Primary Prevention: The Health Sector: An Essential Partner in Preventing Child Abuse/Neglect and Enhancing Young Ch

1. Bettina Schwethelm Inter-SectoralConsultant CEECIS Regional Office Primary Prevention: The Health Sector: An Essential Partner in Preventing Child Abuse/Neglect and Enhancing Young Child Wellbeing

2. Outline • Two case scenarios • Important considerations • Young child needs • Opportunitiesand challenges in the health sector • Regional priorities for action

3. Two Hypothetical Cases • Case 1 • Case 2

4. Important Considerations • Less than 10% of abused children come in contact with child protection services • Domestic violence occurs more frequently in families of younger children (WHO, 2002) • Most abuse and related death in the earliest years • Caregivers most often involved • Impact severe, lifelong, and very costly • The health system is in frequent contact with almost all caregivers during the early years

5. Basic Building Blocks for “Normal” Development during the Early Years • A healthy start (from conception and before) • Health & good nutrition • Contingent responding by caregiver • Warm and nurturing caregiver • Secure attachment • Stimulating environment • Safe environment

6. Equity Gaps Begin Early and Widen Progressively • Biological risks • Chronic under-nutrition • Iron and iodine deficiency • IUGR • HIV infection • Psycho-social risks • Poor caregiver-child interaction • Maternal depression • Institutional rearing • Exposure to violence • Poor learning environment • Protective factors • Good nutrition • Responsive & nurturing parenting • Safe and stimulating environment • Health care (prenatal, maternity, new born, infant) • Adequate family income Lancet, 2011

7. Variables related to Neglect and Abuse

8. Did you know? Research suggests that: • For many parents, crying is the most distressing aspect of baby care. On average, up until the age of three months babies cry for two hours a day (more in the case of the 20% of infants who are diagnosed with colic). • Feeding can be a challenge: short-term feeding problems are common, and chronic feeding problems affect between a quarter and a third of all babies. • The tasks of caring for a baby add up to approximately 35–40 hours of work per week for the average couple household. • In the early months, most of the work is done by mothers; since few fathers take care of newborns on their own, the ‘skills gap’ between mothers and fathers often increases rapidly. (from: UK Department of Health http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_131090.pdf)

9. Common Child Triggers • “7 deadly sins” (colic, awaken at night, separation anxiety, normal exploratory behavior, normal negativism, normal poor appetite, toilet training resistance)

10. Why the Health Sector? • Is in most frequent contact with families • Can prevent many risk factors – primary prevention • Can draw on extensive evidence of what promotes lifelong wellbeing • Interacts/accompaniesfamilies during periods of vulnerability (pregnancy, birth, newborn period…) • Health workers’ advice trusted • Health workers can build relationship with families over time • More likely to reach excluded groups • Can linkwith other community services • Active role in case management

11. Child-Friendly Health Care System : Integration of Development and Child Protection PREGNANCY and CHILDBIRTH CARE • Birth preparedness • Risk assessment for abandonment and relinquishment • BFHI (Plus) • Kangaroo Care for LBW • Psychosocial support to women and families • Birth Registration • Referral and discharge information to PHC system • Screening/treatment for syphilis, PKU and iodine deficiency • REPRODUCTIVE • Post-abortion counseling to prevent unwanted pregnancies • Post-abortion assessment for abuse and neglect NEWBORN, CHILD, and ADOLESCENT CARE • Early detection and treatment of disabilities and other risk factors • Inter-disciplinary and cross-sectoral approach to deal with disabilities, psychosocial risks, and other conditions • Case-management approach with periodic review involving children in formal care and their families • Child and family-centered hospital care Clinical Outreach/outpatient • Transport & accommodation of women from dispersed communities/ • pregnant adolescents with no support • Healthy home care, supported by home visitation • Home and community safety • Healthy life styles, responsive feeding and positive parenting • Early childhood stimulation/education • Detection of abuse and neglect and coordination of multi-sectoral support at the household level • Prevention of substance abuse • Family- and community-based rehabilitation of children with special needs • Promotion of school completion and vocational education • Healthy lifestyles • Promotion of delayed marriage/union • Community-based harm reduction • Peer counseling • Home visitation for birth preparation and parenting education • Assessment of risk for A/R (social support network, financial, VAW…) • Referral of domestic violence Family/community NEWBORN, CHILD, and ADOLESCENT CARE • Parenting education & support • Rehabilitation support • Inter-disciplinary case management of children with disabilities and/or delays • Placement in the least-restrictive environment • Detection and treatment of abuse and neglect and referral • Monitoring of growth and nutrition status and treatment • Healthy life style education for children and youth in coordination with education sector • Injury prevention education • REPRODUCTIVE HEALTH CARE • YFHS • Prevention of unwanted pregnancies, VAW/ girls, and PMTCT • Harm reduction services ANTENATAL CARE • Birth planning and parenting education • Assessment of risk for abandonment/relinquish-ment (social networks, economic needs…) • Prevention of VAW • Comprehensive support for women with HIV POSTNATAL CARE • Support to BF, bonding, attachment • Early detection of parenting difficulties • Treatment of maternal depression • C4D & parenting education FAMILY AND COMMUNITY IntersectoralHealth sector coordination with Social Justice, Social Welfare, Education, and other sectors for the health and well- being of mothers and children Newborn - infant - child - adolescent Pre-pregnancy Pregnancy Birth

12. Common Barriers and Bottlenecks • Weak policy environment • Lack of clear system responsibilities and accountabilities • Provider accountability systems • Provider training in young child development and needs • Provider support systems • Information systems, M&E

13. Provider level • Focus on acute medical needs • Many myths, lack of correct information • Harsh discipline builds character • Infants and young children will forget pain • Newborns with problems are better cared for by professionals in a sterile or special environment • And fears and concerns • Interfering in the private sphere of the family • If a referral is made, what will happen in the other sector?

14. Opportunities

15. UNICEF Health Sector Activities to Promote Child Wellbeing • Hospital level: Improve perinatal care (BFHI, quality of care during delivery, SW, communications and counselingwithbirth registration, shelters) • Hospital Level: Council of Europe Child- Friendly Hospital Policy • PHC: Integrated Care for Child Development • Home visiting

16. Home Visiting – the GlobalEvidence HV can contribute to improved: Parental wellbeing (spaced pregnancies, maternal depression, substance abuse) Parenting skills and behaviours(breastfeeding/ responsive feeding, nurturing responsiveness to infant, less harsh discipline, stimulating and safer home environments…) Child outcomes(health, nutrition, and vaccination; infant sociability, exploration, and cognitive growth…)

17. Case Management A FEW Child Welfare Services • INTENSE • services facilitated through multi- disciplinary case management Alert Link/refer Identify Screen Monitor Support Counsel Advise Inform SOME • ENHANCED • Services counselling, work with caregiver-infant dyad Complexity of services ALL • UNIVERSAL • health promotion, healthy life styles, common childhood problems (feeding, discipline), detection of difficulties, delays and problems in caregiver-infant relationship, access to information, access to benefits

18. “Tool” for Identifying Caregivers At-Risk for Abuse/Neglect Difficult area for research • Relationship of trust • Observations over time • Interactions with caregivers • Community/cultural comparisons • Experience • Intuition • “Tools”

19. Sample Tool (NL, 2004) • Maternal isolation • Mother intimates that she is alone, has few contacts outside family, dissatisfied with contacts, not much support from partner, gloomy expectation…) • Maternal Psychological condition • Expects baby to give abundant love, mother speaks mainly about herself, in stress mother turns helpless, little self-confidence, felt not loved by parents • Maternal style of communication • HV has feeling that info about dealing with baby does not tally. Mother does not keep appointments, atmosphere of secrecy, feels uncomfortable in family, mother does not take advice, mother sets few limits for baby

20. Home Visiting Implementation Plan Assist countries in strengthening community outreach systems/home visiting (HV) to enable caregivers and families • Regional reference and expert groups on HV • Contribute to country assessments of HV systems • Develop policy guidance for a blended HV model • Special focus on reaching vulnerable and excluded groups • Build capacities of home visitors through evidence-based training package (focus: equity and inclusion) • Identify evidence-based tools and approaches • Promote regional exchange (Regional Conference, Ankara)

21. Role of Child Protection in HV • Shared understanding of early child development and long-term impact of ACEs • Shared understanding of the role of child rights and protection within health sector • Shared knowledge of both sectors and referral and collaboration pathways • Joint work on a seamless transition from health to multi-disciplinary case management

22. Useful References • U.K. Health Child Programme http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_107563 • The Pediatrician’s Role in Child Maltreatment Prevention (2010) http://pediatrics.aappublications.org/content/126/4/833.full.pdf+html • American Academy of Pediatrics (Jan 2012). Early childhood adversity, toxic stress, and the role of the pediatrician: Translating developmental science into lifelong health. http://pediatrics.aappublications.org/content/129/1/e224 • Browne, KD, Douglas, J., Hamilton-Giachritsis, C, & Hegarty, J. (2006). A community health approach to the assessment of infants and their parents: The C.A.R.E. Programme. Wiley-Blackwell. • Grietens, H. et al. (2004). A scale for home visiting nurses to identify risks of physical abuse and neglect among mothers with newborn infants. Child Abuse & Neglect, 28, 321-337. • Center on the Developing Child – Harvard University http://developingchild.harvard.edu/

23. Thanks You!