Professor Kevin Browne Director of the Centre for Forensic and Family Psychology

Division of Psychiatry and Applied Psychology University of Nottingham Medical School

Kevin.browne@nottingham.ac.uk

Framework for the assessment of children and families (Department of Health, 2000)

Child Safeguarding & Promoting

Welfare

Child Developmental Needs

Identity and Registration Health (Mental and physical) Physical (Growth & Gross motor skills) Cognitive (Intellectual Skills & Exploration) Adaptive Behaviour (Fine motor skills) Social/Emotional (Interaction & Attachment) Language (vocalisation and proto-speech) Self care skills Education and Achievement

Parental Capacity to Provide

Acceptance, availability & accessibility Basic physical and psychological Care Stimulation and Sensitive Interaction Emotional care, warmth & cooperation Ensuring safety and avoiding danger Guidance, Education and Boundary setting Consistency and Stability Establishing Routines Promoting growth and development

Parenting Style Positive Positive model of self model of others

Available & co-operative Secure + +

Rejecting & controlling Avoidant + -

Neglecting, unreliable Ambivalent - +

Frightening & unavailable Disorganised - - Importance of the first few years of life for the quality of the parent-infant

relationship (i.e. secure attachment) for a range of outcomes. New relationships are developed based on the internal working model, defined from early relationships in childhood – Sroufe et al., (2005).

Attachment theory and the Internal working model (Bowlby, 1969; Ainsworth, 1978; Crittenden, 1988; Main 1989)

Early Intervention with Parents

Parents who are abusive or neglectful often exhibit deficits in: Personal adjustment Parenting responsiveness Parental knowledge Parental skills

They are less empathetic and sympathetic towards their children; often have negative interpretations of a child’s behaviour; Exaggerate the rate of problem behaviour and the child’s behaviour is seen as deliberate and intended to harm parent.

Levels of Prevention

Primary Prevention with Universal Services offered to the whole population on a routine basis to prevent adverse childhood experiences and promote child health, care and protection (Community Health Professionals).

Secondary Prevention with Targeted Services directed at ‘high risk groups’ and offered intervention to alleviate risk factors and potential harm (Community Health and Social Service Professionals).

.

Tertiary Prevention with Specialist Services for treatment of families and communities where parents/caregivers are not meeting the needs of their children. Intervention may occur only after “significant harm” has occurred (Community Health and Social Service Professionals).

The Build up of Health Services that Children and their Families Receive

Targeted Services - 7% of population

Universal Services

Specialist Services - 1/10 of targeted families

Primary Care Teams

Hospital Teams

To all

Interventions and services are based on the same principles as universal service, but involve more intensive personal contact: Hospital and home visits from nurses encourage the development of appropriate routines of child care; community-based, family-centred support (i.e. positive parenting programmes) help parents cope with the stress of a new child and the responsibilities this brings to them; and substance abuse treatment programmes help parents deal with their own problems before they have a chance to be taken out on their child(ren).

Targeted Interventions

The minority of families (5-7%) who have been identified as ‘high priority’ may be offered services and/or treatment before any maltreatment towards the child has occurred.

The aim of the interventions are: 1) to promote protective factors (to counterbalance static

risk factors) and 2) to change/ameliorate dynamic risk factors. High priority is determined by the identification of known

factors that place the child at high risk for maltreatment. The number and characteristics of the risk factors present will indicate the type of intervention and the level of support required.

Targeted Services and Secondary Prevention

Families in a Five Year Home Visitor Study in SE England

Abuse No Abuse Risk Factors (N=106) (N=14146) % % 30.2 1.6 *Violent Partners (RR = 23x) 31.1 3.1 *Indifferent Parents 48.1 6.9 *Single Parents 70.8 12.9 *Socio-Economic Problems 34.9 4.8 *Mental Illness 19.8 1.8 *Parent Abused as Child 21.7 6.9 *Infant Premature 12.3 3.2 *Separated at Birth 29.2 7.7 *Teenage Parent 27.4 6.2 *Step-Parent 16.0 7.5 *Less than 18months between births 2.8 1.1 Disabled Child Significant difference between abusing and non-abusing families

(P<O.05)

K. Browne & M. Herbert, Preventing Family Violence, Wiley, 1997. P120.

NFP Findings after 15 Years Follow Up in the USA (Olds et al, 1993, 1997)

Home visits by community nurses to young first-time mothers with socio-economic problems in the first two years of the child’s life

A randomised trial showed the following differences from families who were not visited: Mothers

Less family aid received 79% reduction in child maltreatment 44% reduction in maternal alcohol/drug difficulties 69% fewer arrests of mothers

Teenagers 54% fewer arrests of 15 year olds 58% fewer sexual partners 51% fewer days consuming alcohol 28% fewer cigarettes smoked

Home visits saved the US Government $180 per family when the cost of the home visits was compared to spending associated with disadvantaged families.

Referrals to the Appropriate Service

Once a family has been identified as at risk and in need of further support, the referral by those in contact with the child(ren) and family needs to be made as soon as possible and to the appropriate services: Health Visiting Service; postnatal depression group,

parental coping group, infant sleep problem group and individual counselling

Health Services; General Practitioner, paediatrician, child and family psychiatrist, community psychiatric nurse, clinical psychologist etc

Voluntary Groups; home start, mother and toddler community groups, family network groups and voluntary counselling

Social Services; nursery placements, re-housing, support for children with special needs, child protection social work, case conferences

Hospital Teams - Specialist Services

Primary Care Teams - Universal & Targeted Services

Police Units Social Service Teams

Multi-sector Referral Pathways

Tertiary Prevention

Prevention at this level is essential even with the implementation of proactive primary and secondary preventative measures, as there will always been some cases that will slip through the prevention net.

The specialist services at the tertiary level offer

protection, treatment and rehabilitation and prevention of maltreatment reoccurrence.

Many of the services incorporate interdisciplinary

and multi-sectoral teams/agencies and work on the ‘In the child’s best interest’ principle.

Does the Child have a condition associated with child abuse and neglect? IF; evidence of physical injury or unusual genital discharge, OR low weight and/or malnutrition, OR developmental delay and/or disability, OR not immunized OR delay in seeking health care. THEN CHECK FOR SIGNS OF CHILD ABUSE AND NEGLECT

OBSERVE AND CHECK Evidence of suspicious physical

condition/injury from likely child abuse (e.g., multiple bruises of different ages, unusual discharge, lesions or scars on genitals or anus, whip marks, immersion scalds and fractures in children less than one year).

Delay by parent/caregiver in seeking help for any injury with no valid reason.

Lack of explanation or story inconsistent with injury or genital discharge.

Inadequate physical care of child: illness ignored, not-immunized, poor condition of skin, teeth, hair and nails, child unsupervised.

Abnormal child behavior: sexualized behavior, aggressive hyperactivity, frozen hypervigelance, avoids visual contact with caregiver.

Abnormal parent/caregiver behavior: careless, punishing, angry, defensive, insensitive, over-anxious, low self-esteem, depressed.

Risky family circumstances: history of family violence, alcohol/drug addiction, mental illness, social isolation, child disability, neglect/abandonment.

•Evidence of suspicious physical condition/injury OR •Delay in seeking help OR •Lack of agreement between story and injury

CHILD

ABUSE AND NEGLECT

LIKELY

URGENT referral to hospital with specialist services. NOTIFY child protection team and/or social services

Classify signs of child abuse

•Inadequate physical care of child OR •Abnormal child behavior OR •Abnormal parent/caregiver behavior OR •Risky family circumstances

CHILD

ABUSE AND NEGLECT POSSIBLE

•Schedule a follow-up clinic or home visit within 10 days •Refer to community health and social services for prevention work •Counsel parents to reinforce positive parenting skills •Inform parents about the developing child and appropriate safety measures

•No signs consistent with the possibility of child abuse and neglect

CHILD ABUSE AND

NEGLECT NOT LIKELY

•Counsel parents to reinforce positive parenting skills (availability and attention, sensitive interaction, cooperation and consistency) •Inform parents about the developing child and appropriate safety measures

Integrated Management of Child Abuse and Neglect

NB: LISTEN TO WHAT THE CHILD SAYS Browne, K., Leth, I., Lynch, M., Mangiaterra, V. and Ostergren, M. (2002)

Is the Child Safe?

Involves the assessment of the home environment, including whether the perpetrator resides in the house with the child, and if so, if this person poses an immediate and future threat to the child’s safety.

If there is found to be an immediate threat to the

child’s safety, then the decision to a) remove the child from the home, or b) remove the individual posing the threat from the home, must be made based on what is in the best interest of the child.

This requires a fine balance between child

protection, family preservation and best interests of the child.

Placement Decisions

Abuse and /or Neglect

Is the child safe?

Placement Decision Child in home/

offender at home

Child removed/ offender at home

Child at home/ offender removed

T R E A T M E N T

S U P E R V I S I O N S U P E R V I S I O N

Placement Options Family rehabilitation can be achieved often by working with

the family in their home but sometimes short-term foster care is necessary where the foster carer acts as a role model to the parents.

Only when the parent is assessed as not responding to

intervention, or is unable to change within the developmental time frame of the child, should long-term alternatives (i.e. long term fostering or adoption) be considered.

Under no circumstances should young children (either with a

disability or not) be placed in residential care institutions (including the use of maternity/paediatric units as a social care facility) without a primary caregiver as this has been shown, similar to neglect, to have significantly detrimental effects on brain development (Glaser, 2000).

Protection/Out of Home Placements

Institution ?? No child under 3

should be in institutional care

International Adoption

Last resort Only in the best

interests of the child

Institutional Care Care in Community Family Support with Day care/therapeutic interventions

Care by Non-offending parent (in the absence of the offender) Kinship Care (grandparent/other relative)

Foster / therapeutic foster home

National Adoption - Only 4% are true orphans!

Numbers of Children in Care by Placement Type

05,000

10,00015,00020,00025,00030,00035,00040,00045,000

1995

1997

1999

2001

2003

2005

Year

Nu

mb

er o

f C

hil

dre

n

Foster placements

Living independently

Residential settings

Placed for adoption

Placement withparentsOtheraccommodation

in England

Primary reason for coming into care: children in care at 31 March 2010 in England

Reasons for Institutional Care in 2003

Reasons For Institutionalisation Of Children Under The Age Of Three - EU Member States

0% 4% 4%

69%

23%orphanabandoneddisabledabused/neglectedother

Reasons For Insitutionalisation Of Children Under The Age Of Three - other surveyed Countries*

6%

32%

23%

14%

25%orphanabandoneddisabledabused/neglectedother

Placement Decisions

2/24/2014

Keep balance between child protection and family preservation

Mothers need shelter as well as Children

United Nations General Assembly Report of the Human Rights Council on its 11th Session (A/HRC/11/37, Section 11/7, p.23) – Guidelines for the Alternative Care of

Children (2010) – Related Publications

Multi-Disciplinary Team Definition (MDT)

A group of professionals from various agencies and disciplines who work together as a team

in a coordinated and collaborative manner to ensure an effective response to parents with problems and reports of child abuse and neglects cases, and promote Child Maltreatment awareness and a community response.

Purpose of Multi-Disciplinary Teams

The purpose of a MDT is NOT to turn nurses and social workers into social police. It is to develop coordination and collaboration among professionals. A team brings together the expertise of each

discipline in the best interest of the child for case conferences and intervention/treatment plans. They act as gatekeepers to social services and public care.

MDT Support for Children and their Families with Disability

Disabled children and their families have needs that require interventions from many different services (e.g. health, education, social services, and housing and benefits agencies) -- cooperation amongst all these different agencies needs to be established.

Lack of parent support and high levels of

parental distress will affect the child’s well-being.

Functions of Multidisciplinary Teams

0 20 40 60 80

Investigation

Treatment Planning

Consultation/Advice

Social Planning

Education

Case Monitoring

Direct Service% of total

Kolbo & Strong, 1997

Multi-Disciplinary Team Functions Include, but are not limited to: Develop a protocol for investigating child abuse

cases and interviewing child victims Standardize investigative procedures Conduct joint investigation/case conferences Eliminate duplicative efforts Identify gaps in service and get better assess to all

resources in community Formalize a case review system Provide case review and coordination of services Provide data collection

Multidisciplinary Child Maltreatment Team Members

Statutory Designated Members Prosecution/District

Attorney Child Welfare Police Medical Mental Health Child Advocacy

Additional Members

Health department Domestic violence Substance abuse Education Youth Services Parents Others

Investigation: Child Perspective

Child Maltreatment is a complex problem and requires a coordinated approach No one professional has the knowledge or

expertise unless you are a legal, medical, mental health, and social work, and a police professionals Parallel investigations can cause secondary

trauma to an already traumatized child victim

Key Components of Child Protection Systems

Awareness/ Knowledge Legal System Services

Data

Media

Education

Advocacy

Courts

CAN Laws

Enforcement

Report/ Investigation

Tertiary/Treatment

Protection/ Placements

Prevention

Primary

Victims

Shelters Foster Care

Group Homes Adoption

? Institutions?

Custody Laws Reporting Laws

Mandatory services(system)

Secondary

Offenders (Adapted from Balachova, Bonner & Chaffin, 2000)

Primary prevention techniques are the most cost effective ways of preventing violence to women and children in the home. Should be considered as an alternative to reactive intervention.

Large overlap between violence to women and children in the home; many interventions (e.g. community health visiting) would appear to be beneficial in preventing and identifying both CAN and DV.

Information sharing across agencies can help to prevent and identify violence against women and children in the home.

Conclusion

Books that support the WHO/UNICEF training and information pack on the prevention of child abuse and neglect, Wiley 2006; 2002.