Chapter 2: Recognising and Responding to Concerns about the Welfare of a Child

AMENDMENTS

This chapter was updated in May 2010 as a result of Working Together to Safeguard Children 2010. The specific changes in 2.69, 2.78 and 2.79 are shown in italics. The practice guidance in relation to information sharing was also amended in May 2010 to include a link to the Information Sharing: Guidance for practitioners and managers issued by the DCSF in October 2008 and to include the seven golden rules for Information Sharing, contained in that document.

ADDITIONAL GUIDANCE

Please refer to the NICE Guidelines - When to suspect child maltreatment.

Also see the NSPCC Report ‘Child Cruelty in the UK 2011’ and the PSCB document ‘Signposts to Neglect’.

	Members of the Public
	Identifying Concerns – Procedures to be followed by practitioners working with children and their families
	Deciding
		Deciding When to Refer – Underage sexual activity
		Deciding When to Refer - Domestic abuse
		Deciding When to Refer – Parental drug and alcohol use
		Deciding When to Refer – Parental mental illness
		Deciding When to Refer - Children with disabilities
		Deciding When to Refer - Child abuse images and the internet
		Deciding When to Refer – Sexually harmful behaviour carried out by children and young people
		Deciding When to Refer - Where a parent has learning disabilities
		Deciding When to Refer - Fabricated or induced illness
	The Referral Process for Children in Need of Protection
	Taking a Referral – Procedures to be followed by Children’s Social Care
	Practice Guidance – Recognising and responding to concerns

Members of the Public

2.1

The LSCB knows that the abuse of children often comes to light due to members of the public being vigilant and reporting concerns to the statutory agencies. This is an important aspect of protecting children from harm and any referral from a member of the public should be responded to in line with the procedures set out in Action to be taken following a Referral to Children's Social Care Procedure and Action to be taken where a child is at Risk of Significant Harm Procedure.

2.2

Government guidance “What to do if you are worried a child is being abused” sets out what should happen when anyone is concerned about the welfare of a child and will help members of the public in making a referral.

Identifying Concerns – Procedures to be followed by practitioners working with children and their families

2.3	Concerns about the welfare of a child may occur: In situations where there have been no previous concerns and the child has not previously received any services, other than those universal services accessed by all children; Where an assessment has taken place by agencies other than Children’s Social Care under the Common Assessment Framework and a plan has been put in place in order to improve the wellbeing of the child; Where the child is already allocated to a worker in Children’s Social Care; Where there is no current involvement by Children’s Social Care but there have been previous referrals.
2.4	The concern should be discussed with a senior member of staff in order to clarify the seriousness and urgency of the situation and decide the next course of action. The senior member of staff may be: A manager; A designated member of staff with responsibility for safeguarding children, for example: designated nurse/named nurse or doctor; designated person in an education setting.
2.5	If, following this discussion, there are still concerns about the welfare of the child, consideration should be given to contacting the duty officer at the local Children’s Social Care Office for advice. This can be done by presenting a ‘what if’ scenario without necessarily naming the child in question. This discussion should be recorded by both parties in a retrievable form. It is the responsibility of Children’s Social Care to ensure appropriate systems are in place. It is possible to have a hypothetical discussion by presenting a “what if” scenario without naming the child in question to seek advice about a future course of action.
2.6	If the practitioner with the concerns believes that a child’s health or development is being impaired without the provision of services by the Local Authority (i.e. the child is a Child in Need), consideration should be given to making a referral to Children’s Social Care. In this circumstance, a Common Assessment should be completed (if this has not already been done) and used as a basis for deciding whether a referral is appropriate. The parent(s) and the child (where appropriate) should be consulted prior to a referral being made.
2.7	If the practitioner believes that a child or young person is suffering, or is likely to be suffering Significant Harm they should always refer their concerns to Children’s Social Care.
2.8	In most situations, concerns should be discussed with the child (as appropriate to their age and understanding), and with their parents, and their agreement sought to a referral being made. However, agreement should not be sought if doing so would place the child at risk of Significant Harm. Where it does not place the child at increased risk of Significant Harm parents should be informed that a referral is being made. In most situations referrals should be discussed with the child as appropriate to their age and understanding.
2.9	The Government guidance on information sharing – ( Information Sharing: Practitioners’ Guide) must be used to inform the decision about what information should be shared at the point of referral. The seven golden rules of information sharing set out in this guidance are in Practice Guidance .

Deciding

2.10

The definitions of Physical Abuse, Emotional Abuse, Neglect and Sexual Abuse in Working Together to Safeguard Children (2010) should be used to assist decision making about when a child is at risk of Significant Harm. See also Practice Guidance, Recognising and Responding to Concerns which is also designed to help professionals understand the concepts of ‘need’ and ‘harm’.

2.11

‘Working Together to Safeguard Children’ states that Local Safeguarding Children Boards should set out the criteria that should be used when deciding whether or not to refer to Children’s Social Care. These criteria are set out in the Table, Deciding when to Refer. Professionals are reminded that they need to use their professional judgment in using these criteria and if in doubt to consult with a designated senior to decide what action to take. A more detailed Vulnerability Matrix for Peterborough is also attached as Appendix 6 to this manual.

2.12

The table and the more detailed Vulnerability Matrix for Peterborough distinguish between children who may need some support to achieve the five outcomes defined by government (children with additional needs) and those whose health or development is likely to impaired without provision of services by the local authority (Children in Need).

2.13

Children with additional needs will be identified through the use of the Common Assessment Framework primarily by professionals in the universal services. Children’s Social Care are responsible for assessing Children in Need referred to them; such children are likely to have complex needs and will include those at risk of Significant Harm. Where an assessment under the Common Assessment Framework has been completed, this should provide a basis for referral and information sharing between agencies.

2.14

The table cannot provide an exhaustive list of indicators, the aim is to assist decision making and to help develop a more consistent approach across Cambridgeshire and Peterborough. The rest of this chapter provides more detailed information in relation to when referrals should be made in respect of children in specific circumstances.

2.15

Children’s Social Care should be mindful of these criteria when deciding how to respond to referrals.

Table - Deciding when to Refer

CHILD IN NEED WHO MAY ALSO BE AT RISK OF SIGNIFICANT HARM

CHILD IN NEED

CHILD WITH ADDITIONAL NEEDS

A REFERRAL TO CHILDREN’S SOCIAL CARE SHOULD ALWAYS BE MADE IN THE FOLLOWING CIRCUMSTANCES

Any allegation of Sexual Abuse;
Physical injury caused by assault or neglect which may or may not require medical attention;
Incidents of physical harm that alone are unlikely to constitute Significant Harm but taken into consideration with other factors may do so;
Children who suffer from persistent Neglect;
Children who live in an environment which is likely to have an adverse impact on their emotional development;
Where parents’ own emotional impoverishment affects their ability to meet their child’s emotional and/or physical needs regardless of material / financial circumstances and assistance;
Where parents’ circumstances are affecting their capacity to meet the child’s needs because of domestic violence, drug and/or alcohol misuse, mental health problems, previous convictions for offences against children;
A child living in a household with, or having significant contact with, a person at risk of sexual offending;
A child under 13 who is sexually active;
An abandoned child;
Bruising to an immobile baby;
Pregnancy where children have been removed;
Suspicion of Fabricated or Induced Illnesses.

A REFERRAL TO CHILDREN’S SOCIAL CARE SHOULD BE CONSIDERED IN THE FOLLOWING CIRCUMSTANCES

A plan to meet the child’s needs following a Common Assessment has not had the desired outcome;
A child may become at risk of harm without the provision of services.

The following is not an exhaustive list, but highlights common situations where a referral should be considered:

Child not achieving milestones with no apparent physical cause;
Child permanently excluded from school or temporarily excluded on a regular basis;
Child who persistently runs away from home or school;
Child who self harms;
Child involved in offending behaviour;
Child who is known to be involved in underage sexual activity and/or exploitation;
Child appears over protected and unable to develop their own identity;
Disabled child with complex needs that cannot be realistically met by the parent or carer;
Child whose communication needs are not being met;
Parents with learning disabilities or parents with learning difficulties whose impairment impacts on their parenting skills;
Parenting skills are inadequate to meet the child’s needs;
Episode(s) of domestic violence;
Episode(s) of mental illness which might affect the child;
Substance misuse which is affecting parenting capacity;
Families who are socially isolated;
Families where lack of access to appropriate housing or income is adversely affecting the child.

A REFERRAL TO CHILDREN’S SOCIAL CARE IS NOT REQUIRED WHEN:

The Common Assessment has resulted in a plan that is enabling the child to achieve their full potential in relation to the five outcomes;
The input of Children’s Social Care is not essential to either service provision or contributing to an assessment of the wellbeing of the child.

A REFERRAL MAY BECOME NECESSARY IF:

A plan has been implemented following completion of a Common Assessment and it is not meeting the needs of the child;
Further information comes to light that indicates that either the child is at risk of Significant Harm or the involvement of Children’s Social Care is essential to the delivery of services.

2.16

Deciding how to act in situations of neglect presents some of the greatest challenges to professionals, and may require careful, close observation of parenting, and child behaviour. 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, and long-term difficulties with social functioning, relationships and educational progress. Neglect can result, in extreme cases, in death.

2.17

Where any of the following are present the practitioner should discuss the child’s needs with a senior member of staff in order to decide the most appropriate course of action.

The basic essential needs of the child not being met. Parental factors contributing to failure to meet needs may be substance misuse, mental ill health, domestic violence or learning disability

Any of the following signs and indicators are present:

Physical signs e.g. growth not within the expected range; recurrent infections; skin conditions; unkempt dirty appearance; inadequate clothing; unmanaged/untreated health conditions; frequent accidents or injuries

Developmental signs e.g. developmental delays; poor attention/concentration; lack of self confidence/poor self esteem; educational underachievement (including erratic or non school attendance)

Behavioural signs e.g. over-active, aggressive, impulsive behaviours; indiscriminate friendliness, withdrawn with poor social relationships, wetting, soiling or destructive behaviours, substance misuse or running away, school non-attendance, sexual promiscuity, self harm, offending behaviours.

Signs in the home environment e.g. dirty, hazardous environment, personal or environmental odour, poor state of children’s bedding, inadequate ventilation or heating, lack of play opportunities, isolation of parents and children from the local community

2.18

If any practitioner has been working with a family for more than 3 months and they are concerned that there may be features of neglect that are not being responded to appropriately by either their own agency or others, they must take the case to supervision for discussion and record a plan of action in the child’s file.

2.19

The Significant Harm threshold will have been met where there is evidence of:

Persistent neglect of a child’s physical and/or emotional needs i.e. occurring over a period of time and/or not likely to change within the child’s time frame;
Repetition of neglectful parenting which is continuing despite interventions;
Severity i.e. severe detrimental outcomes for the health or development of child(ren);
Parents’ own emotional impoverishment affecting their ability to sufficiently meet the child(ren’s) physical and/or emotional needs regardless of material/financial circumstances or assistance.

Deciding When to Refer – Underage sexual activity

2.20	A child under 13 is not legally capable of consenting to sexual activity. Cases involving a child under 13 who is known or suspected to be taking part in underage sexual activity should always be discussed with the child protection lead in the practitioner’s agency.
2.21	Under the Sexual Offences Act 2003 penetrative sex with a child under the age of 13 is classed as rape, regardless of the age of the perpetrator(s).
2.22	Where the allegation is of penetrative sex or other intimate sexual activity with a child under 13, there would always be reasonable cause to suspect that they are suffering or are likely to suffer Significant Harm. In this situation there should be a presumption that the child will be referred to Children’s Social Care.
2.23	Sexual activity with a child under 16 is also an offence. Where the child is aged 13 and up to their 16th birthday, the practitioner should discuss their concerns with their nominated child protection lead and consideration should be given in every case as to whether there should be a discussion with other agencies and whether a referral should be made to Children’s Social Care.
2.24	When an agency has decided that they do have concerns about a child involved in underage sexual activity and they have information about the partner/s, they should check with other agencies, including the police, to establish what else is known. The police should normally share the required information without beginning a full investigation, if the agency making the check requests this.
2.25	The following checklist should be used to assess the extent to which a child may be suffering or at risk of harm: The age of the child. The younger the age the greater the likelihood of cause for concern; The level of maturity and understanding of the child; What is known about the child’s living circumstances or background; Age imbalance – particularly where there is a significant age difference; Overt aggression or power imbalance; Coercion or bribery; Familial child sex offences; Behaviour of the child ( e.g. withdrawn or anxious); The misuse of substances as a disinhibitor; Whether the child’s own behaviour, because of the misuse of substances, places him/her at risk of harm so that he/she is unable to make an informed choice about any activity; Whether any attempts to secure secrecy have been made by the sexual; partner, beyond what would be considered usual in a teenage relationship Where the child denies, minimises or accepts concerns; Whether the methods used are consistent with grooming; Whether the sexual partner/s is known to one of the agencies.
2.26	Where a child is aged 16-17, sexual activity may still involve harm or risk of harm. The above checklist should be used to inform decisions. Concerns and requests for information sharing should be treated in the same way as for those from 13 years up to their sixteenth birthdays.
2.27	It is an offence for a person to have a sexual relationship with a 16 or 17 year old if they hold a position of trust or authority in relation to them. If any professional is aware of such activity they should pass the information to their local police child protection team. Decisions not to refer must be fully documented, with detailed reasons given. Such a decision must be supported by a manager and follow a full and thorough assessment using the checklist in Paragraph 2.25.

Deciding When to Refer - Domestic abuse

Within the context of this document, the terms domestic abuse and domestic violence will be used interchangeably.

2.28	The Inter Ministerial Domestic Violence Group defines domestic violence as "Any incident of threatening behaviour, violence or abuse (psychological, physical, sexual, financial or emotional) between adults who are or have been intimate partners or family members, regardless of gender or sexuality"
2.29	An intimate relationship can refer to relationships involving: Partners; Siblings; Parents in law; Other adult relatives; Parents and child(ren).
2.30	Most reported cases of domestic abuse involve the abuse of women by men, although violence does occur in same sex relationships and men can also be victims. Information currently shows that 77% of victims are women and 23% are men (British Crime Survey 2006/7).
2.31	Domestic violence is one indicator of risk of harm to children. Children experiencing domestic violence are seen as Children in Need and a referral to Children’s Social Care must be considered.
2.32	Prolonged and/or regular exposure to domestic violence can have a serious impact on a child(ren)’s development and emotional well-being, despite the best efforts of the non-abusing parent to protect the child(ren). This can include witnessing or over hearing incidents of domestic violence.
2.33	Domestic violence episodes can begin or escalate during pregnancy. Domestic violence can pose a threat to an unborn child(ren), because assaults on pregnant women frequently involve punches or kicks directed to the abdomen, risking injury to both mother and unborn child(ren).
2.34	Violence and /or threats of violence may continue after separation. Research suggests that victims maybe at greater risk when preparing or attempting to leave, or through contact arrangements.
2.35	Everyone working with women and children should be alert to the possible inter-relationship between domestic violence and the abuse and neglect of children. Where there is evidence of domestic violence, the implications for any children in the household should be considered, including the possibility that the children may themselves be subject to violence or other harm. Conversely, where it is believed that a child(ren) is being abused; workers should be alert to the possibility of domestic violence within the family.
2.36	Children’s behaviours may indicate that they live with domestic violence. Such indicators may include: Refusal or reluctance to discuss own or parents injuries; Withdrawal from physical contact; Child(ren) shows fear of returning home or leaving home; School refusal or a reluctance to leave school; Self-destructive tendencies in children; Aggression towards others; Running away from home; Excessive tiredness; Frequent accidental injuries; Low self esteem; Lack of social relationships; Physical, mental and emotional developmental delay; Over reaction to mistakes; Sudden speech disorders; Sudden changes of demeanour; Neurotic behaviour (e.g. rocking, hair twisting, thumb sucking); Extremes of passivity or aggression; Drug/solvent abuse; Eating disorders. This list is not exhaustive; it should also be noted that these might also be indicators of other forms of abuse or situations in the family, not only domestic violence
2.37	Behaviours in adults may indicate that they live with domestic violence. Such indicators may include: Failure to keep appointments; Alleged abuse of children in the household; Poor health, disability, drug and alcohol abuse; Anxiety over timekeeping; Lack of eye contact; Inconsistent injuries; Untreated injuries; Low self esteem; Living with a known abuser; Always accompanied by partner; Isolation; Constantly deferring to partner; Abuse of pets in household. This is not exhaustive and some of these indicators could also relate to depression, stress, mental illness and being a victim of abuse when younger.
2.38	The Significant Harm threshold is likely to have been reached, when there is evidence that any of the following are present: Parental domestic violence is adversely impacting on the child(ren)’s health and development; The non abusing parent is not able to provide a safe and secure environment for the child(ren).
2.39	The diagram in the Practice Guidance at Figure 2 should be referred to when deciding whether a referral to Children’s Social Care is appropriate.

Deciding When to Refer - Parental drug and alcohol use

2.40

Misuse of drugs and/or alcohol is strongly associated with Significant Harm to children, especially when combined with other features such as domestic violence.

2.41

Anyone who is aware of a parent who uses alcohol or drugs should be alert to the following factors and, if any are present, should refer to Children’s Social Care:

Use of the family resources to finance the parent’s dependency, characterised by inadequate food, heat and clothing for the children;
Children exposed to unsuitable caregivers or visitors, e.g. customers or dealers;
The effects of alcohol leading to an inappropriate display of sexual and/or aggressive behaviour;
Chaotic drug and alcohol use leading to emotional unavailability, irrational behaviour and reduced parental vigilance;
Disturbed moods as a result of withdrawal symptoms or dependency;
Unsafe storage of drugs and/or alcohol or injecting equipment;
Drugs and/or alcohol having an adverse impact on the growth and development of the unborn child.

2.42

The Significant Harm threshold is likely to have been reached, when there is evidence that any of the following are present:

Parental drug and alcohol use is adversely impacting on the child’s health and development;
There is no one parental figure able to provide a stable secure environment for the child;
There is no evidence that parental behaviour will change within a time frame congruent with the needs of the child.

Deciding When to Refer - Parental mental illness

2.43	The majority of parents who experience significant mental ill-health are able to care for and safeguard their children and/or unborn child.
2.44	However, in some cases, enduring and/or severe parental mental ill health will seriously affect the safety, health and development of children. Where professionals believe that this may be the case a referral must be made to Children’s Social Care.
2.45	Where any of the following are present in an adult carer a referral should be made for an assessment to be carried out in order to determine how the child’s needs can be met and the likelihood of Significant Harm: History of severe mental illness; Delusional thinking involving the child; Threats to harm a child; Self-harming behaviour and suicide attempts; Altered states of consciousness e.g. splitting/dissociation, misuse of drugs, alcohol, medication; Obsessional compulsive behaviours involving the child; Non-compliance with treatment, reluctance or difficulty in engaging with necessary services, lack of insight into illness or impact on the child; Disorder designated ‘untreatable’, either totally or within timescales compatible with the child’s best interests; Domestic violence and/or relationship difficulties; Unsupported and/or isolated parents; A child is acting as a young carer for a parent or sibling.
2.46	The threshold for Significant Harm is likely to have been reached when: There is an impact on the child’s growth, development behaviour and/or mental/physical health; The parent/carer’s needs or illnesses are taking precedence over the child’s needs; There is insufficient alternative care for the child within the extended family.

Deciding When to Refer - Children with disabilities

2.47

There is evidence that children with disabilities are significantly more likely to be abused than children without disabilities. The following should be taken into account when making a decision about whether to refer concerns to Children’s Social Care:

Research has shown (Sullivan & Knutson 1998: ‘The association between child maltreatment and disabilities in a hospital based epidemiological study’ Child Abuse and Neglect, 22, 271 - 288) that children with disabilities are approximately four times more likely to be abused than children without disabilities. This should always be taken into account when deciding how to respond to concerns. See also Safeguarding Disabled Children: Practice Guidance which was published by the DCSF in July 2009 and Safeguarding Disabled Children which is a summary of the Government guidance;
Children with disabilities demonstrate the same signs and indicators as children without disabilities; however, these may sometimes be confused with factors associated with the child’s impairment. Where any of the following exist a referral should be made and assessment commenced by Children’s Social Care, in order to understand the situation and needs of the child:
- Challenging behaviour;
- Sexualised behaviour;
- Low self esteem / sadness / passivity / emotional withdrawal;
- Self harm – including such behaviours as head banging / biting / scratching;
- Recurrent injuries;
- Denial of necessary equipment by parents or carers;
- Invasive procedures against the child’s will;
- Failure to follow medical advice / give the child required medication;
- An escalation in requests for short break / respite care;
- Exaggeration of a child’s impairment e.g. insisting on treatment/medical intervention not deemed appropriate by professionals (issues relating to fabricated or induced illness may be relevant in this situation).
The parental factors associated with abuse are also just as likely to be present in families with children with disabilities. It is very important that children with disabilities are not blamed for parental factors such as domestic violence, substance misuse and parental ill health leading to the appropriate action not being taken. Parental factors should be taken into account in decision making about potential harm in the same way as they are for children without disabilities.

2.48

The Significant Harm threshold for children with disabilities will have been met when:

There is clear evidence of abuse;
Needs have previously been identified and parents/carers have not been willing to work with services to change their parenting behaviour within the required time frame.

Deciding When to Refer - Child abuse images and the internet

2.49	The internet provides the opportunity for adults to access and distribute indecent images of children and share stories about their fantasies with other like-minded individuals. It can also be used to make contact with children with a view to grooming them for inappropriate or abusive relationships.
2.50	In this situation there can be no ambiguity as to whether a referral should be made to Children’s Social Care, who will immediately inform the relevant police team
2.51	If you are aware that some one has placed child abuse images on the internet, or is accessing child abuse images, the police child abuse investigation unit must be informed

Deciding When to Refer - Sexually harmful behaviour carried out by children and young people

2.52	Considerable care needs to be taken to determine whether an incident constitutes sexually harmful behaviour and to distinguish it from mutually consenting, age appropriate sexual exploration. If any professional is concerned about the behaviour of a child or young person they should telephone the duty officer at Children’s Social Care for advice.
2.53	In evaluating the likelihood that one child is sexually harming another consideration should be given to: The nature of the relationship between the perpetrator and victim with particular attention to power differentials. The greater the degree of power held by the perpetrator in relation to the victim, the greater the opportunity for sexually harmful behaviours to take place; The nature of the alleged acts i.e. how frequent/persistent; The effect on the victim; The sexualised behaviour of the children involved. i.e. the greater the departure from ‘normal’ sexual activity the stronger the suspicion of sexually harmful behaviour.
2.54	The following should always be referred to Children’s Social Care Attempted or actual oral, vaginal or anal penetration of children, animals or dolls; Using force to touch another’s genitals; Simulated intercourse with peers; Genital injury not explained by accidental cause; Sexually explicit conversations with significantly younger children Touching the genitals of others; Repeated or chronic genital exposure or public masturbation, simulated sexual activity (not intercourse) with peers, animals or toys; Any other significant sexual behaviour.
2.55	Consideration should be given to making a referral and advice sought from the duty officer in Children’s Social Care when there is Preoccupation with sexual themes or masturbation; Non normative level of sexual knowledge; Sexually explicit conversations with peers; Attempts to explore other’s genitals; Mutual or group masturbation; Simulated foreplay with toys or peers.

Deciding When to Refer - Where a parent has learning disabilities

2.56	Parents who have learning disabilities may need additional support to assist them with their parenting. Any parent who has been assessed with an IQ of less than 60 is unlikely to be able to parent effectively alone without additional support (McGaw, S., & Newman, T. (2005) What Works for Parents with Learning Disabilities? London: Barnardos). Other parents with an IQ in the range 60-80 may find the combination of a learning disability, and the complexity of the tasks (e.g. large numbers of children, children with medical needs) compromises their ability to meet the needs of their children without support. In addition, parents with learning disabilities who have experienced trauma in their own past are likely to need additional support (Tymchuk A. J. (1992) Predicting Adequacy of Parenting by People with Mental Retardation Child Abuse and Neglect 16 165 - 178).
2.57	Parents with learning disabilities may also be vulnerable to exploitation and abuse by others, for example they may be targeted by sex offenders.
2.58	Where any of the following exist a referral should be made to Children’s Social Care and an assessment commenced in order to determine whether the needs of the children are being met and what support the parent is likely to need: The parent has been assessed as having an IQ of 60 or less and has few or no supports in their family and social network. The parent(s) are known to have a learning disability and there are other factors which might challenge their ability to care for the child(ren). Such factors will include: A child with their own additional needs; Parental history of trauma / mental ill health; An abusive relationship with their current partner. There is reasonable cause to suspect that known sex offenders are visiting the household.
2.59	The Significant Harm threshold is likely to have been reached when: There is evidence that the child’s health or development is being impaired; The parents are unable to meet the needs of the child despite a child in need plan being in place; There is evidence that sex offenders and/or their associates are visiting the household.

Deciding When to Refer - Fabricated or induced illness

2.60	Fabricated or induced illness is when a child suffers harm caused by the action of a parent or other carer who deliberately fabricates symptoms or induces medical symptoms in a child which would not otherwise be present.
2.61	The following should alert professionals to the possibility of fabricated or induced illness: Reported symptoms and signs found on examination are not explained by any medical condition from which the child is suffering; Physical examination and results of investigations do not explain reported symptoms and signs; or There is an inexplicably poor response to prescribed medication and treatment; or New symptoms are reported on resolution of previous ones; or Reported symptoms and found signs are not observed in the absence of the carer; or The child’s normal, daily life activities are being curtailed beyond that which might be expected from any known medical disorder from which the child is known to suffer.
2.62	The above may be noticed by doctors, nurses and other professionals working with the child as well as professionals who may be working with the child’s parents.
2.63	Where fabricated or induced illness is suspected there should be discussion with the GP or paediatrician responsible for the child’s health. If the person concerned feels their worries are not taken seriously or responded to appropriately they should discuss this with the Designated Doctor or Named Nurse.
2.64	Where there are concerns about fabricated or induced illness a full developmental history and appropriate developmental assessment should be carried out.
2.65	A medical evaluation should: Explore the signs and symptoms for a range of possible diagnoses; Carry out specialist tests or seek specialist advice where a reason cannot be found for the signs and symptoms; Normally result in feedback being given to the parents where an explanation has not been found and the parental response to this information be noted; Ensure that parents are kept informed of further assessments / investigations / tests and of the findings.
2.66	At no time should concerns about the reasons for the child’s signs and symptoms be shared with parents if this information would jeopardise the child’s safety. In these situations convening a professionals’ meeting may be a useful first step.
2.67	The Significant Harm threshold will have been met and a referral should always be made and child protection enquiries commenced when a possible explanation for the signs and symptoms is that, they may have been fabricated or induced by the carer and as a consequence the child’s health or development is likely to be impaired. Also see the Government Guidance Safeguarding Children in Whom Illness is Fabricated or Induced (DCSF 2008)

The Referral Process for Children in Need of Protection

2.68	Where the child is not an open case in Children’s Social Care If there are immediate concerns about the safety of a child a referral should be made by telephone to Children’s Social Care (Contact Centre). At the end of any discussion or dialogue about a child the referrer (if a professional from another service) and Children’s Social Care must record the decision taken in their records.
2.69	Telephone referrals should be followed up in writing within 48 hours. The CAF Form is not a referral form although it may be used to support a referral or a specialist assessment. You may be expected to complete a single service referral form. This, together with detailed local guidance, is available at Peterborough City Council website.
2.70	If concerns are not immediate, but it is believed that a child is a Child in Need, who may also be in need of protection, a referral should be made in writing. Where a Common Assessment has been completed by the referring agency this will form the basis of the referral. Where necessary the assessment should be updated in order to ensure that the most recent information is being passed to Children’s Social Care. It is good practice to discuss the referral with the child (if appropriate) and parents/carers unless doing so would place the child at risk of Significant Harm or, where police may become involved, be likely to prejudice a criminal investigation.
2.71	Where the child is an open case in Children’s Social Care Practitioners from outside Children’s Social Care should contact the allocated worker to express their concerns and follow these up in writing within 48 hours.
2.72	If concerns come to light from within Children’s Social Care in relation to an open case, a decision should be made as to whether or not a Strategy Discussion should be initiated (see Action to be taken where a Child is at Risk of Significant Harm Procedure, Paragraphs 4.4.-4.12). In these circumstances it may not be necessary to undertake an Initial Assessment before deciding what to do next. It may, however be appropriate to undertake a Core Assessment or update a previous one in order to understand the child’s current needs and circumstances and inform future decision making.

Taking a Referral - Procedures to be followed by Children's Social Care

2.73	Where Children’s Social Care have in place a centralised system for receiving and re-directing referrals (for example a contact centre), it is vital that staff have access to immediate consultation and guidance from qualified and experienced workers in order to ensure that all necessary information is gathered and an appropriate response is made.
2.74	As soon as a referral is made about the welfare of a child, records should be checked in order to ascertain whether either the child or the child’s parents/ carers are known to Children’s or Adults’ Social Care. This information must be recorded.
2.75	In the event of a telephone referral which is passed to the relevant social work team the duty worker should: Give their name and designation; Help the referrer give as much information as possible; Clarify the information that the referrer is reporting directly and information that has been obtained from a third party; Clarify who knows about the referral; Clarify the whereabouts of the child and immediate action to be taken; Explain what is going to happen next; When the referrer is a professional, confirm that a written referral will be received within 48 hours; Agree how to re-contact the referrer if further clarification is required; Clarify whether the referrer gives consent for their details to be revealed to the child/family concerned (refusing consent should only be an exception in the event of a referral from another professional – see 2.76 below); Explain how feedback will be given.
2.76	It may be appropriate to agree anonymity where: The referrer is a member of the public; There is evidence of intimidation or threats of violence towards the professional concerned.
2.78	All referrals should record details of: Evidence of domestic violence; Evidence of parental mental ill health, drug or alcohol use, parental learning disability; Any known impairment of the child or parent or carer; Convictions against children or previous suspected abuse. Referrers should be asked specifically if they hold any information about difficulties being experienced by the family/household due to domestic abuse, mental illness, substance misuse, and/or learning difficulties.
2.79	Where the duty worker is not a qualified social worker, the referral details should be passed immediately to a qualified worker for an assessment of the urgency of the situation. Referrers should have an opportunity to discuss their concerns with a qualified social worker.
2.80	Where a written referral is received by Children’s Social Care, the duty manager should decide on next steps within 24 hours.

Practice Guidance - Recognising and responding to concerns

Information Sharing

The following is taken from:

Information Sharing: Guidance for practitioners and managers issued by the DCSF in October 2008

Seven Golden Rules of Information Sharing

Remember that the Data Protection Act is not a barrier to sharing information but provides a framework to ensure that personal information about living persons is shared appropriately;
Be open and honest with the person (and/or their family where appropriate) from the outset about why, what, how and with whom information will, or could be shared, and seek their agreement, unless it is unsafe or inappropriate to do so;
Seek advice if you are in any doubt, without disclosing the identity of the person where possible;
Share with consent where appropriate and, where possible, respect the wishes of those who do not consent to share confidential information. You may still share information without consent if, in your judgement, that lack of consent can be overridden in the public interest. You will need to base your judgment on the facts of the case;
Consider safety and well-being: Base your information sharing decisions on considerations of the safety and wellbeing of the person and others who may be affected by their actions;
Necessary, proportionate, relevant, accurate, timely and secure: Ensure that the information you share is necessary for the purpose for which you are sharing it, is shared only with those people who need to have it, is accurate and up-to-date, is shared in a timely fashion, and is shared securely;
Keep a record of your decision and the reasons for it - whether it is to share information or not. If you decide to share, then record what you have shared, with whom and for what purpose.

Confidentiality

In deciding whether there is a need to share information you need to consider your legal obligations including:

whether the information is confidential;
if it is confidential, whether there is a public interest sufficient to justify sharing.

Information is not confidential if it already in the public domain e.g. a teacher may know that one of her pupils has a parent who misuses drugs. That is information of some sensitivity but may not be confidential if it is widely known or it has been shared with the teacher in circumstances where the person understood it would be shared with others. If however, it is shared with the teacher in a counselling session it would be confidential.

Confidence is only breached where the sharing of confidential information is not authorised by the person who provided it or to whom it relates.

Even where sharing of confidential information is not authorised you may share it if this can be justified in the public interest.

A key factor in deciding whether or not to share confidential information is proportionality, i.e. whether the proposed sharing is a proportionate response to the need to protect the public interest in question.

Where there is a clear risk of Significant Harm to a child, or serious harm to adults, the public interest test will almost certainly be satisfied. However there will be other cases where practitioners will be justified in sharing some confidential information in order to make decisions on sharing further information or taking action – the information shared should be proportionate.

Circumstances in which sharing confidential information without consent will normally be justified in the public interest:

When there is evidence that the child is suffering or is at risk of suffering Significant Harm; or
There is reasonable cause to believe that a child may be suffering or at risk of Significant Harm; or
To prevent Significant Harm arising to children and young people or serious harm to adults, including through the prevention, detection and prosecution of serious crime.

Please note:

It is essential that staff do not give false reassurance that information will be kept confidential when information will need to be shared if a child is at risk of harm.

Do’s and Don’ts (adapted from “What to do if you are worried a child has been abused”, 2006)

Do record full information about the child(ren) or young person(s) at first point of contact, including name(s), address(es), gender, date of birth, name(s) of person(s) with Parental Responsibility (for consent purposes) and primary carer(s), if different, and keep this information up to date;
Do ensure that the child(ren)’s records includes an up-to-date Chronology, and details of the lead worker in the relevant agency – for example, a social worker, GP, health visitor or teacher;
Do know who to contact within your own organisation to express concerns about a child’s welfare;
Do know who to contact in police, health, education and Children’s Social Care to express concerns about a child’s welfare;
Do talk to your manager and other professionals: always share your concerns, and discuss any differences of opinion;
Do listen to what the child or young person has to say and record in their own words what has been said. Sign and date all records;
Do note visible marks or injuries on a body map and document details in your records;
Do NOT attempt to physically examine a child(ren);
Do record any conversation with parents or carers fully and accurately;
Do NOT ask leading questions or attempt to investigate allegations;
Do ensure that you have all the information held by your agency relating to the child(ren) or young person(s), their family and the details of your concern to hand when making a referral;
Do record all concerns, discussions about the child(ren) or young person(s), decisions made, and the reasons for those decisions;
Do follow up your concerns. Always follow up oral communications to other professionals in writing and ensure your message is clear;
Do keep careful and detailed notes;
Do record any unusual events and make a distinction between events reported by the carer and those actually witnessed by others including professionals. Notes should be timed, dated and signed.

Children in Need

Section 17 of the Children Act 1989 confers a general duty on the local authority to:

Safeguard and promote the welfare of children within the area who are in need;
So far as is consistent to promote their upbringing by families.

by providing a range and level of services appropriate to their needs.

Section 53 of the Children Act 2004 amends section 17 to now also require that before determining what if any services to provide, the local authority shall:

Ascertain the child’s wishes and feelings regarding those services; and
Give due consideration to those wishes and feelings.

Children in Need of Protection before Identifying Risk of Harm

Section 47 of the Children Act 1989 confers a duty on the local authority that where a child in the area is:

Subject of an Emergency Protection Order/Police Protection; or
They have reasonable cause to suspect a child is suffering or is likely to suffer Significant Harm.

The authority shall make or cause to be made necessary enquiries to decide whether they should take any action to safeguard or promote the child’s welfare.

Where enquiries are being made the authority should:

Obtain access to him/her or ensure access is obtained by an authorised person.

Section 53 of the Children Act 2004 amends section 47 so that for the purposes of making a determination as to what action to take the authority shall:

Ascertain the child’s wishes and feelings about such action; and
Give due consideration to the child’s wishes and feelings.

Under s31 (9) of the Children Act 1989 as amended by the Adoption and Children Act 2002:

‘Harm’ means the 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’ means physical or mental health; and
‘Ill-treatment’ includes sexual abuse and forms of ill-treatment which are not physical.

Under s31 (10) of the Children Act 1989:

Where the question of whether harm suffered by a child is significant turns on the child’s health and development, his health or development shall be compared with that which could reasonably be expected of a similar child.

Significant Harm may be associated with a single traumatic event but most often it is a compilation of significant events, both acute and longstanding, which interrupt, change or damage the child’s physical and psychological development.

“Harm” is attributable to care given not being what it would be reasonable to expect a parent to give.

To understand and establish Significant Harm, it is necessary to consider:

The nature of harm, in terms of maltreatment or failure to provide adequate care;
The impact on the child’s health and development;
The child’s development within the context of their family and wider environment;
Any needs as a result of the child’s medical condition, physical or mental impairment that may affect the child’s development and care within the family;
The capacity of the parents to meet adequately the child’s needs; and
The wider and environmental family context.

Consideration of whether harm is significant should therefore include:

Accuracy of what has been alleged/reported;
Impact on this particular child - evident now or probable given research studies/information available regarding children in similar situations – taking into account:
- Whether what has been done to, or omitted regarding a child’s care forms a ‘pattern’ of behaviour towards this child - or was it a one off and is it likely that it will it recur or not?
- Severity of abuse/impact - and how the child may have reacted/changed as a result;
- The overall wellbeing and/or robustness of the child;
- Specific vulnerability/ies of the child stemming from young age or impairment;
- The views of the child.
The context in which the act or omission occurred - is all the available past information available and does any still need to be sought – how important might missing information be?
Causal link to parents/carers against what would have been reasonable/is reasonable to expect of any parents in relation to this child and its needs (with or without provision of services);
Parental reaction - both immediately and in the long term;
What protective/positive factors or individuals (e.g. extended family) are there?
What engagement with professionals in recognition of the need for change is there? What acceptance of responsibility/what insight/what capacity and what motivation for changing and sustaining change is there? Are the causes of problems identified and needs established so that clear targets for parents and agencies can be set and linked to clear outcome expectations?

Thresholds and Significant Harm

It must be remembered that when it is identified that a child is at risk of Significant Harm they will also be a Child in Need. The focus on harm should not mean that the overall needs of the child are ignored. Section 47 needs to be understood as a specific “extra” within the overall requirements of Section 17, not separate from it. Complex cases can move between Sections 17 and 47 status in this way rather than ‘get lost’ due to a threshold debate as to whether they are one or the other.

Defining Abuse and Neglect

The following definitions from Working Together to Safeguard Children 2010 should assist practitioners in deciding whether a child is suffering or is likely to suffer Significant Harm. Where abuse is suspected a referral should always be made to Children’s Social Care.

Physical Abuse

Physical abuse may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating, or otherwise causing physical harm to a child. Physical harm may also be caused when a parent or carer fabricates the symptoms or, or deliberately induces illness in a child

Emotional Abuse (as amended in Working Together to Safeguard Children 2010)

The following definition is taken from Working Together to Safeguard Children 2010, paragraph 1.34.

Emotional abuse is a form of Significant Harm which 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 that are beyond the child's developmental capability, as well as overprotection and limitation of exploration and learning, or preventing the child participating in normal social interaction. It may involve seeing or hearing the ill-treatment of another. It may involve serious bullying (including cyberbullying) causing children frequently 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 (as amended in Working Together to Safeguard Children 2010)

The following definition is taken from Working Together to Safeguard Children 2010, paragraph 1.35.

Sexual abuse is a form of Significant Harm which involves forcing or enticing a child or young person to take part 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 assault by 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 (including via the Internet). Sexual abuse is not solely perpetrated by adult males. Women can also commit acts of sexual abuse, as can other children.

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 or development. Neglect may occur during pregnancy as a result of maternal substance abuse. Once a child is born neglect may involve a parent or carer failing to:

Provide adequate food, clothing and shelter (including exclusion from home or abandonment);
Protect a child from physical and emotional harm or danger;
Ensure adequate supervision (including the use of inadequate care-giver);
Ensure access to appropriate medical care or treatment.

It may also include neglect of, or unresponsiveness to, a child’s basic emotional needs.

FIG 2 Tiers of Need and Intervention:

Adapted from Hardiker, Exton & Barker (1991) in Vision for Services for Children and Young People affected by Domestic Violence- guidance for local commissioners of children’s services. (2005) Local Government Association; CAFCASS: Women’s Aid.

Click here to view the Flowchart - Tiers of Need and Intervention.

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