Noxious Neglect: Assessment

1. Noxious Neglect: Assessment VFPMS Neglect Seminar August 2015 Jo Tully & Bindu Bali

2. Outline • Clinical Assessment • NEGLECTING acronym • How should we write up cases? • Activity

3. 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)

4. Definitional issues Reflect 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

5. 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)

6. Neglect Failure 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

7. Emotional Maltreatment Emotional/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 competence Garbarino et al.(1986) defined 5 main behavioural forms: rejecting isolating terrorising ignoring corrupting Some class emotionally neglectful behaviours (rejecting, ignoring) as a form of neglect DANYA GLASER (persistent and harmful)

8. Other: witnessing of family violence A 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

9. Ecological Model of Neglect 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.

10. Current and Potential Harm Physical Injury Psychosocial Cognitive Emotional Development

11. Seriously…

12. Clinical Assessment History Examination (developmental) Opinion Recommendations

13. Clinical Assessment • History

14. 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”

15. Child and Parental characteristics CHILD FACTORS Age – older (PA) Sex – girls (SA) Race Difficult behaviour Disabilities Mental health problems LBW, prematurity PARENTAL FACTORS Domestic violence Substance abuse Mental health problems Stress Intellectual abilities, lack of education Age of mother (<26 PA) Single parent Poverty Corporal punishment (PA) Poor parenting Social isolation (neglect)

16. Identifying extreme risk Household violence Heavy parental use of drugs and alcohol Serious mental illness Child’s vulnerability

17. 3 Main Areas Harmful adult attributes Forms of adult ill treatment Indicators of child impairment PERSISTENT and HARMFUL

18. Clinical Assessment • Examination • Developmental Assessment

19. Clinical Assessment Opinion State clearly Risk Factors Is this Neglect / Emotional Harm – what type and WHY?

20. Clinical Assessment • Recommendations

21. 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

22. Services Table

23. 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

24. Targeted services Identify vulnerable children ‘Child Aware’ framework = epidemiology ACT = 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 +++

25. Targeted services Identify vulnerable children Identify mismatch between child’s needs & parental capacity to meet child’s needs Solutions Extra support & improve parental capacity? Reduce child’s needs / improve health / development? NO potential solution => call it for what it is! Systemic problems for children Incarcerated youth – youth justice, immigrants in detention Severe behaviour problems / mental health Intellectual disability, physical disability, ill Geographically isolated / ‘culturally isolated’

26. Reactive services After maltreatment & neglect Tertiary level / Specialist Forensic evaluation of injury -> report / court Strong 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 standards Accountability and outcomes monitored -> service modified

27. 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

28. Ok….?

29. NEGLECTING Acronym An checklist to help us get through the information Could be used to help structure information gathering or presentation

30. NEGLECTING Acronym Nurture Emotional Maltreatment Growth and Nutrition Learning and Development Environment at Home Clothing Teeth Imms / Infections / Infestations Normal Social Opportunities General Health

31. For all areas Assessment Potential Detrimental Outcomes Recommendations

32. Nurture

33. Emotional Maltreatment

34. Growth and Nutrition

35. Learning and Development

36. Environment at Home

37. Clothing

38. Teeth

39. Immunisation, Infestations and Infections

40. Normal Social Opportunities

41. General Health

42. Putting it all together…

43. Putting it all together Unbiased reporting Opinion Framework for medical reports What would the realistic ideal care be?

44. Activity Risk Factors Neglect? Emotional harm? How do we present this…?

45. 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

46. 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

47. Emotional Harm • Terrorisingbehaviours • Ignoring or denying emotional responsiveness • Corrupting or exploiting behaviours • Unreliable or inconsistent parenting

48. Maladaptive Behaviours Association with maladaptive behaviours Reported? Seen?

49. Presentation of Opinion Summary Risk Factors Can discuss child / caregiver vulnerabilities and strengths? DEFINITIONS of Neglect / Harm Evidence under each heading

50. Recomendations What can be done to improve this child’s life…..