Joanna Alexander, Shanti Raman, Terence Yoong,. Overview Consequence of early childhood adversity...
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The health, developmental and service needs of vulnerable children in South Western Sydney Identifying the best fit model of assessment and care Joanna Alexander, Shanti Raman, Terence Yoong,
Joanna Alexander, Shanti Raman, Terence Yoong,. Overview Consequence of early childhood adversity Community paediatric clinics for vulnerable children
Overview Consequence of early childhood adversity Community
paediatric clinics for vulnerable children Research from our
clinics Best model of assessment and pathways to care
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Early Childhood Adversities Child abuse and neglect Parental
substance abuse Parental mental illness/intellectual disability
Domestic/family violence/family dysfunction Placement into foster
care
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Early Childhood Adversity: effects Range of health,
developmental and behavioural concerns Affect health and wellbeing
through to adulthood Cumulative relationship of exposure and
outcome Intervening early can make a difference Interventions most
effective when commenced before significant health/ behavioural
issues emerge
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Substance Use 10% of children live in households where there is
parental substance abuse or dependence 4.3% of pregnant women 15-44
years illicit drug use (US survey) 75% of clients with drug and
alcohol problems also have a mental health concern
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Out of Home care in Australia 12-13,000 children enter care
every year 35, 895 children < 17 years in care in 2010
Indigenous children over-represented > 8 times New South Wales
largest number of children in care
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South Western Sydney (SWS) Most populous/ethnically diverse
health district: 20% of the NSW population 40% language other than
English spoken at home Significant urban Aboriginal population
Largest child population in NSW Second largest number of children
in OOHC in NSW Rapidly growing area with poor communities: Large
number of recent migrants High unemployment High proportion of
families on welfare
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Community Paediatric Clinics for vulnerable children The target
group are children for whom significant child protection concerns
have been identified Child has experienced abuse, domestic violence
or neglect Child is in out-of-home care Parental mental health
issues Parental substance misuse Parents with developmental
disability
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Community Paediatric Clinics - SWS KARI Clinic Comprehensive
health assessments for Aboriginal children entering foster care
Branches Clinic Targeting children with adverse perinatal risk/OOHC
Substance using parents Parents with a mental illness Parents with
intellectual delay Vulnerable Child Clinic Services children with
child protection concerns
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The KARI Clinic Commenced late 2003 partnership between KARI
Aboriginal Resources Inc (NGO) South Western Sydney Area Health
Service DoCS NSW Multidisciplinary Paediatrician, Psychologist, SP,
OT, PT Culturally appropriate service delivery Standardised
assessment tools used Monitoring and evaluation built into Clinic
Quarterly management meetings of key stakeholders Follow up visits
of clients
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Branches and Vulnerable Child Clinics Branches commenced 10
years ago Service children identified as at risk in perinatal
period Provide out of home care assessment Vulnerable child clinic
Acute assessment clinic for child identified as at risk
Comprehensive medical and psychosocial assessment Referrals from
health workers, case workers (CS or NGOs) Single appointment
Staffed by Community Paediatrician + Psychosocial worker
Standardised assessment tools used rarely
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Strengths-Based Model of Assessment Each child/ family has
strengths supporting development acting as protective factors to
reduce impact of adversity Aim to identify positive /negative
influences on development considering individual, family and
environmental factors Develop solutions which draw on the resources
and protective factors around the child Recommendations building on
existing strengths more likely to be effective in resolving any
issues
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Protective Factors Individual Factors Social skills, easy
temperament Problem solving skills Attachment to family IQ and
School achievement Family Factors Supportive, caring parents
Parental employment Family harmony Access to support networks
Community Factors Positive school climate Sense of belonging /
bonding Opportunities for success at school and recognition of
achievement Access to support networks, pro-social peer groups
Participation in community groups Strong cultural identity
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Risk Factors Individual Factors birth injury/disability/low
birth weight Insecure attachment Poor social skills Low IQ,
educational difficulties Family Factors Poor parental supervision
and discipline Parental substance abuse Family conflict and
domestic violence Social isolation / lack of support networks
Community Factors School failure Negative peer group influences
Bullying Poor attachment to school Neighbourhood violence and crime
Lack of support services Social or cultural discrimination
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Research Audits of Community paediatric clinics Three separate
studies looking at each clinic individually Different researchers
Data looking at clients attending clinics 2003 2009 Summary of the
data from the 3 studies
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Aims To describe the health, psychosocial and developmental
needs of children attending Community Paediatric clinics for
vulnerable children in SWS To describe the referral pathways and
functioning of these clinics To develop recommendations for a model
of assessment that best suits the needs of the children
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Methods Retrospective Analysis of clinical records Kari: First
100 patients attending (from 2003) Branches: 2006-2009 Vulnerable
child clinic: 2007-2008 Data collected Demographics Referral source
Risk exposure Health, developmental, behavioural concerns
Recommendations KARI - Progress
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Patient Profile DemographicsKARIBranchesVulnerable Child Total
Number9912498 Age (years)Mean4.73.954.6 GenderMale54%59%56%
Cultural Background Indigenous100%32%- NESB21%- Caucasian47%-
ReferralsWelfare100%73%79%
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Parental History Kari % (n=99) Branches % (n=124) Vulnerable
Child % (n=98) Substance use897365 Intellectual Delay-7- Mental
Health Disorder 234833 Mental health and drug concerns -37-
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Risk of Harm Concerns Kari % (n=99) Branches % (n=124)
Vulnerable Child % (n=98) Neglect1009257 Domestic Violence357257
Physical Abuse30-19 Sexual abuse19-2 OOHC1006357
Developmental and Behavioural Issues ConcernsKari % (n=99)
Branches % (n=124) Vulnerable Child % (n=98) Global Dev Delay272439
Speech Delay543645 Fine Motor332026 Gross Motor--19
Behavioural454852 Educational64 54
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Discussion Specialised community paediatric clinics established
in SWS for early identification and assessment of vulnerable
children Significant rates of physical health problems and
developmental concerns Encounter barriers in access to health
services including access to preventative health
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Discussion Patient Profile Mean age: 4.4 years Children
referred close to school age Missing out on early intervention
services The majority of children referred to the clinic by
Community Services (>73%) Already exposed to significant adverse
effects
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Discussion Almost a third of the children were indigenous 1% of
the total population of SWS is Indigenous Aboriginal children in
OOHC have a similar range of concerns as other children in care
Needs are exacerbated: immunisation rates Reflects disadvantage
faced by urban Aboriginal population Children of non-English
speaking backgrounds were under-represented May represent
difficulty in accessing services
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Discussion Close to half of children had behavioural concern
2/3 of had educational difficulties found to have developmental
delay Majority had more than one health problem 1/3 needed
specialist medical referral Over 90% of children were referred to
health and early intervention services Most of the health and
developmental problems identified were in the mild range
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Discussion No difference in these needs between children in
OOHC or parental care All have exposure to social adversities
irrespective of present home setting The range of health and
developmental problems identified in our cohort is similar to that
identified in other studies
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16% of children were doing well at first visit 34% of children
reviewed showed improvement Characteristics of children doing well
or improving No significant differences on demographics Stable care
Noted by clinicians to be positive, have pleasing temperament, good
at recruiting adults What about Strengths ? (KARI Clinic)
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Limitation Retrospective cross-sectional design with highly
selected clinic cases and lack of controls Largely welfare-based
referral source A prospective cohort study following up vulnerable
children proactively would be an ideal follow up study
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Conclusion Children exposed to adversity have special needs
Important to identify concerns early to facilitate intervention
Better links between maternity, child health, hospital, community
and welfare services are necessary Ideal to service community
clinics with professionals trained in psychosocial assessment
Strength based mode of care works well in identifying protective
factors and vulnerabilities Although the model of care is
important, good pathways to care between services are
invaluable
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Best-fit Model of Care An appropriately placed service pathway
to assessment and care to help identify at risk children early
Model ideally staffed by Paediatric and Psychosocial workers with
knowledge of early childhood adversities Pathway and model needs to
link well with intervention and multi-disciplinary services Pathway
needs to balance benefits of early identification versus
medicalisation of social problems
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