Child abuse and neglect

This guideline covers recognising and responding to abuse and neglect in children and young people aged under 18. It covers physical, sexual and emotional abuse, and neglect. The guideline aims to help anyone whose work brings them into contact with children and young people to spot signs of abuse and neglect and to know how to respond. It also supports practitioners who carry out assessments and provide early help and interventions to children, young people, parents and carers.

# About this guideline

# What is the purpose of this guideline?
This guideline provides recommendations based on evidence on how to recognise and respond to child abuse and neglect. It offers a robust and rigorous review of the literature, in addition to lessons from practice, and provides an overview of the research into best practice in child protection. As a result it provides a reliable guide to what works and what is cost effective, as indicated by the best available evidence. It offers practitioners and commissioners a clear guide to the interventions and approaches that are most appropriate, and represent best value for money.
The Department for Education's statutory guidance on working together to safeguard children sets out the statutory responsibilities. This guideline will help practitioners to fulfil those responsibilities by providing recommendations for practice which:
Provide more detail about how to discharge duties set out in existing guidance.
Emphasise areas of practice that have been highlighted by research evidence as:
being of particular importance, or
not always working well in current practice.

# Why do we need this guideline?
Cruelty to children and young people is a criminal offence, and child abuse and neglect can have serious adverse health and social consequences for children and young people. These include:
effects on growth and physical development (NSPCC's The impact of abuse and neglect on the health and mental health of children and young people)
impaired language development and behaviour by age 4
impaired ability to socialise, play and learn (NSPCC's Developing an effective response to neglect and emotional harm to children)
increased likelihood of being involved in antisocial behaviour (NSPCC's Child abuse and neglect in the UK today)
increased likelihood of suicidal thoughts and attempts during adolescence.
These negative consequences can persist into adulthood. Adult survivors of childhood abuse are more likely to misuse substances and to experience mental health problems and physical ill health.
Recognising and responding to child abuse and neglect, or its early signs, is complex. Key challenges practitioners face may include:
Knowing 'when to be worried' that a child or young person is being abused or neglected, and how serious a cause for concern different indicators may be.
Assessing levels of risk and need in relation to child abuse and neglect.
Knowing what early help interventions are effective when there are early signs of child abuse and neglect.
Knowing what interventions are effective in helping children and young people to recover following child abuse and neglect, and to support families in which there has been child abuse and neglect.
This guideline makes evidence-based recommendations aiming to support these areas of practice.

# What does it cover?
The guideline makes recommendations about practice in relation to children and young people (under 18, including unborn babies) at risk of, experiencing, or who have experienced, child abuse or neglect, and their parents and carers. It is not a comprehensive manual for frontline practice with children and families; rather, it focuses on areas where practice needs to improve, and where there is a paucity of guidance in existence.
The guideline does not cover people who are suspected or known to abuse children or young people of whom they are not the parent, step-parent, partner of a parent, family member or carer. Abuse perpetrated by this group is covered, but response (interventions) for this group is not. This is because the principal focus of this guideline is on supporting children and young people, including through supporting their parents and carers. It also does not cover adults (aged 18 or older) who experienced abuse or neglect as children.

# What is the status of this guidance?
The application of the recommendations in this guideline is not mandatory. While there is no legal obligation to implement our guidance, health and social care practitioners are actively encouraged to follow our recommendations to help them deliver the highest quality care. Our recommendations are not intended to replace the professional expertise and judgement of practitioners, as they discuss care and support options with people.

# How does it relate to statutory and non-statutory guidance?
Practitioners must comply with the statutory functions of the agencies they work for under the Children Act 1989 and Children Act 2004, the Children and Families Act 2014 and the Children and Social Work Act 2017 and any other legislation relevant to their profession. They must also comply with the Department for Education's statutory guidance on working together to safeguard children. Practitioners should also follow the Department for Education's non-statutory guidance on what to do if you're worried a child is being abused. Links to 'Working together to safeguard children' are highlighted in each section.
This legislation and guidance describes what individuals and agencies need to do to keep children and young people safe. This guideline provides detail on how they can do this, based on best available evidence about effectiveness and cost effectiveness, and lessons from practice. The guideline will, in turn, be complemented by profession-specific guidance, such as the Department for Education's keeping children safe in education and the General Medical Council's protecting children and young people: doctors' responsibilities.
For more information on the statutory framework and other guidance, see appendices B and C of 'Working together to safeguard children'.

# How has it been developed?
This guideline has been developed by a multidisciplinary guideline committee, using an extensive review of research evidence, expert witnesses and input from a children and young people's expert reference group. See the NICE guidelines manual for more information about how the guideline is developed.
Recommendations about who a particular intervention is for are based on the evidence base. This means that not all interventions are recommended for all groups.
Some recommendations are made with more certainty than others. We word our recommendations to reflect this. In the sections on interventions we use 'offer' to reflect a strong recommendation, usually where there is clear evidence of benefit. We use 'consider' to reflect a recommendation for which the evidence of benefit is less certain. For more information see making decisions using NICE guidelines.
In the section on recognition of child abuse and neglect, we use 'suspect' and 'consider' to indicate the extent to which an alerting feature suggests child abuse and neglect, with 'suspect' indicating stronger evidence of child abuse and neglect.

# What evidence is the guideline based on?
To develop the guideline we looked for evidence about:
The views of children, young people, their parents and carers.
What interventions are effective in working with children and young people at risk of, or who have experienced, child abuse and neglect and their parents and carers (evidence from randomised and quasi-randomised control trials).
What helps and hinders professional practice in working with this group. This included evidence from syntheses of Serious Case Review data.
All the interventions recommended in this guideline are based on at least 1 well-designed study (randomised or quasi-randomised controlled trial). It is important to note that much of the evidence on effective interventions came from the US, but the applicability of this in a UK context was carefully considered by the guideline committee when making the recommendations.

# How does it relate to other NICE guidelines?
This guideline builds on the NICE guideline on child maltreatment, which covers clinical features of maltreatment. This guideline is broader: it extends coverage of alerting features for child abuse and neglect to those which may be observed by other professional groups, and also addresses assessment, early help and response. The committee identified recommendations from the NICE guideline on child maltreatment that are relevant to both health and social care practitioners, and adapted them for this guideline (see section 1.3).
This guideline has also adapted recommendations from the NICE guidelines on children's attachment and domestic abuse. Other relevant NICE guidelines include harmful sexual behaviour among children and young people and looked-after children and young people.

# More information
To find out what NICE has said on topics related to this guideline, see our web pages on safeguarding and children and young people.# Recommendations
Recommendations in sections 1.1 to 1.3 are for anyone whose work brings them into contact with children, young people, parents and carers including those who work in early years, social care, health (including staff in A&E and health dropin settings), education (including schools), the police, the voluntary and community sector, youth justice services and adult services.

# Principles for working with children, young people, parents and carers

## Working with children and young people
Take a child-centred approach to all work with children and young people. Involve them in decision-making to the fullest extent possible depending on their age and developmental stage.
Use a range of methods (for example, drawing, books or activities if appropriate) for communicating with children and young people. Tailor communication to:
their age and developmental stage
any disabilities, for example learning disabilities, neurodevelopmental disorders and hearing and visual impairments, seeking assistance from specialists if needed
communication needs, for example by using communication aids or providing an interpreter (ensure the interpreter is not a family member).
In all conversations with children and young people where there are concerns about child abuse and neglect:
explain confidentiality and when you might need to share specific information, and with whom
be sensitive and empathetic
listen actively and use open questions
find out their views and wishes
check your understanding of what the child has told you
be sensitive to any religious or cultural beliefs
use plain language and explain any technical terms
work at the child or young person's pace
give them opportunities to stop the conversation or leave the room, and follow up if this does happen
explain what will happen next and when.
Make sure that conversations take place somewhere private and where the child or young person feels comfortable. Take account of any sensory issues the child or young person may have.
If your interaction with a child or young person involves touching them (for example, a medical examination) explain what you are going to do and ask for consent:
from them if they are over 16 (follow the Mental Capacity Act 2005) or under 16 but Gillick competent or
from their parent or carer if they are under 16 and not Gillick competent.If the child, young person or parent does not agree, respect their wishes unless touching them is essential to their treatment (seek legal advice first unless the need for treatment is immediate). For more guidance on seeking consent for medical examination in children and young people see the General Medical Council's 0-18 years: guidance for all doctors.
Produce a record of conversations with children and young people about child abuse and neglect, and any subsequent interventions as appropriate to their age, developmental stage and language abilities. This could be in writing or another format suitable to meet the child or young person's communication needs. Ensure that you:
Accurately represent their words, using their actual words unless there is a good reason not to, for example if this would include information about another child or young person.
Check that they have understood and agree with what is recorded (this could include both of you signing a written record) and record any disagreements.
Share reports and plans with the child or young person in a way that is appropriate to their age and understanding.
Clearly explain how you will work together with children and young people and do what you have said you will do. If circumstances change and this is no longer possible, explain why as soon as possible, and offer alternative actions.
Agree with the child or young person (if age appropriate) how you will communicate with each other. Give them contact details, including for services available out of hours. When contacting them:
be aware of safety issues such as whether a perpetrator of abuse may have access to a young person's phone
agree what will happen if you contact them and they do not respond, for example following up with their nominated emergency contact.

## Working with parents and carers
Aim to build good working relationships with parents and carers to encourage their engagement and continued participation. This should involve:
actively listening to them, and helping them to deal with any emotional impact of your involvement with their family
being open and honest
seeking to empower them and engaging them in finding solutions
avoiding blame, even if they may be responsible for the child abuse or neglect
inviting, recognising and discussing any worries they have about specific interventions they will be offered
identifying what they are currently doing well, and building on this
making adjustments for any factors which may make it harder for them to get support, such as refugee status, long-term illness, neurodevelopmental disorders, mental health problems, disability or learning disability
being sensitive to religious or cultural beliefs
working in a way that enables trust to develop while maintaining professional boundaries
maintaining professional curiosity and questioning while building good relationships.
When working with parents and carers:
be reliable and available as promised
provide clear information about who to contact, including in an emergency
keep them informed, including explaining what information has been shared, and with whom
support people's communication needs, for example by using communication aids or providing an interpreter
agree records of any conversations, and share relevant documents and plans
be clear about the issues and concerns that have led to your involvement, and inform parents and carers if those concerns are resolved
be clear about the legal context in which your involvement with them is taking place.

## Working with other practitioners
Coordinate your work with practitioners in other agencies so that children, young people, parents and carers do not need to give the same information repeatedly, in line with the Department for Education's advice on information sharing: advice for practitioners providing safeguarding services.

## Critical thinking and analysis
Present information critically and analytically and do not rely solely on protocols, proformas and electronic recording systems to support your professional thinking and planning.

# Factors that increase vulnerability to child abuse and neglect
Vulnerability factors are factors that are known to increase the risk of child abuse and neglect. The presence of these factors does not mean that child abuse or neglect will occur, but practitioners should use their professional judgement to assess their significance in a particular child, young person or family. They should be considered in conjunction with the alerting features in section 1.3.
These recommendations add further detail to the Department for Education's what to do if you're worried a child is being abused about factors that increase vulnerability to child abuse and neglect.
Recognise that vulnerability factors can be interrelated, and that separate factors can combine to increase the risk of harm to a child or young person.
Take into account socioeconomic vulnerability factors for child abuse and neglect, such as poverty and poor housing.

## Family factors
Recognise that the following parental factors increase vulnerability to child abuse and neglect, and that these may be compounded if the parent or carer lacks support from family or friends:
Substance misuse problems.
A history of domestic abuse, including sexual violence or exploitation.
Emotional volatility or having problems managing anger.
Mental health problems which have a significant impact on the tasks of parenting.
Recognise the following as vulnerability factors for recurring or persistent child abuse and neglect:
The parent or carer does not engage with services.
There have been 1 or more previous episodes of child abuse or neglect.
The parent or carer has a mental health or substance misuse problem which has a significant impact on the tasks of parenting.
There is chronic parental stress.
The parent or carer experienced abuse or neglect as a child.
Recognise that neglect and emotional abuse may be more likely to recur or persist than other forms of abuse.

## Child factors
Be aware of the impact of a child or young person's age or gender on their vulnerability to child abuse and neglect, and the likelihood of recognition. For example, boys and young men may be less likely to disclose sexual exploitation (see also the Department for Education's guidance on child sexual exploitation).
Recognise that disabled children and young people are more vulnerable to child abuse or neglect.

# Recognising child abuse and neglect
These recommendations add further detail to the Department for Education's what to do if you're worried a child is being abused on alerting features for child abuse and neglect.

## Children and young people telling others about child abuse or neglect
Recognise that children and young people who are being abused or neglected may find it difficult to tell someone for the first time because:
they may have feelings of confusion, shame, guilt and of being stigmatised
they may not recognise their own experiences as abusive or neglectful
they may be being coerced by (or may be attached to) the person or people abusing or neglecting them
they may fear the consequences of telling someone, for example that no one will believe them, the abuse or neglect might get worse, their family will be split up or excluded by their community, or they will go into care
they may have communication difficulties or may not speak English fluently.
Recognise that children and young people who are being abused or neglected may not acknowledge this when asked, or may not want others to know.
Recognise that children and young people may communicate their abuse or neglect indirectly through their behaviour and appearance (see recommendations 1.3.12 to 1.3.47 and the NICE guideline on child maltreatment).
Take into account that when children and young people communicate their abuse or neglect (either directly or indirectly), it may refer to non-recent abuse or neglect.
Explore your concerns with children and young people in a non-leading way, for example by using open questions, if you are worried that they may be being abused or neglected.
Avoid causing possible prejudice to any formal investigation during early conversations about child abuse and neglect with children and young people by following guidance in the Ministry of Justice's achieving best evidence in criminal proceedings.
If a child or young person tells you they have been abused or neglected, make a referral to children's social care using your local procedures. Explain to the child or young person who you will need to tell, and discuss what will happen next and when.
For people working in regulated professions (healthcare professionals and teachers), if a girl or young woman tells you they have experienced female genital mutilation (FGM), or you observe physical signs of FGM, you must report this to the police, in line with Home Office guidance on mandatory reporting of female genital mutilation.

## Supporting staff to recognise child abuse and neglect
Senior managers should ensure staff working in community settings, including education, can recognise and respond to child abuse and neglect and are aware of child safeguarding guidance relevant to their profession, for example the Department for Education's keeping children safe in education.
Commissioners should ensure all practitioners working in primary care can recognise and respond to child abuse and neglect. Ways to achieve this include:
ensuring that newly qualified practitioners receive training in line with an approved training programme, for example levels 1 to 3 in the Royal College of Paediatrics and Child Health's safeguarding children and young people: roles and competencies for healthcare staff. This should include an understanding of vulnerability factors for child abuse and neglect, such as parental mental health problems, alcohol and substance misuse
giving information to newly qualified practitioners, for example about local resources such as children's centres and parenting groups
giving practitioners advice on how to make a referral to social care.
For guidance on training health and social care practitioners to respond to domestic violence and abuse, follow recommendations 15 and 16 in the NICE guideline on domestic violence and abuse.

## Alerting features for child abuse and neglect
This section describes indicators that should alert practitioners to the possibility of child abuse or neglect. It may be child abuse or neglect occurring now or that has occurred in the past. Note that physical injuries and other clinical indicators are covered in the NICE guideline on child maltreatment.
In this section we use 'consider' and 'suspect' (as defined in the NICE guideline on child maltreatment) to indicate the extent to which an alerting feature suggests child abuse and neglect, with 'suspect' indicating stronger evidence of child abuse and neglect.
If a child is in immediate danger, refer to children's social care and/or the police. Otherwise, in response to any of the alerting features in this section, please follow the steps below in line with the Department for Education's statutory guidance on working together to safeguard children.
For all alerting features:
Seek advice from named or designated colleagues or your organisation's safeguarding lead.
Speak to the child or young person as detailed in recommendations 1.3.5 and 1.3.6, if this is age and developmentally appropriate and it is safe to do so.
For recommendations starting with 'suspect':
Discuss the need for a referral with children's social care using local multi-agency safeguarding procedures.
For recommendations starting with 'consider':
Look for other alerting features in the child or young person's history, presentation or interactions with their parents or carers, now or in the past.
Gather information from other agencies and explain to the family that this information is needed to make an overall assessment of the child or young person. If this is likely to place the child or young person at risk, seek advice from children's social care.
Make sure a review of the child or young person takes place, with the timing depending on your level of concern. Continue to look out for the alerting feature being repeated, or for any other alerting features.
After taking these steps, if your level of concern increases to 'suspect', discuss the need for a referral with children's social care. If you conclude that a referral to children's social care is not required, you may wish to undertake or make a referral for early help assessment in line with local procedures.
As highlighted in the recommendations below, alerting features for child abuse and neglect can be similar to behaviours arising from other causes, such as other stressful life experiences or neurodevelopmental disorders such as autism. However, practitioners should continue to consider the possibility of child abuse or neglect as a cause for behavioural and emotional alerting features, even if they are seemingly explained by another cause.
Practitioners should also recognise that alerting features may be due to non-recent child abuse or neglect. If the alerting features relate to past child abuse or neglect, but the child or young person is now in a place of safety (for example, in an adoptive family), assess the child or young person to see what support they and their parent, carer, foster carer or adoptive parent need to cope with the consequences of the child abuse or neglect.

## Behavioural and emotional alerting features
Consider child abuse and neglect 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 abuse and neglect (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 abuse and neglect 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 , autism spectrum disorders) or other stressful situation that is not part of child abuse or neglect (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
-ver-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 abuse and neglect 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 abuse or neglect 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 abuse and neglect 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 current or past child abuse or neglect if children or young people are showing any of the following behaviours:
substance or alcohol misuse
self-harm
eating disorders
suicidal behaviours
bullying or being bullied.
Consider child abuse and neglect if a child or young person has run away from home or care, or is living in alternative accommodation without the full agreement of their parents or carers.
Consider child abuse and neglect 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 abuse and neglect 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).
For more guidance about responding to potentially harmful sexual behaviours, see the NICE guideline on harmful sexual behaviour among children and young people.
Suspect current or past child abuse and neglect if a child or young person's sexual behaviour is indiscriminate, precocious or coercive.
Suspect child abuse and neglect, and in particular sexual abuse, if a prepubertal child displays or is reported to display repeated or coercive sexualised behaviours or preoccupation (for example, sexual talk associated with knowledge, emulating sexual activity with another child).
Suspect sexual abuse if a pre-pubertal child displays or is reported to display unusual sexualised behaviours. Examples include:
-ralgenital contact with another child or a doll
requesting to be touched in the genital area
inserting or attempting to insert an object, finger or penis into another child's vagina or anus.
Suspect child abuse and neglect if a child repeatedly scavenges, steals, hoards or hides food with no medical explanation (for example PraderWilli syndrome).
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.
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.
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.
Consider neglect if a child displays faltering growth because of lack of provision of an adequate or appropriate diet. NICE has produced a guideline on faltering growth.
Consider current or past physical or emotional child abuse or neglect if a child under 12 shows poorer than expected language abilities for their overall development (particularly in their ability to express their thoughts, wants and needs) that is not explained by other factors, for example neurodevelopmental difficulties or speaking English as a second language.
These recommendations assume that practitioners are seeing a parent or carer and child interacting.
Consider neglect or physical abuse if a child's behaviour towards their parent or carer shows any of the following, particularly if they are not observed in the child's other interactions:
dislike or lack of cooperation
lack of interest or low responsiveness
high levels of anger or annoyance
seeming passive or withdrawn.
Consider emotional abuse if there is concern that parent or carerchild 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.
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 1.3.31 are persistent.
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 1.3.33 is persistent.
Consider child abuse and neglect if parents or carers are seen or reported to punish a child for wetting or soiling despite practitioner advice that the symptom is involuntary.
Consider child abuse and neglect if a parent or carer refuses to allow a child or young person to speak to a practitioner on their own when it is necessary for the assessment of the child or young person.
Consider neglect if parents or carers persistently fail to anticipate dangers and to take precautions to protect their child from harm. However, take into account that achieving a balance between an awareness of risk and allowing children freedom to learn by experience can be difficult.
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 parents or carers fail to administer essential prescribed treatment for their child.
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 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).
Follow recommendations 1.2.11 and 1.2.12 in the NICE guideline on child maltreatment if you have concerns about fabricated or induced illness.

## Recognising child trafficking
Recognise that children and young people may be trafficked for sexual exploitation and other reasons including:
forced marriage
domestic servitude
working for low or no pay, or in illegal industries
being used for benefit fraud.
Recognise that both girls and boys can be trafficked and that children and young people can be trafficked within and from the UK, as well from other countries.
If you suspect a child or young person may have been trafficked:
make a referral to children's social care and the police
a designated first responder should make a referral to the government's National Referral Mechanism
ensure that concerns about their age and immigration status do not override child protection considerations
recognise that choosing an interpreter from the child's community may represent to them the community that has exploited them
aim to ensure continuity with the same independent interpreter, keyworker or independent advocate.

# Assessing risk and need in relation to child abuse and neglect
These recommendations are for practitioners undertaking:
early help assessment (undertaken by a lead professional)
assessment under Section 17 of the Children Act 1989 (led by a social worker) or
enquiry under Section 47 of the Children Act 1989 (led by a social worker, sometimes jointly with police).
Refer to guidance on early help and statutory assessment in the Department for Education's statutory guidance on working together to safeguard children as well as local protocols for assessment. The following recommendations highlight areas or practice which have been shown by evidence as being of particular importance, or as not always working well in practice.

## Carrying out assessments
During assessment:
-bserve the child or young person, including their relationships with parents or carers
communicate directly with the child or young person without their parent or carer being present, with the parent or carer's consent
explore in a non-leading way any presenting signs or possible history of child abuse and neglect. Do not rely solely on information from the parent or carer in an assessment. See also recommendations 1.1.1 to 1.1.11 about working with children, young people, parents and carers.
When assessing a child or young person follow the principles in recommendations 1.1.2 and 1.1.3.
During assessment, focus primarily on the child or young person's needs but also remember to:
address both the strengths and weaknesses of parents, carers and the wider family network
acknowledge that parenting can change over time, meaning that strengths and weaknesses are not fixed and should be reviewed
focus attention equally on male and female parents and carers.
As part of assessment or enquiry into child abuse and neglect under the Children Act 1989, collect and analyse information about all significant people (including siblings) in the child or young person's care environment, unless it is not safe to do so (for example in cases of domestic abuse or forced marriage) or it could affect the nature of a criminal investigation. Use professional judgement to determine the risks and benefits of including people in assessment in these instances. Gather the following information about each person:
Their personal, social and health history.
Their family history, including experiences of being parented.
Any adverse childhood experiences.
The quality of their relationship with the child or young person.
As part of assessment or enquiry into child abuse and neglect under the Children Act 1989, communicate your concerns honestly to families about child abuse and neglect. Take into account what information should be shared, and with whom, to avoid increasing the risk of harm to the child or young person (and adult victims in cases of domestic abuse).
Organisations should ensure that practitioners conducting assessment in relation to abuse or neglect of disabled children or young people, or those with neurodevelopmental disorders, can access a specialist with knowledge about those children and young people's specific needs and impairments.
Analyse the information collected during assessment and use it to develop a plan describing what services and support will be provided. Make sure the plan is agreed with the child or young person and their family (also see recommendations 1.1.7 and 1.1.11). Analysis should include evaluating the impact of any vulnerability factors and considering their implications for the child or young person.
Review assessments and plans regularly.

# Early help for families showing possible signs of child abuse or neglect
These recommendations are for:
Practitioners involved in early help for families showing possible signs of child abuse and neglect. This could include those undertaking the lead professional role (including a GP, family support worker, teacher, health visitor or special educational needs coordinator) or those providing early help interventions, such as family support workers.
Commissioners of early help services for children, young people and families.
These recommendations support the Department for Education's statutory guidance on working together to safeguard children by highlighting evidence-based programmes that could be offered as part of early help support based on the evidence.

## Supporting families at the early help stage
Provide early help in line with local protocols and 'Working together to safeguard children', and based on an assessment of the needs of children, young people and families.
Discuss early help support and interventions with children, young people and families as part of building close working relationships with them and gaining their consent (see section 1.1 for principles for working with children, young people, parents and carers). Explain what the support will involve and how you think it may help.
Give children, young people and their families a choice of proposed interventions if possible. Recognise that some interventions may not suit that person or family.
Early help should include:
practical support, for example help to attend appointments and details of other agencies that can provide food, clothes and toys
emotional support, including empathy and active listening, and help to develop strategies for coping.
Give families information about local services and resources, including advocacy, that they may find useful.

## Knowledge and skills of practitioners who provide early help
Commissioners and managers should ensure that all practitioners working at the early help stage:
have an understanding of typical and atypical child development
are able to tailor interventions to the needs of the child or young person, parents and carers including any disability or learning disability
understand the parental vulnerability factors for child abuse and neglect (see recommendations 1.2.3 to 1.2.5)
are aware of the possibility of escalation of risk, particularly if family circumstances change
understand how to work with families as a whole in order to better support children and young people.

## Parenting programmes
Consider a parenting programme lasting at least 12 weeks for parents or carers at risk of abusing or neglecting their child or children. Tailor parenting programmes to the specific needs of parents or carers and children (see recommendations 1.5.9 to 1.5.12).
When selecting parenting programmes think about whether parents or carers would benefit from help to:
develop skills in positive behaviour management
address negative beliefs about the child and their own parenting
manage difficult emotions, including anger.
Consider the Triple P  Positive Parenting Program (attributional retraining and anger management) for mothers of young children (up to age 7), who are experiencing anger management difficulties.
Consider a parenting programme for vulnerable mothers (for example, those with a low level of education or income or aged under 18) of preschool children. It should be based on a planned activities training model and focus on equipping parents or carers to prevent challenging behaviour by:
planning and explaining activities
establishing rules and consequences
ignoring minor misbehaviour and using positive interaction skills. This can be provided with or without support provided by text message between training sessions.
Consider the Parents Under Pressure programme for mothers taking part in methadone maintenance programmes.
For parents or carers who have substance misuse problems, include content in the parenting programme to help them address their substance misuse in the context of parenting. For example, help them to address parenting stress which may be a trigger for substance misuse.

## Home visiting programmes
For parents or carers at risk of abusing or neglecting their child or children, consider a weekly home visiting programme lasting at least 6 months, for example the Healthy Families model. This should be in addition to universal health visiting services available through the Department of Health's healthy child programme.
Identify parents and carers who could be supported by a home visiting programme during pregnancy or shortly after birth, wherever possible.
Ensure that the home visiting programme is agreed with families and includes:
support to develop positive parentchild relationships, including:
helping parents to understand children's behaviour more positively
modelling positive parenting behaviours
-bserving and giving feedback on parentchild interactions
helping parents to develop problem-solving skills
support for parents to address the impact of any substance use, previous domestic abuse and mental health problems on their parenting
support to access other relevant services, including health and mental health services, substance misuse services, early years, educational services and other community services
referral to children's social care where necessary, for example if current domestic abuse is discovered.
Ensure that the programme of home visits is delivered by a practitioner who has been trained in delivering that particular home visiting programme.

# Multi-agency response to child abuse and neglect
These recommendations are for practitioners working with children, young people and parents or carers where a child or young person has been abused or neglected, including those assessed as 'in need', likely to suffer significant harm or suffering significant harm.
Practitioners must follow the 'Processes for managing individual cases' in the Department for Education's statutory guidance on working together to safeguard children. These recommendations complement the statutory guidance by adding or emphasising detail which has been shown by evidence to be of particular importance, or not currently happening in practice.

## Multi-agency working
Practitioners supporting children and young people who have been assessed as being 'in need', or suffering (or likely to suffer) significant harm in relation to child abuse or neglect should:
build relationships with other practitioners working with that family
-rganise handovers if new staff members from their agency become involved
ensure actions set out in the 'child in need' or child protection plan are completed.

## Supporting children and young people
Practitioners supporting children and young people who have been assessed as being 'in need' or suffering (or likely to suffer) significant harm in relation to child abuse or neglect should, with leadership and coordination by the social worker, do the following as a minimum:
protect them from further abuse or neglect
support them to explore aspects of their experience and express their feelings
provide early emotional support, including building emotional resilience and strategies for coping with symptoms such as nightmares, flashbacks and self-harm
assess their physical health needs
assess the need for further mental health support
support them to reduce the risk of future abuse if appropriate, for example if a young person is at risk of sexual exploitation.

## Children and young people affected by domestic abuse
For guidance on domestic abuse, see recommendations 10 and 11 in the NICE guideline on domestic violence and abuse.

## Child trafficking
When working with children and young people who have been trafficked, follow the government's guidance on safeguarding children who may have been trafficked.

# Therapeutic interventions for children, young people and families after child abuse and neglect
These recommendations are for:
Social workers and others coordinating support for children and young people, to help them decide what services to refer children and young people to.
Child and adolescent mental health practitioners (psychologists, psychotherapists, psychiatrists), practitioners in specialist family intervention teams (for example social workers) and voluntary sector agencies.
Strategic commissioners of services for children and young people who have been abused or neglected.
Where interventions are recommended for particular groups, this reflects the evidence base for this intervention.
Discuss in detail with children, young people, parents and carers any interventions you offer them, explaining what the intervention will involve and how you think it may help (see section 1.1 for principles for working with children, young people, parents and carers).
Give children, young people, parents and carers a choice of proposed interventions if possible. Recognise that some interventions, although effective, may not suit that person or family.
The choice of intervention should be based on a detailed assessment of the child or young person.

## Therapeutic interventions following child physical abuse, emotional abuse or neglect
This section provides a range of options for therapeutic interventions for children and young people who have experienced physical abuse, emotional abuse or neglect. Some interventions involve the parent or carer who abused or neglected the child, and others involve alternative carers such as foster carers or adoptive parents. An overview of interventions is shown below.
For more recommendations about looked-after children, including children in residential care, see the NICE guideline on looked-after children and young people.
Offer an attachment-based intervention, for example Attachment and Biobehavioural Catch-up, to parents or carers who have neglected or physically abused a child under 5.
Deliver the attachment-based intervention in the parent or carer's home, if possible, and provide at least 10 sessions. Aim to:
improve how they nurture their child, including when the child is distressed
improve their understanding of what their child's behaviour means
help them respond positively to cues and expressions of the child's feelings
improve how they manage their feelings when caring for their child.
Consider childparent psychotherapy for parents or carers and their children under 5 if the parent or carer has physically or emotionally abused or neglected the child, or the child has been exposed to domestic violence.
Ensure that childparent psychotherapy:
is based on the Cicchetti and Toth model
consists of weekly sessions (lasting 4560 minutes) over 1 year
is delivered in the parents' home, if possible, by a therapist trained in the intervention
involves directly observing the child and the parentchild interaction
explores the parents' understanding of the child's behaviour
explores the relationship between the emotional reactions of the parents and their perceptions of the child on the one hand, and the parents' own childhood experiences on the other hand.
Offer an attachment-based intervention in the home to foster carers looking after children under 5 who have been abused or neglected. Aim to help foster carers to:
improve how they nurture their foster child, including when the child is distressed
improve their understanding of what the child's behaviour means
respond positively to cues and expressions of the child's feelings
behave in ways that are not frightening to the child
improve how they manage their feelings when caring for their child.
Consider the attachment-based intervention in recommendation 1.7.8 for adoptive parents and those providing permanence (including special guardians, foster carers or kinship carers) for children under 5 who have been abused or neglected.
Consider a comprehensive parenting intervention, for example SafeCare, for parents and children under 12 if the parent or carer has physically or emotionally abused or neglected the child. This should be delivered by a professional trained in the intervention and comprise weekly home visits for at least 6 months that address:
parentchild interactions
caregiving structures and parenting routines
parental stress
home safety
any other issues that caused the family to come to the attention of services. As part of the intervention, help the family to access other services they might find useful.
Consider parentchild interaction therapy for parents or carers and children under 12 if the parent or carer has physically abused or neglected the child. Combine group sessions for these parents with individual childparent sessions focusing on developing child-centred interaction and effective discipline skills.
Offer a group-based parent training intervention, for example KEEP, to foster carers of children aged 5 to 12 who have been abused or neglected and are showing problematic behaviours. Include strategies to manage behaviour and discipline positively. Provide group sessions over at least 16 weeks with groups of 8 to 10 foster carers, including video, role play and homework practice.
Consider the intervention in recommendation 1.7.12 for foster carers of children aged 5 to 12 who have been abused or neglected and are not currently showing problematic behaviours.
Consider multi-systemic therapy for child abuse and neglect (MSTCAN) for parents or carers of children and young people aged 10 to 17 if the parent or carer has abused or neglected their child. This should last 4 to 6 months and:
involve the whole family
address multiple factors contributing to the problem
be delivered in the home or in another convenient location
include a round-the-clock on-call service to support families to manage crises.
For foster carers of children and young people aged 5 to 17 who have been abused or neglected, consider a trauma-informed group parenting intervention, using a trust-based relational intervention as an example. It should last for at least 4 daylong sessions and help foster carers to:
develop the child or young person's capacity for self-regulation
build trusting relationships
develop proactive and reactive strategies for managing behaviour.
Consider the trauma-informed group parenting intervention in recommendation 1.7.15 for adoptive parents and those providing permanence (including special guardians, foster carers or kinship carers) for children aged 5 to 17 who have been abused or neglected.

## Therapeutic interventions for children, young people and families after sexual abuse
This section provides a range of options for therapeutic interventions for children and young people who have experienced sexual abuse. An overview of interventions is shown below.
Offer group or individual trauma-focused cognitive behavioural therapy over 12 to 16 sessions (more if needed) to children and young people (boys or girls) who have been sexually abused and show symptoms of anxiety, sexualised behaviour or post-traumatic stress disorder. When offering this therapy:
discuss it fully with the child or young person before providing it and make clear that there are other options available if they would prefer
provide separate trauma-focused cognitive behavioural therapy sessions for the non-abusing parent or carer.
For children and young people (boys or girls) aged 8 to 17 who have been sexually abused, consider an intervention, for example 'Letting the future in', that:
emphasises the importance of the therapeutic relationship between the child or young person and therapist
-ffers support tailored to the child or young person's needs, drawing on a range of approaches including counselling, socio-educative and creative (such as drama or art)
includes individual work with the child or young person (up to 20 sessions, extending to 30 as needed) and parallel work with non-abusing parents or carers (up to 8 sessions).
For girls aged 6 to 14 who have been sexually abused and who are showing symptoms of emotional or behavioural disturbance, consider one of the following, after assessing carefully and discussing which option would suit her best:
individual focused psychoanalytic therapy (up to 30 sessions) or
group psychotherapeutic and psychoeducational sessions (up to 18 sessions). Provide separate supportive sessions for the non-abusing parent or carer, helping them to support the child's attendance at therapy, as well as addressing issues within the family.

# Planning and delivering services
These recommendations are for senior managers in agencies responsible for planning and delivering services to children and young people. They provide additional detail to the Department for Education's statutory guidance on working together to safeguard children on strategic arrangements for multi-agency working.
Plan services in a way that enables children, young people, parents and carers to work with the same practitioners over time where possible.
Agencies responsible for planning and delivering services for children and young people should agree terminology across agencies relating to child protection roles and processes, and ensure these are well publicised.
Ensure that local threshold documents set out responses to other forms of abuse including child sexual exploitation, female genital mutilation, honour-based abuse (including forced marriage), child trafficking, serious youth violence and gang-related abuse. Ensure that these are communicated to local agencies, including those providing universal services, so that they are aware of these forms of abuse.
To address the risks posed by sexual exploitation and gang-related abuse, agencies responsible for planning and delivering services for children and young people should put in place:
effective leadership within agencies
a local lead who will coordinate planning and information sharing between agencies.

## Supervision and support for staff
Organisations should support staff working with children and families at risk of or experiencing child abuse and neglect, and provide good quality supervision, tailored to their level of involvement in safeguarding work. This should include:
case management
reflective practice
emotional support
continuing professional development.# Terms used in this guideline

# Alerting feature
Symptoms and signs that may indicate that child abuse or neglect is taking place, and which should prompt practitioners to take action.

# Analysis
Analysis involves organising the information collected during assessment, judging its significance and exploring different perspectives, to identify themes and reach conclusions on what these mean for the child or young person and their family. It should draw on knowledge from research and practice combined with an understanding of the child's needs.

# Attachment-based intervention
Interventions which are based on attachment theory. Attachment-based interventions focus on improving the relationships between children and young people and their key attachment figures (often, parents or carers), for example by helping the parent or carer to respond more sensitively to the child or young person.

# Bullying
Persistent behaviour by a person or group of people that intentionally hurts a child or young person either physically or emotionally.

# Child abuse and neglect
In this guideline child abuse and neglect includes inflicting harm on a child or young person and also failing to protect them from harm. Children and young people may be abused by someone they know in a family or in an institutional or community setting or, more rarely, by someone they don't know (for example through the internet). Some indicators of abuse and neglect may be indicators of current or past abuse and neglect.

# Child sexual exploitation
Child sexual exploitation is a form of child sexual abuse. It 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.

# Child trafficking
Recruiting and transporting children and young people for the purposes of exploitation, for example, sexual exploitation, forced labour or services, benefit fraud, domestic servitude or the removal of organs.

# Children and young people
In this guideline 'infant' means aged under 1 year, 'child' means under 13 years and 'young person' means 13 to 17 years.

# Disabled children and young people
Children and young people who meet the Equality Act 2010 definition of disability, namely those who have a physical or mental impairment that has a substantial and long-term negative effect on their ability to do normal daily activities.

# Domestic abuse
Any incident or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse between those aged 16 or over who are, or have been, intimate partners or family members regardless of gender or sexuality.

# Early help
Support provided early as soon as a problem emerges. Early help can prevent a problem from worsening or further problems from arising.

# Emotional abuse
Persistently treating a child or young person in a way that can cause severe adverse effects on their emotional development. For example, conveying to them that they are worthless or unloved; not giving them opportunities to express their views; deliberately silencing them or making fun of them; imposing inappropriate expectations on them for their age or developmental stage; and serious bullying (including cyber bullying).

# Faltering growth
This term is used in relation to infants and young children whose weight gain occurs more slowly than expected for their age and sex. In the past this was often described as a 'failure to thrive' but this is no longer the preferred term.

# Female genital mutilation
A practice involving removal of or injury to any part of a girl's external genitalia for non-medical purposes. Female genital mutilation is illegal in England and Wales according to the Female Genital Mutilation 2003 Act.

# Forced marriage
A marriage in which one or both partners have not consented (or cannot consent because of a learning disability) to be married and pressure or abuse has been used.

# Foster carer
Foster carers care for children and young people who are 'looked after' in the public care system. They must go through a process of assessment and approval, before providing care for the child or young person as a member of their household. Some are 'kinship foster carers', which means they are relatives or friends who are fostering a child or young person who has entered the public care system.

# Honour-based abuse
Honour-based abuse includes forced marriage and female genital mutilation (FGM). It can be described as a collection of practices used to control behaviour within families or other social groups to protect perceived cultural and religious beliefs and/or honour. Such abuse can occur when perpetrators perceive that a relative has shamed the family or community by breaking their honour code.

# Lead professional
A professional who leads the provision of early help support to children, young people, parents and carers by acting as their advocate and coordinating their support. The lead professional role could be undertaken by a GP, family support worker, teacher, health visitor or a special educational needs coordinator.

# Maltreatment
In line with the NICE guideline on child maltreatment this includes neglect; physical, sexual and emotional abuse; and fabricated or induced illness. It is also used as an 'umbrella' term for all categories of child abuse and neglect, including witnessing domestic violence, forced marriage, child trafficking, female genital mutilation and child sexual exploitation.

# Neglect
The persistent failure to meet a child's basic physical and/or psychological needs, likely to result in the serious impairment of the child's health or development. Neglect may occur during pregnancy as a result of maternal substance abuse. Once a child is born, neglect may involve a parent or carer failing to:
provide adequate food, clothing and shelter (including exclusion from home or abandonment)
protect a child from physical and emotional harm or danger
ensure adequate supervision (including the use of inadequate caregivers)
ensure access to appropriate medical care or treatment.
It may also include neglect of, or unresponsiveness to, a child's basic emotional needs.

# Parent or carer
This guideline uses 'parent or carer' to acknowledge that people other than a child or young person's parent may be caring for them. We have defined 'parent' as the person with parental responsibility for a child, including an adoptive parent, and 'carer' as someone other than a parent who is caring for a child. This could include family members, such as the partner of a parent. Where we are referring specifically to paid carers we use the term 'foster carer'.

# Parenting intervention
A psycho-educational intervention focusing on improving parenting skills.

# Past child abuse or neglect
Abuse or neglect that a child or young person may have experienced but which is no longer occurring. For example, abuse which occurred in a previous family environment before the child or young person was placed in care or with an adoptive family.

# Physical abuse
A form of abuse which may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating or otherwise causing physical harm to a child. Physical harm may also be caused when a parent or carer fabricates the symptoms of, or deliberately induces, illness in a child.

# Practitioner
A person working with children and young people who may have a role in safeguarding them.

# Prader-Willi syndrome
A genetic condition leading to a range of symptoms, including over-eating, restricted growth, reduced muscle tone, and learning and behavioural difficulties.

# Regulated profession
Regulated professions as defined in section 5B(2)(a), (11) and (12) of the Female Genital Mutilation Act 2003. A person works in a regulated profession if they are a healthcare professional, a teacher, or (in Wales) if they are a social care worker.

# 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. They may also include non-contact activities, such as involving children in looking at, or in the production of, sexual images, watching sexual activities, encouraging children to behave in sexually inappropriate ways, or grooming a child in preparation for abuse (including through the internet). Sexual abuse is not solely perpetrated by adult males. Women can also commit acts of sexual abuse, as can other children.

# Special guardian
A person who has been granted a special guardianship order (SGO), a private law order which grants someone parental responsibility for a named child or young person. While parents do not lose parental responsibility when an SGO is granted, the special guardian has the exclusive right to exercise it, and make important decisions about the child or young person. Special guardians may also in some circumstances be provided with local authority financial and other support.

# Vulnerability factor
Situations, behaviours or underlying characteristics of children, young people and their parents or carers and their social environment that increase the child or young person's vulnerability to child abuse or neglect.
For other social care terms see the Think Local, Act Personal Care and Support Jargon Buster.# Putting this guideline into practice
Some issues were highlighted that might need specific thought when implementing the recommendations. These were raised during the development of this guideline. They are:
Offering effective therapeutic interventions for children and their parents or carers. Although families who have children on child protection plans usually receive interventions from a social worker, there is a lack of provision of evidence-based therapeutic interventions to support parents, carers, foster carers and adoptive parents to meet the needs of children who have been abused or neglected.
Providing more training and education for all staff who work with children and young people who have experienced abuse and neglect. Training in recognising the signs of child abuse and neglect and when to act on them is a priority, particularly as new forms of abuse emerge. However, increasing training is likely to prove challenging for many organisations because of cuts in resources.
Making multi-agency responses effective across the country. It should begin at the early help stage. Adopting common language and terms, leadership at all levels, agreeing protocols for information sharing and co-locating staff from different agencies who are working on the same, or related, cases or issues all contribute to effective multi-agency working.
Putting recommendations into practice can take time. How long may vary from guideline to guideline, and depends on how much change in practice or services is needed. Implementing change is most effective when aligned with local priorities.
Changes recommended for practice that can be done quickly  such as conducting a baseline assessment (see 3 below)  should be shared quickly. This is because health and social care professionals should use guidelines to guide their work and keep their skills and knowledge up to date  as is required by professional regulating bodies such as the Health and Care Professions Council, General Medical and Nursing and Midwifery Councils.
Changes should be implemented as soon as possible, unless there is a good reason for not doing so (for example, if it would be better value for money if a package of recommendations were all implemented at once).
Different organisations may need different approaches to implementation, depending on their size and function. Sometimes individual practitioners may be able to respond to recommendations to improve their practice more quickly than large organisations.
Here are some pointers to help organisations put NICE guidelines into practice:
. Raise awareness through routine communication channels, such as email or newsletters, regular meetings, internal staff briefings and other communications with all relevant partner organisations. Identify things staff can include in their own practice straight away.
. Identify a lead with an interest in the topic to champion the guideline and motivate others to support its use and make service changes, and to find out any significant issues locally.
. Involve children, young people, parents and carers, foster carers and adoptive parents in identifying how practice needs to change.
. Carry out a baseline assessment against the recommendations to find out whether there are gaps in current service provision.
. Think about what data you need to measure improvement and plan how you will collect it. You may want to work with other health and social care organisations and specialist groups to compare current practice with the recommendations. This may also help identify local issues that will slow or prevent implementation.
. Develop an action plan, with the steps needed to put the guideline into practice, and make sure it is ready as soon as possible. Big, complex changes may take longer to implement, but some may be quick and easy to do. An action plan will help in both cases.
. For very big changes include milestones and a business case, which will set out additional costs, savings and possible areas for disinvestment. A small project group could develop the action plan. The group might include the guideline champion, a senior organisational sponsor, staff involved in the associated services, finance and information professionals.
. Implement the action plan with oversight from the lead and the project group. Big projects may also need project management support.
. Review and monitor how well the guideline is being implemented through the project group. Share progress with those involved in making improvements, as well as relevant boards and local partners.
NICE provides a comprehensive programme of support and resources to maximise uptake and use of evidence and guidance. See our into practice pages for more information.
Also see Leng G, Moore V, Abraham S, editors (2014) Achieving high quality care  practical experience from NICE. Chichester: Wiley.# Recommendations for research 
The guideline committee has made the following recommendations for research.

# Recognition of child sexual abuse
What approaches to practice enable children (both boys and girls) who have been sexually abused to begin to tell practitioners about their experiences earlier, and in a way that does not contaminate the reliability of subsequent court proceedings?

## Why this is important
Research shows that many children and young people who are sexually abused do not tell anyone about their abuse. Among those who do, many delay telling someone for a long time, sometimes until adulthood. We found little research identifying the approaches or techniques that would make it more likely for a child being sexually abused to tell a practitioner about it. Although there is an evidence base on Achieving Best Evidence interviewing as part of a formal investigation, there is less evidence about approaches that can be used at an earlier stage. Studies are needed that would identify effective approaches to enable children to talk about sexual abuse, while ensuring that these early conversations do not contaminate evidence at a later stage in an investigation.

# Recognition of risk and prevention of female genital mutilation
What interventions are effective and cost effective in:
improving practitioners' recognition of children who are at risk of female genital mutilation (FGM) in the UK or overseas?
improving recognition of co-occurring forms of abuse where relevant?
preventing FGM in this group?

## Why this is important
There is a lack of evidence from the UK about how practitioners can be supported to recognise girls and young women who are at risk of FGM and effective interventions to prevent FGM. This is despite evidence that many practitioners are likely to encounter young women at risk of FGM. There is also a lack of evidence about the extent to which FGM is a risk factor or indicator of other forms of abuse, and therefore whether the identification of FGM should be accompanied by other types of assessment and support. The Home Office has developed an FGM recognition and prevention e-learning resource; however, the effectiveness of this resource does not appear to have been evaluated.

# Recognition of risk and prevention of 'honour-based' violence and forced marriage
What interventions are effective and cost effective in:
improving practitioners' recognition of children who are at risk of or experiencing 'honour-based' violence and forced marriage?
preventing 'honour-based' violence and forced marriage?

## Why this is important
There is a lack of evidence from the UK about how practitioners can be supported to recognise children and young people who are at risk of or experiencing 'honour-based' violence, and how to prevent it. There is also little evidence showing which interventions are most effective for recognising young people at risk of forced marriage and for preventing such marriages from taking place. The government's guidance on forced marriage explains the issues around forced marriage, provides a clear definition and distinction from arranged marriage, lists some of the potential warning signs or indicators, and recommends organisational approaches to dealing with forced marriage. However, the effectiveness of these approaches has not been evaluated.

# Early help home visiting
What are the components of effective home visiting programmes for preventing child abuse and neglect in families of children and young people at risk of child abuse and neglect in the UK?

## Why this is important
There are numerous studies, based mostly in the US, involving home visiting programmes for families at risk of child abuse and neglect. The findings of these studies are mixed, with some programmes proving effective but not others. The descriptions of the programmes and their theoretical basis are often poorly reported. It is therefore difficult to ascertain the key 'active ingredients' in a successful home visiting programme. A meta-analytic study seeking to obtain additional information from study authors on the features of home visiting programmes and their effectiveness, for example using statistical modelling, would help in understanding these programmes.

# Effective prevention of child abuse and neglect in the UK
What interventions are effective and cost effective in the UK to prevent abuse and neglect of children and young people in families at risk of, or showing early signs of, abuse and neglect?

## Why this is important
The evidence reviewed for this guideline on the effectiveness of interventions to prevent abuse and neglect of children and young people was predominantly from outside the UK, and focused on home visiting programmes and parenting programmes. High-quality studies (ideally randomised controlled trials) are needed that:
look specifically at the effectiveness of interventions to prevent child abuse and neglect in the UK
focus on interventions already being provided in the UK that may have no or low-quality evidence to support them at present.

# Reducing social isolation and associated child abuse and neglect
What is the impact of social isolation on children, young people and families at risk of abuse and neglect in the UK? What interventions are effective and cost effective in a UK context in reducing social isolation and any associated child abuse and neglect?

## Why this is important
Evidence presented in the NSPCC's how safe are our children? suggests a link between social isolation and child abuse and neglect. However, there is a lack of evidence about what interventions are effective in reducing social isolation and any associated child abuse and neglect. The aim of research should be to inform practitioners and policy-makers of the impact of social isolation, and the methods that lead to successful engagement with socially isolated children, young people and families, and reduction of associated child abuse and neglect.

# Effective interventions for young people who have been abused or neglected
What interventions are effective and cost effective in improving the wellbeing of young people aged 12 to 17 who have experienced abuse or neglect, including those who are now in temporary or permanent alternative care placements or living independently?

## Why this is important
There is little evidence on effective interventions to improve the wellbeing of young people who have experienced abuse and neglect, except for those who have been sexually abused. Studies are needed that evaluate interventions for young people aged 12 and over who have been abused or neglected in the past, but are now in temporary or permanent alternative care placements. These include foster care, kinship care, residential care, special guardianship and adoption.

# Effective interventions for children and young people who have experienced online-facilitated abuse, including online grooming
What interventions are effective and cost effective in improving the wellbeing of children and young people who have experienced online-facilitated abuse, including grooming online?

## Why this is important
There is little evidence on what interventions are effective in helping children and young people recover from trauma following online abuse, including online grooming. In particular, whether existing interventions may be suitable, or whether different kinds of therapeutic support are needed to address the particular features of online abuse.

# Effective interventions for addressing child abuse and neglect in the UK
What interventions, approaches and methodologies provided by social care and voluntary sector services are effective and cost effective in the UK to prevent the recurrence of child abuse and neglect, and to improve the wellbeing of children, young people and families?

## Why this is important
The evidence reviewed for this guideline on the effectiveness of interventions to address abuse and neglect of children and young people was predominantly from outside the UK, and within the health sector (therapeutic interventions). We identified interventions, approaches and methodologies being used by social care and voluntary sector organisations in the UK but many of these could not be included because they have not been evaluated using high-quality research designs. High-quality studies are needed to show policy-makers and practitioners which ones are effective in the UK and in what circumstances.

# Interventions with fathers and male carers
What interventions are effective and cost effective when working with fathers and male carers to improve their parenting in families where children are being, or have been, abused or neglected?

## Why this is important
There is a lack of research evidence from the UK showing what interventions are effective to improve fathers' and male carers' parenting in families where children are being, or have been, abused or neglected. Most studies reviewed for this guideline, both from the UK and elsewhere, focused on female carers. Studies are needed to show what interventions and practices are effective in engaging fathers and male carers, and improving their parenting if needed.

# Interventions with male foster carers and adoptive parents
What interventions are effective and cost effective when working with male foster carers and adoptive parents who are caring for children and young people who have been abused in the past?

## Why this is important
There is a lack of research evidence from the UK on what interventions are effective in working with male foster carers and adoptive parents  much of the existing literature is in relation to female foster carers and adoptive parents.

# Effectiveness of home visiting following child abuse or neglect
Are home visiting interventions effective and cost effective in improving parenting and preventing recurrence of child abuse and neglect in families in which abuse or neglect is occurring or has occurred?

## Why this is important
There is a lack of evidence from the UK on the impact of home visiting on families in which abuse or neglect is occurring or has occurred (as opposed to its impact on prevention). For children who are subject to a child protection plan, home visiting is one of the tools that may be used for monitoring their welfare and their interaction with their parents or carers. It is also used for engaging with parents or carers to address abusive or neglectful behaviours or ensure children are protected. There is a need for studies which identify what practices are effective in ensuring the safety and wellbeing of children and young people.

# Effective interventions for parents or carers with substance misuse problems
What interventions, including family behaviour therapy, are effective and cost effective in improving parenting and preventing recurrence of neglect by parents or carers with substance misuse problems and whose children are on a child protection plan under the category of neglect in the UK?

## Why this is important
There is a lack of evidence from the UK about the impact of family behaviour therapy and other interventions on parents and carers with substance misuse problems who show neglectful parenting. Studies are needed to examine the effectiveness of family behaviour and other interventions, and the timescales for delivering such interventions. In some cases, it may take longer than the 26-week timescale of care proceedings to address parents' substance misuse problems. This research could inform court decisions about whether to extend the time limit if there was a realistic possibility of reunification at the end of the intervention.

# Effectiveness of web-based parenting programmes
Are web-based parenting programmes effective and cost effective for improving parenting and preventing recurrence of child abuse and neglect in families where child abuse or neglect has occurred?

## Why this is important
There is a lack of research data about the impact of web-based parenting programmes on families where child abuse or neglect has occurred. Our review for this guideline identified 1 small-scale US study of a web-based parenting programme for parents of children with abusive head injury. Research would inform practitioners whether this type of parenting programme could be effective for families where child abuse or neglect has occurred, and if so which families would be most likely to benefit.

# Relative effectiveness of interventions to support foster carers
What is the relative effectiveness and cost effectiveness of the KEEP intervention for foster carers of abused or neglected children compared to other interventions?

## Why this is important
There has been no independent UK study of the relative effectiveness of the KEEP intervention for foster carers and abused or neglected children when compared head to head with other interventions for foster carers. (There are effectiveness studies, but these are with a waitlist or service as usual comparator, rather than comparing different forms of support 'head to head'.) Data about outcomes in fostering services which use the KEEP model are kept by the National Implementation Service, which has responsibility for ensuring that model fidelity is maintained, but does not make comparisons with outcomes of other intervention models. A comparison study would help service providers identify the most appropriate model for supporting foster carers and abused or neglected children.

# Peer support for children and young people who have been abused or neglected
What peer support programmes are effective and cost effective in improving the wellbeing of children and young people who have been abused or neglected?

## Why this is important
There is a small amount of research into peer support interventions for children who have been abused or neglected. There is also anecdotal evidence that children who have experienced abuse or neglect would appreciate formally organised peer support in addition to the informal peer support that children often provide each other. A research study, where careful consideration was given to issues like helping peer supporters to manage confidential information about abuse or neglect, could test the success of a formally organised peer support programme.