VFPMS Seminar 2017 Introduction to Child Abuse and Child Protection Why do we do what we do?

1. VFPMS Seminar 2017 Introduction toChild Abuse and Child Protection Why do we do what we do? Anne Smith, Medical Director Victorian Forensic Paediatric Medical Service

2. Content of this presentationBackground information

3. When and why should I think “child protection”? Harm has already occurred – to this child or sibling Psychosocial circumstances = risk of harm Poor parenting / Family Violence Child’s injury or condition raises concern about NAI Neglect – in any of its forms At risk / cumulative harm NB: Each consultation -> Opportunity to identify remediable and modifiable factors to reduce risk of harm

4. When and why think “forensic”? Physical Assault – allegation Suspected physical assault Assault is possible explanation (symptoms and signs) Neglect At risk / cumulative harm (report for Children’s Court of Vic) Sexual assault allegation Possible sexual abuse (broad scope) Poisoning Fabricated / Factitious illness Emotional Abuse & Exposure to Family Violence

5. Paediatricians’ Roles • Prevent • Protect • Suspect and Act when suspicious • Recognise Abuse and Neglect • Exclude the mimics • Raise the alarm • Respond (holistically) – as part of multidisciplinary team & Multiagency intervention • Reduce risk of harm • Remediate / Repair • Monitor progress

6. Primary Prevention of child abuse/neglectPromote good parenting & attachment 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

7. NICE guidance: When to suspect Child Maltreatment in under 18s National Institute of Clinical Excellence Evidence-based guidance July 2009 www.nice.org.uk • Physical, sexual and emotional abuse • Neglect • Fabricated or induced illness

8. Forensic Paediatric Medicine: Evaluates children for abuse, neglect and assault

9. What is clinical forensic medicine? “Clinical Forensic Medicine is that branch of medicine concerned with ‘the provision of forensic medical services primarily to the living and the collection and interpretation of information for the purposes of civil and criminal law, the judiciary and the police. It is that branch of clinical medicine that deals with both the medical and legal aspects of patient care”

10. Or as I like to say…. The branch of medicine serving those who have been, are, and might be affected by crimes against the person… and which also meets the needs of the legal system. • Victims • Suspects • Prisoners • Vulnerable groups…

11. But before we start, let me mentionSelf Care & Resilience Be Self aware Accept probability of “hurt” & develop strategies to manage it Employers + Self = responsible for care Resilience ~ One important person who thinks that you are GREAT! Optimism Locus of Control Topic to Explore later in the Seminar

12. What do the Colleges have to do with Child Protection? • Create Policy • Create Procedural guidelines • Consensus statements • Set Training requirements • Approve training pathways • Certify successful completion of training and award Fellowship • MOPS and CPD (recertification)

13. RACP child protection policy

14. Faculty of CFM RCPA CPD: + 10 hours pa mandated peer review from 2017

15. What do governments have to do with child protection? 1. Policy – Federal Government COAG • National Framework for Protecting Australia’s Children 2009-2020 • 3rd stage 2. Funding 3. Inquiries – Eg Institutional Responses to Child Sexual Abuse

16. National Framework for Protecting Australia’s Children 2009-2020 “Just as a health system is more than hospitals so a system for the protection of children is more than a statutory child protection service”

17. Commonwealth Govt National Framework for Protecting Australia’s Children 2009-2020 - “Protecting children is everyone’s business” (Council of Australian Governments) Outcome areas: • Children live in safe and supportive communities • Children and families access adequate support to promote safety and intervene early • Risk factors for child maltreatment are addressed • Children who have been maltreated receive the support and care they need for their safety and wellbeing • Indigenous children are supported and safe in their families and communities • Child sexual abuse is prevented and survivors receive adequate support National Child Protection Clearinghouse (research unit associated with AIFS)

18. Key messages Long term approach to ensuring the safety and wellbeing of Australia’s children – aims to deliver reduction in child abuse and neglect over time “Protecting Children in Everyone’s Business” • Children live in safe and supportive families / communities • Access adequate support to promote safety and intervene early • Support those children who have been abused / neglected and identify risk factors • Indigenous children supported in their own communities • Prevention of CSA and child exploitation

19. National CP Framework – what does this mean for us?

20. Commonwealth Govt funding Delivers universal support and services and targeted early intervention services to help families raise their children • Income & family support payments • Medicare, employment services, child & parenting support services, family relationship services and family law system, housing, disability services • Mental health, substance abuse, intensive parenting services, intensive employment assistance, and allowances for young people transitioning from out-of-home care to independent living

21. State Governments Each state and territory in Aust has its own approach. Funding, structures & programs differ Active agenda - social policy Differing Legislation re child protection Legislation re crimes Agencies for child protection / reporting criteria and processes Police and courts / Youth Justice Targeted support and intervention programs Interagency collaborations (silos)

22. Australian State Legislation protecting children Children and Young People Act 2008 (ACT) Children and Young Persons (Care and Protection) Act 1998 (NSW) Care and Protection of Children Act 2007 (NT) Child Protection Act 1999 (Qld) Children’s Protection Act 1993 (SA) Children, Young Persons and their Families Act 1997 (Tas) Children, Youth and Families Act 2005 (Vic) Children and Community Services Act 2004 (WA)

23. Targeted services to protect children Identify vulnerable children ‘Child Aware’ framework = epidemiological risk assessment = CRAF 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 +++

24. 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’

25. Reactive services After maltreatment & neglect Tertiary level prevention (prevent recurrence) Specialists – medical, forensic, police, child protection, courts Forensic evaluation of injury -> report / court Strong PREVENTION role • legal intervention (proof of assault / harm / neglect) • get 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

26. 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

27. What do Hospitals have to do with Child Protection? • Create policy and procedures • Clarify roles and responsibilities • Create clinical practice guidelines • Child Safe Standards (set by CCYP) • Committees • (eg Vulnerable Children’s Committees) • Morbidity and Mortality • Establish and support teams • Monitor workforce performance • Respond to complaints and critical incidents (VHIMS) • Report to authorities

28. www.rch.org.au/vfpms/

29. What is VFPMS? A forensic medical service for under 18 year olds Assessments and care for abused, assaulted & neglected children & young people. Monash Children’s & Royal Children’s Hospitals Melb Assistance to obtain a service in regional Vic (spokes vs hub) Funded by Dept of Health / DHHS. Face-to-face service 24/7. Criteria determine access / priority Appointments can be arranged by calling 1300 66 11 42

30. Hospitals “embraced” responsibility to better protect children in 1800s “Psychological / Social medicine” • Foundling hospitals • Charity hospitals • Academic / research activity • Environment fosters advancements in health and care • Children’s rights • Better health care vs neglect • Preventive health care • immunisation • Wellness • Bio-psycho-social origins of health and disease

31. Summary- General considerations Policy – comes from a variety of sources • Guidelines / Advice / local procedures Prevention • Public health approach to CAN Within the Health sector • Where are vulnerable children? • How do we recognise and respond? • How do we “manage” (do our jobs)? • How do we advocate?

32. Operation of the system for protecting children It is bigger than just the child protection statutory agency Includes health, education and welfare systems (+ housing, disability…) • + legal system and courts • Involves government, public services (and public servants) + NGOs • Involves the public! • Family, neighbours, community, everyone

33. Definitions Vary across regions Data collection “rigor” varies too… (fruit salad) Definitions rarely mutually exclusive Organisational culture influences “coding” Data are frequently not complete or accurate

34. Physical abuse Non-accidental use of physical force against a child that results in harm to the child +/- intent Some physical forces are considered abusive even if no injury results (eg shaking a baby) Includes shoving, hitting, slapping, shaking, throwing, punching, kicking biting, burning, strangling and poisoning Includes fabricated/induced illness by a parent or carer

35. 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 Pearl (1998) suggested 7 categories: ignoring, rejecting, isolating, terrorising, corrupting, verbally assaulting and over-pressuring. Some class emotionally neglectful behaviours (rejecting, ignoring) as a form of neglect. DANYA GLASER (NB parental behaviour that is persistent and harmful)

36. Observed behaviours – attributed to fear (impact of trauma) Maladaptive behaviours • Hypervigilance – anticipate threat • Inattentive – scanning environment • Memory – both incorporating new memories and recall of old ones • Learning difficulties, low levels of educational achievement • Angry and defensive / combative (anticipate conflict) easily-angered • Poor attachment, lack of trust (difficulty forming trusting relationships) • Emotionally isolated, “hard to get close to”

37. 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 (some consider this medical neglect) • emotional neglect - lack of caregiver warmth, nurturance, encouragement and support • educational neglect • environmental neglect

38. Sexual abuse Complicated - varies depending on the relationship between victim and offender • The involvement of a child in sexual activity that he or she does not fully comprehend, is unable to give informed consent to ... or that violate the laws or social taboos of society. Child sexual abuse is evidenced by this activity between a child and an adult or another child who by age or development is in a relationship of responsibility, trust or power, the activity being intended to gratify or satisfy the needs of the other person. (WHO, 1999, p. 15) Very general definition - "the use of a child for sexual gratification by an adult or significantly older child/adolescent" Tomison (1995) “Any act which exposes a child to, or involves a child in, sexual processes beyond his or her understanding or contrary to accepted community standards" Broadbent & Bentley (1997) Behaviours can include the fondling of genitals, masturbation, oral sex, vaginal or anal penetration by a penis, finger or any other object, fondling of breasts, voyeurism, exhibitionism and exposing the child to or involving the child in pornography

39. Other: eg., 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 - affects self-concept, world view, sense of the future, relationships and may result in fearfulness and maladaptive behaviours

40. What is Family Violence? DHHS definition • “…any violent, threatening, coercive or controlling behaviour • occurs in current / past family, domestic or intimate relationships. • This includes • physical injury • direct or indirect threats, • sexual assault, • emotional and psychological torment, • economic control, • damage to property, • social isolation • any behaviour which causes a person to live in fear’.

41. Witnessing violence by someone of any age towards someone of any age is harmful to children This includes exposure to siblings’ violent behaviour (rage / destruction of property) This includes violence directed by an adult or a child to towards a child’s siblings Includes physical punishment Includes cruel & controlling behaviour Includes emotionally abusive behaviours

42. Additional forms of child maltreatment • fetal abuse • bullying, or peer abuse • sibling abuse • witnessing community violence, war • institutional abuse • organised exploitation, • state-sanctioned abuse – neglect in orphanages, stolen generation, “forced” adoption • FGM, initiation rites eg Indigenous Australians

43. DATA What do we know? What don’t we know? Lies, damn lies and statistics…

44. FAQ: What is a reasonable belief? 1. A belief is a state of mind. 2. A reasonable belief is a belief based on reasonable grounds. 3. A belief is based on reasonable grounds when: i. all known considerations relevant to the formation of a belief are taken into account including matters of opinion, and ii. those known considerations are objectively assessed. A just and fair judgement that reasonable grounds exist in support of a belief can be made when all known considerations are taken into account and objectively assessed A reasonable belief requires a stronger level of knowledge than a mere suspicion. Generally it would involve direct knowledge or observation of the behaviour which gives rise to the notification, or, in the case of an employer, it could also involve a report from a reliable source or sources. Mere speculation, rumours, gossip or innuendo are not enough to form a reasonable belief. AHPRA

45. AIHW definitions Notification – contact made to child protection department regarding allegations of harm to a child Investigation – obtain more information to determine if notification is substantiated or not substantiated Substantiation – sufficient reason to believe that a child has been, is being or is likely to be abused, neglected or otherwise harmed

46. Australia: Child Protection DATA 2015-2016 42 per 1000 children AIHW Child Protection 2015-2016

50. Types of abuse substantiated across Australia 2014-15