THE LOUDOUN TRUST
RESPONSE TO THE DRAFT NICE
WHAT TO NOTICE, HOW TO RESPOND:
SIGNS AND INDICATORS IN A CHILD THAT
MIGHT POINT TO PHYSICAL AND/OR SEXUAL ABUSE
DAVID MILLAR March 2017
Medical diagnoses of illnesses can be made with a high degree of accuracy
whether they range from the common (the cold vs the ‘flu) to the complex
(bronchitis vs asthma). Such diagnoses can still be problematic but
physiological symptoms create an evidential trail that usually leads to a
differential diagnosis. The exigencies of finding the evidential trail in
psychological symptoms, on the other hand, are more complicated and may lead to
conflicting or even misleading diagnoses.
With this is mind let us look at the most recent consultation document
produced by NICE offering certain specific guidelines on how to look for ‘soft’
signs of child (physical, emotional and sexual) abuse. It is obvious that no
such document could be exhaustive but the NICE Guidelines do suggest quite a
comprehensive list which appears below:
* Excessive clinginess
* Low self-esteem
* Recurrent nightmares
* Over-friendliness towards strangers/indiscriminate contact or
* Wetting and soiling
* Aggressive behaviour
* Withdrawing communication
* Habitual body-rocking
* Persistently seeking attention
* A child regularly attending school unkempt or with apparent injuries
* Overtly sexualised behaviour in children below the age of puberty
* Parents using excessive punishment
Any single or combination of presenting symptoms on this list could be an
effective forewarning that a child is being abused. However, at the same time,
any single or combination of symptoms of this list could ALSO indicate:
* A child who has suffered trauma other than (physical or sexual) abuse
* A child going through an acrimonious divorce/separation by parents
* A child being bullied at school or on the internet
* A severely disabled child with, say, an emotionally-laden co-morbidity
* A child going through major medical treatment or surgery, perhaps, for
cancer or a chronic illness
* A child experiencing emotional neglect, conflict or confusion other than
physical or sexual abuse
I am sure other ‘exceptions’ occur but the point to be made here is that
although such symptoms should never be over-looked (as the guidelines suggest)
there is still the risk that an accurate diagnosis can remain problematic.
Dr Danya Glaser, Consultant Child and Adolescent Psychiatrist, and a member
of the NICE guideline development committee, rightly exhorts professionals
(teachers, police, social workers, clinicians) to use ‘a mixture of instinct and
experience’ to make a judgement.
This is sound advice but I’m sure Dr Glaser is also aware that child
protection case conferences often display a range of ‘instincts’ and
‘experiences’ amongst committee members as they don’t always agree.
Importantly though, she does go on to point out that there is far more
‘under-recognition of child abuse than over-reporting that turned out to be
untrue’. She adds that these guidelines ‘may not always be proof of abuse … but
they underline when to check on a child’s wellbeing’. This realistic note of
caution – or reminding us of the need to make an accurate differential diagnosis
– is what the Loudoun Trust is also drawing attention to.
So, do we leave it there? Does Loudoun have anything further to add? I
suppose what comes next is: Who are the professionals/clinicians who make the
final diagnosis. Often the scenario is that teachers, residential workers,
health visitors, child clinicians report the type of symptoms indicated above to
the police and/or social care.
The question then needs to be asked: What are the guidelines to be followed
by these two agencies? Further, if abuse is then proven or openly acknowledged
then what agency (agencies) are these post-conviction cases passed on to and
what are their guidelines?
Of course anyone, professional or lay, could accurately assess certain
children who have been the victims of abuse if the symptoms and circumstances
and evidence are clear and non-contentious and what are the guidelines for the
general public to follow in such cases? Perhaps there is a need for a series of
inter-connected guidelines to make sure that each and every child is dealt with
as comprehensively as possible.
In my experience many child protection referrals from my (NHS ) agency to
social care/the police are met with the response: ‘This referral does not meet
our threshold criteria to launch an investigation’. This is sometimes code for
‘We don’t have enough staff/resources to investigate all referrals’.
We are all aware of recent publicity by at least one national police force
who commented on the number of referrals of adults (almost exclusively men) who
were reported for viewing images of child pornography. They said they were
overwhelmed by such referrals and believed certain ‘low-level’ examples of these
referrals should not face a criminal investigation but be passed on instead to a
This might make sense to some but it begs the question(s): who are these
agencies and are they sufficiently staffed to meet the demand? Is there an
argument here for another set of guidelines in ‘low-level’ cases?
I think we all understand that working in this particular area is fraught
with complications and competing demands but, nonetheless, I feel we should be
reminded of them.
Finally, this brings us to another ‘category’ that does not appear anywhere
in the NICE Guidelines: disclosures.
It might seem obvious that a child making a ‘direct disclosure’ does not
appear in the list of NICE guidelines, above. A disclosure, after all is not
merely an indicator but a clear admission by the child that they have been
abused. So, do we need to consider disclosures any further let alone put them
in the nebulous category of ‘symptoms’?
There are, it seems to me, certain factors that need to be drawn to all of
our attention that cover disclosures. Firstly, there can be false disclosures
even if the likelihood is quite small. Some reasons that ought to be borne in
mind why a false declaration might be made are:
* A deliberate or malicious attempt to get someone into trouble (e.g. a
parent or teacher)
* A persistent delusion or even a psychotic phantasy of being abused
* A proxy admission i.e. on someone else’s behalf
* Envy, which might seem unlikely but sometimes one sibling might be envious
or jealous, say, of a sibling who is getting more attention – even inappropriate
sexualised attention – than they are.
I am sure this list could be added to but it will probably always remain a
small list. At the same time, such phenomena do exist and deserve our
Secondly, let us turn to actual or real disclosures. It is an obvious
assumption to make that children disclose in order to be heard and protected and
for the child’s wish for the offender to be dealt with. This is a reasonable
and logical assumption. I suspect that the majority of disclosures probably
fall into this category but in my thirty-five year clinical experience as a
Child and Adolescent Psychotherapist in the NHS this has not been my personal
My first-hand experience of my own cases and my second-hand experience of
colleagues’ cases is that when a child, often tentatively, broaches the subject
they say that they first want to talk about it. This usually means: “Can we talk
about it before we do anything else?”
The child may or may not have an idea as to where it might lead or what
consequences might follow – but they first just want to talk. Even for those
who know the likely outcome they may still want to talk about their abuse, often
at length, before any information is passed on to ‘the authorities’. In such
cases, it is virtually impossible as professional standards now stand
(irrespective of statutory reporting) for a clinician to allow any extended
period of discussion to take place. An immediate (i.e. within 48 hours)
referral to police/social care is the usual professional injunction for all
public sector workers to follow.
This existing professional mandatory reporting (as opposed to legal statutory
reporting) does not allow time for the child or adolescent to talk through or
even express their confusion, doubt, anxiety, fear of consequences,
bewilderment, anger, rage whatever it is they might be going through.
Returning to the NICE Guidelines, they express quite well the need to use
‘experience and instinct’ in assessing ‘soft’ symptoms that might be (hidden)
indicators of child abuse.
What I have tried to illustrate is how we need to use our experience and
instincts both before as well as after such referrals are made to the police or
Equally, we need to use our experience and instincts – and training - to
govern the long-term therapy of such youngsters – crucial stages that the NICE
Guidelines have not yet addressed.
Consultant (NHS) Child and Adolescent Psychotherapist (Retired)