National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people


Chapter 3. Child health
Preventing child maltreatment - Supporting families to optimise child safety and wellbeing
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Recommendations: Preventing child maltreatment – Supporting families to optimise child safety and wellbeing

Preventive intervention type

Target population

What should be done?

How often?

Level/ strength of evidence

References

Screening

All pregnant women

Assess risk of child maltreatment by exploring psychosocial risk factors such as alcohol and other drug use, personal history of family abuse and violence (Box 1; and refer to Chapter 16: Family abuse and violence), housing adequacy, engagement with and accessibility of antenatal care, and supportive factors including social and family supports

At first and subsequent antenatal visits (refer to Chapter 2: Antenatal care)

GPP

4, 18

All children

Conduct routine monitoring of developmental milestones (refer to Chapter 3: Child health, ‘Growth failure’)

Opportunistic and as part of a routine health assessment

GPP

18, 15

All families

Assess the risk of child maltreatment and the need for support (Box 1)

Offer referral to a culturally informed parenting program where services are available as a universal precaution in the prevention of child maltreatment (refer to ‘Resources’)

Opportunistic and as part of an annual health assessment

GPP

18, 28, 31, 36

 

Families identified as being at risk (Box 1)

Conduct a comprehensive psychosocial assessment, including mental health, trauma, alcohol and other drug use (refer to Chapter 4: The health of young people, and Chapter 17: Mental health), and assess for the availability of social supports with an emphasis on building trust and engagement with healthcare (refer to ‘Resources’)

Opportunistic

 

4, 11

Behavioural

Children with identified developmental delay, behavioural disturbance, harmful child–parent interactions

Recommend referral to community paediatrician for comprehensive health, behaviour and development assessment

Consider referral to other services depending on the specific developmental issue such as mental health, speech (refer to Chapter 3: Child health, ‘Growth failure’).

Complete GP Management Plan and Team Care Arrangements and/or GP Mental Health Treatment Plan as appropriate to facilitate access to MBS-funded specialist services

Opportunistic

GPP

18

Families identified as being at risk (Box 1)

Offer referral to Aboriginal and Torres Strait Islander–specific support services, including a home visiting program where available

Consider offering referral to a culturally informed parenting program if available (refer to ‘Resources’)

Opportunistic

III-2 GPP

28 ,15, 28

 

Children when there are serious concerns or evidence of maltreatment, including neglect

Children when there are serious concerns or evidence of maltreatment, including neglect Become familiar with health and support services for Aboriginal and Torres Strait Islander peoples in your area, particularly family support services Involve extended family members and/or culturally specific support services whenever possible

Opportunistic

GPP

34, 36, 37

Environmental

 

Health professionals should consider attending cultural competence training programs and become familiar with principles of traumainformed practice (refer to ‘Resources’)

 

GPP

36

Box 1. Family risk factors for child maltreatment

  • Significant parental mental health issues, trauma, and alcohol or other drug issues
  • History of family violence
  • Parental experience of child protection services
  • Homelessness or risk of homelessness
  • Parental incarceration
  • Social isolation


Background


Child maltreatment, or abuse, is defined as a failure to provide for the basic physical, emotional, health and/ or educational needs of a child, including the failure to protect a child from harm. Some definitions also include the witnessing of family violence.1,2 It is commonly categorised into four types:

  • physical abuse
  • sexual abuse
  • emotional abuse
  • neglect.

The development of children is profoundly shaped by the quality of relationship with their caregivers. Children are more likely to thrive within loving environments, being looked after by at least one attuned and responsive caregiver.3 This occurs primarily, but not necessarily exclusively, within the family context and means that the capability of parents to care for children is a key factor in the primary prevention of child maltreatment.4 There is substantial evidence of the negative impact on quality of life and lifelong health from child maltreatment and neglect,5–7 and of the importance of early intervention to positively influence life trajectory, long-term health and other outcomes.8–11

The true prevalence of child maltreatment is difficult to establish for several reasons:

  • Child maltreatment usually occurs in the context and dynamics of family relationships that are largely private and unobserved.
  • There is a wide range of understanding, much of which is culturally informed, of the needs of children and of attitudes towards behaviours of children. There is also a spectrum of maltreatment – obvious and hidden, severe and subtle. Consequently, there may not be agreement between individuals, health practitioners, government and other agencies about what constitutes harm, giving rise to different definitions, knowledge and understandings of impact, and therefore different responses.
  • Approaches to child protection vary across state and territory jurisdictions within Australia, and this creates inconsistencies in major domains such as legislative frameworks, identification of child maltreatment and service responses.
  • Child maltreatment may present as behavioural disturbance, developmental delay and/or other health or learning issues without being recognised as child maltreatment.
  • Child protection data only reflect statutory child protection service activity; that is, notifications, investigations, substantiations and formal legal orders including children in out-of-home care (OOHC).

In 2009, in recognition of increasing rates of child maltreatment nationally and the need for a more effective response, the Council of Australian Governments (COAG) committed to the development of the National Framework for Protecting Australia’s Children 2009–2020.12 As well as supporting a national approach, which in itself is a significant commitment, the framework identifies ‘shared responsibility’ of parents, communities, governments and business, and the need for accurate data to inform policy, service response and outcome measures. Since 2013, the Australian Institute of Health and Welfare (AIHW) has compiled data annually from state and territory jurisdictions as part of the Child Protection National Minimum Data Set (CP NMDS).13 The total number of cases of substantiated reports of harm, children on statutory orders and children in OOHC has steadily increased over recent years.14 In Victoria, for example, Aboriginal and Torres Strait Islander children in OOHC increased by 59% between 2013 and 2015.15 Aboriginal and Torres Strait Islander children are disproportionately represented in child protection and OOHC services, being approximately seven times more likely to be the subject of substantiated reports of harm, as shown in Table 1.14
 

Table 1. Number of children aged 0–17 years who were the subject of substantiated reports of harm or risk of harm, rates per 1000 children by Aboriginal and Torres Strait Islander status 2015–16

State/territory

Indigenous
(per 1000 children)

Non-Indigenous
(per 1000 children)

All children
(per 1000 children)

Rate ratio
Indigenous/non-
Indigenous

NSW

57.2

7.4

10.1

7.8

Vic

80.2

9.7

10.8

8.3

Qld

21.8

3.3

5.0

6.6

WA

48.3

4.3

7.1

11.3

SA

35.9

2.8

4.6

12.7

Tas

14.5

5.1

7.0

2.8

ACT

45.5

3.5

5.1

13.2

NT

49.6

6.8

24.8

7.3

Total

43.6

6.4

8.5

6.9

Reproduced from Child Family Community Australia. Child protection and Aboriginal and Torres Strait Islander children. CFCA Resource Sheet. Canberra: Australian Institute of Family Studies, 2017.  [Accessed 28 November 2017].


Neglect and emotional abuse are the commonest forms of child maltreatment.13 A comparison between Aboriginal and Torres Strait Islander and non-Indigenous children with reference to the type of child maltreatment is shown in Figure 1.14

Figure 1. Breakdown of primary substantiated maltreatment types in 2015–16, by percentage, Aboriginal and Torres Strait Islander and non-Indigenous children
Breakdown of primary substantiated maltreatment types in 2015–16
Reproduced from Child Family Community Australia. Child protection and Aboriginal and Torres Strait Islander children. CFCA Resource Sheet. Canberra: Australian Institute of Family Studies, 2017.  [Accessed 28 November 2017].

There are multiple factors contributing to the high rates of Aboriginal and Torres Strait Islander families represented in these data. Some may relate to the social determinants of family functioning, and others to the interface between Aboriginal and Torres Strait Islander families and child protection systems. In an Australian study that compared Aboriginal and non-Aboriginal children, parental factors that were associated with increased risk of child maltreatment were:

  • low socioeconomic status
  • parental hospital admissions related to mental health
  • substance misuse
  • assault.16

Aboriginal parents were more likely than non-Aboriginal parents to be subject to all of these factors. In a 2014–16 review of 980 Aboriginal and Torres Strait Islander children and young people in statutory care in Victoria,15 87% of children had been exposed to parental alcohol and/or other substance misuse, 88% had experienced significant family violence and almost 60% were affected by parental mental illness. Other major factors included housing instability and homelessness, parental experience of child protection in their own family of origin, and incarceration. In addition, the enquiry found that there were systemic failures in continuity, coordination and quality of healthcare, both primary healthcare and responses to complex health needs.15

 

Interventions


Many English-speaking countries, including Australia, have historically allocated the majority of child protection resources toward a tertiary response; that is, once child maltreatment has occurred. This approach has an emphasis on risk management and relies heavily on legal frameworks that can frequently be adversarial and divisive for families. Other countries respond primarily in ways that support families, are child-focused and aim to prevent harm.17 Prevention strategies aim to ‘reduce the underlying causes and risk factors and to strengthen the protective factors’18 and require commitment at all levels of government and across service sectors.12,19

There is growing recognition of the value of taking a public health approach to reduce both notifications to child protection authorities and statutory orders relating to the care of a child.17,18,20 The public health approach includes:

  • primary prevention – making health and education services universally available to all families, supporting families and strengthening parenting capabilities, and implementing public information campaigns
  • secondary prevention – screening, early detection and providing targeted interventions where risk of harm is identified
  • tertiary prevention – providing targeted interventions where actual harm is identified.21

Comprehensive primary healthcare

Access to comprehensive primary healthcare for all children and families supports better health and wellbeing outcomes.4,18,22,23 With respect to preventing child maltreatment, the World Health Organization (WHO) specifically identifies the importance of access to medical care, maternal and child health services, mental health services, pregnancy-related advice and care, identification of the risk of child maltreatment (Box 1), and other healthcare as needed.18 As well as recommending comprehensive primary healthcare for all children and families (universal services), the WHO identifies that interventions in the context of high risk and/or identified harm may be preventive of either further harm to a child and/or maltreatment of other children in a family, thus constituting important secondary and tertiary preventive functions.18

In Australia, in the absence of guidelines, national standards for OOHC were developed as a priority of the National Framework for Protecting Australia’s Children 2009–2020.12 These include standards around healthcare and the importance of ongoing primary healthcare for children who have experienced maltreatment.24 The standards specifically identify the need for:25

  • a preliminary health check on entry to OOHC
  • a comprehensive health and developmental assessment provided by a specialist service
  • ongoing monitoring and assessment of health and development.25

The key role for GPs at all levels of prevention is to provide comprehensive primary healthcare, to make appropriate referrals and to ensure follow up and continuity of care.

Specific attention needs to be paid to children at risk of and/or experiencing harm. These children are more likely to have complex health and development needs and less likely to receive both standard and specialised health services.7,14

Prevention through parenting and home visiting programs

The evidence base for primary prevention of child maltreatment is limited and there are few evidence-based guidelines about the primary prevention of child maltreatment. For example, the US Preventive Services Task Force (USPSTF) concludes there is insufficient evidence to make recommendations about interventions in the primary care setting for children who do not have signs and symptoms of maltreatment.26 The only relevant UK national guideline pertains to identification rather than prevention of child maltreatment.27

Few Australian studies have specifically evaluated the effectiveness of interventions in Aboriginal and Torres Strait Islander families and communities. Most of the existing literature is descriptive in nature, particularly documenting inequities and gaps, rather than testing interventions. In addition, there is an emphasis on Aboriginal and Torres Strait Islander child health research in rural and remote settings when in fact just over half of Aboriginal and Torres Strait Islander peoples live in metropolitan and inner regional areas.28 However, there is some evidence for the prevention of child maltreatment from home visiting programs and parenting programs.29 Some parenting programs have demonstrated benefit in either preventing child maltreatment in at-risk, non-maltreating families or reducing the incidence of maltreatment in families where maltreatment has occurred.30,31 In addition, there are other benefits described from parenting programs (eg Brighter Futures, Invest To Grow, Indigenous Triple P, Tuning in to Kids/Teens, Circle of Security), particularly improvement in parent–child interactions, management of difficult behaviours and parental confidence.28,32 The indications are that parenting programs may be of greater benefit as universal programs and are less effective for families identified at high risk of maltreatment.31,32

In the Australian context, home visiting programs vary between having a health focus, usually led by a nurse (eg Australian Nurse Family Partnership adapted from Nurse Family Partnership, Family Home Visiting), and an early-learning educational focus (eg HIPPY, Parents as Teachers).28 There are numerous descriptions of locally-adapted service models, particularly in the Aboriginal Community Controlled Health Service sector, that include outreach and home visiting in their design but these have not generally been rigorously evaluated. Other reported outcomes of these programs include greater uptake of healthcare, improved handling of challenging behaviours (HIPPY, Indigenous Triple P), greater knowledge about health and development (HIPPY, Family Home Visiting), and more positive parenting (HIPPY, Nurse Family Partnership, Circle of Security, Tuning in to Kids/Teens).10,32,33 Outcomes seem to be highly dependent on the duration of the programs, which vary from weeks to years, and specific program content and style, although a lack of rigorous methodology and evaluation makes these factors hard to reproduce.

The following elements have been identified as being the most effective in parenting support and home visiting programs:

  • use of cultural consultants in conjunction with professional parent education facilitators and home visitors
  • long-term rather than short-term programs (although the literature does not specify the optimal duration)
  • a focus on the needs of parents/carers and the child
  • a supportive approach that focuses on family strengths
  • use of structured early intervention program content while also responding flexibly to families.31


Culturally informed and trauma-informed services


Strategies for the development of culturally informed services include:34

  • specific investment in developing relationships between providers and patient/family/community to establish trust and engagement
  • service design that combines cultural and community knowledge, values and practice with technical/ clinical evidence-based components
  • strong presence of Aboriginal and Torres Strait Islander peoples in design and, whenever possible, delivery of services
  • family-centered, strengths-based, flexible approaches including outreach and home-visiting models of service design
  • services that take into account the complexity of social factors that impact on health and health service access, such as housing, legal issues, employment, income, health literacy and food security.

In addition, it is widely acknowledged that Aboriginal and Torres Strait Islander peoples have experienced multi-layered and complex grief, loss and trauma. These are historical and current, intergenerational, and both collective and personal. What is much less acknowledged, and often poorly understood, is how this may manifest as parental mental health issues, alcohol and other drug use, family violence and general health issues, which can impact profoundly and detrimentally on the capacity to parent effectively and to provide a safe and nurturing environment for children. It is in this context that child maltreatment, most commonly neglect and emotional abuse, may occur.

As a consequence, child maltreatment in general, and the involvement of child protection services in particular, is a highly sensitive issue for Aboriginal and Torres Strait Islander peoples. It cannot be considered separately from the impact and legacy of colonisation, particularly the forced removal of children, often under the guise of ‘welfare’ concerns, that gave rise to the Stolen Generations.35
Given that child maltreatment most commonly occurs in the context of parental trauma, there is a growing awareness of the value of trauma-informed care and services.36,37 The following underlying principles can guide healthcare providers to deliver trauma-informed care:

  •  acknowledging trauma and its effects on families
  • giving attention to ensuring safety and building trust
  • adopting collaborative approaches between providers and clients/patients
  • making integrated and linked health and social support services available.

Service models that are underpinned by these principles, that are culturally resonant and reflect an understanding of the impact of trauma, are likely to be much more acceptable to and accessed by Aboriginal and Torres Strait Islander peoples.1,31,38
Consistent with a strengths-based approach, it is also important to acknowledge the endurance and resilience of Aboriginal and Torres Strait Islander peoples and that most individuals and families are thriving.
 

Resources

Community directories

• Explore a community directory for social support services in your jurisdiction – an example of a search engine in Townsville

Parenting programs

Specific program information is available at the following sites, which may also be searched for local availability:

 

National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people

 





 
 
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