Sammi: Good evening everybody and welcome to this evening’s twilight online Child Protection and Wellbeing in General Practice webinar. My name is Samantha and I am your host for this evening. Before we make a start, I would like to make an Acknowledgement of Country. We recognise the traditional custodians of the land and sea on which we live and work and we pay our respects to elders past and present. So I would like to introduce our presenters for this evening. We are joined by our presenters, Dr Michael Fasher, and Rosemary Fitzgerald and our facilitator for this evening is Dr Tim Senior. So, Michael was a GP in Blacktown for 38 years and is the Chair of the RACGP’s Child and Young Person’s Health Specific Interest Network. Michael enjoys working with the College to improve the capacity of GPs to support families and raise healthy, well-adjusted young people. And Rosemary is the Director of the Child Wellbeing Unit for New South Wales Health. She has led the operation of New South Wales Health Child Wellbeing Unit since they were established in 2010. Rosemary is committed to building a better equipped and more integrated health sector so that families, children and young people about whom there is a safety or wellbeing concern, get the help they need sooner. Rosemary also holds a Bachelor of Social Work from the University of New South Wales. And finally, our presenter Tim for this evening. Tim is a GP at Tharawal Aboriginal Corporation in South Western Sydney. He is also an RACGP medical advisor for the National Faculty of Aboriginal and Torres Strait Islander Health, and Senior Lecturer in General Practice and Indigenous Health at UWS. Alrighty, I will hand over to Tim now to take us through our learning outcomes for this evening, and we will then hand over to Rosemary and Michael to go through the rest of this evening’s presentation.
Tim: Lovely. Thank you very much. Good evening to everyone. Thank you for joining us. Tonight is an evening where we welcome New South Wales GPs, but if you are a Queenslander as well, we also welcome you. Possibly the only place in New South Wales to do that tonight. These are the learning outcomes which essentially is education-speak for what we hope you will get out of the webinar tonight. So at the end of this online activity, you should be able to access the New South Wales Health Child Wellbeing Unit to seek advice when you have concerns about a child or a young person’s safety, welfare or wellbeing. You should be able to explain to patients the exceptions to confidentiality when you need to consult with others about a child or young person’s safety, welfare or wellbeing. And we are hoping that you will be able to report that you have increased competence in having a conversation with a parent about their child’s safety, welfare and wellbeing. And before the webinar, we sent out a link to this TED talk by Dr Nadine Bourke Harris, where she describes her experience, learning and putting into practice, adverse childhood experiences. I hope as many of you as possible had a chance to look at that video. It is very interesting and while it is presented in America, it is certainly relevant to the experiences that we see in Australia and we are going to start by talking a bit more about adverse childhood experiences which are responsible for a great deal of what we see in health problems. Michael, over to you.
Michael: Thanks, Tim and good evening everybody. Just to endorse Nadine Bourke Harris’s TED talk, for those who have not seen it, I strongly recommend it. It gets five stars for entertainment and five stars for education. The adverse – I remember exactly where I was when I first about the Adverse Child Experience, that it absolutely changed my life. In the late 1980s, Dr Felitti in California was running a weight management clinic and he noticed that many of the people who were doing quite well in losing weight were leaving the clinic. He studied about 200 or so of them and discovered that the majority had actually suffered a child, sexual abuse in childhood. So this led him to think that maybe gaining weight was protective for those who had been traumatised by sexual abuse in childhood. Indeed, one of his patients said to him when asked why are you putting weight back on, she said, Dr Felitti men are starting to look at me again and so I am putting weight back on. So this led Felitti then to survey over 17,000 patients signed up with Kaiser Permanente about their adverse childhood experience and as a result of that survey each individual could score between naught and ten as an ACE-score, an adverse child experience score. Now, for anybody who is not aware of this study, a quick introduction is on Wikipedia and I strongly recommend you have a look. Because what the study absolutely established is that there is a gradient between the quantity and quality of adverse child experience and almost any health and social outcome in mid-life and beyond that you want to count. So we have that strong correlation that is linear. The other thing that moves it towards a causal relationship is that we are increasingly understanding how stress hormones in early life affect the developing brain structure and chemistry, how these stress hormones also affect the immune system and the inflammation system in young children. So the ACE study is a really important study and I believe it points us towards our number one public health issue.
Tim: Rosemary is going to tell us a bit about what the Child Wellbeing Unit is, and what has changed for GPs.
Rosemary: Thank you, Tim and I really welcome the opportunity to come here this evening and talk about the role of CWU as we call it, and information exchange. And it is really good to see that 46% have contacted the CWU and obviously we would like feedback, so any that you would like to give at any time tonight or afterwards would be great to hear. And obviously that might lead to some questions this evening as well.
So, what has changed for GPs in recent years? In recognition of the important role GPs play in child protection and wellbeing, there was a change to legislation fairly recently. It was actually in 2016. That has enabled all registered medical practitioners in New South Wales and general practice nurses to contact the New South Wales Health Child Wellbeing Unit. Linked to that is a change at the same time in information exchange provisions about all doctors in New South Wales. So these two changes were obviously linked and they really have been in recognition of the fact that GPs have constraints in your knowledge about what is happening for children and families, what you might know about what your patients might be able to tell you about their circumstances, and your decision making about what to do next is so crucial that we need to provide assistance and assist as best we can.
Michael: So Rosemary, this is really a new system designed to be supportive.
Michael: For colleagues who might find themselves lost and wondering what the hell to do.
Rosemary: That is absolutely right. The Child Wellbeing Unit is New South Wales Health and we keep saying that because we are not FaCS, we are funded, we are New South Wales Health employees. We have been around since 2010 and initially we were only a service for New South Wales Health employees, but that has been expanded. We also take calls from Aboriginal medical services as well. And the expansion has as I said seen that we want to ensure that GPs are an integral part of the communications about families and that you are getting the advice that you might need as to what you might need to do. And the notion of a Child Wellbeing Unit is also saying that we do not, we want to act early. As Michael said from the ACE study, we want to make sure that we are being pro-active and as soon as some concerns are emerging, that you may know what steps you can take. Rather than leaving it till things might get potentially worse.
So, moving on to the next slide which is about what we actually do. I am a social worker. Most of the staff who will pick up the phone at the Child Wellbeing Unit are either social workers or psychologists. We have three of our, we actually have 20 assessment officers we call them who will answer the phone. We have three Aboriginal staff as part of that. So, if you ring and particularly might want to see if an Aboriginal staff member is available then that is a possibility as well.
So, we have a number of roles. We are legislated because reporting to us or contacting us, is part of your mandatory reporting responsibilities. If you ring us instead of the help line and it does require a report to Community Services, then having rung us that has fulfilled your responsibilities in the first instance, noting that often you ringing Community Services might be the next step.
So, the first part of our role is obviously helping to assess the level of harm and the safety, welfare and wellbeing of a child, or a young person, or an unborn child. 20% of the calls we get are about expectant parents, to look at what is the level of harm and what initial action you might need to take. We really do that by taking you through a series of questions that are based on a reporting guide that we use in New South Wales, to look at the most serious aspects of the harm first, and then really sort of summarising what action we might need to take.
Michael: Rosemary, may I ask how long people should put aside? What is the typical time for that conversation?
Rosemary: Look, on average it is about 15 minutes that initial call to our health workers who ring including GPs. When you ring, you might need to wait a couple of minutes on the phone to get through. We have on our message service, we have on our phone that you can leave a message and we will ring back normally the same business day. So I would leave say 20 minutes or so. I know time is precious, so it is when you have a break from your patients if you have the luxury of time to have lunch or afterwards. We are open business hours. We take calls business hours. After hours, leave a message. It is as simple as that and we will ring you back or try and get in touch with you the next as best we can the next day.
Michael: And that message would include the time that people are available.
Rosemary: Yes, so just letting us know your contact details which includes the best time to ring you back. It is also really good if you are leaving a message, if you give us the name of the child you are concerned about, their date of birth and where they live. That means we can look up our database before we ring you back to find out if we have any current information about them.
Michael: Could I just ask in there. We are going to come to 16A later, but this is a really important time to mention that doctors, clinicians who are worried about the safety of a foetus or a child can ring the unit, share information and are protected by legislation.
Rosemary: Absolutely. That is the significant change in how we work. We would not be able to do our job without those legal provisions. And it means, and we will get on to 16A, but it means we can have those conversations with the people that ring us. We can share the information that is relevant to a child’s safety or wellbeing, that is always the test, with people who have rung us.
Michael: But my colleagues might be sitting at home a bit anxious about giving away names and dates of birth and addresses to an organisation that they have not met. But our message to them is, that this is a secure service and that if you are concerned for the safety of a foetus or child then you are absolutely protected.
Rosemary: Similarly, when we get someone on the phone, we need to make sure we are talking to the right person, so that is why we ask for your ARPO registration number when you ring, so if we are concerned we can check you are who you say you are when you ring. So it works both ways.
Michael: So it is an important thing to bring up. If you are going to ring, make sure you have got your ARPO number handy.
Rosemary: Yes, yes, that is right. So we, just getting onto that sharing of information, we have our child wellbeing database is directly linked to the FaCS database, to the Police Child Wellbeing Unit and to the Education Child Wellbeing Unit. So when someone rings us about a child, we will always search and we will be able to find out whether FaCS are currently involved or have been involved in the past, whether the Police Child Wellbeing Unit has recorded any concerns that Police in New South Wales have had about the family. Same for the Education Child Wellbeing Unit. The Police Child Wellbeing Unit is linked to their COPS database.
Michael: Is it called COPS?
Rosemary: Yes, the Police database is actually called COPS. And we do not get a full look into that information. The idea is we will see whether there is a matter that they have been concerned about and we just see a little short description about what the concern might be. So, for example for Police we will see that two months ago, they were called out to a home because of a domestic violence incident where a child was involved. So that is the sort of information we see there. For education, when Principals ring their Child Wellbeing Unit for advice, we see a short description about what they might be concerned about there. With FaCS similarly, we just see that there have been reports made in the past. If there is, we get lots of calls about people wondering whether FaCS are currently involved and we can give you that information and we can tell you that yes, they have a case worker currently or not. We can obviously see if people have had other children removed in the past or there has been fairly serious FaCS action. So that really helps put some perspective on whether there is a lot of background information relating to that family on the system. And, getting on to 16A, it is all about safety, welfare and wellbeing so we are sharing information relevant to the current issue.
And then our other key role is obviously what should happen next. Should a report to FaCS occur. Are there local services we know about? What plans should be put in place for the family. So just on to the next slide, the sorts of issues that people ring us about, doctors ring us, social workers in health ring us, nurses ring us, mental health workers et cetera. The things up on the screen now, domestic violence is obviously a key concern when it is impacting on children. We do get calls about what you could also call I suppose medical neglect, that parents are not following medical advice or treatment for children. Lots of contacts about sexual abuse or sexually harmful behaviours that might be being exhibited. Parents just not coping. Not for medical reasons, but really when there are personal social issues happening at the same time. Obviously physical abuse when there are concerns about suspicious injuries and parents misusing drugs or alcohol or have unmanaged mental health. We are obviously not clinicians. We are social workers so in terms of, we cannot give you clinical advice, that is not our, in terms of physical injuries, that is when reports or some specialist advice might be needed by contacting your own professional contacts.
So, as I have said before, as I said a bit earlier, who else is involved in this family? That is a really common question we get asked and it is a really important one because often you are thinking, am I the only person that is concerned here? Significantly, more than half the calls we get, we do have records about the family that we can say might be relevant to the concerns you have. Just talking through what you are concerned about is, that we really focus on risk and harm and need, rather than on other components of what might be happening for that family. How can I get extra support? Who can I refer them too? And the big question is, should I report to FaCS or not? What our stats really show is that in most cases, what we get contacted about does not require report to community services, FaCS. About at the moment 15% to 20% of the calls do. We would be giving you that advice. The majority it is really about who else you might need to talk to, what supports might be needed or having that conversation with the family about your concern going forward. So, importantly one other point, obviously for the information that we might be giving back to you, not having the patient in the room with you when you ring us is really important because if we do have some information to give you, the sensitive nature of it and the safety of information we provide it is really to talk to you in the first instance.
Michael: So I think that is really important. So, we need to make sure that the patient and the family is not with us when we ring you.
Rosemary: Yes. On the bottom of that screen, obviously the urgent, serious harm that you are concerned about you can ring FaCS straight away. That is obviously, we are dealing with should I report this or not type questions, and what else do I need to know, rather than clear reportable concerns that you have that you should be talking directly to them about.
Sammi: We are just going to show a quick video before we carry on the Child Wellbeing Unit, so we will get that started now.
Video: Our role is ultimately to help you respond as soon as possible to any identified concerns for a child or young person. When you call us, “the Child Wellbeing Unit, this is Monique speaking”, we will have a conversation and I will record your concerns. I can access a database that actually links in with Family and Community Services. That database provides a lot of information as to any child protection involvement in the family, any child protection alerts, any reports made by the Police and the Department of Education, as well as any reports made by health workers. And then we can look at strategies and ways to work with the families, “I am just going to have a look on our database”. Prior to calling us, definitely take the health records. They can provide you with a whole lot of information as to who is involved with the family. The health records for the parents, the child and the siblings. And also that can give you information about services to contact or people who may have been involved in the family and apply the MRG prior to calling us. And that helps us to draw on a larger base to appraise the risk to that child that you are ringing about. Health workers are really good at identifying risk and they are also able to articulate the impact on the child. However, it is not always black and white. Health workers are not aware fully of what is happening, it is often fragmented, there are pieces of information hidden from various agencies, so that is where we come in. We draw the information together. By looking at the clinical indicators and the risk factors for the family, we strongly advocate on behalf of health workers to assist you in making reports to FaCS where there is a risk of significant harm to a child.
Tim: So it might be helpful to use a couple of case studies to nut out some of the complexities of what we do in real life situations. And so this case is Anton and Donna, and as we are going through, we will go through the first slide and I just want you to put into your chat box, what issues you are wanting to know more about with this. What are your initial thoughts, just on this first slide first of all and we will go through the case over the next few slides. So Anton is an 11-year-old child with a body mass index in the obese range who has come to see you, and you are their regular GP, prompted by bullying incidents at school with concerns about his weight gain. His mother Donna, has struggled with her weight in the past. His father has a normal BMI. Anton attends the appointment with his mother. After seeing Anton, we will hear a bit more about what Donna tells us. But what thoughts are going through your mind at the moment about issues that may be going on for Anton and Donna? Just put that in the chat box.
And I am just looking at those to see if they come through. There we go. So, getting responses. Possible domestic violence. Mother’s understanding of healthy eating. Trigger for weight gain. Psychological wellbeing of the child. Possible sexual abuse. Obesity. Is he safe at school? Eating disorders history in mum and child. Underlying medical problem. So, coping ability of the family. History of the timeline. Confidence. What the family situation is. Find out more about the bullying and perceptions of eating. So Michael, any comments or thoughts on your initial thoughts of the first slide there?
Michael: Tim, I think it is encouraging that the audience is taking seriously the view that, pardon me, that the biological enquiry and the psychosocial enquiry should proceed in parallel. No one has just seized on the obesity and is pursuing that to the end. Everybody is starting to think about, what is the relevance of the context in which Anton is living his life. And that is marvellously encouraging.
Tim: So, let us find out what Donna tells us if we move on to the next slide.
Michael: Just before we move on. Another point is that of course what we are seeing here laid out before us is a complete history and that is not how it works in real life. We know that the GP who collected this history would have had to spend several consultations to understand the context and what is going on, and a marvellous thing to point out is that he, he or she, has made sure that for the next consultation, the mother alone is there, and Anton does not have to sit through a consultation listening to his mother telling the doctor about what is terrible at home.
Simon: Yes, absolutely, that is a really important point. So Donna tells us that Anton is miserable at home and Donna cannot stop him eating excessively. Donna is struggling to follow your previous advice about Anton’s diet and exercise. Anthon’s father, Todd is also not following the advice. Todd works shift hours. He blames Donna for Anton’s weight problems and expects her to manage this. Anton gets very angry and swears at Donna whenever she tries to talk to him about his eating. He says it is all her fault. Anthon says he is bullied at school because of his weight. The school has contacted Donna about Anton being disruptive and aggressive towards other students.
And on the next slide we get a bit more information from Donna as well.
Michael: Can we ask people what they think about that, Tim?
Tim: Yes, we certainly can. So if we move back one slide again. Any thoughts on that for people in the text box about what they think about that and what the approach might be at this point?
So somebody has answered the impact of bullying. A comment that Anton is modelling Todd’s behaviour. The father is not active. There are disruptive family conditions and psychological issues with Anton. Possibility of underlying depression in both Donna and Anton. Importance of a collateral history perhaps from the teacher. Raising the question about domestic violence in the family or relationship problems between the parents. What the father’s personality is like and what his parenting is like. Whether there is any eating disorders and a poorer self-esteem for all the family. Donna being bullied by both her husband and the son who is himself is being bullied at school. And involvement of the school counsellor possibly as well. Thank you very much.
Michael: So Tim, I think it is marvellous that the audience are again very curious about the impact of the social context on Anton and indeed Donna’s life. For me, we have moved now right away from obesity and an eating problem. Though that remains on the back burner. But we are never going to deal with Anton’s weight problem whilst we have this complex morass of social issues at home. So for me, the weight problem is going to be dealt with down the track. We have immediate problems of the context in which he is living.
Tim: Absolutely. So Donna gives us more information. Anton’s father Todd, ceased seeing a psychologist and stopped taking medication for obsessive compulsive disorder three years ago. Todd has hit her in the past, last incident was one month ago. And she describes him as having a short fuse. Donna worries that Anton’s continuing weight gain will set his dad off again. Todd puts Anton down a lot and calls him fatty and a lot worse. Todd threw food in Anton’s face last night. Donna has been making Anton stay in his room for hours and to behave when his dad is home to help keep the peace. Donna is at the end of her tether and is frightened that she is going to lose it with Anton. So questions on the next slide about this case.
For people, what is the most serious concern you have for Anton and Donna and what additional concerns do you have about this family? So people are putting in the domestic violence and their immediate safety living with Todd, and recognising that both Donna and Anton are at risk from violence in the family. Everyone is concerned about their immediate safety and the lack of support for Donna as well. Someone commenting that everyone is unhappy and potentially destructive. Powder keg. Abuse and neglect as well as domestic violence. All three people in this scenario need proper assessment and appropriate referral to psychology and health, that there is issues perhaps of neglect as well, that all three people need support and anger management for the father perhaps. So there are the comments we have got coming through, Michael.
Michael: Marvellous. Rosemary and I are very encouraged by the quality of the audience’s response. For me, because time is short, I would just highlight who in fact is amongst the many, and I agree with what the audience has pointed to. Notice Anton gets very angry and swears at his mother and the school reports that he is disruptive and aggressive. Now these traits are very common in developing brains that have been damaged by early childhood trauma. Trauma in the first 2,000 days of life. And it leads me to share with the audience an approach that I find very helpful when children present with behaviour problems, is not to leap quickly to the question, what is wrong with this child, but to ask first, what has happened to this child? And in this case history we can see that a lot has happened to Anton. In fact I would give him an ACE score of at least 5. He suffered physical abuse. He has a household member with mental illness. He has been exposed to domestic violence. He is suffering ongoing emotional abuse. He has got emotional neglect. He has been emotionally neglected and big red flag jumping out of the screen at me here is that his mother, who is his one slight hope of a safe, sustained nurturing relationship is about to lose it. I think that that points to a red flag and crisis. I would be on the line to the Wellbeing Unit very quickly.
Tim: And so that moves us on to the next slide. I think Michael has given you one of the answers there. What would be your initial steps in this scenario? How do you respond to Donna and Anton? Who do you consult with? Would you report to FaCS? What follow-up appointments do you think are needed? Who do you refer to? So, just looking at some of the answers. There is, thank you to the person who is mentioning Brighter Futures at Tharawal which is where I work. I agree it is a really good program that looks after children and families and supports families who are risk of further involvement from FaCS. It actually prevents those problems, so thank you for mentioning them. If you did not, I would have done. So people in general are saying that they would report to FaCS. Might enquire a bit more about safety right now. They would consult with the Child Wellbeing Unit, refer to FaCS in the area. Some are saying they would discuss with the CWU initially, the Child Wellbeing Unit. Remain supportive and non-judgmental. New South Wales Child Wellbeing Unit and I think that is it.
Tim: Absolutely. Rosemary, is there anything you would like to say about what the CWU would do for a GP calling up about this family? I, we would be supporting their making a report to FaCS. Often people do not know the mechanisms for doing that or what, you know, what might be required as part of that process so we can talk people through that process if you have not reported. I assume a lot of GPs have already been down that road. So if you need to understand that. I would expect in this case we would have some information in our holdings I would imagine, particularly say at the school, and perhaps things have been tried by other agencies before perhaps the school has tried to be supportive of the family and we might be able to give you some more information about that, but definitely you know supporting you in a report to FaCS and validating that as being an important step.
Michael: Rosemary, I think endorsing our colleagues in the audience who said maintain a supportive empathic relationship. I think it is really important to see that talking both with the Wellbeing Unit and indeed with FaCS in the 21st Century is at its best empathic and supportive. So, we are reporting, not to have a child taken away from his family, but to engage the community in providing support that maximises the chance of this very dysfunctional family getting back on its feet for Anton’s benefit.
Tim: Absolutely. I think some else has commented about by giving Donna the RESPECT number regarding domestic violence and the College also does have guidelines in the White Book about abuse and violence in families which would be useful guidelines to use here too. Any final comments on case 1? I think it is worth reflecting anything, if Anton was an Aboriginal child, the, if there were other services or other approaches that we might need to take relating to Anton. So somebody said involve an Aboriginal health worker. Brighter Futures. Absolutely. So they are a service who as I was saying, who support families to bring up children who are at risk at involvement from FaCS and they do that very well. So, cultural support. Call the Child Wellbeing Unit and ask for the Aboriginal health worker. That would be important, Rosemary. So, and some people are talking about the extended family, close family being there even if mum and dad are not. Possibly the extended family might be important. And I think the other thing which has not been mentioned but I would be acknowledging that it does not remove any of your legal obligations on you around discussing with the Child Wellbeing Unit or reporting to FaCS. That is important, the legal obligations are the same. But the engagement with the family needs to be handled well and carefully because of the historical perspective of child removal in history and FaCS are often seen as just removing children. And so maintaining that relationship and the involvement of Aboriginal health workers might be really important if this was an Aboriginal family.
Tim: Lovely. Any final comments, Rosemary or Michael on case 1?
Michael: I think we have covered that very well. Let us move on.
Tim: Lovely. So the next case is Grace and Ling. So you regularly see Grace who has significant mental health problems and you also see Ling, Grace’s 18-month-old daughter. You are starting to be concerned about Ling because her language development seems delayed and she seems passive, lacking in interest and engagement. You observe that when Ling approaches, Grace ignores her. You remember that Grace had some support from the early childhood nurse in the past, but you are not sure if that has continued. So again as you did before, any initial thoughts or concerns about Grace and Ling? Put them in the chat box, thank you.
So some people are worried about post-natal depression and that this may mean that Grace is neglecting Ling. Avoidance detachment. Raising the possibility of autism. Post-natal depression. Full history and examination, any signs of injury or harm. Is there any immediate risk of harm to Ling? Talking about bonding issues. A routine of eating, feeding and sleeping. Mental health issues. What are Ling’s other milestones like and what is her growth like? Talking about mum’s mental health and whether the child is ill or sick or any signs of abuse on examination. Adjustment disorder in the mother possibly. Is there any sign of fear when Grace approaches? Are mum and baby bonding? What is that like and how is mum coping? So, Michael, any thoughts on those comments and your thoughts on that case?
Michael: Again, I am very proud of the audience. They are all crucial issues and I think that the GP who actually noticed the fact that Grace ignores, I am just sorting out who is who. So, Grace is the daughter. So, when the mother approaches the daughter, the daughter ignores her. That is a really important observation. Part of the physical examination if you like. And as someone in the audience has pointed out, there is clearly an attachment issue here, whatever its cause.
Tim: So, in the next slide I have some further specific questions for you about Grace and Ling at the moment. So how do you raise your concerns with Grace and ask her about any support she has such as Ling’s father or other family or friends. Which other services have been involved and how you might find that out, and how you explain to Grace what your concerns are so as to plan with Grace further supports. And then the final hypothetical on this slide, if Grace does not engage in the conversation, what do you do then?
So, talking about discussing this in a non-judgmental manner. Get consent from Grace to contact her family or friends for collateral history. Ask Grace how she feels about having an 18-month-old baby. How is she coping? Ask if she has any family or friends or extended family who live in the same city or state. Again, people are asking the actual questions they would ask, how are you coping? Visit by community mental health nurse. Asking about previous mental health issues and how they were managed. Ask her about how things are going at home with the baby, does she have supports? Does she see a GP or nurse regularly? So those are repeat of similar answers. If possible, speak to the partner to provide support. How do you cope when you are extremely tired and someone is suggesting doing the Edinburgh post-natal depression screening questionnaire.
Tim: So, any comments on that, Michael?
Michael: Well, the Edinburgh of course will be high. We do not know if she is suicidal and that would be important to establish. And how do you raise concerns with Grace? Well I think a GP would start being empathic and saying something like, “Grace, being a mother is really hard work”. And then keeping quiet and seeing what Grace came back with, and then the conversation would flow from that, exploring the things that our audience has identified as areas to be explored. I would be very surprised if Grace did not engage with conversation after that introduction, but if she did not, then I have no way of being part of keeping the baby safe and so I would be ringing the Wellbeing Unit.
Tim: Rosemary, yes?
Rosemary: If you did ring us, and I will talking further about how else she can contact as well. The other point that I wanted to make is that the reason why we have a New South Wales Health Child Wellbeing Unit as opposed to that earlier question why do we not just have a unit for FaCS, why doesn’t FaCS have one, is that it is recognised that we need, that our staff do have special knowledge of health and health issues and the health system. So, being able to talk through when people know what the Edinburgh Depression Scale is et cetera, is part and parcel of the work we do. So, I just wanted to add that.
Tim: Excellent. One of the questions that has come through is actually to be discussed on the next slide. We have had people asking what you say to families if you are going to contact the Child Wellbeing Unit and what happens with regard to consent?
Rosemary: So we are up to that.
Tim: We are up to that.
Michael: Do you want to take that, Rosemary?
Rosemary: So, obviously you decide you need to talk to the Early Childhood Nurse, because you want to find out about that involvement and also want to contact another service that you believe she has been attending. If she does not open up and agree to contact, for you to contact others, that is where the legislation does allow you, enable you to contact other services and health staff et cetera without mum’s consent. That is the big change that has been around for a while, because we want to make sure that concerns about the child’s safety, welfare and wellbeing takes precedence over the consent issue. That is what the legislation has been introduced to do. You can ring the Child Wellbeing Unit to talk through your concerns, but also the legislation enables you to just contact the Early Childhood Nurse or who else you might need to if you know their details, without going through us obviously, so.
Tim: So good practise I think would mean that you do let the family know what you are doing and get consent, but you are protected by legislation for sharing information.
Rosemary: Yes. And obviously we have a lot of health workers who say to their patients, look I do want to talk to someone else about what I am concerned about, and get advice about what sort of services might be available to you, or how we can help you to improve how you are coping with your child et cetera. So, those sorts of conversations just to raise that you have concerns and that it is normal practise for you to talk to other professionals about situations that come up for you.
Michael: So, at the start we have got – we raised this slightly earlier, we mentioned chapter 16A and that is on the slide in front of you which is about the recent change to the legislation which allows us to discuss with the other health professionals in the Child Wellbeing Unit.
Rosemary: So, this slide just sort of explains where that legislation sits. It sits in the Children and Young Person’s Care and Protection Act. For about 10 years or so, that piece of legislation has been there, but it was extended in May 2016, so that prior to that there was a more limited range of professionals who could use that piece of legislation and as you can see, we are now talking about all registered medical practitioners, psychologists, speech pathologists, OTs in New South Wales as well as you know, teachers, police, FaCS, welfare agencies et cetera. So there is a broad range of people who come under that legislation. The Royal Commission was very interested in how this New South Wales legislation can be extended across Australia because of the need to have those conversations broader than New South Wales. So we are looking at cross-border legislation that enables information to be shared across borders. At the moment as I said, it is normally in New South Wales with some provisions for some family court et cetera coming into the legislation. But it is there to enable those conversations to be had when it is not wise to seek the consent of parents up front I suppose or young people.
Tim: And so the next slide quickly shows us why 16A was enacted. The next two tell us first of all, what information can be shared and then after that, who can share information. So this is the information that can be shared. Anything to say about that, Rosemary?
Rosemary: Just with the “what information,” we always think of the safety, welfare and wellbeing test. Is what I need to ask and what I want to find out, or what I want to tell someone else, because you can proactively ring someone to express your concern, is it about the child’s current safety, welfare and wellbeing? So it is much broader than just a reporting scenario. It is about welfare and wellbeing, so it is, you can share by just having a conversation. If someone asked you for information under 16A, you do not have to provide the medical record, that is not really what this provision is about. It is about just picking up on what needs to be talked across agencies to really look at the current situation with regard to that child.
Michael: So, a GP might be asked, have you ever had a concern about the safety of this child?
Rosemary: Yes. Or you might be raising a concern with someone else, but it is not about getting reports or getting detailed information. It is really about saying what do we need to talk about now to look at the current situation for the child. There is, on that slide it did mention also the provisions do also take in concerns about employees, and FaCS uses those provisions and out of home services uses those provisions if they have concern about a foster carer for example. That is just another sort of side clause in it. So who can share that stuff up on the screen? I think we have covered that off.
Michael: Tim, we are rushing towards the end. I think just one other thing to say. In yours and mine and the audiences experiences, when you bring the issue to, we are all interested in working for the benefit of your child, most parents will happily give consent. What we are talking about here tonight is that if you cannot get that, then 16A protects you taking steps to get advice about the child. And the other thing to say, is there are times when seeking consent might be dangerous and you clearly would never do that if the perpetrator of domestic violence or the perpetrator of sexual violence or the perpetrator of any violence was in the room with you. You would not be seeking their consent.
Tim: That is right. Exactly right.
Rosemary: And similarly, you might be contacted by health or other professionals seeking information from you as I said. So again, we are assuming that they are doing that because they, it is not appropriate for them to seek consent.
Tim: Yes. And so the next slide is about starting the conversation. And just as we absorb this slide a little bit, there are a couple of questions. Is the age cut off 16 or 18 for the Child Welfare Unit?
Rosemary: We take concerns up until, you know, children up until, children and young people up until they turn 18.
Tim: And then what happens to records after the children are older than 18? Are they kept or are they destroyed? That was a question from the audience.
Rosemary: Seeing as all our records are within the database, they are subject to the State Records Act, so that they are maintained. Obviously we do not share information about adults unless it is about a particular current child, so we do not have people contacting us or talking about people as adults. We are talking about children and young people.
Tim: I would say it is worth everyone thinking about as we come towards the end, and Michael I might just get you to talk about this, about how you might start the conversation with children and young people and parents about their wellbeing and possible discussion with other agencies and the Child Wellbeing Unit.
Michael: Well we are rushing towards the end and I would remind the audience that looking for a script and ways of actually practising having these conversations, you can actually find throughout the White Book of the RACGP, and the exceptions to confidentiality are really very easy to raise and should be raised with older children and adolescents routinely, because we know that concerns about confidentiality are for them high. So you might say what they tell you will be confidential unless I am worried about your safety, I think someone is going to hurt you, I think you are going to hurt somebody else or I think somebody is going to hurt you, then I am going to have to break confidentiality only enough to keep you safe.
Tim: Excellent. That is good. And so finally, sharing information essentially helps coordinate services. That is what is on the slide.
Rosemary: Yes. We are sharing information for a purpose, to get services for families. That is really ultimately what we are talking about. We are not sharing information so just to document concerns, we are sharing information to make things happen.
Tim: And most parents and families will be very happy to be able to get the services that are going to help them.
So the next slide is just some thinking here about the sorts of thoughts that we have in dealing with child wellbeing. Anything you would like to say about this, Michael?
Michael: Oh, look I think they are lovely though bubbles for the audience to think about as they turn to have that cup of coffee.
Tim: Absolutely. A cup of coffee or watching the Rugby League game that might be on TV. The next slide is some of the resources and it is worth everyone watching that TED talk on adverse childhood experiences if you have not looked at that as well.
Sorry, go on Michael.
Michael: Five stars for the TED talk. The resources are innumerable but colleagues should look to the White Book. It is just packed with great stuff.
Tim: Absolutely. So, if we finish by looking at where we started again, these were the learning outcomes and so we hope that having reached the end of this activity, that we should know more about the Child Health – Child Wellbeing Unit and be able to access it to seek advice. We should be able to explain to patients and families the exceptions to confidentiality when we need to consult with others, and hopefully we are all the more competent in having a conversation with the parents about their child’s safety, welfare and wellbeing. Which finishes off just on time. Thank you very much to Michael and thank you to Rosemary for such a good conversation and thank you to Sammi for making it all run so smoothly through the evening. Thank you very much and we do hope you all have a good evening.
Sammi: thank you again, Tim, Michael and Rosemary and thank you for everyone on line. We hope you enjoy the rest of your night.
Tim: Good night everyone.
Michael: Good night all.