltreatment if an alerting feature is encountered5
National Institute for Health and Care Excellence (NICE) (2009) CG89. When to suspect child maltreatment. London: NICE. Reproduced with permission. Available from www.nice.org.uk/CG89

Acting on possible maltreatment

Maltreatment is often a hidden problem, which can be difficult to recognise because there is so much overlap with other reasons for a clinical feature. The first step in improving recognition of maltreatment is to raise the awareness of professionals in contact with children. They also need to be able to act with confidence when they become aware that maltreatment of a child might be possible. Providing a framework for discussion and advising that it is appropriate to seek advice from more experienced colleagues is vital.1,5

The NICE guideline proposes the following process if child maltreatment is a possible explanation:1,4,5

1. Listen and observe
A holistic assessment of the child should be adopted and should include:

  • the history provided
  • reports of maltreatment, or disclosure from a child or young person, or third party
  • the child’s appearance, behaviour, or demeanour
  • whether symptoms, signs, and investigations fit the explanation given, and observations of the interaction between child, parents or carers, and others.

2. Seek an explanation
Seek an explanation for any injury or presentation from both the parent or carer and the child. This should be performed in an open and non-judgemental way. An unsuitable explanation is one that is implausible, inadequate, inconsistent, or is based on cultural practice (because this should not justify hurting a child or young person). Professionals should be aware that disabilities in a child may make identification of maltreatment more difficult.

3. Record
Records should be kept as to what is observed, heard and from whom and when. The reason why this is of concern should be documented.

At this point the healthcare professional may consider, suspect, or exclude child maltreatment from the differential diagnosis.

Consider maltreatment
If an alerting feature prompts the consideration of maltreatment:

  • look for other alerting features of maltreatment in the child or young person’s history, presentation, or parent/carer–child interactions now or previously.

Then do one or more of the following:

  • Discuss concerns with a more experienced colleague, a community paediatrician, child and adolescent mental health service colleague, or a named or designated professional for safeguarding children
  • Collect collateral information from other agencies and health disciplines
  • Ensure review of the child or young person at a date appropriate to the concern, looking out for repeated presentations of this or any other alerting features.

Suspect maltreatment

  • If an alerting feature or considering child maltreatment prompts suspicion of child maltreatment refer the child or young person to children’s social care, following local safeguarding children board procedures.7

Exclude maltreatment
Child maltreatment should be excluded if a suitable explanation is found for an alerting feature. This may occur after discussion of the case with a more experienced colleague or after gathering collateral information as part of considering child maltreatment.

The actions of professionals after they come to suspect maltreatment are outside the scope of this guidance.

Changes in current practice

Many of the alerting features covered will be very familiar to GPs and others; for example, signs of physical injury. In these clinical situations, the guidance will be welcomed for bringing together information in an accessible and comprehensive way. The guidance also encourages professionals to consider aspects of presentation in a way that may be new for them. It may be helpful to think about observing parent– or carer–child interactions as part of the holistic assessment of a child. Persistent harmful interactions should lead the professional to think about emotional abuse and its significant long-term harm. Persistent emotional unavailability and unresponsiveness from the parent or carer towards the child may indicate emotional neglect. These are particularly significant areas as it is possible to imagine, for example, that intervention to treat a parental depression or provide education on parenting skills would bring long-term benefits for both parent and child.1

The idea of putting child maltreatment into a medical differential diagnosis is particularly useful in the area of fabricated or induced illness. Too often this form of maltreatment has been considered as a ‘diagnosis of exclusion’, only considered after rare medical diagnoses. In practice it may be much more appropriate to put maltreatment into the list of possible causes at a much earlier stage. This would lead staff to be alert to other co-existent indicators at the same time as pursuing medical tests.

The guideline will provide both help in day-to-day contact with children and families and serve as a more detailed resource when there is a need to access information on a specific indicator. It also provides a starting point for those responsible for the training of professionals. A slide set for this purpose can be downloaded from the NICE website (www.nice.org.uk). Teachers and trainers will find that it is useful to discuss the process of decision making when skilled professionals are considering whether maltreatment should be suspected in a particular child.


This guidance puts child maltreatment firmly alongside all the other reasons for symptoms, signs, and behaviours observed by front-line healthcare professionals. It encourages them to think about possible causes of indicators and feel more confident about verbalising these concerns with appropriate colleagues and other agencies. The recommendations are evidence based whenever high-quality research is available; and founded on a rigorous approach to consensus building for areas of practice not covered by sufficient research. Both the GDG and the review process included input from professionals with specialist knowledge and those based in day-to-day community and hospital practice. Members came from a wide range of backgrounds, including healthcare workers, those from other professions and consumer representatives, and the process of development of the guideline constantly challenged assumptions and preconceptions. The guideline bridges research evidence, experience, and ‘real-world’ practice; and has been welcomed by practitioners and those with responsibility for their teaching and training.

NICE implementation tools

NICE has developed the following tools to support implementation of the NICE guideline When to suspect child maltreatment. They are now available to download from the NICE website: www.nice.org.uk

Slide set

The slides are aimed at supporting organisations to raise awareness of the guideline and resulting implementation issues at a local level, and can be edited to cater for local audiences. This information does not supersede or replace the guidance itself. The slides can be used both during training of healthcare professionals and to stimulate discussion with commissioners of services.

Costing statement

This highlights the difficulties in providing estimates of the direct and indirect costs to society of child maltreatment. In the short term, increased recognition of child maltreatment will have cost implications, but is likely to give highly significant long-term savings.

Audit support

This tool has been developed to support the implementation of the NICE guideline on child maltreatment. The aim is to help NHS organisations with a baseline assessment and to assist with the audit process, thereby helping to ensure that practice is in line with the NICE recommendations. The audit support is based on the key recommendations of the guidance and includes criteria and data collection tools.

  1. National Institute for Health and Care Excellence. When to suspect child maltreatment. Clinical Guideline 89. London: NICE, 2009. Available at: www.nice.org.uk/guidance/CG89
  2. Cawson P. Child maltreatment in the family: the experience of a national sample of young people. London: NSPCC, 2002.
  3. National Institute for Health and Care Excellence. Costing statement: when to suspect child maltreatment. London: NICE, 2009. Available at: www.nice.org.uk/guidance/CG89
  4. National Collaborating Centre for Women’s and Children’s Health. When to suspect child maltreatment. Clinical Guideline. London: RCOG, 2009. Available at: www.nice.org.uk/guidance/CG89
  5. National Institute for Health and Care Excellence. When to suspect child maltreatment. Quick reference guide. London: NICE, 2009. Available at: www.nice.org.uk/guidance/CG89
  6. National Institute for Health and Care Excellence. Understanding NICE guidance: when to suspect child maltreatment. Information about NICE Clinical Guideline 89. London: NICE, 2009. Available at: www.nice.org.uk/guidance/CG89
  7. Department for Children, Schools and Families. Local safeguarding children boards website. www.dcsf.gov.uk/everychildmatters/safeguardingandsocialcare/safeguardingchildren/localsafeguardingchildrenboards/lscb/ (accessed 12 October 2009). G