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It is important to note that safeguarding issues surrounding children can be distressing. Please seek help from an organisation in your area if you have any worries or concerns.
Safeguarding is the practice of promoting welfare of people and protecting them from harm. This particularly applies to children and to adults who have care and support needs and cannot protect themselves from abuse or neglect, such as some older people and some disabled people. This article will focus specifically on child safeguarding, but it is always important to consider the safeguarding of other vulnerable people. It is everyone’s responsibility to look out for the wellbeing of children. Healthcare workers have a key role in spotting and raising concerns for child safeguarding due to their privileged access to the child’s medical information and family circumstances.
Child safeguarding is described as a “jigsaw of risk”. Each individual organisation only sees certain aspects of the child’s life, meaning it can sometimes be hard to ‘see the whole picture’. This often leads to abuse being missed.
When we look at child safeguarding and welfare we use the assessment framework triangle. It looks at three areas: the child’s developmental needs, the capacity of the parents/carers, and family and environmental factors. Each of these areas is made up of several elements, as shown in the diagram below.
Diagram - The Assessment Framework Triangle, a tool used to assess the development of a child, their family environment, and the capacity of their parents
SimpleMed original by Dr. Tom Bradley
When all the needs in each category are met, a very suitable environment is created for a child to grow up happy and healthy. However, if concerns exist about whether these needs are being met, a social worker will become involved in the child’s life and determine the best situation for that child’s needs to be met. If the child’s welfare is deemed at great risk, they will be taken into social care by the care workers. This can happen when the child is at significant risk of neglect, harm, and any of the types of abuse described later on in this article. Note that in general this is a last resort, and social workers will work with families to try and resolve issues.
If you suspect any form of abuse is occurring, act on your concern straight away. Follow your workplace safeguarding policy. Discuss your concern with your manager, supervisor or safeguarding lead (the person in your workplace who is responsible for child protection). Anyone who is worried about a child’s welfare should consider referring the child to children’s social care (the local authority team that protects children). They should do so immediately if there is a concern that the child is suffering, or is likely to suffer, significant harm. If a child is in immediate danger, call 999.
Physical abuse is the action of purposefully, physically harming a child through any method. Examples of actions include, but are not limited to hitting, slapping, kicking, shaking, poisoning, burning, biting, mutilating, or drowning. Parents can sometimes fabricate symptoms or deliberately cause illness in a child, a pattern recognised as fabricated or induced illness (FII), where subsequent medical investigation or treatment may itself cause harm.
Physical abuse can present with marks to the skin (e.g. bruises, burns, or scarring). It can also present without any marks. A child with unexplained drowsiness, vomiting, or breathing difficulties may have a non-accidental head injury (a head injury caused by someone hurting the child), so abuse should be considered. Not all head injuries are caused by abuse. Sudden unexplained worsening (exacerbations) of a medical condition such as asthma may point to medical neglect (for example, prescribed treatment not being given) or to fabricated or induced illness. Both are described in this article.
Babies who are not yet independently mobile are particularly vulnerable to abuse. This means they cannot yet crawl, bottom shuffle, pull themselves up to stand, cruise (move along holding onto furniture) or walk. For example, a caregiver may become frustrated when a baby will not stop crying. Bruises and fractures are more likely to be intentional rather than accidental in babies and very young children, especially when they are not mobile. Because of this, any bruise or mark on these babies should be investigated and recorded carefully. NICE (the National Institute for Health and Care Excellence) advises suspecting child maltreatment (abuse or neglect) if there is bruising that is not caused by a medical condition and the explanation for it is unsuitable. It gives bruising in a child who is not independently mobile as an example.
The law on smacking differs across the UK. It is illegal in Scotland (since November 2020) and in Wales (since March 2022). In England and Northern Ireland, a parent who is charged with common assault (an assault that causes only minor injury, such as grazes or reddening of the skin) can still argue that the punishment was “reasonable punishment”. The court looks at the nature and context of the punishment, how long it lasted, its physical and mental effects, and the child’s age and personal characteristics. This defence is not available for more serious charges, such as wounding, causing grievous bodily harm (very serious injury), actual bodily harm (for example a black eye) or child cruelty. An injury of this kind is physical abuse. Safeguarding guidance also lists hitting as physical abuse, so concerns should be acted on whatever the legal position.
This section covers three topics: child sexual exploitation (CSE), direct sexual abuse, and female genital mutilation (FGM). CSE is a form of child sexual abuse. FGM is a form of child abuse that has its own legal duties, which are described below.
The child may not understand that it is happening, especially if they have been groomed (when an abuser gains the child’s trust and power over them in preparation for abuse) to assume that this is normal. The abuser may be a family member or caregiver, someone else the child knows, or a stranger, including online. It is important to remember that it can happen anywhere, by anyone to any child at any time. Many children who are sexually abused are abused by someone they know, such as a family member or friend. The internet also places children at risk from people they do not know. Disabled children are at greater risk of abuse. Reasons include needing help with personal care from carers and other adults, being more isolated, and finding it harder to tell someone about the abuse.
Child sexual exploitation occurs when children and young people are exploited into taking part in sexual activities. It can be achieved through gaining the child’s trust or threatening them with violence or blackmail. Some children are given gifts or attention in exchange for performing sexual activities. They can often think that this is part of a normal or even loving relationship with the abuser. Gaining a child’s trust in this way, in preparation for abuse, is known as grooming. It can happen in person, online, or both. Online, abusers may persuade or force a child to send sexual images or videos, or to take part in sexual activities by webcam or smartphone. Note that some adults pretend to be the same age as the child online to gain their trust.
Often once an abuser has images they can blackmail the child into taking part in other activities against their will. Young people can be invited to gatherings and given drugs/alcohol to make them more susceptible to being abused.
Signs of child sexual exploitation include, but are not limited to a dramatic change in the child’s mood or character, being secretive, alcohol/drug misuse, being frightened of particular people/places, or having unexplained new things/money.
Direct sexual abuse is separated into contact and non-contact abuse.
Contact abuse involves physical contact with the child. This includes sexually touching them with a body part or object, whether or not they are clothed. It also includes forcing children to undress and touch people, or forcing them to take part in sexual activities. Contact abuse can be penetrative or non-penetrative. Penetrative abuse means penetration of the child’s vagina, anus or mouth, for example rape or oral sex. Non-penetrative contact abuse includes sexual touching (including outside of clothing), kissing, rubbing and masturbation.
Non-contact abuse is where abuse occurs without the abuser touching the child. It can happen online or in person. It may include showing pornography to children, flashing (exposing genitals to a child), or forcing a child to masturbate. It can also involve children in looking at, or in the production of, sexual images or videos, or in online sexual activities.
Physical signs of sexual abuse include unexplained bruises, sexually transmitted infections (STIs), or any bleeding or soreness at their genitals or anal area. More emotional signs can include using sexual language inappropriate for their age, being inexplicably afraid of someone, self-harm, alcohol/drug misuse, or any changes in eating habits. If they are being abused online, they may spend an abnormal amount of time online or on social media. They may be secretive about what they do online. They may appear upset or angry after using the internet or social media.
It is important to know that children under the age of 13 are unable to consent to any form of sexual activity. Sexual activity with a child under the age of 16 is illegal, even if the child appears to agree. If both people are of a similar age (for example, both aged 13 to 15), prosecutors have more discretion. They consider the age gap, the maturity of each person, whether the agreement was free, and any exploitation, coercion (pressure) or threat. A decision not to prosecute does not mean there is no safeguarding concern. Follow your safeguarding policy and discuss any concern with your safeguarding lead.
The Fraser Guidelines relate to contraceptive advice and treatment for a young person under 16 without parental consent. The practitioner should be satisfied that: the young person understands the advice; they cannot be persuaded to tell their parents or carers (or to let the practitioner tell them); they are very likely to continue having sex with or without contraception; their physical or mental health (or both) is likely to suffer without the advice or treatment; and it is in their best interests to receive it without parental consent. Gillick competence is the wider test of whether a child is mature enough to make their own decisions and understand what they mean. Always consider whether there are child protection concerns, because underage sexual activity can be a sign of child sexual exploitation.
Female genital mutilation (FGM) is the deliberate alteration or removal of the female genitals for non-medical purposes. It is illegal in the UK under the Female Genital Mutilation Act 2003 (England, Wales and Northern Ireland) and the Prohibition of Female Genital Mutilation (Scotland) Act 2005. It is also an offence to take a girl abroad for FGM. The Crown Prosecution Service describes FGM as “a form of violence against women and girls”, and when it is done to a child it is child abuse. FGM is the term used in UK law. In communities where it happens, other terms may be used, such as “female circumcision” or “cutting”. It is carried out in many parts of Africa, the Middle East and Asia (including Indonesia), and it may be carried out anywhere in the world. It is often considered a necessary part of raising a girl, and a way to prepare her for adulthood and marriage. It can occur at any age in the girl’s life from just after birth to before marriage and during pregnancy. It is more common if any female relative has themselves had FGM.
There is no evidence of any health benefits of FGM. The process can cause significant harm, including severe pain and repeated infections. Long-term problems include infertility (difficulty getting pregnant), dyspareunia (pain when having sex), incontinence (problems controlling the passing of urine), problems during labour and childbirth, and mental health problems. Some girls die from blood loss or infection as a direct result of the procedure.
The process is often carried out by someone from the community who has no medical training. Anaesthetics and antiseptics (substances that kill germs) are not generally used. Instruments such as knives, scissors, scalpels, pieces of glass or razor blades are often used. The girl may be physically forced to have it done. FGM can cause severe pain, heavy bleeding, shock and infection. In some countries it is carried out by health workers in clinics, but this does not make it safe or acceptable.
The World Health Organization (WHO) classifies FGM into four types. Type 1 (clitoridectomy) is partial or total removal of the clitoris (a small, sensitive part of the female genitals). Type 2 (excision) is partial or total removal of the clitoris and the labia minora, with or without removal of the labia majora (the labia are the “lips” that surround the vagina). Type 3 (infibulation) is narrowing of the vaginal opening by creating a covering seal. Type 4 covers all other harmful procedures to the female genitals for non-medical purposes. Types 1, 2 and 3 are all offences under the FGM Act 2003. Type 4 is an offence only if it involves mutilation. All four types count as significant harm in family law.
Women and girls who have had FGM can get help from a specialist NHS gynaecologist (a doctor who specialises in the female reproductive system) or FGM service. A GP, midwife or other healthcare professional can advise about services in the area. Surgery to open up the vagina, called deinfibulation, can be carried out if necessary. It may be recommended for women who cannot have sex or have difficulty passing urine, and for pregnant women at risk of problems in labour or delivery. It is sometimes called a reversal, but this name is misleading because the procedure does not replace any removed tissue and will not undo the damage caused.
In England and Wales, healthcare professionals and teachers (and, in Wales, social care workers) have a legal duty to report FGM. If they discover that FGM appears to have been carried out on a girl under 18, they must notify the police. This applies whether the girl tells them or they see physical signs. The notification must be made within one month. If there is a specific risk that a girl will be cut, for example plans to take her abroad, refer her to children’s social care.
For more information about FGM, please see the second article of the Reproductive series entitled Anatomy of the Woman.
Male infant circumcision for religious reasons is not classified as female genital mutilation in the UK and is generally lawful when carried out with appropriate consent and in the child’s best interests, although ethical and legal debates continue.
Emotional abuse occurs when there is long-term emotional mistreatment of a child, a practice that can have hugely adverse effects on the child’s cognitive (thinking and learning) and emotional development and psychological wellbeing. It can involve making children feel that they are useless, worthless, and unloved or only there to serve a purpose. This can be done through making fun of things the child is trying to say or preventing them from speaking their views or imposing inappropriate expectations on the child. It can also be done through neglecting the child.
Children brought up in homes with domestic abuse, or with parents who have substance abuse or mental illness, can have an increased likelihood of being emotionally abused. This is because traumatic events known as adverse childhood experiences are more commonplace in these homes. This has an ongoing effect on the child and can lead to more health problems further on in their life.
Overprotecting children can also be a form of emotional abuse. It can involve preventing them from participating in social interactions and limiting them from exploring and learning. This can happen even when there is no malicious intention. It can harm the child’s emotional and social development.
Emotional abuse is involved in every type of child abuse in some way, as all forms can have long lasting emotional effects on the child. It can also occur on its own.
Signs of emotional abuse in children include an unexplained extreme lack of confidence, struggling to control their emotions, and difficulties in maintaining relationships. Younger children may be overly affectionate to people they don’t know or be more aggressive and jealous of other children. Older children may have few friends and lack social skills.
Emotional abuse can increase the risk of a child developing mental health problems, both during childhood and later in life.
Neglect is defined as a persistent failure to meet the basic physical and psychological needs of a child and can come in many forms. It commonly results in poor health and stunted development of the child.
Examples of neglect include:
- Maternal substance abuse during pregnancy, e.g. alcohol.
- Failure to provide adequate food and shelter for the child.
- Failure to keep the child clean and appropriately clothed, e.g. not wearing a jacket during winter.
- Failure to protect the child from harm, both physical and emotional.
- Failure to give the child access to any appropriate medical treatment.
- Failure to supervise the child adequately, e.g. leaving a child home alone when they are too young to look after themselves.
Medical neglect is a subset of neglect where the child’s medical needs are ignored, required medication is not administered, or medical attention is not sought when needed. It also covers mothers who do not prepare appropriately for childbirth and take part in activities that will place the newborn at risk, such as substance abuse. Missed appointments can be a sign of medical neglect. Good practice is to record a child’s missed hospital or GP appointment as “was not brought” (WNB) instead of “did not attend”. A child relies on a parent or carer to bring them, so it is the parent’s or carer’s duty to make sure the child attends. A WNB should prompt the clinician to ask why the child was not brought (for example illness, transport problems or cost) and to consider whether there is a safeguarding concern, especially if it keeps happening. It does not automatically mean neglect.
In England, every death of a child is reviewed. The aims are to establish the cause of death and any factors that may have contributed to it, to learn from it and prevent future child deaths from similar scenarios, and to support the family as they go through a traumatic experience. This section describes the system in England.
Information about every child death in England is recorded on the National Child Mortality Database (NCMD) so that lessons can be learned to improve and save children’s lives in the future. Some deaths also need a joint agency response. This is a coordinated response from an on-call health professional, a police investigator and a duty social worker. It is triggered if a child’s death is sudden with no immediately apparent cause, or is or could be due to external causes (for example, an injury). It is also triggered if the death occurs in custody, happens while the child was detained under the Mental Health Act, or raises any suspicion that it may not have been natural. A stillbirth (a baby born without signs of life after 24 weeks) also triggers it if no healthcare professional was in attendance. Different groups involved in these reviews include social workers, coroners (officials who investigate sudden or unexplained deaths), and health care workers.
Edited by: Dr. Maddie Swannack
Reviewed by: Dr. Thomas Burnell and Dr. Marcus Judge
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