Noxious Neglect Assessment VFPMS Neglect Seminar August 2015

Noxious Neglect: Assessment VFPMS Neglect Seminar August 2015 Jo Tully & Bindu Bali

Outline • Clinical Assessment • NEGLECTING acronym • How should we write up cases? • Activity

Child Abuse definitions (AIFS) Child abuse and neglect = Child maltreatment refers to any non-accidental behaviour by parents, caregivers, other adults or older adolescents that is outside the norms of conduct and entails a substantial risk of causing physical or emotional harm to a child or young person. Such behaviours may be intentional or unintentional and can include acts of omission (i. e. , neglect) and commission (i. e. , abuse)

Definitional issues Reflect cultural values and beliefs Parental behaviour that is appropriate at one developmental stage may be inappropriate at another Need to define potential perpetrators, so as not to inadvertently exclude particular behaviours and contexts Categorical definitions Either using abusive or neglectful adult behaviours or by the harm caused to the child as a result of such behaviours Although perpetrator intent to maltreat a child is often a useful indicator, there are instances where abuse or neglect can occur even though the perpetrator did not intend to commit it

Points to consider • Emotional abuse and neglect were the most common types of abuse / neglect. Also, the most likely types of cooccuring abuse or neglect • ATSI children continue to be overrepresented (136 vs 19. 0 per 1, 000) • Infants most at risk (vulnerability)

Neglect Failure by a parent or caregiver to provide a child (where they are in a position to do so) with the conditions that are culturally accepted as being essential for their physical and emotional development and wellbeing Different sub-categories include: • physical neglect – hygiene, clothing, housing, food, health care (subtype of supervisory neglect) • emotional neglect - lack of caregiver warmth, nurturance, encouragement and support • educational neglect • medical neglect

Emotional Maltreatment Emotional/psychological abuse/maltreatment Parent or caregiver's inappropriate verbal or symbolic acts toward a child and/or a pattern of failure over time to provide a child with adequate non-physical nurture and emotional availability Can damage a child's self-esteem or social competence Garbarino et al. (1986) defined 5 main behavioural forms: rejecting isolating terrorising ignoring corrupting Some class emotionally neglectful behaviours (rejecting, ignoring) as a form of neglect DANYA GLASER (persistent and harmful)

Other: witnessing of family violence A child being present (hearing or seeing) while a parent or sibling is subjected to physical abuse, sexual abuse or emotional maltreatment, or is visually exposed to the damage caused to persons or property by a family member's violent behaviour, (Higgins, 1998) Some classify this as a special form of emotional maltreatment Children can experience significant disruptions in their psychosocial wellbeing – maladaptive behaviours

Ecological Model of Neglect • Child’s basic needs are not met • Consider modifiable and non modifiable factors at the level of the child, caregiver, family, community and society. • Repetitive, chronic, subthreshold – greater risk of long term psychosocial, developmental and cognitive adverse effects than “critical” events.

Current and Potential Harm • Physical Injury • Psychosocial • Cognitive • Emotional Development

Seriously…

Clinical Assessment • History • Examination (developmental) • Opinion • Recommendations

Clinical Assessment • History

Sources of Information • Who reported what, when and where • Unbiased View • Time to gather the information • We can express our opinion after we have gathered the “facts”

Child and Parental characteristics CHILD FACTORS Age – older (PA) Sex – girls (SA) Race Difficult behaviour Disabilities Mental health problems LBW, prematurity PARENTAL FACTORS Domestic violence Substance abuse Mental health problems Stress Intellectual abilities, lack of education Age of mother (<26 PA) Single parent Poverty Corporal punishment (PA) Poor parenting Social isolation (neglect)

Identifying extreme risk • Household violence • Heavy parental use of drugs and alcohol • Serious mental illness • Child’s vulnerability

3 Main Areas • Harmful adult attributes • Forms of adult ill treatment • Indicators of child impairment • PERSISTENT and HARMFUL

Clinical Assessment • Examination • Developmental Assessment

Clinical Assessment • Opinion • State clearly 1. Risk Factors 2. Is this Neglect / Emotional Harm – what type and WHY?

Clinical Assessment • Recommendations

Think about • • • What does the child need? What has the child not obtained? What interventions have been tried? What has achieved / failed? What needs to be supplied to meet the childs needs

Services Table

Promote good parenting • collaborate with many, many others • start early • share goals & strategies to achieve • e. g. , secondary schools ‘health & relationships’ agenda – behaviour > biology • antenatal care / neonatal care • maternal & infant care – promote attachment • NB fathers (+ extended family) • mother-baby units • early childhood centres • PPP programs & similar • identify modifiable & remediable factors that might affect capacity to parent well

Targeted services Identify vulnerable children ‘Child Aware’ framework = epidemiology ACT = intervene to reduce risk (support & refer for treatment) • ACT • instead of Child FIRST • as well as Child FIRST • early intervention services for children with extra needs • health checks for children entering out-of-home-care • ATSI children • (parental) treatment programs • parenting support / financial support (+ Centrelink benefits) • involve a broad range of govt. & NGO agencies +++

Targeted services Identify vulnerable children Identify mismatch between child’s needs & parental capacity to meet child’s needs Solutions Extra support & improve parental capacity? Reduce child’s needs / improve health / development? NO potential solution => call it for what it is! Systemic problems for children Incarcerated youth – youth justice, immigrants in detention Severe behaviour problems / mental health Intellectual disability, physical disability, ill Geographically isolated / ‘culturally isolated’

Reactive services After maltreatment & neglect Tertiary level / Specialist Forensic evaluation of injury -> report / court Strong PREVENTION role • legal intervention (proof of assault / harm / neglect) • offenders off the street / no contact with child • protect other children, too Accurate diagnosis is paramount! Quality & safety – practice standards Accountability and outcomes monitored -> service modified

Reactive services After maltreatment & neglect Centres of excellence • hub for state-wide CAN health services • research & publication • education, teaching & training • set standards, set benchmarks • opinion re. cause of injury & RECOMMENDATIONS re. child’s future needs & how best to meet • partners in investigations of serious assaults Networks within Health system for advice Leadership

NEGLECTING Acronym • An checklist to help us get through the information • Could be used to help structure information gathering or presentation

NEGLECTING Acronym • • • Nurture Emotional Maltreatment Growth and Nutrition Learning and Development Environment at Home Clothing Teeth Imms / Infections / Infestations Normal Social Opportunities General Health

For all areas • Assessment • Potential Detrimental Outcomes • Recommendations

Nurture Assessment Detrimental Outcomes Recommendations Security of attachment to primary caregiver/s Relationship with carers Child’s wellbeing made a priority by caregivers Indicators of emotional neglect or unresponsiveness Poor/insecure attachment Over-familiarity with strangers, attentionseeking behaviours Separation anxiety Controlling behaviours – hostility, ODD Later psychopathology – depression, anxiety, disordered perception of self, dissociation Child and family psychology/therapy Family supports (eg CHILD FIRST) Parental education/support

Emotional Maltreatment Assessment Detrimental Outcomes Recommendations Evidence of exposure to; IPV and conflict Parental drug/alcohol abuse Parental mental illness Emotionally abusive behaviours – rejecting, isolating, terrorising, corrupting, exploiting Low self-esteem, depression, anxiety. Anger and poor impulse control, anti-social behaviour, delinquency, difficulty with interpersonal relationships. Eating disorders, substance abuse. Low academic achievement. Poor physical health. Parental drug/alcohol rehabilitation programs. Men’s behaviour change programs. Parental mental health assessment. Individualised child psychology/therapy. Parenting programs. Moral guidance present to encourage good citizenship Evidence of parentification of older children

Growth and Nutrition Assessment Detrimental Outcomes Recommendations Diet – suitability, regular provision of food, food provided at school? Growth parameters and history Adolescents – body image Clinical evidence nutritional deficiencies Consider nutritional bloods FTT; Delayed puberty/low bone density/dentition problems/decreased growth potential Obesity; Social isolation, low selfesteem, bullying HT, Fatty liver, type 2 DM, long term CV effects FTT – medical Ix as/if required plus paediatric F/U 3 monthly, dietician. Obesity –Dietician, weight clinic, bloods for fatty liver and lipid profile, exercise advice.

Learning and Development Assessment Detrimental Outcomes Recommendations Brigance assessment D/W kinder or school teachers regarding; Attendance and punctuality Homework Achieving learning potential Attention/behaviour at school/kinder Parental engagement/cooperation Educational underachievement and all associated social disadvantage of this Poor behaviour and social isolation Developmental F/U Consider further multidisciplinary assessment (eg ASD, ADHD) or Ix/review for genetic, metabolic causes of DD Enrol in F/T childcare (beneficial for disadvantaged children) Educational psychology assessment if required

Environment at Home Assessment Detrimental Outcomes Recommendations Stability/Transience Evidence of environmental neglect Exposure to hazards/safety in the home Supervision in the home (left alone/unsupervised) Inability to form/maintain community relationships/supports and to be monitored (“slipping through the net”) Risk of injury Risk of vermin bites GI and other infections Risk of fire/flood/structural damage to property Housing recommendations/suppo rt Enrol in childcare Removal from home until cleaned up Ongoing commitment to improving environment necessary Parental mental health assessments - hoarding

Clothing Assessment Detrimental Outcomes Recommendations Clean Well-fitting Appropriate for weather Low self esteem Social isolation, bullying Parenting education/ support Accessing financial supports in place

Teeth Assessment Detrimental Outcomes Recommendations Good dental hygiene Routine teeth cleaning (owns a toothbrush) No caries, healthy gums and oral soft tissues Halitosis, low self-esteem, Dental review dental abscess formation and seeding, poor appetite and nutrition, risk of long term CV disease

Immunisation, Infestations and Infections Assessment Detrimental Outcomes Recommendations Immunisations up to date – check ACIR Lice, scabies, worms GIT, ear, skin infections Vaccine preventable infections and long-term effects of these Poor sleep and behaviour (itching) Social isolation and bullying S&L delay Organise vaccination catch-up (RCH or MMC immunisation clinics) Treatment and effectiveness/compliance with Audiology r/v

Normal Social Opportunities Assessment Detrimental Outcomes Recommendations Time to play/screen time appropriate Suitable toys provided Engages with peers (d/w school/kinder) Caregivers promote spiritual and cultural identity and sense of belonging Developmental delay Poor social relationships and isolation Increase time in childcare Parenting education/support

General Health Assessment Detrimental Outcomes Recommendations Vision and hearing Hospital OPA’s and FTA’s Number of different Dr’s consulted Sexual health Mental health (adolescents, suicide risk etc) Consider factitious illness by proxy Poor educational achievement (sight and hearing, missed schooling) ‘Medicalisation’ effects Vision and hearing checks Proscribe re attendance at scheduled OPA’s Refer for regular paed f/u if required Register with local GP

Putting it all together…

Putting it all together • Unbiased reporting • Opinion • Framework for medical reports • What would the realistic ideal care be?

Activity Risk Factors Neglect? Emotional harm? How do we present this…?

Risk Factors • Exposure to intimate partner violence • Exposure to adult substance abuse • Exposure to maternal mental health issues • Possible exposure to illegal activity • Erratic and inconsistent caregiver arrangements

Neglect • Form of maltreatment that arises when a child’s basic needs are not met • Defined as failure to provide for the development of the child in all spheres – health / education / emotional development / nutrition / shelter and safe living conditions • In the context of the resources being reasonably available to the carer • High chance of causing harm to the child’s health or development. • This includes failure to supervise and protect from harm as much as is feasible

Emotional Harm • Terrorising behaviours • Ignoring or denying emotional responsiveness • Corrupting or exploiting behaviours • Unreliable or inconsistent parenting

Maladaptive Behaviours • Association with maladaptive behaviours • Reported? • Seen?

Presentation of Opinion Summary Risk Factors Can discuss child / caregiver vulnerabilities and strengths? DEFINITIONS of Neglect / Harm Evidence under each heading

Recomendations • What can be done to improve this child’s life…. .

Presentation of Recommendations • As detailed as possible • Consider what follow-up you can offer • Consider how CP could enforce any if this?

Presentation in Court • Unbiased • Not an advocate – an observer with an opinion about childrens’ wellbeing • Calm and collected

References • Challenges in the Evaluation of Child Neglect – APSAC 2008 • Danya Galser • Anne Smith and Jo Tully • www. aihw. org. au • www. aracy. org. au