Noxious Neglect: Assessment

VFPMS Neglect Seminar August 2015Jo 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

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 issuesReflect 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 co-occuring abuse or neglect

• ATSI children continue to be over-represented (136 vs 19.0 per 1,000)

• Infants most at risk (vulnerability)

NeglectFailure 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 MaltreatmentEmotional/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 competenceGarbarino et al.(1986) defined 5 main behavioural forms:

rejecting isolating terrorisingignoring corrupting

Some class emotionally neglectful behaviours (rejecting, ignoring) as a form of neglect DANYA GLASER (persistent and harmful)

Other: witnessing of family violenceA 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

• 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.

Ecological Model of Neglect

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 characteristicsCHILD FACTORSAge – older (PA)Sex – girls (SA)RaceDifficult behaviourDisabilitiesMental health problemsLBW, prematurity

PARENTAL FACTORSDomestic violenceSubstance abuseMental health problemsStressIntellectual abilities, lack of

educationAge of mother (<26 PA)Single parent PovertyCorporal punishment (PA)Poor parentingSocial 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 Factors2.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 = epidemiologyACT = 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 needsSolutions

Extra support & improve parental capacity?Reduce child’s needs / improve health / development?NO potential solution => call it for what it is!

Systemic problems for childrenIncarcerated youth – youth justice, immigrants in detentionSevere behaviour problems / mental health Intellectual disability, physical disability, illGeographically isolated / ‘culturally isolated’

Reactive services After maltreatment & neglect

Tertiary level / Specialist Forensic evaluation of injury -> report / courtStrong 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 standardsAccountability 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

Ok….?

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

NurtureAssessment Detrimental Outcomes Recommendations

Security of attachment to primary caregiver/sRelationship with carersChild’s wellbeing made a priority by caregiversIndicators of emotional neglect or unresponsiveness

Poor/insecure attachmentOver-familiarity with strangers, attention-seeking behavioursSeparation anxietyControlling behaviours – hostility, ODDLater psychopathology – depression, anxiety, disordered perception of self, dissociation

Child and family psychology/therapyFamily supports (eg CHILD FIRST)Parental education/support

Emotional MaltreatmentAssessment Detrimental Outcomes Recommendations

Evidence of exposure to;IPV and conflictParental drug/alcohol abuseParental mental illnessEmotionally abusive behaviours – rejecting, isolating, terrorising, corrupting, exploiting Moral guidance present to encourage good citizenshipEvidence of parentification of older children

Low self-esteem, depression, anxiety.Anger and poor impulse control, anti-social behaviour, delinquency, difficulty with inter-personal 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.

Growth and NutritionAssessment Detrimental Outcomes Recommendations

Diet – suitability, regular provision of food, food provided at school?Growth parameters and historyAdolescents – body imageClinical evidence nutritional deficienciesConsider nutritional bloods

FTT; Delayed puberty/low bone density/dentition problems/decreased growth potentialObesity;Social isolation, low self-esteem, bullyingHT, 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 DevelopmentAssessment Detrimental Outcomes Recommendations

Brigance assessmentD/W kinder or school teachers regarding;Attendance and punctualityHomeworkAchieving learning potentialAttention/behaviour at school/kinderParental engagement/cooperation

Educational underachievement and all associated social disadvantage of thisPoor behaviour and social isolation

Developmental F/UConsider further multi-disciplinary assessment (eg ASD, ADHD) or Ix/review for genetic, metabolic causes of DDEnrol in F/T childcare (beneficial for disadvantaged children)Educational psychology assessment if required

Environment at HomeAssessment Detrimental Outcomes Recommendations

Stability/TransienceEvidence of environmental neglectExposure to hazards/safety in the homeSupervision in the home (left alone/unsupervised)

Inability to form/maintain community relationships/supports and to be monitored (“slipping through the net”)Risk of injuryRisk of vermin bitesGI and other infectionsRisk of fire/flood/structural damage to property

Housing recommendations/supportEnrol in childcareRemoval from home until cleaned upOngoing commitment to improving environment necessaryParental mental health assessments - hoarding

ClothingAssessment Detrimental Outcomes Recommendations

CleanWell-fittingAppropriate for weather

Low self esteemSocial isolation, bullying

Parenting education/ supportAccessing financial supports in place

TeethAssessment Detrimental Outcomes Recommendations

Good dental hygieneRoutine teeth cleaning (owns a toothbrush)No caries, healthy gums and oral soft tissues

Halitosis, low self-esteem, dental abscess formation and seeding, poor appetite and nutrition, risk of long term CV disease

Dental review

Immunisation, Infestations and InfectionsAssessment Detrimental Outcomes Recommendations

Immunisations up to date – check ACIRLice, scabies, wormsGIT, ear, skin infections

Vaccine preventable infections and long-term effects of thesePoor sleep and behaviour (itching)Social isolation and bullyingS&L delay

Organise vaccination catch-up (RCH or MMC immunisation clinics)Treatment and effectiveness/compliance withAudiology r/v

Normal Social OpportunitiesAssessment Detrimental Outcomes Recommendations

Time to play/screen time appropriateSuitable toys providedEngages with peers (d/w school/kinder)Caregivers promote spiritual and cultural identity and sense of belonging

Developmental delayPoor social relationships and isolation

Increase time in childcareParenting education/support

General HealthAssessment Detrimental Outcomes Recommendations

Vision and hearingHospital OPA’s and FTA’sNumber of different Dr’s consultedSexual healthMental health (adolescents, suicide risk etc)Consider factitious illness by proxy

Poor educational achievement (sight and hearing, missed schooling)‘Medicalisation’ effects

Vision and hearing checksProscribe re attendance at scheduled OPA’sRefer for regular paed f/u if requiredRegister 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 FactorsCan discuss child / caregiver vulnerabilities and strengths?

DEFINITIONS of Neglect / HarmEvidence 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