3.1 Recognition of Abuse and Neglect

The Children Act 1989 provides the legal framework for defining the situations in which a local authority must make enquiries about what, if any, action to take to safeguard or promote a child's welfare.

Section 47 of the Act requires that if a local authority has 'reasonable cause to suspect that a child who lives or is found in their area is suffering or is likely to suffer Significant Harm,  the authority shall make, or cause to be made, such enquiries as they consider necessary…'

In Section 31 Children Act 1989 as amended by the Adoption and Children Act 2002:

• 'Harm' means ill-treatment, or the impairment of health or development, including, for example, impairment suffered from seeing or hearing the ill-treatment of another;
• 'Development' means physical, intellectual, emotional, social or behavioural development;
• 'Health' includes physical and mental health;
• 'Ill treatment' includes Sexual Abuse and forms of ill-treatment, which are not physical; and
• Where the question of whether harm suffered by the child is significant turns on the child's health and development, his/her health and development must be compared with that which could reasonably be expected of a similar child.

There are no absolute criteria on which to rely to determine what constitutes Significant Harm. It is often a compilation of significant events, both acute and longstanding, which impact on the child's physical and psychological development. Children's Services must consider all the circumstances when determining whether a referral about abuse and / or neglect to a child satisfies the criteria for a section 47 Enquiry - for further details, please see Section 47 Enquiries Procedure.

Abuse and neglect are forms of maltreatment of a child. Somebody may cause or neglect a child by inflicting harm or failing to act to prevent harm. Children may be abused in a family, or in an institutional or community setting, by those known to them or, more rarely by a stranger. They may be abused by an adult or adults or another child or children.

Working Together to Safeguard Children, 2018  includes definitions of the four broad categories of abuse that are used for recognition:

• Physical Abuse
• Emotional Abuse
• Sexual Abuse
• Neglect.

These categories overlap, and an abused child does frequently suffer more than one type of abuse. This chapter provides definitions of these categories and information to help identify potential abuse and neglect and the required response.

Professionals are encouraged to 'think the unthinkable' when working with families.   Safeguarding requires professionals to think about the worst-case scenario (the unthinkable), even if it is then dismissed, based on evidence.

Physical Abuse

Physical abuse may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating, or otherwise causing physical harm to a child.

It may also be caused when a parent or carer fabricates the symptoms of, or deliberately induces illness in a child. This unusual and potentially dangerous form of abuse is described as fabricated or induced illness in a child (see Fabricated or induced illness (FII) and Perplexing Presentations (including FII by carers)).

See also Recognising Physical Abuse 

Emotional Abuse

Emotional abuse involves the persistent emotional maltreatment of a child, such as to cause severe and persistent adverse effects on the child's emotional development.

It may involve conveying to children that they are worthless or unloved, inadequate, or valued only insofar as they meet the needs of another person. It may include not giving the child opportunities to express their views, deliberately silencing them or 'making fun' of what they say or how they communicate. It may feature age or developmentally inappropriate expectations being imposed on children.

These may include interactions beyond the child's developmental capability, overprotection and limitation of exploration and learning, or preventing the child from participating in normal social interaction. It may involve seeing or hearing the ill-treatment of another. It may involve serious bullying, causing children to feel frightened or in danger or the exploitation or corruption of children.

Some level of Emotional Abuse is involved in all types of maltreatment of a child, though it may occur alone.

Sexual Abuse

Sexual abuse involves forcing or enticing a child or young person to participate 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 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. Sexual abuse can take place online, and technology can be used to facilitate offline abuse. Sexual abuse may be part of criminal exploitation or gang activity.

Practitioners must consider the increased risk of Honour Based Abuse (HBA) to victims of sexual abuse, particularly those of ethnic minority. 

Sexual Abuse is not solely perpetrated by adult males. Women can also commit acts of Sexual Abuse. 

The Sexual Offences Act 2003 introduced a range of new sexual offences designed to address all inappropriate activity with children.

Child Sexual Abuse includes:

• Rape, vaginal, anal or oral penetration committed by a male on a female or male without consent (this is the only sexual offence that can be committed exclusively by a man, as the penetration must be by a penis);
• Sexual assault by penetration: penetration of the vagina or anus with a part of the body or anything else (this is a new offence that replaces indecent assault and recognises the seriousness of penetration);
• Sexual assault:  touching a person sexually without consent (this also replaces the offence of indecent assault and covers non-penetrative touching of a victim and would include fondling, masturbation, digital penetration and oral-genital contact);
• Sexual activity with a child:  a person 18 or over intentionally sexually touching a child under 16 (this offence replaces the offences of indecent assault and unlawful sexual intercourse - a separate offence deals with the situation where both persons involved are under 18 and reduces the penalty); these offences include situations where there is consent between the parties; where this consent exists, and the parties are of a similar age, it is not anticipated that any criminal proceedings will take place;
• Causing or inciting a child to engage in sexual activity:  a person aged 18 or over  making a child under 16 commit a sexual act on another person (including making a child touch the offender);
• Other forms of sexual activity e.g. taking indecent photographs of children or exposing children to abusive images of children.
• Children can be sexually harmed through exploitation as part of criminal or gang activity - see also, Safeguarding Children and Young People Who May be Affected by Gang Activity

In law, children under 16 years of age cannot consent to any sexual activity occurring, although in practice, young people may be involved in sexual contact to which, as individuals, they may have agreed.  Children under 13 years cannot in law under any circumstances consent to sexual activity, and specific offences, including rape, exist for child victims under this age (see Sexually Active Children Procedure).

Neglect

Neglect is 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 and development.

Neglect may occur during pregnancy as a result of maternal substance misuse.

Once the child is born, neglect may involve a parent or carer: 

• Not meeting a child's basic needs, such as food, clothing or shelter
• Refusal of/delay in healthcare- Failure or delay in seeking and obtaining appropriate healthcare services for a child/young person
• Abandonment/expulsion- Abandoning a child or excluding a child from the family home and refusing to accept their return
• Other custody issues- Repeated 'shuttling' of a child from one household to another due to an apparent unwillingness to maintain custody/care, or chronically and repeatedly leaving a child with others for days/weeks at a time
• failing to protect a child from physical and emotional harm or danger
• failing to ensure adequate supervision- Child left unsupervised or inadequately supervised for extended periods or not providing for their safety
• Parental failure to engage with an appropriate management plan in a child who is severely obese and/or is developing serious complications of obesity should be considered a safeguarding issue.

Severe neglect of young children is associated with major impairment of growth and intellectual development. Persistent neglect can lead to serious impairment of health and development, long-term difficulties with social functioning, relationships and educational progress. Neglect can also result, in extreme cases, in death.

The factors described in this section are frequently found in cases of child abuse. Their presence is not proof that abuse has occurred, but:

• Must be regarded as indicators of possible Significant Harm;
• Must prompt the professional to seek further information;
• Justify the need for careful assessment and discussion with designated/named / lead person, manager, (or in the absence of all those individuals, an experienced colleague);
• May require consultation with and/or referral to Children's Services - see the Making a Referral Procedure.

In an abusive relationship, the child may:

• Appear frightened of the parent(s)
• Act in a way that is inappropriate to her/his age and development  (though full account needs to be taken of different patterns of development and different ethnic groups).

The parent or carer may:

• Persistently avoid child health services and treatment of the child's illnesses
• Have unrealistic expectations of the child
• Frequently complain about / to the child and fail to provide attention or praise (a high criticism / low warmth environment)
• Be absent
• Be misusing substances
• Persistently refuse to allow access on home visits
• Be involved in domestic abuse
• Be socially isolated
• Failing to protect the child from harm.

Consideration must be given to the impact on the care of the child of any issues/problems affecting parenting, e.g. domestic abuse, which may include physical violence; coercive and controlling behaviour, substance misuse, mental health problems, learning disabilities, childhood experiences of severe neglect or abuse; including sexual abuse. Consideration should be given to whether the parent can understand and predict risk and subsequently make appropriate decisions to protect their child from harm

The Home Office definition of Domestic violence and abuse was updated in May 2018 as:

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 (including gender identity) or sexuality. The abuse can encompass, but is not limited to:

• Psychological
• Physical
• Sexual
• Financial
• Emotional

Controlling behaviour is a range of acts designed to make a person subordinate and/or dependent by isolating them from sources of support, exploiting their resources and capacities for personal gain, depriving them of the means needed for independence, resistance and escape and regulating their everyday behaviour.

Coercive behaviour is an act or a pattern of acts of assault, threats, humiliation and intimidation or other abuse used to harm, punish, or frighten their victim.

Staff should be aware of the potential risk to children of witnessing or being injured due to domestic abuse when a new partner is introduced into the family home or has substantial access to the children and is known as a perpetrator of domestic abuse. Individuals who have been in an abusive relationship are more likely to enter into other unhealthy or abusive relationship. If concerns are raised, an application under Clare's Law should be made as either a 'right to know' made by professionals or a 'right to ask', made by individuals, so the parent can understand any risks posed by their new partner to make an informed choice about the relationship.

Working Together to Safeguard Children, 2018, introduced the concept of Contextual Safeguarding which recognises that as well as threats to the welfare of children from within their families, children may be vulnerable to abuse or exploitation from outside their families. These extra-familial threats might arise at school and other educational establishments, from within peer groups, or more widely from within the wider community and/or online. These threats can take various forms, and children can be vulnerable to multiple threats, including exploitation by criminal gangs and organised crime groups such as county lines, trafficking, online abuse, sexual exploitation and the influences of extremism leading to radicalisation.

Staff should be aware of the potential risk to children when individuals, previously known or suspected to have abused children, move into or have substantial access in the household (see Risk Management of Known Offenders and Those who Pose a Risk).

It should be recognised that those who pose a risk to children often will not be honest with others. Staff should be mindful of this. Of particular note are carers who present a risk due to either fabricating or inducing illnesses within the children they are responsible for - see Fabricated or induced illness (FII) and Perplexing Presentations (including FII by carers) 

Practitioners should, in particular, be alert to the potential need for early help for a child who:

• is disabled and has specific additional needs
• has special educational needs (whether or not they have a statutory Education, Health and Care Plan)
• is a young carer
• is showing signs of being drawn in to anti-social or criminal behaviour, including gang involvement and association with organised crime groups
• is frequently missing/goes missing from care or from home
• is at risk of modern slavery - National Referral Mechanism Digital Referral System: Report Modern Slavery, trafficking or exploitation
• is at risk of being radicalised or exploited
• is in a family circumstance presenting challenges for the child, such as drug and alcohol misuse, adult mental health issues and domestic abuse
• is misusing drugs or alcohol themselves
• has returned home to their family from care
• is a privately fostered child
• has a parent/carer in custody

In schools, it is important that staff are aware that mental health problems can, in some cases, be an indicator that a child has suffered or is at risk of suffering abuse, neglect or exploitation. Only appropriately trained professionals should attempt to make a diagnosis of a mental health problem, however school staff are well placed to observe children day-to-day and identify those whose behaviour suggests that they may be experiencing a mental health problem or be at risk of developing one. Where children have suffered abuse and neglect, or other potentially traumatic adverse childhood experiences, this can have a lasting impact throughout childhood, adolescence and into adulthood. It is key that school staff are aware of how these children’s experiences can impact on their mental health, behaviour and education. 

This section provides information about the sites and characteristics of physical injuries that may be observed in abused children. It is intended primarily to assist staff in recognition of bruises, burns and bites, which should be referred to Children’s Services and/or require a medical assessment

Further useful information can be found on the RCPCH website, about a series of systematic reviews defining the evidence base for the recognition and investigation of physical child abuse and neglect.

The following are bruises/injuries/burns that should prompt a thorough assessment:

• Not independently mobile Babies
• Unexplained sub-conjunctival haemorrhages and other eye injuries (A sub- conjunctival haemorrhage occurs when a tiny blood vessel breaks just underneath the clear surface of your eye (conjunctiva). A sub-conjunctival haemorrhage appears as a bright red or dark red dot or mark/patch on the white of the eye. There are a number of possible causes of SCHs that need to be considered, including non-accidental causes). 
• Buttocks
• Forearm, upper arm & hands
• Face, neck & ears
• Abdomen (soft tummy area) or hip
• The backs of legs & feet

See 'Bruising' below for more information on bruising.

Babies and young children can also sustain serious head and neck injuries as a result of abusive head trauma. Physical signs include reduced conscious levels, vomiting, irritability, apnoea (a pause/temporary stopping of breathing) or irregular breathing.

The following are often regarded as indicators of concern:

• Reluctance to give information or mention previous injuries.
• Family use of different doctors and A&E departments;
• Repeated presentation of minor injuries (which may represent a 'cry for help' and if ignored could lead to a more serious injury) or may represent fabricated or induced illness (see Fabricated or induced illness (FII) and Perplexing Presentations (including FII by carers) 
• Parents who are absent without good reason when their child is presented for treatment;
• Parents/carers who are uninterested or undisturbed by an accident or injury;
• Unexplained delay in seeking treatment;
• Several different explanations provided for an injury;
• An explanation that is inconsistent with an injury;
• Injuries that are suspected or reported to be due to domestic abuse within their own (age 16 & 17 yrs) or parent/carer (s) relationship. Consideration should also be given to abusive relationships of other young people age 15 and under; although not defined as domestic abuse may indicate the need for additional support.

For all young people, broader contextual safeguarding risks should be considered when there is an unexplained injury; consider individual vulnerabilities, e.g. exploitation into criminality/gangs/drugs/sexual; radicalisation; who has brought them/come with them for treatment. 

Bruising

The Child Protection Evidence Systematic Review on Bruising (Royal College of Paediatrics and Child Health, 2020) found that bruising was the most common injury in children who have been abused. It is also a common injury in non-abused children, the exception to this being pre‑mobile infants where accidental bruising is rare (0-1.3%). The number of bruises a child sustains through normal activity increases as they get older and their level of independent mobility increases.

Children can have accidental bruising, but the following must be considered as highly suspicious of a non-accidental injury unless there is an adequate explanation provided and experienced medical opinion sought:

• Any bruising or other soft tissue injury to a pre-crawling or pre-walking (immobile) infant to include cruising or bottom shuffling, and those unable to roll over, or non-mobile disabled child;
• Bruising in or around the mouth, particularly in small babies may indicate force feeding;
• Bruising around the eyes or injury on the eyes (including sub-conjunctival haemorrhages- A subconjunctival haemorrhage occurs when a tiny blood vessel breaks just underneath the clear surface of your eye (conjunctiva). A subconjunctival haemorrhage appears as a bright red or dark red dot or mark/patch on the white of the eye.There are a number of possible causes of SCHs that need to be considered, including non-accidental causes)
• Linear marks, haemorrhages or pale scars may be caused by ligature, especially at wrists, ankles, neck, male genitalia;
• Bruising or tears on, around, or behind, the earlobe(s) indicating injury by blunt force trauma,  pulling or twisting;
• Broken teeth and mouth injuries (a torn frenulum - the flap of tissue in the midline under the upper lip - is highly suspicious);
• Bruising on the genitalia, arms, buttocks and thighs may be an indicator of physical and sexual abuse.
• Bruises that are accompanied by petechiae (small pinpoint red spots), in the absence of underlying bleeding disorders.
• Areas that were rarely bruised accidentally in disabled children were lower legs, ears, neck, chin, anterior chest and genitalia and therefore NAI should be strongly considered.
• Multiple bruises of uniform shape
• Multiple bruises in clusters
• Bruises that carry the imprint of implement used or a ligature
•  Bruises that are seen away from bony prominences
•  Bruises to the face, abdomen, arms, buttocks, ears, neck, and hands

See also Bruises on children: Core info leaflet | NSPCC Learning

see also Patterns of Bruising in Mobile Children

See also Unexplained Injuries to Young Children 

 Click here to view Flowchart on Injuries to Young Children.

Bruise Pathway - Bruising/injuries in Children who are Not Independently Mobile (NIM) Guidance (Reviewed Feb 2023)

Brief Resolved Unexplained Episode (BRUE), previously known as Acute Life-Threatening Event (ALTE)

Most BRUEs have a medical or physiological basis, although a precise explanation is not always found. Some have unnatural causes, and assessment should always consider these through careful and detailed history taking, examination and investigations. Abusive Head Trauma (AHT) can present with irregular breathing, seizures or apnoeas.

AHT must be considered in children presenting with BRUEs, and Child protection checks must be initiated for the child and any siblings. Any suspicions must be reported immediately to the duty social worker. 

It is not possible to age bruises. 

Bite Marks

• Bite marks can leave clear impressions of the teeth. Human bite marks are oval or crescent-shaped. Those over 3cm in diameter are more likely to have been caused by an adult or older child.

A medical opinion from a forensic dentist/odontologist should be sought where there is any doubt over the bite's origin.

Burns and Scalds

It can be challenging to distinguish between accidental and non-accidental burns and scalds and will always require experienced medical opinion. Any burn with a clear outline may be suspicious, e.g:

• Circular burns from cigarettes are characteristically punched out lesions 0.6 - 0.7 cm in diameter, and healing, usually leaves a scar
• Friction burns resulting from being dragged
• Linear burns from hot metal rods or electrical fire elements
• Burns of uniform depth over a large area
• Scalds that have a line indicating immersion or poured liquid (a child getting into hot water of their own accord will struggle to get out and cause splash marks)
• Old scars indicating previous burns/scalds which did not have appropriate treatment or adequate explanation.

Scalds to the buttocks of a small child, particularly in the absence of burns to the feet, are indicative of dipping into a hot liquid or bath.

Fractures

Fractures may cause pain, swelling and discolouration over a bone or joint.

Non-mobile children rarely sustain fractures.

There are grounds for concern if:

• The history provided is vague, non-existent or inconsistent with the fracture type
• There are multiple fractures or old fractures (in the absence of major trauma, birth injury or underlying bone disease)
• Medical attention is sought after a period of delay when a fracture has caused symptoms e.g. swelling, pain or loss of movement
• There is an unexplained fracture in the first year of life.

Scars

A large number of scars or scars of different sizes or ages, or on different parts of the body, may suggest abuse.

Abusive Head Trauma (previously known as Shaken Baby Syndrome)

Shaking and/or inflicting an impact injury on a baby often results in no visible external injury. Nevertheless, significant internal injuries may be caused, e.g. intracranial bleeding, brain injury, small fractures to the ends of the long bones, other fractures (such as ribs and neck) and retinal haemorrhages (a retinal haemorrhage is bleeding from the blood vessels in the retina at the back of the eye). Signs and symptoms can be non-specific, which may result in a delay in seeking advice. See also Unexplained Injuries to Young Children 

Young children and infants are highly vulnerable and may have a serious injury without obvious physical signs, e.g. shaking and/or impact injuries may result in internal head and other injuries. Nevertheless, significant internal injuries may be caused and result in:

• Lethargy, poor feeding, apnoea or irregular breathing
• Vomiting
• Fits
• Variable levels of consciousness (irritability & drowsiness)
• Intra-cranial bleeding and retinal haemorrhages
• Skull and rib fractures
• Death.

A full paediatric assessment must be carried out in suspected cases, including an ophthalmological examination, blood tests, and CT/MRI scans/skeletal survey (according to the RCR/RCPCH guidance).

Self-Harming or injury caused by Siblings

Caution must be used when interpreting an explanation by parents/carers that an injury or series of injuries was self-inflicted or caused by a sibling. This is especially important in young or disabled children not able to offer a reliable explanation themselves.

Due consideration must be given to the possibility that the injury may:

• Be non-accidental, particularly if the explanation appears discrepant for the nature of the injury
• Possibly have occurred in circumstances where neglect is a consideration.

In these circumstances, a referral to Children’s Services should be made following the Making a Referral Procedure 

Emotional Abuse may be difficult to recognise, as the signs are usually behavioural rather than physical.

Emotional abuse is an extremely damaging form of abuse, which may occur in isolation or may co-exist with neglect and other forms of abuse.

Recognition of Emotional Abuse is usually based on observations over time and the following offer some associated indicators:

Parent / Carer and Child Relationship Factors

• Abnormal attachment between a child and parent/carer e.g. anxious, indiscriminate or failure to attach
• Persistent negative comments about the child or 'scape-goating' within the family
• Inappropriate or inconsistent expectations of the child e.g. over-protection or limited exploration.

Fabricated or induced illness falls under the wider umbrella term of emotional abuse. Cases of both FII and perplexing presentations also often involve or occur in association with other forms of abuse, particularly the various forms of emotional abuse. See also  8.21 Fabricated or induced illness (FII) and Perplexing Presentations (including FII by carers) | Sussex Child Protection and Safeguarding Procedures Manual

 Child Presentation Concerns

• Delay in achieving developmental, cognitive and/or other educational milestones
• Failure to thrive / faltering growth
• Behavioural problems e.g. aggression, attention-seeking
• Frozen watchfulness, particularly in preschool children
• Low self-esteem, lack of confidence, fearful, distressed, anxious
• Poor relationships with peers, including withdrawn or isolated behaviour.

Parent / Carer Related Issues

• Dysfunctional family relationships including domestic violence
• Parental problems that may lead to lack of awareness of child's needs e.g. mental illness, substance misuse, learning difficulties
• Parent or carer emotionally or psychologically distant from the child

Contextual factors may include:

• Child left unsupervised/unattended
• Child left with multiple carers
• Child regularly late attending, or, not being collected from school
• Child repeatedly reported lost/missing
• Parent/carer regularly unaware of child's whereabouts
• Child regularly not available for meetings with childcare workers.

Please also see:

• CSA Pathway
• Contacting SARC Scenarios
•  Sussex Children's SARC (Sexual Assault Referral Centre) Guidance for Police Officers and Social Workers on arranging medical examinations for possible Child Sexual Abuse (CSA)
• The Saturn Centre
• Supporting practice in tackling child sexual abuse - CSA Centre

child sexual abuse often remains hidden and is the most secretive and difficult type of abuse for children and young people to disclose. It may be particularly difficult to disclose abuse by a sibling.

Many children and young people do not recognise themselves as victims of sexual abuse - a child may not understand what is happening and may not even understand that it is wrong. As a result, this type of abuse is considered to be under-reported.

Where there are any concerns about the sexual abuse of a child in a household, consideration must be given to the possibility that other children in the household may also be at risk.

Sexual abuse often occurs in conjunction with the other categories of child abuse, especially emotional abuse in order to maintain control and secrecy. It is also important to consider the possibility that children are being sexually abused in houses where neglect is happening.  

Child sexual abuse can be perpetrated by any one of any gender and professionals are urged to use their professional curiosity.

There may be a range of signs of child sexual abuse but any one sign doesn't necessarily mean that a child is being sexually abused, however, the presence of a number of signs should indicate that professionals need to consider the potential for abuse and consult with others who know the child to see whether they also have concerns.

Behavioural Indicators

• Inappropriate sexualised behaviour, e.g inserting objects into the vagina or anus 
• Sexual harm of siblings 
• Sexually explicit behaviour, play or conversation, inappropriate to the child's age
• Continual and inappropriate or excessive masturbation
• Self-harm (including eating disorder), self-mutilation and suicide attempts
• child on child harmful sexual behaviour
• Sexual or criminal exploitation
• An anxious unwillingness to remove clothes for - e.g. sports events (but this may be related to cultural norms or physical difficulties)
• Running away
• Changes in behaviour, including becoming more aggressive, withdrawn, clingy
• Problems in school, difficulty concentrating, drop off in academic performance
• Sleep problems or regressed behaviours i.e. bedwetting
• Frightened of or seeking to avoid spending time with a particular person.

Physical Indicators

• Difficulty walking or sitting down
• Pain or itching of the genital area
• Vaginal discharge (discoloured/strong odour)
• Pregnancy in adolescents where the identity of the father is vague or secret
• Sexually transmitted infections including genital ulcers and anogenital warts (up to 58% of AGWs in children may be sexually transmitted and therefore, all cases of unexplained AGWs in children who are not sexually active should prompt consideration of CSA)
• STIs, e.g Chlamydia and Gonorrhoea
• Bloodborne viruses (hepatitis B/C) and HIV
• Blood on underclothes 
  • please note there are medical causes of ano-genital bleeding which must be considered alongside the possibility of CSA. Children presenting with ano-genital bleeding require a thorough general paediatric/surgical assessment and if there are concerns about CSA and/or the bleeding is unexplained the CSA Pathway should be followed. Paediatricians should follow the relevant guidance in the RCPCH Child Protection Companion. 
• Injuries and bruises on the genitalia and on parts of the body where other explanations are not available, especially bruises, bite marks or other injuries to breasts, buttocks, lower abdomen or inner thighs
• injuries to the mouth, which may be noted by dental practitioners
• Presence of semen on the labia and external genitalia, inside the vagina, anus,  or clothing
• Persistent or recurring pain during urination or bowel movements
• Urinary tract infections could be indicated by a child frequently asking to go to the toilet, fidgeting in their seat or holding themselves in a way that indicates discomfort

The Centre of Expertise on Child Sexual Abuse uses a model proposed by Finkelhor and Browne, (1986) to describe four likely impacts of CSA:

1. Traumatic sexualisation (where sexuality, sexual feelings and attitudes may develop inappropriately).
2. A sense of betrayal (because of harm caused by someone the child vitally depended upon).
3. A sense of powerlessness (because the child's will is constantly contravened).
4. Stigmatisation (where shame or guilt may be reinforced and become part of the child's self-image).

In addition, the Centre highlights the impact that secrecy (including the fear and isolation this creates) and confusion (because the child is involved in behaviour that feels wrong but has been instigated by trusted adults) has on the child.

In the long term, people who have been sexually abused are more likely to suffer with depression, anxiety, eating disorders and post-traumatic stress disorder (PTSD). They are also more likely to self-harm, become involved in criminal behaviour, misuse drugs and alcohol, and to commit suicide as young adults.

Neglect of any type (physical, supervisory, medical, educational or emotional) remains the most common reason for a child to be the subject of a child protection plan in the UK

Evidence of neglect is built up over a period of time and can cover different aspects of parenting.

Cases of both FII and perplexing presentations also often involve or occur in association with other forms of abuse, particularly neglect.

Child Related Indicators

• An unkempt, inadequately clothed, dirty or smelly child
• A child who is perceived to be frequently hungry
• A child who is observed to be listless, apathetic and unresponsive with no apparent medical cause; displaying anxious attachment; aggression or indiscriminate friendliness
• Failure of a child to grow or develop within normal expected patterns with an accompanying weight loss or speech/language delay
• Recurrent/untreated infections or skin conditions e.g. severe nappy rash, eczema or persistent head lice/scabies
• Unmanaged/untreated health / medical conditions including poor dental health - see more here Supporting practitioners to identify dental neglect (Level of need matrix) and also  2- Recognising 2.5 Dental neglect (bda.org) 
• Frequent accidents or injuries
• A child persistently absent from or late at school - see also  Safeguarding children who are absent from education | Sussex Child Protection and Safeguarding Procedures Manual
• Poor self-esteem
• A child who thrives away from the home environment
• Obesity
• Non-attendance at or repeated cancellations of appointments and lack of access to the child on visits are indicators that should increase concern about the child's welfare. All NHS providers should have policies for the management of children not brought to health care appointments. 

Indicators in the Care Provided

• Failure by parents or carers to meet basic essential needs e.g. adequate food, clothes, warmth, hygiene, sleep
• Failure by parents or carers to meet the child's health and medical needs e.g. poor dental health, failure to attend or keep appointments with the health visitor, GP or hospital, lack of GP registration, failure to seek or comply with appropriate medical treatment
• Failure by parents or cares to meet the child's education needs - see also Safeguarding children who are absent from education | Sussex Child Protection and Safeguarding Procedures Manual
• A dangerous or hazardous home environment including failure to use home safety equipment, risk from animals
• Poor state of home environment e.g. unhygienic facilities, lack of appropriate sleeping arrangements, inadequate ventilation (including passive smoking) and lack of adequate heating;
• A lack of opportunities for the child to play and learn
• Child left with adults who are intoxicated or violent
• Child abandoned or left alone for excessive periods
• Neglect of pets.

Where there are any concerns about the neglect of a child in a household, consideration must be given to the possibility that other children in the household may also be at risk of neglect or abuse.

Neglect in teenagers aged 13-18: Read more : https://learning.nspcc.org.uk/media/1058/core-info-neglect-emotional-abuse-teenagers-13-18.pdf

Where there are any concerns about the neglect of a child in a household, consideration must be given to the possibility that other children in the household may also be at risk of neglect or abuse.

Obesity

Obesity in children is an increasingly common problem in the general population and differentiating when there is a safeguarding issue can be difficult and complex. Neglect can result in poor supervision of food intake, or an inappropriate diet being offered to the child with resultant excessive weight gain. A sedentary lifestyle with limited opportunity for physical activity, when combined with an inappropriate diet, can result in excessive weight gain.

It is important to take into account:

• The impact of the obesity on the child, particularly evidence that the child is developing medical complications (e.g. undue breathlessness), restrictions in day to day activities or social/emotional difficulties as a result of their obesity;
• The context / is there other evidence of emotional harm or neglect.

Excessive calorie intake is the cause of most childhood obesity. In a very small proportion of obese children, there is an underlying medical cause. The parent/carer is responsible for monitoring their child's diet and seeking appropriate advice/support if the child or adolescent is overweight or obese. The management of obesity in children, therefore, requires parental engagement to enable and support their child to adopt healthy eating patterns, participate in age-appropriate levels of physical activity and attend medical and dietetic appointments as necessary. Parental failure to engage with an appropriate management plan in a child who is severely obese and/or is developing serious complications of obesity should be considered a safeguarding issue.