Indicators of Risk
448. This section gives additional information on dealing with specific conditions that may impact adversely on children as well as addressing operational considerations in certain circumstances. While a range of special or specific circumstances are covered, the national guidance does not provide detailed guidelines on areas of practice/policy that are contained elsewhere; rather, it signposts to relevant policies and materials and/or provides a framework of standards that local policies will need to consider.
449. When making judgements about the risks and needs of a child, there are a range of indicators that should trigger assessment and, where appropriate, action  . Not all the indicators set out here are common; nor should their presence lead to any immediate assumptions about the levels of risk for an individual child. Where identified, though, they should act as a prompt for all staff, whether in an adult or child care setting, to consider how they may impact on a child. In the sections below, indicators of potential risk are considered separately but they will often - particularly for children in vulnerable circumstances - occur together. Indicators of risk should therefore be considered not in isolation but in relation to all the relevant aspects of a child and family's circumstances for example, a young person involved in offending behaviour is often a young person in need of care and protection. Where there are a number of risk factors in a child's life, practitioners should pay particular attention to the cumulative impact on the child. Where a range of different services is involved, it is particularly important to maintain the focus on the child's needs.
450. The sections below provide summaries of key aspects of the different indicators of risk. The further information sections provide links to important resources that will support practitioner judgements.
451. Domestic abuse describes any behaviour that involves exerting control over a partner or ex-partner's life choices and that undermines their personal autonomy. It is an assault on their human rights. Although most victims are women, men can also suffer domestic abuse, and it can occur in same-sex relationships as well as heterosexual ones. Children and young people living with domestic abuse are at increased risk of significant harm, both as a result of witnessing the abuse and being abused themselves. Children can also be affected by abuse even when they are not witnessing it or being subjected to abuse themselves. Domestic abuse can profoundly disrupt a child's environment, undermining their stability and damaging their physical, mental and emotional health.
The Criminal Justice and Licensing (Scotland) Act 2010, provides for a statutory offence of 'stalking' specifically criminalising stalking. Conduct which might be described as harassment or stalking can be prosecuted under Scots law as a breach of the peace. This common law offence covers all behaviour (including single incidents) which is severe enough to cause alarm to ordinary people and threaten serious disturbance to the community. Section 38 provides for an offence of 'threatening and abusive behaviour; it is an offence for a person to behave in a threatening or abusive manner towards someone if that behaviour would be such as to be likely to cause a reasonable person to feel fear or alarm.
452. The impact of domestic abuse on a child will vary, depending on factors including the frequency, severity and length of exposure to the abuse and the ability of others in the household (particularly the non-abusive parent/carer) to provide parenting support under such adverse conditions. If the non-abusive parent/carer is not safe, it is unlikely that the children will be. Indeed, children frequently come to the attention of practitioners when the severity and length of exposure to abuse has compromised the non-abusing parent's/carer's ability to nurture and care for them.
453. The best way to keep both children and non-abusive parents/carers safe is to focus on early identification, assessment and intervention through skilled and attentive staff in universal services. Domestic abuse is widely under-reported to the police. Given the reticence of victims to come forward, it is crucial that staff are aware of the signs of domestic abuse and routinely make appropriate enquiries.
454. When undertaking assessment or planning for any child affected by domestic abuse, it is crucial that practitioners recognise that domestic abuse involves both an adult and a child victim. The impact of domestic abuse on a child should be understood as a consequence of the perpetrator choosing to abuse rather than of the non-abusing parent's/carer's failure to protect. Every effort should be made to work with the non-abusing parent/carer to ensure adequate and appropriate support and protection is in place to enable them to make choices that are safe for them and the child. At the same time, staff should be maintaining a focus on the perpetrator and monitoring any risk resulting from ongoing abuse. The ultimate aim should be to support the non-abusing parent/carer in re-establishing a stable and nurturing home for the child; in the meantime, in some instances, protecting the child may mean them having to live apart from the non-abusing parent/carer for a time. In such circumstances, staff should work to ensure as much stability and continuity for the child as possible. Agencies should always work to ensure that they are addressing the protection of both the child and the non-abusing parent/carer.
455. Protection should be ongoing, and should not cease if and when the abuser and the non-abusing parent/carer separate. Indeed, separation may trigger an escalation of violence, increasing the risk to both the child and their non-abusing parent/carer. One area of critical concern is the child's contact with the perpetrator, which can provide a channel for continuing and even increasing the domestic abuse. Any decisions made in regard to contact by both social work services and/or the civil courts should be based on an assessment of risk to both the non-abusing parent/carer and the child. It is important to note that the Children's Hearing may also make decisions about contact.
456. For more information, see the following.
- National Domestic Abuse Delivery Plan for Children and Young People . 
- Safer Lives: Changed Lives - A Shared Approach to Tackling Violence against Women in Scotland . 
- In Partnership, Challenging Domestic Abuse - Joint Protocol between Association of Chief Police Officers in Scotland ( ACPOS) and Crown Office and Procurator Fiscal Service . 
- Section 39, Criminal Justice and Licensing (Scotland) Act 2010 (relevant to the offence of stalking)
Key messages for practice
- Domestic abuse can have a profound impact on children, both in the short and long term.
- Staff need to be alert to the indicators, the dynamics and the impacts of domestic abuse.
- Supporting the adult victim of domestic abuse ultimately supports the child.
- Risk of domestic abuse can increase at the point of separation.
- Contact between the perpetrator and the child should be subject to a risk assessment before proceeding.
Parental problematic alcohol and drug misuse
457. Problematic parental substance use can involve alcohol and/or drug use (including prescription as well as illegal drugs). The risks to, and impacts, on children of parents and carers who use alcohol and drugs are known and well-researched. Alcohol and/or drug use during pregnancy can have significant health impacts on the unborn child. Problematic parental alcohol and/or drug use can also result in sustained abuse, neglect, maltreatment, behavioural problems, disruption in primary care-giving, social isolation and stigma of children. Parents and carers with drug and/ or alcohol problems often lack the ability to provide structure or discipline in family life. Poor parenting can impede child development through poor attachment and the long-term effects of maltreatment can be complex. The capability of parents/carers to be consistent, warm and emotionally responsive to their children can be undermined.
458. It is important that all practitioners working with parents affected by problematic drug and/or alcohol use know the potential impact that this has on children, both in terms of the impact on the care environment through direct exposure to alcohol and/or drug use, and also the potential practical and emotional challenges presented in terms of the recovery process. Addiction staff also need to know when and how to share information to keep children safe, and should understand the contribution they can make to assessing risks and needs and planning. Planning is vital, particularly in the case of unborn children, and will often include input from agencies that do not have a frontline child care role. The best interests of the child should always be the principal concern.
459. Getting our Priorities Right  notes that all services have a part to play in helping to identify children that may be at risk from their parent's problem alcohol and/or drug use and at an early stage. Services need to respond in a co-ordinated way with other services to any emerging problems. This information should also take account of any wider factors that may affect the family's ability to manage and parent effectively. It should also take account of any strengths within the family that may be utilised.
460. Local areas should ensure there are robust policies and guidance in place for the identification, assessment and management of children affected by parental problematic alcohol and/or drug use. For example, guidance for staff when there are custody issues between parents, working with asylum seekers and in situations where parents do not engage with community addiction services. Local procedures should reflect the multi- and single agency roles and responsibilities in this complex area of work. These will be framed by local strategies, whose development should be led by Alcohol and Drug Partnerships working in conjunction with Child Protection Committees, that cover partnership working, commissioning of services, training to ensure that all staff have the skills needed to deal with adult- and child-specific issues and a performance monitoring framework.
461. Local guidance should be developed in line with the key wider national change programmes and frameworks relevant to children affected by parental alcohol and/or drug misuse. Currently, these are the National Drug Strategy, The Road to Recovery , and the National Alcohol Framework, Changing Scotland's Relationship with Alcohol: a Framework for Action , as well as Getting Our Priorities Right (2012) and GIRFEC. In addition, it is important that local guidance should include the following.
- Reference to the evidence base on the impact of parental problematic alcohol and/or drug use on children. This should include specific reference to fetal alcohol syndrome and neo-natal abstinence syndrome as well as best practice guidance on blood-borne viruses - for example, in relation to breast-feeding, testing, immunisation of mothers and infants, and treatment and care of affected children. Local guidance should also include an evidence base for effective interventions with parents, carers and families affected by problem drug and alcohol use This should include ante-natal and post-natal care pathways for parents/carers where there are alcohol and/or drug use problems. Separate guidance on the management of young people with problem alcohol and/or drug use and families affected by young people's alcohol and/or drug use should also be in place.
- A clear statement about partnership working and the roles and responsibilities of the Named Person, practitioners and agencies involved with families at key stages. Effective intervention will depend on robust working relationships between practitioners within both a child and adult care setting. When identifying and responding to concerns about a child, the Named Person will require to call upon expertise in child protection and addiction services to ensure the child receives a robust, joined-up service. Particular attention should be paid to information-sharing (including resolution of disputes on information-sharing) and best practice. The advice statement issued by the Information Commissioners Office clarifies the current situation. However, the Children and Young People (Scotland) Act 2014 contains provisions which, when enacted, will introduce a legal duty on a range of public bodies to share information which is likely to be relevant to their function, with a child's Named person. Statutory guidance relating to these provisions will be issued.
- Advice on including a Family Support Plan element within planning for children. This should take account of issues affecting parents/carers, not just mothers and children. In particular, the Family Support Plan model can be useful when dealing with families affected by problematic alcohol and/or drug use.
462. A Lead Professional should be identified in cases where several services are involved. In child protection cases, this role is likely to be assigned to a social worker. In other situations, local guidance should provide direction as to:
- the practitioners and agencies who should undertake this role;
- when in the process of assessing an individual child's needs a Lead Professional should be appointed; and
- the relevant governance arrangements and accountability.
463. Local services should have an agreed risk assessment framework for children affected by parental problematic alcohol and/or drug use. There should also be a strategy for training staff involved in this area of work. This should include staff in addiction services who need to know about child development/maltreatment, as well as social services/health staff who will require training on drug and alcohol problems  .
464. For more information, see the following.
- The Road to Recovery: A New Approach to Tackling Scotland's Drug Problem. 
- Changing Scotland's Relationship with Alcohol: A Framework for Action. 
- Getting our Priorities Right. 
Key messages for practice
- Addiction staff must consider the needs of any children when working with adults affected by problematic drug and/or alcohol use and know when and how to share any concerns.
- Local areas should have robust policies and guidance in place for identifying, assessing and managing children affected by problematic alcohol and/or drug use.
- A Lead Professional should be identified in cases where several services are involved.
- Local services should have an agreed risk assessment framework for children affected by parental alcohol and/or drug misuse.
465. The definition of 'disabled children' includes children and young people with a comprehensive range of physical, emotional, developmental, learning, communication and health care needs. Disabled children are defined as a child in need under section 93(4) of the Children (Scotland) Act 1995.
466. Disabled children are vulnerable to the same types of abuse as their able-bodied peers. Children with behavioural disorders, learning disabilities and/or sensory impairments are particularly at risk. Neglect is the most frequently reported form of abuse, followed by emotional abuse.
467. Abuse of disabled children is significantly under-reported. Local services need to ensure their systems for collecting information about disabled children are sufficiently robust. Where a child has a disability, the type and, if relevant, the severity of that disability should be recorded, along with the implications for the child's support and communication needs.
468. Disabled children are more likely to be dependent on support for communication, mobility, manual handling, intimate care, feeding and/or invasive procedures. There may be increased parental stress, multiple carers and care in different settings (including residential); there may also be reluctance among adults, including practitioners, to believe that disabled children are abused. Disabled children are likely to be less able to protect themselves from abuse. Limited mobility can add to their vulnerability. In addition, the network of carers around the child is likely to be larger than for a non-disabled child, which can be a risk factor in itself. While the majority of parents/carers provide the highest standard of care for their child, it must be acknowledged that in some cases they themselves will be perpetrators of abuse.
469. Children looked after by parents/carers in the community can have complex health care needs which include life-threatening conditions. Caring responsibilities, which may involve complex clinical procedures, can lead to considerable pressure on families. Reliance on physical, mechanical and chemical interventions to manage health and behaviour can leave these children particularly vulnerable to harm. Disabled children's dependence on medication may leave them exposed to further abuse, for example where medication is wrongly - or simply not administered - either deliberately or through lack of knowledge and understanding.
470. Disabled children are often highly dependent on their carers. They may be less resilient and failure to treat even minor ailments can have serious consequences. Practitioners may have an unrealistic view of parents/carers' ability to cope. Parents/carers may be reluctant to admit that they can't cope. To protect disabled children, assessments must cover the ability and capacity of parents/carers to cope with the demands being placed on them.
471. When responding to concerns about a disabled child, expertise in child protection and disability should be brought together to ensure the child receives the same standard of service as a non-disabled child. It may be helpful to involve practitioners with experience of working with disabled children, such as speech and language therapists or residential workers. Local guidance should set out processes and available support and be sensitive to the particular needs of disabled children during child protection investigations, for example when they need to be examined, give consent or communicate evidence. Where a disabled child is deaf or hard of hearing or has learning disabilities, special attention should be paid to the child's communication support needs, ascertaining the child's perception of events, and understanding their wishes and feelings. Practitioners should be aware of non-verbal communication systems, when they might be useful and how to access them, and should know how to contact suitable interpreters or facilitators. Assumptions should not be made about the inability of a disabled child to give credible evidence or withstand the rigours of the court process. Each child should be assessed carefully and supported to participate in the process where this is in their best interests.
472. Local services need to provide training for those involved in child protection work on the particular vulnerability of disabled children. Local guidelines should encourage practitioners to make contact with key workers as early as possible, for advice on the child's impairment, how it is likely to impact on the investigation and the support needed for the child. Specialist advice should be sought at an early stage. Investigation planning should include: providing support to the child, including with communication; identifying a suitable location including, where needed, any communication boards/loop system; and allowing additional time for the investigation, including time to brief the support staff and time for breaks in line with the child's needs.
473. Disabled children can progress into adult protection. The Protection of Vulnerable Groups (Scotland) Act 2007 recognises the vulnerability of disabled adults. Transition to adult services can be a traumatic time for disabled children and their families. Local services should consider the development of transition plans that reflect the complexity of transition from child to adult services.
474. Children can also be affected by the disability of those caring for them. Disabled parents/carers/siblings may have additional support needs relating to physical and or sensory impairments, mental illness, learning disabilities, serious or terminal illness, or degenerative conditions. These may impact on the safety and wellbeing of their children, affecting their education, physical and emotional development. A full assessment of parents' needs, and of the support they need in order to fulfil their parenting responsibilities, should be carried out as well as an assessment of the needs of the child. Joint working between specialist disability and child protection services will be needed. For further information, see the section on mental health.
475. For more information, see the following:
- Safeguarding Disabled Children: Practice Guidance .  The guidance covers England and Wales, but is nevertheless valuable for practitioners working in Scotland.
- Triangle is an independent organisation that works directly with children and their families but also offers training and consultancy to practitioners and agencies.
- Capability Scotland is a third sector agency providing education, employment opportunities and support for disabled people.
- Child Protection and The Needs and Rights of Disabled Children and Young People: A Scoping Study . 
- Scottish Good Practice Guidelines for Supporting Parents with Learning Disabilities, which provides practical guidance to agencies that support people with learning disabilities who become parents.
Key messages for practice
- Local services need to ensure that systems for collecting information about disabled children are sufficiently robust.
- Assessments for disabled children need to include the ability and capacity of parents/carers to cope with their demands.
- When responding to concerns about a disabled child, expertise in child protection and disability should be brought together.
- Local guidance should set out processes and available support and be sensitive to the particular needs of disabled children during the conduct of child protection investigations.
- Local services need to provide training for those involved in child protection work on the particular vulnerability of disabled children.
- Specialist advice should be sought at an early stage to help inform decision-making.
- Local services should consider the development of transition plans that reflect the complexity of transition from child to adult services.
- Local Child Protection Committees should ensure that there are specific, and appropriate arrangements in place through guidance, protocols or procedures, which are known and implemented by relevant services.
476. Evidence  shows that some adults will deliberately evade practitioner interventions aimed at protecting a child. In many cases of child abuse and neglect, this is a clear and deliberate strategy adopted by one or more of the adults with responsibility for the care of a child. It is also the case that the nature of child protection work can result in parents/carers behaving in a negative and hostile way towards practitioners.
477. The terms 'non-engagement' and 'non-compliance' are used to describe a range of deliberate behaviour and attitudes, such as:
- failure to enable necessary contact (for example missing appointments) or refusing to allow access to the child or to the home;
- active non-compliance with the actions set out in the Child's Plan (or Child Protection Plan contained therin);
- disguised non-compliance, where the parent/carer appears to co-operate without actually carrying out actions or enabling them to be effective; and
- threats of violence or other intimidation towards practitioners.
478. Consideration needs to be given to determining which family member(s) is or are stopping engagement from taking place and why. For example, it may be the case that one partner is 'silencing' the other and that domestic abuse is a factor. Service users may find it easier to work with some practitioners than others. For example, young parents may agree to work with a health visitor/public health nurse but not a social worker.
479. When considering non-engagement, practitioners should check that the child protection concerns and necessary actions have been explained clearly, taking into account issues of language, culture and disability, so that parents or carers fully understand the concerns and the impact on themselves and their child.
480. If there are risk factors associated with the care of children, risk is likely to be increased where any of the responsible adults with caring responsibilities fail to engage or comply with child protection services.  Non-engagement and non-compliance, including disguised compliance, should be taken account of in information collection and assessment. Non-engagement and non-compliance may point to a need for compulsory or emergency measures. In what will often be challenging situations, staff may need access to additional or specialist advice to inform their assessments and plans.
481. There is a risk of 'drift' setting in before non-engagement is identified and action taken. If letters are ignored, or appointments not kept, weeks can pass without practitioner contact with the child. If parents/carers fail to undertake or support necessary actions, this should be monitored and the impact regularly evaluated. Good records must be kept, including contacts and whether they are successful or not, particularly during periods of high risk when children are not in nursery or school, for example, Christmas and summer holidays. Staff need to be clear what action should be taken when contact is not maintained. Where the child is subject to compulsory measures of supervision, the Reporter should be notified if agencies are unable to gain access to the child.
482. Core groups need to work effectively and collaboratively to deal with and counter non-engagement. Different agencies and practitioners will have different responsibilities. Effective multi-agency approaches provide flexibility so that, for example, responsibility for certain actions can be given to those practitioners or agencies that are most likely to achieve positive engagement. All services should be ready to take a flexible approach.
483. Given the nature of child protection work, non-engagement can sometimes involve direct hostility and threats or actual violence towards staff. All agencies should have protocols to deal with this, including practical measures to promote the safety of staff who have direct contact with families. In addition, staff should have the opportunity for debriefing after any incidents.
484. Families or carers who are directly hostile are very challenging to practitioners. However, services to children should not be withdrawn without putting other protective measures in place. Local child protection guidance should state that key safeguards and services should be maintained for children who are at risk of harm.
Key messages for practice
- Local protocols should provide details of specialist advice that can be sought when assessing concerns about non-compliance.
- Records should include details about contact, or lack of contact, with a family.
- Where the child is subject to compulsory measures of supervision, the Reporter should be notified if agencies are unable to gain access to the child.
- All agencies should have protocols for dealing with threats to staff.
Services should not be withdrawn unless other protective measures have been put in place for the child.
Children and young people experiencing or affected by mental health problems
485. Two separate but not unconnected issues should be considered in identifying, assessing and managing the risks faced by children affected by mental health problems:
- children and young people who are experiencing mental health problems themselves; and
- children and young people whose lives are affected by the mental illness or mental health problems of a parent/carer.
These two issues are dealt with in turn below.
Children and young people experiencing mental health problems
486. The emotional wellbeing of children and young people is just as important as their physical health. Most children grow up mentally healthy, but certain risk factors make some more likely to experience problems than others. Evidence also suggests that more children and young people have problems with their mental health today than 30 years ago. Traumatic events in themselves will not usually lead to mental health problems, but they may trigger problems in those children and young people whose mental health is not robust  .
487. Changes, such as moving home or changing school, can act as triggers. Teenagers often experience emotional turmoil as their minds and bodies change and develop. Some find it hard to cope and turn to alcohol or drugs.
488. For some young people, mental health problems will severely limit their capacity to participate actively in everyday life and will continue to affect them into adulthood. Some may go on to develop severe difficulties and display behaviour that challenges families and services, including personality disorders. A small number of children with mental health problems may pose risks to themselves and others. For some, their vulnerability, suggestibility and risk levels may be heightened as a result of their mental illness. For others, a need to control, coupled with lack of insight into, or regard for, others' feelings and needs may lead to them preying on the vulnerabilities of other children. It is imperative that services work closely together to address these issues and mitigate risks for these children and for others.
489. Separated children may be particularly vulnerable to mental health problems, particularly where they have experienced traumatic events. These can be compounded by feelings of alienation, loneliness, disorientation and 'survivor's guilt'. Many will have no awareness of the support available to them, making it difficult for them to access services.
490. Certain risk factors make some children and young people more likely to experience mental health problems than others. These include:
- having a long-term physical illness;
- having a parent or carer who has had mental health problems, problems with alcohol/drugs or a history of offending behaviour;
- experiencing the death of someone close to them;
- having parents who separate or divorce;
- having been severely bullied or physically or sexually abused;
- living in poverty or being homeless;
- having a learning disability;
- experiencing discrimination, perhaps because of their race, nationality, sexuality or religion;
- acting as a carer for a relative;
- having long-standing educational difficulties; and
- forming insecure attachments with their primary carer.
491. Children and young people can experience a range of mental health problems, from depression and anxiety through to psychosis. While most will recover, many are left with unresolved difficulties or undiagnosed illnesses that can follow them into adult life. Child protection is a crucial component of the service response to children and young people experiencing mental health problems. Local training and polices should reflect the need for awareness of these issues.
492. Children and young people experiencing such difficulties must have access to the right support and services, and know that their issues are being taken seriously. The same is true for parents and carers who may be bewildered or frightened by their child's behaviour or concerned that they are the cause of such behaviour.
493. CAMHS can provide an important resource in helping children and young people overcome the emotional and psychological effects of abuse and neglect. It is important that children and young people's mental health is not seen solely as the preserve of psychiatric services; the causes of mental ill-health are bound up with a range of environmental, social, educational and biological factors. Waiting to access these services should not be a justification for inactivity on the part of other agencies.
494. For more information, see the following.
- The SCIE Report, Think child, think parent, think family  identifies the need for a multi-agency approach with senior level commitment and includes recommendations for practice in relation to assessment, care planning /provision and review at practitioner, organisational and strategic level. The guidance covers England and Wales, but is nevertheless valuable for practitioners working in Scotland.
- The Mental Health of Children and Young People: A framework for promotion, prevention and care . 
- The COMPASS mental health team is dedicated to asylum seekers and refugees.
- Working with Children and Adults Who May be at Risk of Self-harm: Practice Guidance on Information Sharing, Protection and Confidentiality 
Key messages for practice
- Local training and child protection policies should highlight awareness of the factors affecting children and young people who experience mental health problems.
- Services need to work effectively together to understand the particular vulnerabilities and risks young people may experience or pose to others.
Children and young people affected by parental mental health problems
495. It is not inevitable that living with a parent/carer with mental health issues will have a detrimental impact on a child's development and many adults who experience mental health problems can parent effectively. However, there is evidence to suggest that many families in this situation are more vulnerable.
496. A number of features can contribute to the risk experienced by a child or young person living with a parent or carer who has mental health problems. These include:
- the parent/carer being unable to anticipate the needs of the child or put the needs of the child before their own;
- the child becoming involved in the parent/carer's delusional system or obsessional compulsive behaviour;
- the child becoming the focus for parental aggression or rejection;
- the child witnessing disturbing behaviour arising from the mental illness (often with little or no explanation);
- the child being separated from a mentally ill parent, for example because the latter is hospitalised; and
- the child taking on caring responsibilities which are inappropriate for his/her age.
497. There are also factors which may impact on parenting capacity including:
- maladaptive coping strategies or misuse of alcohol and/or drugs;
- lack of insight into the impact of the illness (on both the parent/carer and child); and
- poor engagement with services or non-compliance with treatment.
498. This list is not exhaustive. A number of other factors may need to be considered, including the attachment relationship and any instances of domestic abuse. Services involved with the parent/carer should consider the impact of these factors on the child's needs. Where concerns are identified, these should be shared with children's services.
499. The stigma associated with mental health problems means that many families are reluctant to access services because of a fear about what will happen next. Parents/carers may worry about being judged and that they will be deemed incapable of caring for their children. Many will therefore view asking for services or support as a high-risk strategy.
500. Where parents experience mental health problems, their needs may at times conflict with the needs of their child. Staff should bear in mind the importance of putting the child's interests first. Effective partnership working across services is needed to ensure that children are protected and their short and longer-term needs met appropriately. A holistic approach to assessment is fundamental to providing appropriate services to both parents/carers and children in families dealing with mental health problems. However, it needs to be recognised that this work is not limited to specialist services. Universal services must also be aware of the potential impact of adult mental illness on parenting capacity and, therefore, on children and young people. Practitioners must develop a sound knowledge of, and relationship with, other services to facilitate joint working and shared case management.
501. For more information, see the following.
- Scottish Good Practice Guidelines for Supporting Parents with Learning Disabilities is aimed at providing practical guidance to agencies that support people with learning disabilities who become parents.
- See Me is Scotland's national campaign to end stigma and discrimination associated with mental ill health.
- The National Patient Safety Agency Rapid response report on preventing harm to children from parents with mental needs makes a number of recommendations for practice. NHS boards in Scotland have been asked to consider and review their local arrangements in light of these recommendations.
Key messages for practice
- The child's needs should always be considered by services involved with the parent or carer. Where concerns are identified, these should be shared with children's services.
- Joint working across adult and child services is essential to ensuring children are protected and their needs met. Understanding of the differing roles should be promoted locally.
- Mental health practitioners working in hospitals have a duty to children affected by parental mental health (Mental Health (Care and Treatment) (Scotland) Act 2003
Children and young people who display harmful or problematic sexual behaviour
502. Harmful or problematic sexual behaviour in children and young people can be difficult to identify. It is not always easy to distinguish between what is abusive and/or inappropriate and what constitutes normal adolescent experimentation. Practitioners' ability to determine if a child's sexual behaviour is developmentally typical, inappropriate or abusive will be based on an understanding of what constitutes healthy sexual behaviour in childhood as well as issues of informed consent, power imbalance and exploitation.
503. In managing and reducing risk, the diversity of potential behaviour and motivation for such behaviour must be taken into account. Children and young people display a wide range of sexual behaviour in terms of: the nature of behaviour; degree of force; motivation; level of intent; level of sexual arousal; and age and gender of victims. Children and young people who have displayed harmful or problematic sexual behaviour may themselves have been or have been been abused or harmed in some way. Broader developmental issues must also be taken into account, including the age of the young person, their family and background, their intellectual capacities and stage of development. Young people with learning difficulties are a particularly vulnerable and often overlooked group who may need specific types of interventions.
504. Where abuse of a child or young person is reported to have been carried out by another child or young person, such behaviour should always be treated seriously and be subject to a discussion between relevant agencies that covers both the victim and the perpetrator. In all cases where a child or young person displays problematic sexual behaviour, immediate consideration should be given to whether action needs to be taken under child protection procedures, either in order to protect the victim or to tackle concerns about what has caused the child/young person to behave in such a way.
505. Identifying children and young people with problem sexual behaviour raises a number of dilemmas and issues for practitioners. When children and young people engage in such behaviour throughout childhood it can be developmentally and psychologically damaging to them as well as to others. They will normally require input from youth justice workers as well as health and education services. Other practitioners may also be involved, for example criminal justice workers (including MAPPA on some occasions). The interface with child protection processes, and occasionally with adult protection, also needs to be considered.
506. All Child Protection Committees should have clear guidance in place to support staff working in such situations and should ensure that appropriate training is provided, including for youth justice workers who will often be the practitioners undertaking the risk assessment and ongoing risk management tasks with the child or young person and their family. All cases need to be considered on an individual basis and an appropriate, proportionate and timely risk assessment should be carried out. A risk assessment should be carried out to determine whether the child or young person should remain within the family home and, if necessary, to inform the decision as to what might be an appropriate alternative placement. In the event that an alternative placement is needed, residential staff or foster carers need to be fully informed about the harmful or problematic sexual behaviour and a risk management plan drawn up to support the placement. In most instances, a referral should be made to the Children's Reporter so that the need for compulsory measures of supervision can be considered where these are not already in place.
507. The two key aims of addressing harmful sexual behaviour are risk management and risk reduction. They will be best achieved when children and young people learn to manage their sexual behaviour within the broader aim of learning to meet their needs in a socially acceptable and personally satisfying way.
508. Risk management covers actions taken to reduce opportunities for the harmful sexual behaviour to occur. A good risk management process should identify those children and young people who are most likely to commit further sexually abusive behaviour and who therefore need high levels of supervision. It should provide a robust mechanism through which concerns about a young person's harmful behaviour can be shared with relevant agencies so that appropriate risk management measures can be taken.
509. To manage risk effectively it is essential that:
- risk management is embedded in the systems around the child and promoted by those who supervise and monitor the child on a daily basis; and
- safety plans are drawn up in the relevant environments (for example, home, schools, communities and residential units).
For further information, see the section on Identifying and managing risk.
510. Risk reduction is a planned programme of work aimed at helping the child or young person develop appropriate skills and insights to reduce their need to engage in harmful sexual behaviour. In so doing, attention will naturally be paid to improving the child/young person's psychological wellbeing. This will mean:
- ensuring that the assessment process includes means of identifying the most relevant areas for intervention with each child/young person;
- viewing individual intervention as part of a systemic approach rather than as an isolated consideration;
- designing interventions that support long-term maintenance of therapeutic change by empowering the child and
- regularly evaluating the effectiveness of interventions.
511. Practitioners may find dealing with problematic or harmful sexual behaviour difficult and stressful. An agreed risk management framework, based on research and best practice and supported by training, will help. It should include shared definitions and language, make provision for joint ownership of risk reduction and management and promote a collaborative approach.
512. For more information, see the following.
- The Centre for Youth and Criminal Justice supports improvement in youth justice and aims to strengthen the creation, sharing and use of knowledge and expertise.
- The Handbook of Clinical Interventions with Young People who Sexually Abuse. 
- National Youth Justice Practice Guidance (2013)
- Framework for Risk Assessment Management and Evaluation ( FRAME) Planning for Local Authorities and partners (2011)
Key messages for practice
- In all cases where a child or young person presents problem sexual behaviour, immediate consideration should be given to whether action should be taken under child protection procedures, either to protect the victim or because there is concern about what has caused the child/young person to behave this way.
- Local guidance should highlight the interface between child protection and other public protection agendas.
- All Child Protection Committees should have clear guidance in place to support staff working in such situations and should ensure that appropriate training is provided.
- Local areas should have an agreed risk management framework based on research and best practice supported by training.
- In most instances, a referral should be made to the Children's Reporter to consider whether Compulsory Measures of Supervision are required.
Female genital mutilation
513. Female genital mutilation is a culture-specific abusive practice affecting some communities. It should always trigger child protection concerns. The legal definition of female genital mutilation is 'to excise, infibulate or otherwise mutilate the whole or any part of the labia majora, labia minora, prepuce of the clitoris, clitoris or vagina'.  It includes all procedures which involve the total or partial removal of the external female genital organs for non-medical reasons. There are four types of female genital mutilation ranging from a symbolic jab to the vagina to the partial or total removal of the external female genitalia. The Prohibition of Female Genital Mutilation (Scotland) Act 2005 makes it illegal to perform or arrange to have female genital mutilation carried out in Scotland or abroad. A sentence of 14 years' imprisonment can be imposed. There are also several options that should be considered to protect children and prevent female genital mutilation occurring including Child Protection Orders.
514. The procedure performed at various ages including babies and adolescents, but more commonly carried out on children aged between four and ten years. It is a deeply rooted cultural practice in certain African, Asian and Middle Eastern communities. Justifications for female genital mutilation may include:
- family honour;
- increased male sexual pleasure;
- hygiene; and
- fear of exclusion from communities.
515. A range of health problems, both immediate and long-term, are associated with the procedure, and in some cases can lead to death. Short-term effects can include haemorrhage and pain, shock and infection. Longer-term effects include bladder problems, menstrual and sexual difficulties and problems giving birth, and consideration should be given to this during pregnancy through anti-natal appointments. The emotional effects of female genital mutilation may include flashbacks, insomnia, anger, difficulties in adolescence, panic attacks and anxiety. In Western cultures, the young person may also be disturbed by Western opinions of a practice which they perceive as an intrinsic part of being female.
516. Female genital mutilation is usually done for strong cultural reasons and this must always be kept in mind, however, cultural considerations and sensitivities should not override the professional need to take action to protect a child. Action should be taken in close collaboration with other agencies. Care should be exercised in the use of interpreters and lay advisors from the same local community as the victim. Where possible, workers with knowledge of the culture involved may be able to assist but the welfare of the child must always be paramount. Female genital mutilation should always be seen as a cause of significant harm and normal child protection procedures should be invoked. Some distinctive factors will need consideration:
- female genital mutilation is usually a single event of physical abuse (albeit with very severe physical and mental consequences);
- there is a risk that a child or young person is likely to be sent abroad to have the procedure performed;
- where a child or young person within a family has been subjected to female genital mutilation, consideration needs to be given to other female siblings or close relatives who may also be at risk;
- a planning meeting should be arranged if the above conditions are met, where appropriate specialist health expertise should be sought;
- where other child protection concerns are present they should be part of the risk assessment process. They may include factors such as trafficking or forced marriage.
- legal advice should be obtained where appropriate; and
- appropriate interpreters who are totally independent of the child or young person's family should be used.
517. Local guidelines should be in place to ensure a co-ordinated response from all agencies and highlight the issue for all staff that may have contact with children who are at risk from female genital mutilation. As with other forms of child protection work this should be done as far as possible in partnership with parents/carers unless they themselves are the source of the risk.
518. For more information, see the following.
- Prohibition of Female Genital Mutilation (Scotland) Act 2005.
- FORWARD .
- List of UK hospitals and clinics offering specialist female genital mutilation services.
- UNICEF website for female genital mutilation
- HM Government (2011) Multi-agency Practice Guidelines: Female Genital Mutilation.
Key messages for practice
- Female genital mutilation should always be seen as a cause of significant harm and normal child protection procedures should be invoked.
- Where a child or young person within a family has already been subjected to female genital mutilation, consideration must be given to other female siblings or close relatives who may also be at risk.
- Local guidelines should be in place to ensure a co-ordinated response from all agencies and highlight the issue for all staff that may come into contact with children who are at risk from female genital mutilation.
Honour-based violence and forced marriage
519. Honour-based violence is a spectrum of criminal conduct with threats and abuse at one end and honour killing at the other. Such violence can occur when perpetrators believe that a relative/community member, who may be a child, has shamed the family and/or the community by breaking their honour code. The punishment may include assault, abduction, confinement, threats and murder.  The type of incidents that constitute a perceived transgression include:
- perceived inappropriate make-up or dress;
- having a boyfriend/girlfriend;
- forming an inter-faith relationship;
- kissing or intimacy in a public place;
- pregnancy outside marriage; and
- rejecting a forced marriage.
520. A forced marriage is defined as a marriage conducted without the full and free consent of both parties and where duress is a factor. Duress can include physical, psychological, financial, sexual and emotional pressure.  A clear distinction must be made between a forced marriage and an arranged marriage. An arranged marriage is one in which the families of both spouses are primarily responsible for choosing a marriage partner for their child or relative, but the final decision as to whether or not to accept the arrangement lies with the potential spouses. Both spouses give their full and free consent. The tradition of arranged marriage has operated successfully within many communities for generations.
521. In Scotland, a couple cannot be legally married unless both parties are at least 16 on the day of the wedding and are capable of understanding the nature of a marriage ceremony and of consenting to the marriage. Parental consent is not required.
522. The consequences of forced marriage can be devastating to the whole family, but especially to the young people affected. They may become estranged from their families and wider communities, lose out on educational opportunities or suffer domestic abuse. Rates of suicide and self-harm within forced marriages are high. Some of the potential indicators of honour-based violence and forced marriage are listed below.
- Absence and persistent absence from education.
- Request for extended leave of absence and failure to return from visits to country of origin.
- Decline in behaviour, engagement, performance or punctuality.
- Being withdrawn from school by those with parental responsibility.
- Being prevented from attending extra-curricular activities.
- Being prevented from going on to further/higher education.
- Attempted suicide.
- Eating disorders.
- Accompanied to doctors or clinics and prevented from speaking to health practitioner in confidence.
- Female genital mutilation.
- Reports of domestic abuse, harassment or breaches of the peace at the family home.
- Threats to kill and attempts to kill or harm.
- Truancy or persistent absence from school.
523. Cases of honour-based violence/forced marriage can involve complex and sensitive issues and care must be taken to make sure that interventions do not worsen the situation. For example, mediation and involving the family can increase the risks to a child or young person and should not be undertaken as a response to forced marriage or honour-based violence. Efforts should be made to ensure that families are not alerted to a concern that may result in them removing the child or young person from the country or placing them in further danger.
524. Concerns may be expressed by a child or young person themselves about going overseas. They may have been told that the purpose is to visit relatives or attend a wedding. On arrival, their documents, passports, money and mobile phones are often taken away from them. These concerns should be taken seriously, although practitioners must also be careful to avoid making assumptions. Such cases may initially be reported to the joint Home Office/Foreign and Commonwealth Office Forced Marriage Unit. There are also several options that should be considered to protect children including Child Protection Orders.
525. As with all cases of forced marriage, confidentiality and discretion are vitally important. It is not advisable to immediately contact an overseas organisation to make enquiries. If a family becomes aware that enquiries are being made, they may move the child or young person to another location or expedite the forced marriage.
526. When a child or young person has already been forced to marry, they will sometimes approach children's social work services or the police because they are concerned that they may need to act as a sponsor for their spouse's immigration to the UK. Practitioners should reassure the child or young person that they cannot be required to act as a sponsor until they are 21. Confronting the family may be extremely risky for the child or young person and result in their being put under increased pressure to support the visa application. These risks need to be discussed with the child or young person.
527. Cases of forced marriage may initially be reported to police or social work services as cases of domestic abuse. Spouses forced into marriage may suffer domestic abuse but feel unable to leave due to a lack of family support, economic pressures and other social circumstances. In some cases, they may fear having their own children taken away from them. In all cases, the social worker should discuss the range of options available to the child or young person and the possible consequences. A spouse who is the victim of a forced marriage can initiate nullity or divorce proceedings to end the marriage, but should be made aware that a religious divorce will not end the marriage under UK law. In all cases, the social worker should discuss the range of options available to the child or the young person including additional specialist support.
528. For more information, see the following.
- Forced marriage: A wrong not a right.
- Forced Marriage (Protection and Jurisdiction) (Scotland) Act 2011
- Forced Marriage Scotland
- Scottish Government (2011) Responding to Forced Marriage: Multiagency practice guidelines
- Safer Lives: Changed Lives: A shared approach to tackling violence against women in Scotland .
- HM Government (2009) Multi-agency practice guidelines: Handling cases of Forced Marriage .
Key messages for practice
- Cases of honour-based violence/forced marriage can involve complex and sensitive issues and care must be taken to ensure that interventions do not place the child or young person in further danger.
- Concerns about a young person being forced to go overseas in cases of honour-based violence or forced marriage may initially be reported to the joint Home Office/Foreign and Commonwealth Office Forced Marriage Unit.
- Local areas should consider what multi-agency arrangements can be put in place to ensure safe accommodation of a repatriated child or young person while legal remedies and action are considered.
Fabricated or induced illness
529. Fabricated or induced illness in children is not a common form of child abuse, but practitioners should nevertheless be able to understand its significance. Although it can affect children of any age, fabricated and induced illness is most commonly identified in younger children. Where concerns do exist about the fabrication or induction of illness in a child, practitioners must work together, considering all the available evidence, in order to reach an understanding of the reasons for the child's signs and symptoms of illnesses. A careful medical evaluation is always required to consider a range of possible diagnoses and a range of practitioners and disciplines will be required to assess and evaluate the child's needs and family history.
530. There are three main ways in which a parent/carer can fabricate or induce illness in a child. These are not mutually exclusive and include:
- fabrication of signs and symptoms, including fabricating the child's past medical history;
- fabrication of signs and symptoms and falsification of hospital charts, records and specimens of bodily fluids. This may also include falsification of letters and documents; and
- induction of illness by a variety of means.
531. For those children who are suffering, or at risk of suffering significant harm, joint working is essential both to protect the child and where necessary to take action, within the criminal justice and child protection systems, against the perpetrators of crimes against children. All agencies and practitioners should:
- be alert to potential indicators of illness being fabricated or induced in a child;
- be alert to the risk of harm that individual abusers, or potential abusers, may pose to children in whom illness is being fabricated or induced;
- share, and help to analyse, information so that an informed assessment can be made of the child's needs and circumstances;
- contribute to whatever actions (including the cessation of unnecessary medical tests and treatments) and services are required to safeguard and promote the child's welfare;
- regularly review the outcomes for the child against specific planned outcomes;
- work co-operatively with parents/carers unless to do so would place the child at increased risk of harm; and
- assist in providing relevant evidence in any criminal or civil proceedings, should this course of action be deemed necessary.
532. The majority of cases of fabricated or induced illness in children are confirmed in a hospital setting. The first task for the paediatrician is to find out whether a child's illness and individual symptoms and signs can be accounted for by natural causes. If not, the possibility that the illness has been fabricated or induced must be considered. CAMHS may be called in to look at the effects on the child and establish whether the parent/carer suffers from an underlying disorder. Police must investigate a possible crime. Social workers, in consultation with the Named Person, will co-ordinate the assessment of concerns about the child's wellbeing or the risk of harm and support to parents/carers during the assessment. Co-ordinated planning and assessment is essential in the investigation of fabricated or induced illness. Some methods, such as the use of covert video surveillance, should be discussed and agreed by all services involved before being implemented.
533. Fabrication of illness may not necessarily result in the child experiencing physical harm. However, there may still be concern about them suffering emotional harm and a thorough assessment of the child's needs should be carried out.
534. For more information, see the following.
- Safeguarding Children in whom Illness is Fabricated or Induced - Supplementary Guidance to Working Together to Safeguard Children.
- Fabricated or Induced Illness by Carers: A Practical Guide for Paediatricians.
Both documents, while providing useful guidance on how agencies should respond when concerns are raised about fabricated or induced illness, are written for practitioners in England and Wales and would need to be considered within a context of Scottish legislation and processes.
Key messages for practice
- A careful medical evaluation should consider all possible diagnoses. A range of practitioners and disciplines should be involved in assessing and evaluating the child's needs and the family's history.
- All agencies and practitioners should be alert to potential indicators of illness being fabricated or induced in a child and to the risk of harm posed to children.
- Co-ordinated planning and assessment is essential in the investigation of fabricated or induced illness. Methods such as the use of covert video surveillance should be discussed and agreed by all services involved.
Sudden unexpected death in infants and children
535. Only a small number of children die during infancy in Scotland. While the majority of such deaths are as a result of natural causes, physical defects or accidents, a small proportion are caused by neglect, violence, malicious administration of substances or by the careless use of drugs.
536. One of the implications of Section 2 of the Human Rights Act 1998 (Article 2 of the European Convention on Human Rights) is that public authorities have a responsibility to investigate the cause of a suspicious or unlawful death. This will help to support the grieving parents and relatives of the child and it will also enable medical services to understand the cause of death and, if necessary, formulate interventions to prevent future deaths.
537. There are occasions where the cause of death cannot be established. In such cases pathologists may classify the death as Unascertained, pending investigations or as a Sudden Unexplained Death in Infancy ( SUDI). Alternatively, they may choose to record the cause of death as Sudden Infant Death Syndrome (by definition a death due to natural causes which have not been determined).
538. The six guiding principles that underpin the work of practitioners dealing with any infant or child death investigations are:
- open mind/balanced approach;
- appropriate response to the circumstances;
- an inter-agency response;
- sharing of information; and
- preservation of evidence.
539. When the death of a child is reported to the police, a senior investigating officer should always be appointed to oversee the investigation, whether or not there are any obvious suspicious circumstances.
540. It is important that the police and hospital/medical staff establish a collaborative approach to any such investigation. While it is appreciated that police and health practitioners have specific duties to perform, they should be sensitive to the nature of the inquiry and respect each other's role. Relevant information-sharing between police and health staff is expected to ensure that a comprehensive picture of what is jointly known is established at the outset and can then be updated throughout the subsequent investigation.
541. During such an investigation, the Senior Investigating Officer should consider using suitably trained officers from the local policing division's Public Protection Unit for more specialist tasks during, such as:
- interviewing child witnesses;
- obtaining other background information from specialist police databases and other agency records; and
- liaising with the relevant local authority social work services to ensure their records are checked, including the Child Protection Register (and previous registrations if possible), and involve them in a strategy discussion, if appropriate.
542. In cases where the child and their family were either not resident in or had recently moved to the area where the death occurred, the Senior Investigating Officer will ensure that information is sought from local policing divisions/police forces and partner agencies in any area where the child is known to have recently resided.
543. It is recognised that investigations into the death of an infant/child will be particularly challenging. Nevertheless, it is essential that a full and thorough investigation takes place and that it is undertaken in a tactful, sensitive and sympathetic manner. Practitioners should collaborate to ensure that the fullest possible information is gathered and considered. Chief Officers need to ensure that staff have appropriate support during any investigations, particularly if the circumstances of the case lead to a significant case review.
544. For further information, see the following:
- Healthcare Improvement Scotland ( HIS) has progressed a programme of work on SUDI:
- SUDI Scotland Toolkit - For Professionals
Key messages for practice
- The police have a key role in the investigation of infant and child deaths. Their prime responsibility is to the child, as well as to existing siblings and any children who may be born into the family in future.
- Police and hospital/medical staff should ensure that all investigations are collaborative.
- Chief Officers must make staff receive appropriate support during any investigations, particularly if the circumstances of the case lead to a significant case review.