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5.9.6 Children with Disabilities and Complex Health Needs


For additional guidance, please see Safeguarding Disabled Children: Practice Guidance (issued by the DfE in July 2009).

The NSPCC has published webpages for professionals on how their organisations can protect deaf and disabled children from abuse and neglect.

In Rochdale, see also the Rochdale Interagency Protocol for Children with Complex/Continuing Health Care Needs.

In Salford, see also our Lead Professional Handbook which helps to clarify roles depending on the status of the child e.g. complex health cases.


This chapter was updated in December 2018. A link was added to the Salford Lead Professional Handbook. Minor amendments were made throughout in line with local practice.


  1. Introduction
  2. The Child
  3. The Safeguards
  4. Concerns
  5. Challenging Carers
  6. Communications

1. Introduction

The available UK evidence on the extent of abuse among children with disabilities suggests that they are at increased risk of abuse, and that the presence of multiple disabilities appears to increase the risk of both abuse and neglect (see Standards 5, 7 and 8 of the National Framework for Children, Young People and Maternity Services).

Research also indicates that, as well as being the least protected, children with disabilities are also the least consulted in routine assessments.

The Greater Manchester Local Safeguarding Children Partnership seek to address and challenge these practices by affirming their understanding of the issues facing children with disabilities and its commitment to removing the barriers that prevent children with disabilities from accessing their rights.

Where the words ‘child’ or ‘children’ are used in this document, the meaning is ‘child and young person’ or ‘children and young people’.

2. The Child

A child could be considered to have disabilities if he or she has significant problems with communication, comprehension, vision, hearing or physical functioning.

The Equality Act 2010 defines a person with a disability as someone who has a physical or mental impairment that has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities. The definition of disability encompasses a broader range of impairments than might be commonly assumed, including children on the autistic spectrum, those with Tourette’s syndrome and those with communication difficulties.

Children with complex health issues e.g. short gut syndrome are disabled and should be considered a Child In Need (Children Act 1989). See Thresholds for Children’s Social Care Procedure.

Many factors can make a child with disabilities more vulnerable to abuse than a non-disabled child of the same age. Safeguarding children with disabilities demands a greater awareness of their vulnerability, individuality and particular needs.

Children with disabilities may be especially vulnerable to abuse for a number of reasons. Some children with disabilities may:

  • Have fewer outside contacts than other children;
  • Receive intimate care possible from a number of carers, which may increase the risk of exposure to abusive behaviour and make it more difficult to set and maintain physical boundaries;
  • Have an impaired capacity to recognise, resist or avoid abuse;
  • Have communication difficulties that may make it difficult to tell others what is happening;
  • Be inhibited about complaining for fear of losing services;
  • Be less able to defend themselves and advocate for themselves;
  • Be more vulnerable than other children to abuse by their peers.

Additional factors may be:

  • The child's dependence on carers could result in the child having a problem in recognising what is abuse. The child may have little privacy, a poor body image or low self-esteem;
  • Carers and staff may lack the ability to communicate adequately with the child;
  • A lack of continuity in care leading to an increased risk that behavioural changes may go unnoticed;
  • Lack of access to 'keep safe' strategies available to others;
  • Children with disabilities living away from home in poorly managed settings are particularly vulnerable to over medication, poor feeding and toileting arrangements, issues around control of challenging behaviour, lack of stimulations and emotional support;
  • Parents'/carers' own needs and ways of coping may conflict with the needs of the child;
  • Professional sympathy for carers who are seen as ‘saints’;
  • Some adult abusers may target children with disabilities in the belief that they are less likely to be detected;
  • Signs and indicators can be inappropriately attributed to disability e.g. developmental delay seen as a symptom of the condition and not due to a lack of stimulation and encouragement; bruises attributed to reasonable restraint and changes in behaviour not seen as an indicator that something is wrong;
  • Children with disabilities are less likely to be consulted in matters affecting them and as a result may feel they have no choice about whether to accept or reject sexual advances.

It should be remembered that children with disabilities are children first and foremost, and have the same rights to protection as any other child. People caring for and working with children with disabilities need to be alert to the signs and symptoms of abuse.

Children with disabilities must be responded to as individuals with their own specific needs, feelings, thoughts and opinions.

In addition to the universal indicators of abuse/neglect listed in the Signs and Indicators of Abuse, the following abusive behaviours must be considered:

  • Force feeding;
  • Unjustified or excessive physical restraint;
  • Restriction of liberty including inappropriate locking of doors;
  • Rough handling;
  • Extreme behaviour modification including the deprivation of liquid, medication, food or clothing;
  • Misuse of medication, sedation, heavy tranquillisation;
  • Procedures which are not in the child’s best interests which may include inappropriate use of splints or excessive medical appointments due to the carer’s anxiety;
  • Deliberate failure to follow medically recommended regimes;
  • Non compliance with prescribed or recommended programmes or regimes e.g. toileting or physiotherapy;
  • Failure to address ill-fitting equipment e.g. callipers, sleep boards which may cause injury or pain, inappropriate splinting;
  • Misappropriation/misuse of a child's finances;
  • Emotional abuse e.g. taunting or teasing.
Where a child is unable to tell someone of the abuse they may convey anxiety or distress in some other way, e.g. changes in behaviour or in physical symptoms which carers and staff must be alert to.

3. The Safeguards

Safeguards for children with disabilities are essentially the same as all other children. Particular attention should be paid to promoting a high level of awareness of the risks of harm and to securing high standards of practice among professionals and practitioners. Attention should also be given to increasing the capacity of children and their families to safeguard themselves at all times. See Underlying Principles and Values Procedure, Assessing Capacity.

Measures should:

  • Make it common practice to enable children with disabilities to make their wishes and feelings known in respect of their care and treatment;
  • Ensure that children with disabilities receive appropriate personal, health and social education (including relationships and sex education);
  • Promote the capacity of all children with disabilities to know how to raise concerns and give them access to a range of adults with whom they can communicate. This could mean using interpreters and facilitators who are skilled in using the child’s preferred method of communication;
  • Recognise and utilise all possible sources of support and information which may be of benefit to the child including staff in schools such as support workers, friends and family members where appropriate;
  • Ensure that there is an explicit commitment to and understanding of the safety and welfare of children with disabilities among all providers of services used by children with disabilities;
  • Develop the safe support services that families want, and a culture of openness and joint working with parents and carers;
  • Provide guidelines and training for staff on: good practice in intimate care; working with children of the opposite sex; managing behaviour that challenges families and services; issues around consent to treatment; anti-bullying and inclusion strategies; sexuality and safe sexual behaviour among young people and monitoring and challenging placement arrangements for young people living away from home.

4. Concerns

Concerns about the welfare of a child with disabilities should be acted upon in the same way as any other child in accordance with the Making Referrals to Children's Social Care Procedure. The same thresholds for action apply.

Expertise and resources in both safeguarding and promoting the welfare of children and in working with disability have to be brought together to ensure that children with disabilities receive the same levels of protection from harm as other children. Therefore other specialist workers or teams may become involved in the investigative process for example Children with Disabilities Teams, in accordance with local arrangements.

Professionals working with complex child health cases and where there are barriers to open dialogue and challenge discuss this in safeguarding supervision and ensure concerns are shared with lead professional.

See Resolving Professional Differences/Escalation Policy.

5. Challenging Carers

Carers are relied upon (whether family, paid carers or volunteers) as a source of information about children with disabilities and to interpret and explain behaviour or symptoms.

Professional staff can potentially feel out of their depth in terms of knowledge of the impairment of a child with disabilities, where the familiar developmental milestones may not apply. Therefore, when assessing the risks to a child with disabilities, an additional/different approach is required because of their vulnerability.

Children with disabilities should not be left in situations where there is a high level of neglect or other forms of abuse, because a professional feels the parent, carer or service “is doing their best”. Sympathy for the family should not outweigh the child’s needs and wellbeing: the needs of the child are paramount at all times.

Carers will need to be challenged in the same way as carers of non-disabled children.

See Dealing with Persistent Non-Engagement with Services by Uncooperative Families Procedure.

6. Communications

There is likely to be a greater number of services and staff involved than for a non-disabled child. Therefore, throughout any Assessment process, including a Section 47 Enquiry, all service providers must ensure that they communicate clearly with the child with disabilities and the family and with one another. All steps must be taken to avoid confusion so that the welfare and protection of the child remains the focus. It is important from the offset to identify who is the lead professional.

Where there are communication impairments or learning difficulties, particular attention should be paid to the communications strengths of the child to ascertain the child’s perception of events and his or her wishes and feelings.

The Children’s Social Care Services and the Police should be aware of alternative communication systems and should know how to contact suitable interpreters and facilitators.

Agencies must not make assumptions about the inability of a child with disabilities to give credible evidence, or to withstand the rigours of the Court process.

Each child should be assessed carefully and supported where relevant to participate in the criminal justice system when this is in their interests. The process is set out in Achieving Best Evidence which includes comprehensive guidance on planning and conducting interviews with children and a specific section about interviewing children with disabilities.

Participation in planning for the child, to the extent that the child is able to participate, and in all forms of meetings such as Child Protection Conferences and Core Groups must be encouraged and facilitated and take into account any issues about access.

The full range of service providers and carers must be represented at all meetings.