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1. ABOUT THIS PRESENTATION: When you get to the alerting features section of this slide set, you will need to ask your audience to refer to the NICE quick reference guide to examine the detail of the alerting features to consider or suspect child maltreatment. This presentation has been written to help you raise awareness of the NICE clinical guideline on when to suspect child maltreatment. This guideline has been written for all healthcare professionals working in the NHS. The guideline is available in a number of formats, including a quick reference guide. We recommend that you hand out copies of the quick reference guide at your presentation so that your audience can refer to it. For printed copies of the quick reference guide or ‘Understanding NICE guidance’, phone NICE publications on 0845 003 7783 or email [email protected] and quote reference numbers N1901 (quick reference guide) and/or N1900 (‘Understanding NICE guidance’). You can add your own organisation’s logo alongside the NICE logo. We have included notes for presenters, broken down into ‘key points to raise’, which you can highlight in your presentation, and ‘additional information’ that you may want to draw on, such as a rationale or an explanation of the evidence for a recommendation. Where necessary, the recommendation will be given in full. DISCLAIMER This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself. PROMOTING EQUALITY Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties. ABOUT THIS PRESENTATION: When you get to the alerting features section of this slide set, you will need to ask your audience to refer to the NICE quick reference guide to examine the detail of the alerting features to consider or suspect child maltreatment. This presentation has been written to help you raise awareness of the NICE clinical guideline on when to suspect child maltreatment. This guideline has been written for all healthcare professionals working in the NHS. The guideline is available in a number of formats, including a quick reference guide. We recommend that you hand out copies of the quick reference guide at your presentation so that your audience can refer to it. For printed copies of the quick reference guide or ‘Understanding NICE guidance’, phone NICE publications on 0845 003 7783 or email [email protected] and quote reference numbers N1901 (quick reference guide) and/or N1900 (‘Understanding NICE guidance’). You can add your own organisation’s logo alongside the NICE logo. We have included notes for presenters, broken down into ‘key points to raise’, which you can highlight in your presentation, and ‘additional information’ that you may want to draw on, such as a rationale or an explanation of the evidence for a recommendation. Where necessary, the recommendation will be given in full. DISCLAIMER This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself. PROMOTING EQUALITY Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties.

2. What this presentation covers Scope Definitions How to use this guidance Alerting features Sharing information Obstacles Discussion Find out more NOTES FOR PRESENTERS: In this presentation we will start by providing some background to the guideline and why it is important. We will then describe the definitions of terms used. Afterwards we will set out how to use the guidance. We will then present the areas that the alerting features cover. Next, we will summarise how information should be shared, before looking at obstacles. Then we will open the meeting up with a list of questions to help prompt a discussion on local issues for incorporating the guidance into practice. Finally, we will end the presentation with further information about the support provided by NICE. NOTES FOR PRESENTERS: In this presentation we will start by providing some background to the guideline and why it is important. We will then describe the definitions of terms used. Afterwards we will set out how to use the guidance. We will then present the areas that the alerting features cover. Next, we will summarise how information should be shared, before looking at obstacles. Then we will open the meeting up with a list of questions to help prompt a discussion on local issues for incorporating the guidance into practice. Finally, we will end the presentation with further information about the support provided by NICE.

3. Scope This guidance provides a summary of the alerting features associated with child maltreatment. Its purpose is: to raise awareness help healthcare professionals who are not specialist in child maltreatment It does not how to diagnose, confirm or disprove child maltreatment. NOTES FOR PRESENTERS: Key points to raise: 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. All healthcare professionals have an important role to play in child protection. The effects of child maltreatment can be severe and last into adulthood. Obstacles to identifying child maltreatment exist (for example, concern about missing a treatable disorder, fear of losing positive relationship with a family). All agencies have a duty to be proactive, share information and cooperate at the earliest possible time to effectively protect children from maltreatment. For details of the exclusions from the guidance invite your audience to refer to page 7 of the quick reference guide when presenting this slide. NOTES FOR PRESENTERS: Key points to raise: 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. All healthcare professionals have an important role to play in child protection. The effects of child maltreatment can be severe and last into adulthood. Obstacles to identifying child maltreatment exist (for example, concern about missing a treatable disorder, fear of losing positive relationship with a family). All agencies have a duty to be proactive, share information and cooperate at the earliest possible time to effectively protect children from maltreatment. For details of the exclusions from the guidance invite your audience to refer to page 7 of the quick reference guide when presenting this slide.

4. Child maltreatment includes neglect, physical, sexual and emotional abuse, and fabricated or induced illness. To consider child maltreatment means maltreatment is one possible explanation for the alerting feature or is included in the differential diagnosis. To suspect child maltreatment means a serious level of concern about the possibility of child maltreatment but is not proof of it. Definitions NOTES FOR PRESENTERS: Key points to raise: 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. 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 13–17 years). 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 document ‘Working Together to Safeguard Children’, available from: www.dcsf.gov.uk/everychildmatters/safeguardingandsocialcare/safeguardingchildren/workingtogether/workingtogethertosafeguardchildren [Accessed 6 July 2009] Additional information: Supplementary guidance to Working Together includes: Department of Health, Home Office (2000) Safeguarding children involved in prostitution; Department of Health, Home Office, Department for Education and Skills, Welsh Assembly Government (2002) Safeguarding children in whom illness is fabricated or induced; Home Office. Female Circumcision Act 1985, Female Genital Mutilation Act 2003, Home Office Circular 10/2004; Association of Directors of Social Services, Department of Education and Skills, Department of Heath, Home Office, Foreign and Commonwealth Office (2004) Young people and vulnerable adults facing forced marriage. NOTES FOR PRESENTERS: Key points to raise: 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. 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 13–17 years). 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 document ‘Working Together to Safeguard Children’, available from: www.dcsf.gov.uk/everychildmatters/safeguardingandsocialcare/safeguardingchildren/workingtogether/workingtogethertosafeguardchildren [Accessed 6 July 2009] Additional information: Supplementary guidance to Working Together includes: Department of Health, Home Office (2000) Safeguarding children involved in prostitution; Department of Health, Home Office, Department for Education and Skills, Welsh Assembly Government (2002) Safeguarding children in whom illness is fabricated or induced; Home Office. Female Circumcision Act 1985, Female Genital Mutilation Act 2003, Home Office Circular 10/2004; Association of Directors of Social Services, Department of Education and Skills, Department of Heath, Home Office, Foreign and Commonwealth Office (2004) Young people and vulnerable adults facing forced marriage.

5. It is good practice to follow this process to consider, suspect or exclude child maltreatment: How to use this guidance NOTES FOR PRESENTERS: Key points to raise: Before covering the alerting features and recommendations of whether to consider or suspect child maltreatment, we will consider how best to use this guidance using the process NICE has outlined for good practice.NOTES FOR PRESENTERS: Key points to raise: Before covering the alerting features and recommendations of whether to consider or suspect child maltreatment, we will consider how best to use this guidance using the process NICE has outlined for good practice.

6. Take into account the whole picture of the child or young person. Sources of information include: history report of maltreatment, or disclosure child’s appearance, demeanour or behaviour symptom physical sign result of an investigation interaction between parent or carer and the child or young person Listen and observe NOTES FOR PRESENTERS: In full from the quick reference guide: 1. Listen and observe Take into account the whole picture of the child or young person. Sources of information that help to do this include: any history that is given report of maltreatment, or disclosure from a child or young person or third party child’s appearance, demeanour or behaviour symptom physical sign result of an investigation interaction between the parent or carer and child or young person. 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). NOTES FOR PRESENTERS: In full from the quick reference guide: 1. Listen and observeTake into account the whole picture of the child or young person. Sources of information that help to do this include: any history that is given report of maltreatment, or disclosure from a child or young person or third party child’s appearance, demeanour or behaviour symptom physical sign result of an investigation interaction between the parent or carer and child or young person. 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).

7. Seek an explanation in an open and non-judgemental manner. Seek appropriate expertise if you are concerned about a child or young person with a disability. Seek an explanation NOTES FOR PRESENTERS: In full from the NICE version of the guidance: 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. NOTES FOR PRESENTERS: In full from the NICE version of the guidance: 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.

8. 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, or account compared to that given by parent and carers between parents or carers or between accounts over time Cultural practice is an unsuitable explanation for hurting a child or young person. An unsuitable explanation NOTES FOR PRESENTERS: NOTES FOR PRESENTERS:

9. 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. Record NOTES FOR PRESENTERS: Key points to raise: At this point the healthcare professional may consider, suspect or exclude child maltreatment from the differential diagnosis. You may wish to consider discussing a local example at this point in the presentation. NOTES FOR PRESENTERS: Key points to raise: At this point the healthcare professional may consider, suspect or exclude child maltreatment from the differential diagnosis. You may wish to consider discussing a local example at this point in the presentation.

10. When hearing about or observing an alerting feature, look for other alerting features of maltreatment, then do one or more of the following: Discuss with a relevant child health specialist or designated professional for safeguarding children Gather collateral information Ensure review at a date appropriate to the concern Look out for repeated presentations of this or any other alerting features At any stage during the process of considering maltreatment the level of concern may change and lead to exclude or suspect maltreatment. Consider maltreatment NOTES FOR PRESENTERS: Key points to raise: If an alerting feature prompts you to consider child maltreatment: Look for other alerting features of maltreatment in the child or young person’s history, presentation or parent– or carer–child interactions now or in the past. Then do one or more of the following: Discuss the case 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. At any stage during the process of considering maltreatment the level of concern may change and lead to exclude or suspect maltreatment. NOTES FOR PRESENTERS: Key points to raise: If an alerting feature prompts you to consider child maltreatment: Look for other alerting features of maltreatment in the child or young person’s history, presentation or parent– or carer–child interactions now or in the past. Then do one or more of the following: Discuss the case 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. At any stage during the process of considering maltreatment the level of concern may change and lead to exclude or suspect maltreatment.

11. If an alerting feature or consideration prompts you to suspect child maltreatment refer to children’s social care. This may trigger a child protection investigation. Supportive services may be offered to the family following an assessment or alternative explanations may be identified. Suspect maltreatment NOTES FOR PRESENTERS: Key points to raise: 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 Safeguarding Children Board procedures. This may trigger a child protection investigation, supportive services may be offered to the family following an assessment or alternative explanations may be identified.NOTES FOR PRESENTERS: Key points to raise: 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 Safeguarding Children Board procedures. This may trigger a child protection investigation, supportive services may be offered to the family following an assessment or alternative explanations may be identified.

12. Exclude maltreatment when a suitable explanation is found for alerting features. Exclude maltreatment NOTES FOR PRESENTERS: Key points to raise: 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.NOTES FOR PRESENTERS: Key points to raise: 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.

13. Record all actions taken in previous stages and the outcome. Record NOTES FOR PRESENTERS: Key points to raise: You may wish to consider discussing a local example at this point in the presentation.NOTES FOR PRESENTERS: Key points to raise: You may wish to consider discussing a local example at this point in the presentation.

14. Alerting features The following forms of alerting features that may lead you to consider or suspect child maltreatment are covered: Physical features Sexual abuse Neglect Emotional, behavioural, interpersonal and social functioning Clinical presentations Fabricated or induced illness Parent– or carer–child interactions NOTES FOR PRESENTERS: We recommend that you invite your audience to refer to the quick reference guide in conjunction with this section of the slide set to examine the detail of alerting features to consider, suspect or exclude child maltreatment. NOTES FOR PRESENTERS: We recommend that you invite your audience to refer to the quick reference guide in conjunction with this section of the slide set to examine the detail of alerting features to consider, suspect or exclude child maltreatment.

15. Physical features NOTES FOR PRESENTERS: Key points to raise: Invite your audience to refer to page 8 of the quick reference guide when presenting this slide. The slide provides one example of an alerting feature that should prompt healthcare professionals to consider maltreatment and one example of an alerting feature that should prompt healthcare professionals to suspect maltreatment. Each alerting feature has particular characteristics or circumstances that are important in assessment, for full details on the alerting features please see the quick reference guide. NOTES FOR PRESENTERS: Key points to raise: Invite your audience to refer to page 8 of the quick reference guide when presenting this slide. The slide provides one example of an alerting feature that should prompt healthcare professionals to consider maltreatment and one example of an alerting feature that should prompt healthcare professionals to suspect maltreatment. Each alerting feature has particular characteristics or circumstances that are important in assessment, for full details on the alerting features please see the quick reference guide.

16. Sexual abuse NOTES FOR PRESENTERS: Key points to raise: Invite your audience to refer to page 10 of the quick reference guide when presenting this slide. The slide provides one example of an alerting feature that should prompt healthcare professionals to consider maltreatment and one example of an alerting feature that should prompt healthcare professionals to suspect maltreatment. Each alerting feature has particular characteristics or circumstances that are important in assessment, for full details on the alerting features please see the quick reference guide. Pregnancy in a child under 13 years (sex with a child under 13 years is unlawful, therefore pregnancy in a girl of this age means she has been maltreated). NOTES FOR PRESENTERS: Key points to raise: Invite your audience to refer to page 10 of the quick reference guide when presenting this slide. The slide provides one example of an alerting feature that should prompt healthcare professionals to consider maltreatment and one example of an alerting feature that should prompt healthcare professionals to suspect maltreatment. Each alerting feature has particular characteristics or circumstances that are important in assessment, for full details on the alerting features please see the quick reference guide. Pregnancy in a child under 13 years (sex with a child under 13 years is unlawful, therefore pregnancy in a girl of this age means she has been maltreated).

17. Neglect NOTES FOR PRESENTERS: Key points to raise: Invite your audience to refer to pages 12 and 13 of the quick reference guide when presenting this slide. The slide provides one example of an alerting feature that should prompt healthcare professionals to consider maltreatment and one example of an alerting feature that should prompt healthcare professionals to suspect maltreatment. Each alerting feature has particular characteristics or circumstances that are important in assessment, for full details on the alerting features please see the quick reference guide. When highlighting the suspect example on the slide, it is important to note that children often become smelly or dirty during the course of the day. However, the nature of the child’s smell may be so overwhelming that the possibility of persistent lack of provision or care should be taken into account. Examples include: child seen at times of the day when it is unlikely that they would have had an opportunity to become smelly or dirty (for example, an early morning visit) if the dirtiness is ingrained. If a child has been abandoned this is child maltreatment.NOTES FOR PRESENTERS: Key points to raise: Invite your audience to refer to pages 12 and 13 of the quick reference guide when presenting this slide. The slide provides one example of an alerting feature that should prompt healthcare professionals to consider maltreatment and one example of an alerting feature that should prompt healthcare professionals to suspect maltreatment. Each alerting feature has particular characteristics or circumstances that are important in assessment, for full details on the alerting features please see the quick reference guide. When highlighting the suspect example on the slide, it is important to note that children often become smelly or dirty during the course of the day. However, the nature of the child’s smell may be so overwhelming that the possibility of persistent lack of provision or care should be taken into account. Examples include: child seen at times of the day when it is unlikely that they would have had an opportunity to become smelly or dirty (for example, an early morning visit) if the dirtiness is ingrained. If a child has been abandoned this is child maltreatment.

18. Emotional, behavioural, interpersonal and social functioning NOTES FOR PRESENTERS: Key points to raise: Invite your audience to refer to page 14 of the quick reference guide when presenting this slide. The slide provides one example of an alerting feature that should prompt healthcare professionals to consider maltreatment and one example of an alerting feature that should prompt healthcare professionals to suspect maltreatment. Each alerting feature has particular characteristics or circumstances that are important in assessment, for full details on the alerting features please see the quick reference guide.NOTES FOR PRESENTERS: Key points to raise: Invite your audience to refer to page 14 of the quick reference guide when presenting this slide. The slide provides one example of an alerting feature that should prompt healthcare professionals to consider maltreatment and one example of an alerting feature that should prompt healthcare professionals to suspect maltreatment. Each alerting feature has particular characteristics or circumstances that are important in assessment, for full details on the alerting features please see the quick reference guide.

19. Clinical presentations NOTES FOR PRESENTERES: Key points to raise: Invite your audience to refer page 16 of the quick reference guide when presenting this slide. The slide provides one example of an alerting feature that should prompt healthcare professionals to consider maltreatment and one example of an alerting feature that should prompt healthcare professionals to suspect maltreatment. Each alerting feature has particular characteristics or circumstances that are important in assessment, for full details on the alerting features please see the quick reference guide. NOTES FOR PRESENTERES: Key points to raise: Invite your audience to refer page 16 of the quick reference guide when presenting this slide. The slide provides one example of an alerting feature that should prompt healthcare professionals to consider maltreatment and one example of an alerting feature that should prompt healthcare professionals to suspect maltreatment. Each alerting feature has particular characteristics or circumstances that are important in assessment, for full details on the alerting features please see the quick reference guide.

20. Fabricated or induced illness NOTES FOR PRESENTERS: Key points to raise: Invite your audience to refer to pages 16 and 17 of the QRG when presenting this slide. In full from the quick reference guide: Child maltreatment should be considered when the child’s history, physical or psychological presentation, or findings of assessments, examinations or investigations, leads to a discrepancy with a recognised clinical picture, even if the child has a past or concurrent physical or psychological condition. Child maltreatment should be suspected when the child’s history, physical or psychological presentation, or findings of assessments, examinations or investigations leads to a discrepancy with a recognised clinical picture plus one or more of the following, even if the child has a past or concurrent physical or psychological condition: - reported symptoms and signs are only observed by, or appear in the presence of, the parent or carer - an inexplicably poor response to prescribed medication or other treatment - new symptoms are reported as soon as previous symptoms stop - biologically unlikely history of events - 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 - child’s normal daily activities (for example, school attendance) are limited, or they are using aids to daily living (for example, wheelchairs) more than expected from any medical condition that the child has. Each alerting feature has particular characteristics or circumstances that are important in assessment, for full details on the alerting features please see the quick reference guide. NOTES FOR PRESENTERS: Key points to raise: Invite your audience to refer to pages 16 and 17 of the QRG when presenting this slide. In full from the quick reference guide: Child maltreatment should be considered when the child’s history, physical or psychological presentation, or findings of assessments, examinations or investigations, leads to a discrepancy with a recognised clinical picture, even if the child has a past or concurrent physical or psychological condition. Child maltreatment should be suspected when the child’s history, physical or psychological presentation, or findings of assessments, examinations or investigations leads to a discrepancy with a recognised clinical picture plus one or more of the following, even if the child has a past or concurrent physical or psychological condition: - reported symptoms and signs are only observed by, or appear in the presence of, the parent or carer - an inexplicably poor response to prescribed medication or other treatment - new symptoms are reported as soon as previous symptoms stop - biologically unlikely history of events - 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 - child’s normal daily activities (for example, school attendance) are limited, or they are using aids to daily living (for example, wheelchairs) more than expected from any medical condition that the child has. Each alerting feature has particular characteristics or circumstances that are important in assessment, for full details on the alerting features please see the quick reference guide.

21. Parent– or carer– child interactions NOTES FOR PRESENTERS: Key points to raise: Invite your audience to refer to page 17 of the quick reference guide when presenting this slide. The slide provides one example of an alerting feature that should prompt healthcare professionals to consider maltreatment and one example of an alerting feature that should prompt healthcare professionals to suspect maltreatment. Each alerting feature has particular characteristics or circumstances that are important in assessment, for full details on the alerting features please see the quick reference guide. NOTES FOR PRESENTERS: Key points to raise: Invite your audience to refer to page 17 of the quick reference guide when presenting this slide. The slide provides one example of an alerting feature that should prompt healthcare professionals to consider maltreatment and one example of an alerting feature that should prompt healthcare professionals to suspect maltreatment. Each alerting feature has particular characteristics or circumstances that are important in assessment, for full details on the alerting features please see the quick reference guide.

22. Good communication between all parties is essential. If worried, seek advice from designated professionals for safeguarding children. If concerns are based on information given by a child, explain to the child: that you may be unable to maintain confidentiality explore the child’s concerns about sharing this information reassure the child that they will continue to be kept informed Sharing information about children and young people NOTES FOR PRESENTERS: In full from quick reference guide: If you are worried about sharing information about a child or young person, seek advice from named or designated professionals for safeguarding children. If your concerns are based on information given by a child, explain to the child that you may be 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 who the information is being shared with and what action is being taken. When gathering collateral information from other health disciplines and agencies, use judgement about whether to explain to the child or young person the need to gather this information for their overall assessment. Additional information: This may provide a useful focus for discussion at the end of your presentation to allow your audience to share experience of these communication issues and how they could be resolved.NOTES FOR PRESENTERS: In full from quick reference guide: If you are worried about sharing information about a child or young person, seek advice from named or designated professionals for safeguarding children. If your concerns are based on information given by a child, explain to the child that you may be 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 who the information is being shared with and what action is being taken. When gathering collateral information from other health disciplines and agencies, use judgement about whether to explain to the child or young person the need to gather this information for their overall assessment. Additional information: This may provide a useful focus for discussion at the end of your presentation to allow your audience to share experience of these communication issues and how they could be resolved.

23. Obstacles should not stop acting to prevent harm. They include: concern about missing a treatable disorder fear of losing positive relationship with a family already under care divided duties to adult and child patients and breaching confidentiality an understanding of the reasons for the maltreatment, and no intention to harm the child losing control over the child protection process and doubts about its benefits stress, personal safety, fear of complaints Obstacles NOTES FOR PRESENTERS: Key points to raise: Obstacles to identifying child maltreatment exist. These should not stop healthcare professionals from acting to prevent harm to the child. Examples of possible obstacles include: 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. Additional information: This may provide a useful focus for discussion at the end of your presentation to allow your audience to reflect on these obstacles and how they could be resolved.NOTES FOR PRESENTERS: Key points to raise: Obstacles to identifying child maltreatment exist. These should not stop healthcare professionals from acting to prevent harm to the child. Examples of possible obstacles include: 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. Additional information: This may provide a useful focus for discussion at the end of your presentation to allow your audience to reflect on these obstacles and how they could be resolved.

24. Discussion How can we ensure that this guidance reaches all healthcare professionals working in the NHS locally who work with children? How can we overcome the obstacles? To what extent are people trained to be able to respond to the guidance? How can we ensure that information is recorded so that patterns are recognised over time and place? NOTES FOR PRESENTERS: We have provided some general questions to help provide a prompt for a discussion at the end of your presentation – please edit and adapt these to suit your local situation. There are a number of potential discussion areas that may be relevant to your audience. You may wish to create questions that will enable: further interrogation of the alerting features described in the quick reference guide discussion of the obstacles and the opportunity to find possible solutions the airing of concerns about sharing information about children and young people. NOTES FOR PRESENTERS: We have provided some general questions to help provide a prompt for a discussion at the end of your presentation – please edit and adapt these to suit your local situation. There are a number of potential discussion areas that may be relevant to your audience. You may wish to create questions that will enable: further interrogation of the alerting features described in the quick reference guide discussion of the obstacles and the opportunity to find possible solutions the airing of concerns about sharing information about children and young people.

25. Find out more Visit www.nice.org.uk/CG89 for: the guideline the quick reference guide ‘Understanding NICE guidance’ costing statement audit support A&E slide set NOTES FOR PRESENTERS: You can download the guidance documents from the NICE website. The NICE guideline – all the recommendations. A quick reference guide – a summary of the recommendations for healthcare professionals. ‘Understanding NICE guidance’ – information for patients and carers. The full guideline – all the recommendations, details of how they were developed, and reviews of the evidence they were based on. For printed copies of the quick reference guide or ‘Understanding NICE guidance’, phone NICE publications on 0845 003 7783 or email [email protected] and quote reference numbers N1901 (quick reference guide) and/or N1900 (‘Understanding NICE guidance’). NICE has developed tools to help organisations implement this guideline, which can be found on the NICE website. Costing statement – details of the likely costs and savings when the cost impact of the guideline is not considered to be significant. Audit support – for monitoring local practice. A&E slide set to aid awareness-raising and training within A&E.NOTES FOR PRESENTERS: You can download the guidance documents from the NICE website. The NICE guideline – all the recommendations. A quick reference guide – a summary of the recommendations for healthcare professionals. ‘Understanding NICE guidance’ – information for patients and carers. The full guideline – all the recommendations, details of how they were developed, and reviews of the evidence they were based on. For printed copies of the quick reference guide or ‘Understanding NICE guidance’, phone NICE publications on 0845 003 7783 or email [email protected] and quote reference numbers N1901 (quick reference guide) and/or N1900 (‘Understanding NICE guidance’). NICE has developed tools to help organisations implement this guideline, which can be found on the NICE website. Costing statement – details of the likely costs and savings when the cost impact of the guideline is not considered to be significant. Audit support – for monitoring local practice. A&E slide set to aid awareness-raising and training within A&E.

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