Healthcare professionals - supporting children and young people who may have experienced child sexual abuse: clinical pathway

6 Clinical pathway

The diagram below provides a high level summary of the clinical pathway and the specific steps to take during the process. Details on each step are provided in the sections of the pathway following the diagram.

1. Disclosure by child / young person, suspicion of abuse by a professional or other adult or indication from clinical presentation (section 6.1)

2. Inter-agency Referral Discussion (section 6.2) and Child Protection Procedures

• Health:
  • Holistic assessment of physical and emotional healthcare needs; examinaton or forensic examination if indicated (section 6)
• Social Work:
  • Assessment of welfare, support needs and any requirement for a compulsory supervision order
• Police:
  • Investigation of potential crime (section 6.3)

3. Inter-agency Child Protection Procedures and safety plan

Where Multi-agency support is put in place (section 6.4)

6.1 Disclosure of/cause for concern about child sexual abuse

Any disclosure of sexual abuse by a child under 16 years of age must be considered as a child protection concern. For those who may be victims of sexual offences aged 16 and 17, child protection procedures should be considered and must be applied when there is concern about sexual exploitation or trafficking.

Initial concerns about the sexual abuse of a child or young person may arise in many ways, or concerns may be raised from their behaviour or presenting symptoms. Often it can take some time for a disclosure to become apparent (NSPCC). It is important that there is a robust, timely, trauma-informed and consistent response to cases of recent sexual abuse as well as to concerns about or disclosures of non-recent abuse. There may be signs of child sexual exploitation.

At all points in the pathway, the primary focus is the child or young person and their immediate and future wellbeing, informed by the GIRFEC^[37] principles and values. Services should ensure that appropriate support is put in place for non-abusing parent/carer(s) and other people close to the child.

Sexual abuse in children and young people may present in a number of ways including but not limited to:

• Disclosure by the child of previous or ongoing abuse
• A clear disclosure may not be made at an early stage in the process as the abuser may groom and/or threaten the child. If the child recent sexual abuse urgent action is required
• Pregnancy or sexually transmitted infection in a child under 16 years – this should always prompt further enquiry and exploration
• Behavioural change including sexualised behaviour
• Unexplained genital bleeding with an injury or history not compatible with symptoms and examination
• Any sexual activity in a child who is under 13 years
• Foreign body present in vagina or anus
• Recurrent or new onset wetting or soiling
• A child suspected of sexually abusing another child who may be, or may have been, a victim themselves

There may be no overt symptoms or signs.

6.2 Inter-agency Referral Discussion (IRD)

Where information is received by police, health or social work that a child may have been abused or neglected and/or is suffering or is likely to suffer significant harm, an IRD must be convened as soon as reasonably practical.

The IRD process may have to begin out with core hours, with a focus on immediate protective actions and interim safety planning. A comprehensive IRD must be completed as soon as practical. This should normally be on the next working day.

The IRD is the start of the formal process of information sharing, assessment, analysis and decision making following reported concern about abuse or neglect of a child or young person in relation to familial and non-familial concerns; and of siblings or other children within the same context.

IRDs are required to ensure coordinated inter-agency child protection processes up until the point a Child Protection Planning Meeting (CPPM) is held; or until a decision is made that a CPPM is not required. An IRD is not usually a one-off discussion. It is a series of discussions between representatives of each of the core agencies as to what the coordinated response should be - a process where it may be necessary to reconvene the IRD as enquiries progress to review strategies and evaluate outcomes.

All aspects of the IRD must be recorded, responsibility for which must be agreed/confirmed at the outset in line with local protocols. The record must include the time and reason for starting an IRD, the professionals attending, the information shared, discussions held, reasoned decisions (including considered options), any lack of consensus, and the manner in which lack of consensus has been escalated and resolved, without delay. This will form a single core IRD record, to be shared by participant agencies.

Where there is a risk to the life of a child or the likelihood of immediate risk or significant harm, intervention must not be delayed pending information gathering/sharing. Police and social work must use their statutory child protection powers and act immediately.

Where a self-referral examination has been undertaken and it later becomes apparent that the individual is under the age of 16, an IRD should be convened as soon as reasonably practical.

Essential considerations of the IRD

Those involved in joint planning and decision-making will consider:

• How information about investigation can best be exchanged and shared with the child taking into account their capacity and maturity
• How information can best be exchanged and shared with family and whether information should not be shared if this may jeopardise a police investigation or place the child, or any other child, at risk of significant harm
• Feelings and views of the child about aspects of investigation, including consent to medical examination
• How the IRD decisions can be reviewed as necessary if significant new information arises
• Keeping a named person appropriately informed and involved; identifying a lead professional and professionals in the Core Group who will work with the interim safety plan

Decisions and planning within an IRD

Participants must consider how priority considerations above will lead to decisions about:

• What decisions must be taken about the immediate safety and wellbeing of this child and/or other children involved?
• Is an inter-agency child protection investigation required?
• Is a single-agency investigation and follow-up preferred and why?
• If no further investigation is required, what are the reasons for this?
• Is a joint investigative interview (JII) required and, if so, what are the arrangements for this? (Including who will carry it out, location of interview and in what timescales.)
• Is a medical examination required? If so, should this be a comprehensive medical examination, a specialist paediatric forensic examination or Joint Paediatric Forensic Examination for cases of potential non-accidental injury or suspected sexual abuse? (See below on types of medical examinations.)
• Is early referral to the Principal Reporter needed for consideration of grounds for compulsory measures?
• Whether a compulsory supervision order might be necessary leading to early referral to the Principal Reporter^[38]

The main types of medical examination that may be undertaken within the child protection process are outlined in section 7 of this guidance.

For further information on the roles and responsibilities of professionals involved in the clinical pathway, see Appendix F.

6.3 Police and social work

Joint Investigative Interview (JII)

JII is the formal interview process carried out by police and social work investigative interviewers for evidential purposes and to assess whether the child (or any other child) needs protection.

These are formal interviews conducted by trained police officers and social workers where there is a concern that a child is a victim of, or witness to, criminal conduct and where there is information to suggest that the child has been or is being abused or neglected or may be at risk of significant harm.

The interview is conducted in a way that treats the best interests of the child as a primary consideration and includes the gathering of evidence when it is suspected a crime may have been committed against or witnessed by the child. The purposes of a JII include:

• To learn the child’s account of the circumstances that prompted the enquiry
• Gather information to permit decision making on whether the child in question, or any other child, is in need of protection
• Gather sufficient evidence to suggest whether a crime may have been committed against the child or anyone else
• Gather sufficient evidence which may lead to a ground of referral to a children’s hearing being established

Information obtained during the JII is fed back into the IRD process to allow further discussion and decision making. The joint investigation can also provide evidence for court proceedings, such as a criminal trial or a Children’s Hearing proof.

6.4 Inter-agency child protection procedures and safety plan

All local authority areas have their own inter-agency child protection guidelines – please refer to them for further information. These are based on a national framework within which agencies and practitioners can understand and agree processes for working together to support, promote and safeguard all children.

Immediate safety planning involves all professionals sharing information and collaboratively working with non-abusing parent/carer(s) and children to develop and implement a safety plan that leaves everyone confident that the child is safe. It will involve monitoring and reviewing this plan to be satisfied that the plan is working and should include further subsequent follow up which includes addressing health and emotional needs.