Primary Prevention: The Health Sector: An Essential Partner in

Preventing Child Abuse/Neglect and Enhancing Young Child Wellbeing

Bettina SchwethelmInter-Sectoral ConsultantCEECIS Regional Office

Outline

• Two case scenarios• Important considerations• Young child needs• Opportunities and challenges in the health

sector• Regional priorities for action

Two Hypothetical Cases

• Case 1• Case 2

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

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

Equity Gaps Begin Early and Widen Progressively

Lancet, 2011

Biological risks

Chronic under-nutritionIron and iodine deficiencyIUGRHIV infection

Psycho-social risks

Poor caregiver-child interaction

Maternal depressionInstitutional rearingExposure to violencePoor learning environment

Protective factors

Good nutritionResponsive & nurturing

parentingSafe and stimulating

environmentHealth care (prenatal,

maternity, new born, infant)

Adequate family income

Variables related to Neglect and AbuseChild Parent EnvironmentDemanding infantSpecial health care needsDevelopmental, emotional or behavioral disability PrematureUnplanned, unwanted

Poor parenting experience, abused, neglected…Stressors Low self esteemPoor impulse controlSubstance/alcohol abuse Young ageLow maternal education Mental illness/maternal depressionLack of knowledge about child rearing, develop-mentally inappropriate expectations of child

Lack of social support PovertyUnemploymentSingle parent familyLiving with non-biologically related maleIntimate partner violence

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 Healthhttp://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_131090.pdf)

Common Child Triggers

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

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/accompanies families 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 link with other community services • Active role in case management

Newborn - infant - child - adolescentPre-pregnancy Pregnancy

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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

– Home visitation for birth preparation and parenting education–Assessment of risk for A/R (social support network, financial, VAW…)– Referral of domestic violence

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

–Transport & accommodation of women from dispersed communities/pregnant adolescents with no support

– Healthy lifestyles– Promotion of delayed marriage/union–Community-based harm reduction– Peer counseling

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

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

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

REPRODUCTIVE– Post-abortion counseling to prevent unwanted pregnancies– Post-abortion assessment for abuse and neglect

REPRODUCTIVE HEALTH CARE–YFHS– Prevention of unwanted pregnancies, VAW/ girls, and PMTCT– Harm reduction services

Intersectoral Health sector coordination with Social Justice, Social Welfare, Education, and other sectors for the health and well- being of mothers and children

Birth

FAMILY AND COMMUNITY

Child-Friendly Health Care System : Integration of Development and Child Protection

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

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?

Opportunities

(In patient)

FACILITY BASEDChild birth, illness

Almost universal hospital deliveries, pediatric care

Opportunities:Significant contact, support

mother-child dyad, link with other sectors (social workers)

Promote good parenting

(Out patient)

FACILITY BASEDAnte- & postnatal visits, well and sick-child servicesOpportunities:Relatively regular, brief contactCan be used for information, guidance, screening, testing, and linking with other sectors and services

HOME BASEDPrenatal, post-partum, child/mother/father/familyBy community/patronage nurses, Roma Health Mediators,…

Opportunities:On family territory (all stressors visible)Non-stigmatizing, when universalSee caregiver-infant relationship unfoldContinuum of care within and across sectors

UNICEF Health Sector Activities to Promote Child Wellbeing

• Hospital level: Improve perinatal care (BFHI, quality of care during delivery, SW, communications and counseling withbirth registration, shelters)

• Hospital Level: Council of Europe Child- Friendly Hospital Policy

• PHC: Integrated Care for Child Development• Home visiting

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…)

Home Visiting – the Global Evidence

AlertLink/refer

IdentifyScreen

MonitorSupportCounselAdviseInform

UNIVERSALhealth 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

ENHANCED Services counselling, work with caregiver-

infant dyad

INTENSE services facilitated through multi-

disciplinary case management

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“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”

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

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)

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

Useful References• U.K. Health Child Programmehttp://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 Universityhttp://developingchild.harvard.edu/

Thanks You!