Joanna Alexander, Shanti Raman, Terence Yoong,

1. 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,

2. Overview • Consequence of early childhood adversity • Community paediatric clinics for vulnerable children • Research from our clinics • Best model of assessment and pathways to care

3. Consequences of Early Childhood Adversity

4. Early Childhood Adversities • Child abuse and neglect • Parental substance abuse • Parental mental illness/intellectual disability • Domestic/family violence/family dysfunction • Placement into foster care

5. 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

6. 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

7. 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

8. Community Paediatric Clinics for vulnerable children in South Western Sydney

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. Research

18. 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

19. 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

20. 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

21. Patient Profile

22. Parental History

23. Risk of Harm Concerns

24. Health Issues

25. Developmental and Behavioural Issues

26. 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

27. 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

28. 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

29. Discussion • Close to half of children had behavioural concern • 2/3 of had educational difficulties • ¼ 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

30. 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

31. What about Strengths? (KARI Clinic) • 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

32. 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

33. 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

34. 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

35. References • Australian Institute of Health and Welfare. Child Protection Australia 2006-07. Child welfare series no 43. Cat no CWS 31 Canberra Australia AIHW. 2008 • Health Series Profile (2006) Our Population: Demographic Profile of Sdney South West Area Health Service. • Cashmore, J. (2011); The link between child maltreatment and adolescent offending: systems neglect of adolescents; Family Matters; Issue 89; pp 31-41; Australian Institute of Family Studies • Daniel, B & Wassell, S (2002); Assessing and Promoting Resilience in Vulnerable Children, Vol 1 - The Early Years; Jessica Kingsley Publishers; UK • Delima, J & Vimpani, G (2011); The neurobiological effects of childhood maltreatment; Family Matters; Issue 89; pp 42-52; Australian Institute of Family Studies • Dubowitz, H., Kim, J., Black, M., Weisbart, C., Semiatin, J. & Magder, L., (2011a);Identifying children at high risk for a child maltreatment report; Child Abuse & Neglect; No 35; pp 96-104; • Felitti, VJ., Anda, RF., Nordenberg, D., Williamson., DF., Spitz, AM., Edwards, V., Koss, MP. & Marks, JS. (1998), Relationship of childhood abuse and household dysfunction to may of the leading causes of death in adults: The Adverse Childhood Experience (ACE) study; American Journal of Preventative Medicine, Vol 14(4), pp354-364 • Burke NJ etal (2011). The impact of adverse childhood experiences on an urban population. Child abuse and neglect, 35, 408-413.

36. Thank you • ? Questions