Upload
albert-hopkins
View
215
Download
3
Tags:
Embed Size (px)
Citation preview
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