Child maltreatment: when to suspect maltreatment in under 18s

This guideline covers the signs of possible child maltreatment in children and young people aged under 18 years. It aims to raise awareness and help health professionals who are not child protection specialists to identify the features of physical, sexual and emotional abuse, neglect and fabricated or induced illness.

# Introduction
This guidance provides a summary of clinical features associated with child maltreatment (alerting features) that may be observed when a child presents to healthcare professionals. Its purpose is to raise awareness and help healthcare professionals who are not specialists in child protection to identify children who may be being maltreated. It does not give healthcare professionals recommendations on how to diagnose, confirm or disprove child maltreatment.
Children may present with both physical and psychological symptoms and signs that constitute alerting features of one or more types of maltreatment, and maltreatment may be observed in parent or carerchild interactions.
There is strong evidence of the harmful short- and long-term effects of child maltreatment. All aspects of the child's health, development and wellbeing can be affected. The effects of child maltreatment can last throughout adulthood and include anxiety, depression, substance misuse, and self-destructive, oppositional or antisocial behaviours. In adulthood, there may be difficulties in forming or sustaining close relationships, sustaining employment and parenting capacity. Physical abuse may result in lifelong disability or physical scarring and harmful psychological consequences, and may even be fatal. The National Service Framework (NSF) for Children, Young People and Maternity Services for England states 'The high cost of abuse and neglect both to individuals (and to society) underpins the duty on all agencies to be proactive in safeguarding children.'

# Definitions

## Child maltreatment
Child maltreatment includes neglect, physical, sexual and emotional abuse, and fabricated or induced illness. This guidance uses the definitions of child maltreatment as set out in the Department for Education's statutory guidance on inter-agency working to safeguard and promote the welfare of children. This also includes an appendix of further relevant guidance from the Department for Education, other government departments and agencies, and external organisations.

## Age groups
This guidance uses the following terms to describe children of different ages:
infant (aged under 1 year)
child (aged under 13 years)
young person (aged 1317 years).
Exclusions from the guideline
The following topics were outside the scope of this guideline and have therefore not been covered:
risk factors for child maltreatment, which are well recognised. Examples include
parental or carer drug or alcohol misuse
parental or carer mental health problems
intra-familial violence or history of violent offending
previous child maltreatment in members of the family
known maltreatment of animals by the parent or carer
vulnerable and unsupported parents or carers
pre-existing disability in the child
protection of the unborn child
children who have died as a result of child maltreatment. It should be noted that there are special procedures that should be followed when a child dies unexpectedly.
diagnostic assessment and investigations (for example, X-rays)
treatment and care of the child if maltreatment is suspected
how healthcare professionals should proceed once they suspect maltreatment
healthcare professionals' competency, training and behaviour
service organisation
child protection procedures
communication of suspicions to parents or carers, or the child or young person
education and information for parents or carers, or the child or young person.
Communicating with and about the child or young person
Good communication between healthcare professionals and the child or young person, as well as with their families and carers, is essential. Communication should take into account additional needs such as physical, sensory or learning disabilities, or the inability to speak or read English. Consideration should be given to cultural needs of children or young people and their families and carers.
If healthcare professionals have concerns about sharing information with others, they should obtain advice from named or designated professionals for safeguarding children. If concerns are based on information given by a child, healthcare professionals should explain to the child when they are unable to maintain confidentiality, explore the child's concerns about sharing this information and reassure the child that they will continue to be kept informed about what is happening. When gathering collateral information from other health disciplines and other agencies, professionals need to use judgement about whether to explain to the family the need to gather this information for the overall assessment of the child.
Potential obstacles to recognising and responding to possible maltreatment
Healthcare professionals may come across many different obstacles in the process of identifying maltreatment but these should not prevent them from following the appropriate course of action to prevent further harm to the child or young person. Examples of potential obstacles include the following:
Concern about missing a treatable disorder.
Healthcare professionals are used to working with parents and carers in the care of children and fear 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.# Recommendations
The following guidance is based on the best available evidence. The full guidance gives details of the methods and the evidence used to develop the guidance.

# Definitions of terms used in this guidance
The alerting features in this guidance have been divided into two, according to the level of concern, with recommendations to either 'consider' or 'suspect' maltreatment.

## Consider
For the purposes of this guidance, to consider child maltreatment means that maltreatment is one possible explanation for the alerting feature or is included in the differential diagnosis.

## Multi-agency safeguarding arrangements
The responsibility for these arrangements is with 3 safeguarding partners: the local authority, clinical commissioning group for an area, and the chief officer of police for a police area. They have a shared and equal duty to work together to safeguard and promote the welfare of all children in a local area.

## Suspect
For the purposes of this guidance, to suspect child maltreatment means a serious level of concern about the possibility of child maltreatment but is not proof of it.

## Unsuitable explanation
For the purposes of this guidance, an unsuitable explanation for an injury or presentation is one that is implausible, inadequate or inconsistent:
with the child or young person's
presentation
normal activities
existing medical condition
age or developmental stage
account compared to that given by parent and carers
between parents or carers
between accounts over time.
An explanation based on cultural practice is also unsuitable because this should not justify hurting a child or young person.

# Using this guidance
If a healthcare professional encounters an alerting feature of possible child maltreatment that prompts them to consider, suspect or exclude child maltreatment as a possible explanation, it is good practice to follow the process outlined in 15 below:

## . Listen and observe
Identifying or excluding child maltreatment involves piecing together information from many sources so that the whole picture of the child or young person is taken into account. This information may come from different sources and agencies and includes:
any history that is given
report of maltreatment, or disclosure from a child or young person or third party. It is standard practice to refer to children's social services when a child or young person makes a disclosure of maltreatment (even though it may not be precise in every detail).
child's appearance
child's behaviour or demeanour
symptom
physical sign
result of an investigation
interaction between the parent or carer and child or young person.

## . Seek an explanation
Seek an explanation for any injury or presentation from both the parent or carer and the child or young person in an open and non-judgemental manner.
Alerting features of maltreatment in children with disabilities may also be features of the disability, making identification of maltreatment more difficult.Healthcare professionals may need to seek appropriate expertise if they are concerned about a child or young person with a disability.

## . Record
Record in the child or young person's clinical record exactly what is observed and heard from whom and when.
Record why this is of concern.
At this point the healthcare professional may consider, suspect or exclude child maltreatment from the differential diagnosis.

## . Consider, suspect or exclude maltreatment
At any stage during the process of considering maltreatment the level of concern may change and lead to exclude or suspect maltreatment.
When hearing about or observing an alerting feature in the guidance:
look for other alerting features of maltreatment in the child or young person's history, presentation or parent or carerinteraction with the child or young person now or in the past. Then do one or more of the following:
Discuss your 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.
Gather collateral information from other agencies and health disciplines, having used professional judgement about whether to explain the need to gather this information for an overall assessment of the child.
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.
If an alerting feature or considering child maltreatment prompts a healthcare professional to suspect child maltreatment they should refer the child or young person to children's social care, following local multi-agency safeguarding arrangements.
This may trigger a child protection investigation, supportive services may be offered to the family following an assessment or alternative explanations may be identified.
Exclude maltreatment when a suitable explanation is found for alerting features. This may be the decision following discussion of the case with a more experienced colleague or after gathering collateral information as part of considering child maltreatment.

## . Record
Record all actions taken in 4 and the outcome.

# Physical features
For the purposes of recommendations 1.1.2, 1.1.5, 1.1.6, 1.1.8 to 1.1.10, 1.1.13, 1.1.14, 1.1.16, 1.2.6 and 1.2.8, an unsuitable explanation for an injury or presentation is one that is implausible, inadequate or inconsistent. Also see the definitions of suspect and consider.

## Bruises
Suspect child maltreatment if a child or young person has bruising in the shape of a hand, ligature, stick, teeth mark, grip or implement.
Suspect child maltreatment if there is bruising or petechiae (tiny red or purple spots) that are not caused by a medical condition (for example, a causative coagulation disorder) and if the explanation for the bruising is unsuitable. Examples include:
bruising in a child who is not independently mobile
multiple bruises or bruises in clusters
bruises of a similar shape and size
bruises on any non-bony part of the body or face including the eyes, ears and buttocks
bruises on the neck that look like attempted strangulation
bruises on the ankles and wrists that look like ligature marks.

## Bites
Suspect child maltreatment if there is a report or appearance of a human bite mark that is thought unlikely to have been caused by a young child.
Consider neglect if there is a report or appearance of an animal bite on a child who has been inadequately supervised.

## Lacerations (cuts), abrasions and scars
Suspect child maltreatment if a child has lacerations, abrasions or scars and the explanation is unsuitable. Examples include lacerations, abrasions or scars:
-n a child who is not independently mobile
that are multiple
with a symmetrical distribution
-n areas usually protected by clothing (for example, back, chest, abdomen, axilla, genital area)
-n the eyes, ears and sides of face
-n the neck, ankles and wrists that look like ligature marks.

## Thermal injuries
Suspect child maltreatment if a child has burn or scald injuries:
if the explanation for the injury is absent or unsuitable or
if the child is not independently mobile or
-n any soft tissue area that would not be expected to come into contact with a hot object in an accident (for example, the backs of hands, soles of feet, buttocks, back) or
in the shape of an implement (for example, cigarette, iron) or
that indicate forced immersion, for example:
scalds to buttocks, perineum and lower limbs
scalds to limbs in a glove or stocking distribution
scalds to limbs with symmetrical distribution
scalds with sharply delineated borders.

## Cold injury
Consider child maltreatment if a child has cold injuries (for example, swollen, red hands or feet) with no obvious medical explanation.
Consider child maltreatment if a child presents with hypothermia and the explanation is unsuitable.

## Fractures
Suspect child maltreatment if a child has one or more fractures in the absence of a medical condition that predisposes to fragile bones (for example, osteogenesis imperfecta, osteopenia of prematurity) or if the explanation is absent or unsuitable. Presentations include:
fractures of different ages
X-ray evidence of occult fractures (fractures identified on X-rays that were not clinically evident). For example, rib fractures in infants.

## Intracranial injuries
Suspect child maltreatment if a child has an intracranial injury in the absence of major confirmed accidental trauma or known medical cause, in one or more of the following circumstances:
the explanation is absent or unsuitable
the child is aged under 3 years
there are also:
retinal haemorrhages or
rib or long bone fractures or
-ther associated inflicted injuries
there are multiple subdural haemorrhages with or without subarachnoid haemorrhage with or without hypoxic ischaemic damage (damage due to lack of blood and oxygen supply) to the brain.

## Eye trauma
Suspect child maltreatment if a child has retinal haemorrhages or injury to the eye in the absence of major confirmed accidental trauma or a known medical explanation, including birth-related causes.

## Spinal injuries
Suspect physical abuse if a child presents with signs of a spinal injury (injury to vertebrae or within the spinal canal) in the absence of major confirmed accidental trauma. Spinal injury may present as:
a finding on skeletal survey or magnetic resonance imaging
cervical injury in association with inflicted head injury
thoracolumbar injury in association with focal neurology or unexplained kyphosis (curvature or deformity of the spine).

## Visceral injuries
Suspect child maltreatment if a child has an intra-abdominal or intrathoracic injury in the absence of major confirmed accidental trauma and there is an absent or unsuitable explanation, or a delay in presentation. There may be no external bruising or other injury.

## Oral injury
Consider child maltreatment if a child has an oral injury and the explanation is absent or unsuitable.

## General injuries
Consider child maltreatment if there is no suitable explanation for a serious or unusual injury.

## Ano-genital signs and symptoms
Suspect sexual abuse if a girl or boy has a genital, anal or perianal injury (as evidenced by bruising, laceration, swelling or abrasion) and the explanation is absent or unsuitable.
Suspect sexual abuse if a girl or boy has a persistent or recurrent genital or anal symptom (for example, bleeding or discharge) that is associated with behavioural or emotional change and that has no medical explanation.
Suspect sexual abuse if a girl or boy has an anal laceration, and constipation, Crohn's disease and passing hard stools have been excluded as the cause.
Consider sexual abuse if an anus exhibiting dynamic anal dilation in a girl or boy is observed during an examination and there is no medical explanation (for example, a neurological disorder or severe constipation).
Consider sexual abuse if a girl or boy has a genital or anal symptom (for example, bleeding or discharge) without a medical explanation.
Consider sexual abuse if a girl or boy has dysuria (discomfort on passing urine) or ano-genital discomfort that is persistent or recurrent and does not have a medical explanation (for example, worms, urinary infection, skin conditions, poor hygiene or known allergies).
Consider sexual abuse if there is evidence of one or more foreign bodies in the vagina or anus. Foreign bodies in the vagina may be indicated by offensive vaginal discharge.

## Sexually transmitted infections
Consider sexual abuse if a child younger than 13 years has hepatitis B unless there is clear evidence of mother-to-child transmission during birth, non-sexual transmission from a member of the household or blood contamination.
Consider sexual abuse if a child younger than 13 years has anogenital warts unless there is clear evidence of mother-to-child transmission during birth or non-sexual transmission from a member of the household.
Suspect sexual abuse if a child younger than 13 years has gonorrhoea, chlamydia, syphilis, genital herpes, hepatitis C, HIV or trichomonas infection unless there is clear evidence of mother-to-child transmission during birth or blood contamination.
Consider sexual abuse if a young person aged 13 to 15 years has hepatitis B unless there is clear evidence of mother-to-child transmission during birth, non-sexual transmission from a member of the household, blood contamination or that the infection was acquired from consensual sexual activity with a peer.
Consider sexual abuse if a young person aged 13 to 15 years has anogenital warts unless there is clear evidence of mother-to-child transmission during birth, non-sexual transmission from a member of the household, or that the infection was acquired from consensual sexual activity with a peer.
Consider sexual abuse if a young person aged 13 to 15 years has gonorrhoea, chlamydia, syphilis, genital herpes, hepatitis C, HIV or trichomonas infection unless there is clear evidence of mother-to-child transmission during birth, blood contamination, or that the sexually transmitted infection (STI) was acquired from consensual sexual activity with a peer. In these circumstances, consider should include discussion of your concerns with a named or designated professional for safeguarding children.
Consider sexual abuse if a young person aged 16 or 17 years has hepatitis B and there is:
no clear evidence of mother-to-child transmission during birth, non-sexual transmission from a member of the household, blood contamination or that the infection was acquired from consensual sexual activity and
a clear difference in power or mental capacity between the young person and their sexual partner, in particular when the relationship is incestuous or is with a person in a position of trust (for example, teacher, sports coach, minister of religion) or
concern that the young person is being exploited.
Consider sexual abuse if a young person aged 16 or 17 years has anogenital warts and there is:
no clear evidence of non-sexual transmission from a member of the household or that the infection was acquired from consensual sexual activity and
a clear difference in power or mental capacity between the young person and their sexual partner, in particular when the relationship is incestuous or is with a person in a position of trust (for example, teacher, sports coach, minister of religion) or
concern that the young person is being exploited.
Consider sexual abuse if a young person aged 16 or 17 years has gonorrhoea, chlamydia, syphilis, genital herpes, hepatitis C, HIV or trichomonas infection and there is:
no clear evidence of blood contamination or that the STI was acquired from consensual sexual activity and
a clear difference in power or mental capacity between the young person and their sexual partner, in particular when the relationship is incestuous or is with a person in a position of trust (for example, teacher, sports coach, minister of religion) or
concern that the young person is being exploited.

# Clinical presentations

## Pregnancy
Be aware that sexual intercourse with a child younger than 13 years is unlawful and therefore pregnancy in such a child means the child has been maltreated. Under the Sexual Offences Act 2003, any sexual intercourse with a child younger than 13 years is unlawful. See the Crown Prosecution Service guidance about the act for further information about consent to sexual intercourse in people under 18.
Consider sexual abuse if a young woman aged 13 to 15 years is pregnant. Under the Sexual Offences Act 2003, any sexual intercourse with a child aged 13 to 15 years is unlawful. See the Crown Prosecution Service guidance about the act for further information about consent to sexual intercourse in people under 18.
Consider sexual abuse if a young woman aged 16 or 17 years is pregnant and there is:
a clear difference in power or mental capacity between the young woman and the putative father, in particular when the relationship is incestuous or is with a person in a position of trust (for example, teacher, sports coach, minister of religion) or
concern that the young woman is being exploited or
concern that the sexual activity was not consensual.

## Apparent life-threatening event
Suspect child maltreatment if a child has repeated apparent life-threatening events, the onset is witnessed only by one parent or carer and a medical explanation has not been identified.
Consider child maltreatment if an infant has an apparent life-threatening event with bleeding from the nose or mouth and a medical explanation has not been identified.

## Poisoning
Suspect child maltreatment in cases of poisoning in children if:
there is a report of deliberate administration of inappropriate substances, including prescribed and non-prescribed drugs or
there are unexpected blood levels of drugs not prescribed for the child or
there is reported or biochemical evidence of ingestions of one or more toxic substances or
the child was unable to access the substance independently or
the explanation for the poisoning or how the substance came to be in the child is absent or unsuitable or
there have been repeated presentations of ingestions in the child or other children in the household.
Consider child maltreatment in cases of hypernatraemia (abnormally high levels of sodium in the blood) and a medical explanation has not been identified.

## Non-fatal submersion injury
Suspect child maltreatment if a child has a non-fatal submersion incident (near-drowning) and the explanation is absent or unsuitable or if the child's presentation is inconsistent with the account.
Consider child maltreatment if a non-fatal submersion incident suggests a lack of supervision.

## Attendance at medical services
Consider child maltreatment if there is an unusual pattern of presentation to and contact with healthcare providers, or there are frequent presentations or reports of injuries.

## Fabricated or induced illness
Consider fabricated or induced illness if a child's history, physical or psychological presentations or findings of assessments, examinations or investigations leads to a discrepancy with a recognised clinical picture. Fabricated or induced illness is a possible explanation even if the child has a past or concurrent physical or psychological condition.
Suspect fabricated or induced illness if a child's history, physical or psychological presentations or findings of assessments, examinations or investigations leads to a discrepancy with a recognised clinical picture and one or more of the following is present:
Reported symptoms and signs only appear or reappear when the parent or carer is present.
Reported symptoms are only observed by the parent or carer.
An inexplicably poor response to prescribed medication or other treatment.
New symptoms are reported as soon as previous ones have resolved.
There is a history of events that is biologically unlikely (for example, infants with a history of very large blood losses who do not become unwell or anaemic).
Despite a definitive clinical opinion being reached, multiple opinions from both primary and secondary care are sought and disputed by the parent or carer and the child continues to be presented for investigation and treatment with a range of signs and symptoms.
The child's normal daily activities (for example, school attendance) are being compromised, or the child is using aids to daily living (for example, wheelchairs) more than would be expected for any medical condition that the child has.Fabricated or induced illness is a likely explanation even if the child has a past or concurrent physical or psychological condition.

## Inappropriately explained poor school attendance
Consider child maltreatment if a child has poor school attendance that the parents or carers know about that has no justification on health, including mental health, grounds and home education is not being provided.

# Neglect  failure of provision and failure of supervision
Neglect is a situation involving risk to the child or young person. It is the persistent failure to meet the child or young person's basic physical or psychological needs that is likely to result in the serious impairment of their health or development. This may or may not be deliberate. There are differences in how parents and carers choose to raise their children, including the choices they make about their children's healthcare. However, failure to recognise and respond to the child or young person's needs may amount to neglect.
There is no diagnostic gold standard for neglect and therefore decision-making in situations of apparent neglect can be very difficult and thresholds hard to establish. It is essential to place the child or young person at the centre of the assessment.

## Provision of basic needs
Consider neglect if a child has severe and persistent infestations, such as scabies or head lice.
Consider neglect if a child's clothing or footwear is consistently inappropriate (for example, for the weather or the child's size). Take into account that instances of inadequate clothing that have a suitable explanation (for example, a sudden change in the weather, slippers worn because they were closest to hand when leaving the house in a rush) or resulting from behaviour associated with neurodevelopmental disorders such as autism would not be alerting features for possible neglect.
Suspect neglect if a child is persistently smelly and dirty.Take into account that children often become dirty and smelly during the course of the day. Use judgement to determine if persistent lack of provision or care is a possibility. Examples include:
child seen at times of the day when it is unlikely that they would have had an opportunity to become dirty or smelly (for example, an early morning visit)
if the dirtiness is ingrained.
Suspect neglect if you repeatedly observe or hear reports of any of the following in the home that is in the parents' or carers' control:
a poor standard of hygiene that affects a child's health
inadequate provision of food
a living environment that is unsafe for the child's developmental stage.Be aware that it may be difficult to distinguish between neglect and material poverty. However, care should be taken to balance recognition of the constraints on the parents' or carers' ability to meet their children's needs for food, clothing and shelter with an appreciation of how people in similar circumstances have been able to meet those needs.
Be aware that abandoning a child is a form of maltreatment.

## Malnutrition
Consider neglect if a child displays faltering growth because of lack of provision of an adequate or appropriate diet. See NICE's guideline on faltering growth.

## Supervision
Achieving a balance between an awareness of risk and allowing children freedom to learn by experience can be difficult. However, if parents or carers persistently fail to anticipate dangers and to take precautions to protect their child from harm it may constitute neglect.
Consider neglect if the explanation for an injury (for example, a burn, sunburn or an ingestion of a harmful substance) suggests a lack of appropriate supervision.
Consider neglect if a child or young person is not being cared for by a person who is able to provide adequate care.

## Ensuring access to appropriate medical care or treatment
Consider neglect if parents or carers fail to administer essential prescribed treatment for their child.
Consider neglect if parents or carers repeatedly fail to bring their child to follow-up appointments that are essential for their child's health and wellbeing.
Consider neglect if parents or carers persistently fail to engage with relevant child health promotion programmes, which include:
immunisation
health and development reviews
screening.
Consider neglect if parents or carers have access to but persistently fail to obtain treatment for their child's dental caries (tooth decay).
Suspect neglect if parents or carers fail to seek medical advice for their child to the extent that the child's health and wellbeing is compromised, including if the child is in ongoing pain.

# Emotional, behavioural, interpersonal and social functioning

## Emotional and behavioural states
Consider child maltreatment if a child or young person displays or is reported to display a marked change in behaviour or emotional state (see examples below) that is a departure from what would be expected for their age and developmental stage and is not fully explained by a known stressful situation that is not part of child maltreatment (for example, bereavement or parental separation) or medical cause. Examples include:
recurrent nightmares containing similar themes
extreme distress
markedly oppositional behaviour
withdrawal of communication
becoming withdrawn.
Consider child maltreatment if a child's behaviour or emotional state is not consistent with their age and developmental stage or cannot be fully explained by medical causes, neurodevelopmental disorders (for example, attention deficit hyperactivity disorder , autism spectrum disorders) or other stressful situation that is not part of child maltreatment (for example, bereavement or parental separation). Examples of behaviour or emotional states that may fit this description include:
Emotional states:
fearful, withdrawn, low self-esteem
Behaviour:
aggressive, oppositional
habitual body rocking
Interpersonal behaviours:
indiscriminate contact or affection seeking
-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 maltreatment if a child shows repeated, extreme or sustained emotional responses that are out of proportion to a situation and are not expected for the child's age or developmental stage or fully explained by a medical cause, neurodevelopmental disorder (for example, ADHD, autism spectrum disorders) or bipolar disorder and the effects of any known past maltreatment have been explored. Examples of these emotional responses include:
anger or frustration expressed as a temper tantrum in a school-aged child
frequent rages at minor provocation
distress expressed as inconsolable crying.
Consider child maltreatment if a child shows dissociation (transient episodes of detachment that are outside the child's control and that are distinguished from daydreaming, seizures or deliberate avoidance of interaction) that is not fully explained by a known traumatic event unrelated to maltreatment.
Consider child maltreatment if a child or young person regularly has responsibilities that interfere with the child's essential normal daily activities (for example, school attendance).
Consider child maltreatment if a child responds to a health examination or assessment in an unusual, unexpected or developmentally inappropriate way (for example, extreme passivity, resistance or refusal).

## Behavioural disorders or abnormalities either seen or heard about
Consider past or current child maltreatment, particularly sexual, physical or emotional abuse, if a child or young person is deliberately self-harming. Self-harm includes cutting, scratching, picking, biting or tearing skin to cause injury, pulling out hair or eyelashes and deliberately taking prescribed or non-prescribed drugs at higher than therapeutic doses.
Suspect child maltreatment if a child repeatedly scavenges, steals, hoards or hides food with no medical explanation (for example PraderWilli syndrome, a genetic condition leading to a range of symptoms, including over-eating, restricted growth, reduced muscle tone, and learning and behavioural difficulties).
Consider child maltreatment if a child has secondary day- or night-time wetting that persists despite adequate assessment and management unless there is a medical explanation (for example, urinary tract infection) or clearly identified stressful situation that is not part of maltreatment (for example, bereavement, parental separation).
Consider child maltreatment if a child is reported to be deliberately wetting.
Consider child maltreatment if a child shows encopresis (repeatedly defecating a normal stool in an inappropriate place) or repeated, deliberate smearing of faeces.
Suspect child maltreatment, and in particular sexual abuse, if a pre-pubertal 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 current or past child maltreatment if a child or young person's sexual behaviour is indiscriminate, precocious or coercive.
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.
Consider child maltreatment 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.

# Parentchild interactions
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, including domestic abuse.
Using the child for the fulfilment of the adult's needs (for example, in marital disputes).
Failure to promote the child's appropriate socialisation (for example, involving children in unlawful activities, isolation, not providing stimulation or education).
Suspect emotional abuse if the interactions observed in recommendation 1.5.1 are persistent.
Consider child maltreatment if parents or carers are seen or reported to punish a child for wetting or soiling despite professional advice that the symptom is involuntary.
Consider emotional neglect if there is emotional unavailability and unresponsiveness from the parent or carer towards a child or young person and in particular towards an infant.
Suspect emotional neglect if the interaction observed in recommendation 1.5.4 is persistent.
Consider child maltreatment if a parent or carer refuses to allow a child or young person to speak to a healthcare professional on their own when it is necessary for the assessment of the child or young person.# Recommendations for research
The guideline development group has made the following recommendations for research, based on its review of evidence, to improve NICE guidance and patient care in the future. The guideline development group's full set of research recommendations is detailed in the full guideline.

# Fractures
How can abusive fractures be differentiated from those resulting from conditions that lead to bone fragility and those resulting from accidents, particularly in relation to metaphyseal fractures?

## Why this is important
The existing evidence base does not fully account for the features that differentiate fractures from different causes in infants and pre-school age children. A prospective comparative study of fractures in physical abuse, those resulting from conditions that lead to bone fragility and those resulting from accidental trauma would help address this question. Any such study should encompass a study of metaphyseal fractures.

# Anogenital warts
What is the association between anogenital warts and sexual abuse in children of different ages?

## Why this is important
Anogenital warts can be acquired by vertical transmission, sexual contact and by non-sexual transmission within households. A thorough prospective study is needed to investigate the differential causes of anogenital warts in children. Such a study should include full viral typing of the warts in the index case and contacts where possible.

# Fabricated or induced illness
Are the indicators of fabricated or induced illness as described in the recommendations (see recommendations 1.2.11 and 1.2.12) valid for discriminating fabricated or induced illness from other explanations?

## Why this is important
Although the alerting signs have been developed based on clinical experience and are considered clinically useful in detecting fabricated or induced illness, there is a need to establish their discriminant validity. This could be achieved by a prospective longitudinal study.

# Emotional and behavioural states
What aspects of behaviours and emotional states as alerting individual signs discriminate maltreated children from non-maltreated children in the healthcare setting?

## Why this is important
Much of the research in this area uses composite scores from instruments or scenarios to discriminate maltreated from non-maltreated children. To translate these scores into items that are usable for healthcare professionals who are meeting children for the first time, it is necessary to know whether particular behavioural and emotional states can be used to identify maltreated children. A prospective comparative study in the healthcare setting is required.

# Recurrent abdominal pain
What is the association between unexplained recurrent abdominal pain and child maltreatment?

## Why this is important
Recurrent abdominal pain is a common presentation in primary care and is often unexplained. A large observational study on the association between unexplained recurrent abdominal pain and child maltreatment is needed.