Sammi: Good evening everybody and thank you for joining us for this evening’s General Practice for Children and Young People in Out of Home Care. My name is Samantha and I am your host for this evening. Before we jump in, I would just like to make a quick 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.
I would like to introduce our presenter and facilitator for this evening. We are joined by Dr Michael Fasher, Kat Deveney and Dr Linda Mann. Michael was a GP in Blacktown for 38 years and is the immediate past 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, support families and raise healthy, well-adjusted young people.
Kat is the acting Out of Home Care Coordinator for Western Sydney and has been working in Western Sydney for 16 years as a registered nurse, registered midwife, Child and Family Health Nurse and international board certified lactation consultant, and also holds a Masters in Child and Family Health Nursing. Kat has a passion for the community we serve. She believes that the effect we have on the people we make contact with in health impacts on the wider community and with that comes great responsibility.
And our facilitator for this evening, Linda. Linda is a Fellow of the RACGP and member of the RACGP Antenatal and Postnatal Care Network. Linda has both local and international medical experience, especially in genetics and women’s health. She is a GP representative on various national and local government committees and is an experienced medical educator. So, welcome Michael, Kat and Linda and thank you for joining us this evening.
Alrighty. So I will hand over to Linda now and Linda will take us through the learning outcomes for this evening. We will then hand over to Michael to begin the presentation. So away you go, Linda.
Linda: The learning outcomes for this evening’s webinar are just by the end of this online QI and CPD activity, you should be able to be aware of the principles for trauma informed care for children and young people in out of home care, share information to assist in clinical assessment and care of children and young people in out of home care, and access information and resources about the Out of Home Care Health Pathway Program. So, over to you, Michael.
Michael: Thanks Linda. Good evening all. So, amazingly the adverse child experience, or ACE study was now published 20 years ago. What astonishes me, is how little known this really important study is. So this study 20 years ago clearly established a correlation between adverse early childhood experiences and the outcome of any variety of physical, biological, mental, spiritual and social health outcomes that you could care to name. The correlation is very tight at the population level and over the last 20 years, the neuroscience has opened up very plausible pathways of how adverse early childhood experience or toxic stress from conception through childhood results in these negative outcomes. It was what one of the authors of that paper has called a demonstration in how we turn gold – that is a beautiful young baby full of potential, into lead. Reverse alchemy. And tonight we are having another discussion about making sure we do what we can to be sure we are burnishing gold rather than turning it into lead. It is important I guess, before we move on to say, this is epidemiological data, so we are talking about effects at the population level. There will always be individuals with quite high ACE scores that are thriving and doing really well, and exploring where that resilience arises is one of the exciting questions from the neuroscience.
Kat: In New South Wales there are approximately 17,000 children and young people in out of home care in New South Wales. 40% of them are Aboriginal and that is 2.5% of the New South Wales population. The areas where those Aboriginal people live, there are a lot in Western Sydney and…
Michael: There sure are.
Kat: Quite a few in Western Sydney and all over the State but there seems to be a larger concentration in that area. The children in out of home care often have quite a number of unmet health needs. They are more disadvantaged than other children because of that out of home care status. Children on the Out of Home Care Health Pathways Program are on that program because they have met with family and community services staff. There is that risk. And that is why they have been removed from their family. So that is the group of children that we are talking about tonight.
Michael: So by definition, when in general practice we work with children in out of home care, we can be sure they have risk of adverse early childhood experience.
Kat: Very high. And some of these children have left their families, their birth families at birth, and any of them can be up to that age of 18. A lot of these children have been in multiple placements. 40% of the children have been in between two and five placements. Some of those placements can happen very quickly. There are some families that we meet that have been in two or three placements within in the first six months of leaving their birth family. So it can happen very quickly, and that can be when we meet them very early on in that piece. And 15% have experienced between six and ten placements. 32% of children in out of home care have had more than 11 placements.
Michael: That is the most astonishing statistic in this whole slide there. 32% with more than 11 placements. So in theory, a child who has had one placement has clearly being exposed to toxic stress. As distinct from stress that supports thriving. We are not looking for stress-free childhoods. But if you have more than 11 placements, the accumulation of toxic stress is substantial. Okay. I am astonished.
Kat: So, onto the next slide. Because of those changes, because of the change within caring families, the foster families that they are in, that is the short term or long term placements, their health care is fragmented. They may get to meet one Child and Family Health Nurse. They might be lucky enough to meet two, and they often meet quite a few different GPs and paediatricians and other Allied Health staff along the way. So they do not get a really good relationship a lot of the time. Some are lucky that do, but often it is quite fragmented. A lot of the children that I have met along the pathway have been to a number of paediatricians. Those paediatricians and GPs do not get the full story. They only get parts of the story that the carers or case workers know.
Michael: So the fact that the health system is fragmented, is really what is driving all the moves to reform.
Michael: New South Wales is very big in integrating care. And that whole movement, the healthcare home, the patient centred medical home, integrated care, HealthOne, are all really trying to say that for the general population fragmented care is not good care. But for this population it is particularly disadvantageous and indeed can be experienced as re-traumatising.
Kat: Very much so.
Michael: So out of all that, this new program was born called the Out of Home Health Care Health Pathway Program.
Kat: Yes. And it started in July 2010, so it has been around for a little while. It is also State-wide so there are coordinators in every Local Health District and it does have certain criteria. So they have to have certain legal orders, there has to be current involvement with Family and Community Services.
Michael: Sure. Well the RACGP policy statement on the nature of general practice and its statement on child healthcare, seems really to meet the needs of this population at least in aspiration, extremely well. So you can see from those dot points the College has now a long standing policy which means that general practice is really in a good place to be of assistance to these children and young people. We aspire to offer care that is person-centred, continuing, comprehensive, whole person healthcare for individuals and their families in their communities. Now of course one of the reasons that we are behind health system reform is we know that that is an aspiration. But I think there is a fascinating parallel between what these traumatised young people need, which is in a sentence, safe, sustained, nurturing relationships. SSNRs. Safe, sustained, nurturing relationships. It seems to me that the ambition of organised general practice is to provide exactly that kind of relationship for our patients and families. So, to the polling question.
Sammi: Fantastic. So I am just launching a polling question for everybody online now. We would like you to just select yes or no. We are just wanting to find out prior to this webinar, where you aware of the Out of Home Care Health Pathway Program? So if you can click yes or no now, and then we will share the results quickly before moving on.
No worries, so we have closed that off there and I will share those responses now so everyone can see. So 23% of people said yes. So only 23% of people had heard of the Out of Home Care Health Pathway Program prior to this webinar. So that is great, we are reaching a lot of new people. Happy to move on Michael, or did you want to?
Michael: Kat can use the opening to tell us about the Health Pathway Program in which you work.
Kat: So, as I mentioned before, it started in 2010. So it is a joint initiative between Health and FACS and it comes under the Keep Them Safe funding. So that is where is coming from with that. There are Out of Home Care coordinators in each Local Health District, so there is one for each Local Health District that you work in, and you are able to contact them. We are there as a resource and to do as much as we can, so provide guidance, assist with funding and health records as well. So hopefully with some more knowledge, reducing some of the broken links and help with communication across a lot of areas. So, not just for public health but for private health as well.
Michael: So care coordinators in this program really do know how to coordinate care.
Kat: Yes. And what we do in this program, is we create a Health Management Plan and there are opportunities to have a look at a version of that. And that, depending on who has done the assessment, will be more thorough in some areas than others and depending on what information has been available. But it looks at physical health needs and psychosocial health needs of that child or young person. And that is for any child or young person up to the age of 18.
Kat: So, for a child to be on the Out of Home Health Care Pathway Program, the coordinator needs to find out about that child or young person through FACS. So Family and Community Services are the ones that do the referrals to that Pathway. If you find out about a child that is in Out of Home Care, you can contact the coordinator and sometimes we remind the case workers that this is one of the things we can help them with. So once we receive that referral, a primary health screen is organised for that child. Each Local Health District does do it a different way, so a lot of GPs may be asked to do that assessment and it is quite a detailed assessment. You are looking at a lot of information. From the information that is received from that Health Management Plan, a comprehensive assessment which is a slightly more thorough assessment may be needed, may be required. And from that health screening, a Health Management Plan is created.
Michael: Are the bulk of those assessments done by nurses?
Kat: Depending on which Local Health District you are in. So usually for the zero to fives, Child and Family Health Nurses do do a lot of those assessments because they fit with a lot of those.
Kat: Depending on which Local Health District you are in, there are some clinical specialists that do those primary aged children, and then again depending on which area you are in for youth health, there are Youth Health Nurses in some Local Health Districts that do do those assessments. Sometimes, we do use GPs because it works better for the program.
Michael: And who make that decision? The care giver? The family care giver or the NGOs?
Kat: A lot of it is run by the carers and depending on which district they are in.
Michael: And their relationships with local health professionals including their GPs. So what is the difference between step one and step two? What is the difference between the assessment and then screening?
Kat: The health assessment is starting the program. So it is receiving a referral. Looking at where that screening needs to be held, who needs to complete that screening. And it is basically trying to compile the file so that we have got a bit of background information for that young person for whoever is going to be doing that screening. So it is entering them onto that pathway.
Michael: Okay. So we have got assessment. We have got screening. Presumably this management plan is developed in collaboration preferably with the young person if they are old enough to collaborate and their carers or the NGO involved in looking after them.
Kat: Yes. And Allied Health. So depending on where you are working, we have got Allied Health, so there can be speech therapists, occupational therapists that will help us with completing information for that Health Management Plan.
Michael: So when is a Management Plan developed?
Kat: It is ongoing.
Michael: Do the carers carry the plan? I mean how does a GP get to see the plan?
Kat: So if Western Sydney completes a Health Management Plan, we send it out to the case worker to provide a copy to the carer and a copy for the GP, so that is what we are expecting.
Michael: Unless that breaks down.
Kat: Yes, as happens with any communication.
Michael: So we are in a position to be able to ask, where is your Out of Home Care Health Management Plan?
Kat: Yes, and that means if you have got information on there, there might be information in there about further screening that is needed or you might be out to go, hang on, I see something here and that means, I feel, as a GP that needs further assessment. So you are able to influence it as well.
Michael: So that gets us to step four.
Kat: So, depending on what is needed. It may be something as simple as the child needs referral for audiology screening, hearing screening. But it may also be that we are seeing that there is a lot more intervention that is needed for young people. So it may be a child that is assessed and we see that they need a paediatrician. The family, most carers need to go to a GP to get that referral to a non-GP specialist, don’t they.
Michael: Yes, well I guess through the PHN, there is the primary mental health care program and with that Out of Home Care Health Management Plan which could easily be warped and weaved into a mental health plan, these families should be able to receive some psychological help.
Michael: Sorry what was that, Linda?
Linda: It certainly is in Central and Eastern PHN, that is the PSS program.
Michael: So it has got a lot of names. It is basically Commonwealth funded PHN role to facilitate families getting the psychological help they need.
Kat: And, periodic review and assessment. Children under five years should be reviewed every six months, over five years every 12 months. So it is an ongoing review process. Because we know as children grow their needs change.
Michael: So, as you look at this slide, the GP role here is not so different from the role in general practice we have for children and families in general. I think that the difference here are the forms required to monitor progress in the program which I applaud and keeping in mind at all times that there is a high risk of re-traumatising these particular children because of their background. But we will come to that shortly. One of the things that is not on this slide that I would like to see, another dot point, is caring for the carers. So if it is true that what all children need, but particularly traumatised children need, is sustained, nurturing relationships. Then if we want carers or parents to provide those sorts of relationships for their children, they too need safe, sustained, nurturing relationships. And it is really important that we think about their welfare. I think that will come up in one of the cases we are going to discuss.
So, to the coordinators role.
Kat: As I mentioned before, there is one in every Local Health District. So we help to coordinate those Health Assessments and the reviews of those Health Assessments. And there is a lot of information that is held by different places, so trying to compile that into hopefully an accessible place. So if the coordinator knows that the child has had a regular GP, before or after entering care, that can be a point of contact to receive and to share information. Some of these children move between Local Health Districts so we do organise the transfer of those electronic health records between Local Health Districts. And we are there as a resource to help GPs and other health professionals.
Michael: Fantastic. Well you are actually our, my care coordinator in Western Sydney and you can be sure you will be getting phone calls from me from now on because there is nothing more – well, there are two frustrating things. There is seeing people with complex issues being asked to do things like write referrals, write prescriptions without any idea of the context. And the other problem is NGOs who really do not understand what general practice is about and just see it as referral clerks. So I think that the coordinator and the program can help both GP carers and NGOs involved do better for these kids. But there are some children who are not in the Health Pathway Program, right?
Kat: So, some of these might be children that have an informal agreement. They might be living with kinship, with family, but may not have those legal orders.
Michael: And are those who entered into care before July 2010?
Kat: There are some, yes. Those ones, because they do not fit that criteria of that plan, depending on their age. We are able to help navigate some other alternatives and so at least these areas are resourced as well as have case workers.
Michael: So seeing this last dot point keeps on emphasising that GPs have a valuable role in providing oversite and coordination, but to do that we need help. We actually need a team. And it sounds to me as though the coordinator is a highly placed team member, which enables us to do exactly that.
Linda: Michael, can I ask a question as a GP who has less experience than you? All this talk about management and plans and stuff sounds awfully much like General Practice Management Plans and such. Would it be appropriate for a GP looking after such a patient to use some of the information that has been provided by the coordinator to create such a Management Plan to facilitate some of the Medicare funded use of Allied Health folk?
Michael: Absolutely appropriate, Linda and without a program providing the background and the detail, it is very hard to write a good management plan or a good mental health plan, all of which would be consistent with the programs Management Plan. So yes, I agree.
Kat: And I think that goes both ways. If there was information that a GP had that would help the Health Pathways as well.
Linda: Would the coordinators want a copy of the document that the GP creates for this person?
Kat: Yes. Because that would help inform other referrals as needed.
Linda: Thank you.
Michael: Moving towards having an electronic care plan available at every point of care. We are on the way, even if we are still in paper form. So, our first case study. Are you going to?
Kat: Okay. So, our first case study is Jane. Jane is an 8-year-old child who has come to see you with her fourth carer in 12 months. You have not met the carer Kate before. Jane has been in Kate’s care for the past six weeks.
Michael: There are also red flags here flying high for me. And Jane clearly has significant damage. Of course we have yet to discover what her significant strengths are, and whilst keeping the trauma damage in mind, it is also important in parallel that we keep looking for her strengths, interests and resilience. Now being eight years old and not being able to sustain or not being sustained, she has not had a safe, sustained nurturing relationship. Every 8-year-old needs that. Fourth carer in 12 months. We are already in big trouble. Really important here for the GP not to suddenly become overwhelmed by oh my God, what I am going to do? What do they expect me to do about this? So no one expects that the GP be a either a magician or have a magical wand that is going to sort out Jane’s problems, let alone Kate’s. It is a question after this webinar hopefully, sitting back saying, great, I can make a difference here. But the first thing I want to do, is to build a relationship with Kate. Ultimately we want this relationship with Jane to flourish, but I as a GP cannot be of any help to Jane, the 8-year-old unless I have got a good relationship with her fourth carer, Kate. And so, instead of my mind thinking, oh my God, this is not what I want at 11 o’clock on a busy morning, I am thinking, okay well over time I am a GP, I do not have to get everything done today. What I need to do over time is build a relationship with these two and see what emerges. So.
Kat: So, the case worker has requested a health check as the school is finding it hard to manage Jane’s behaviour and is thinking about suspension. Kate is struggling. She has four other out of home care children in her care with ages ranging from 4-14 years. She is a single parent and is currently not working. Jane finds it difficult to make friends and seems behind in her emotional development.
Michael: So, this is overwhelmingly complex.
Michael: What the carer Kate needs to know, is to feel that the doctor is warm, empathetic and thinks that she is a hero. Because it is very unlikely that either I or any of my colleagues would be able to do as good a job as Kate is doing. And I think that is sometimes worth explicitly saying. You are doing the real work here. It is my job to do what I can to help you along this very, very difficult journey. And so here we are talking about paediatrics and children. As a GP I am now thinking, okay it is going to take several consultations. It may take several weeks, it may take longer to build the relationship with Kate. But the first job is going to be ringing up my coordinator and talking about how are we going to have wrap around support for this carer to prevent her becoming the fifth carer, to prevent Jane going on to a fifth carer? So, supporting this little family unit is crucial for Jane, and it becomes before sorting out Jane. In inverted commas.
Linda: Michael, I am an overwhelmed GP looking at this family, and when Kate tells me that there are other issues, I am thinking what do I have to do first. I understand what you are saying about having a relationship, but I have been given this paperwork, and I have got to do this task. How do I sort that through?
Michael: Well, first of all, remain in charge. And the form may be on your desk and what you have to write on the form might be just what we said. Look, this is enormously complex. We cannot get to this today. This is where I, in conversation with Kate, I think we are up to. This is a broad outline in the plan. But the first aim, is that I develop some more understanding and a good relationship with these two people. And that is what I write on the form, even if there was not a place to write it.
Michael: And I think the coordinator would see your point.
Kat: Yes. So because it is the case worker that has requested it, they have not requested that it is done in one session. As long as there is something done. And as you said, in building that relationship it might just be the first time that she has been to a GP in a long time, and it is a different environment. So getting to see an environment where there is someone that cares and listens.
Michael: And the response to Linda is really important because we are volume oriented in general practice. We always have a waiting room that is full. We are always running behind. And if we allow ourselves to panic in this situation, oh my God what do they expect me to do? Our body language and tone of voice is likely to be punishing to Kate. Not because we intend it, but just because we are stressed. And so our stress then makes Kate’s situation worse. She is stressed enough. We have to I think in a way, Linda, think about well it is the reason for having the webinar really. One of the reasons we are having the webinar is planning what our response is going to be when we are confronted by these complexities. And it does not matter that it happened in out of home care, by the way. I mean, it is not an uncommon GP experience.
Kat: Okay, so when you see Kate and Jane in the appointment, you notice that Jane is very busy in the waiting room. She sought attention from every person in that waiting room. In the clinic room, Jane appears to ignore Kate, but starts at a loud noise and seeks comfort from you. Kate discloses that Jane rubs herself on the sofa and looks off into the distance. She worries that the behaviour indicates that she has been sexually assaulted and does not know if she can manage this with the other children in her home.
Michael: So is it appropriate to ask the audience if they see any red flags in this part of the case?
Sammi: We will give you a moment to type your responses in.
Michael: What are the phrases that jump out at you as needing attention here?
Sammi: Nothing is coming through yet. Anyone have anything they want to say?
Michael: Okay, well the phrases that jump out at me are, that young Jane, eight years old is running around seeking affection and embrace from everybody in the waiting room. Well that is clearly inappropriate if you are eight. And it does make you think, what has gone on in the past? Is this 8-year-old showing to us that she has been neglected in the past? Does it show us, it certainly suggests that she has as a child experienced toxic stress that has been toxic. Then of course, she starts at a loud noise and seeks comfort from the strange doctor rather than the carer who she does not know very well anyway because she has only been with her for six weeks. But whoever wrote the case is meaning us to see that, you would expect a child who got startled to turn to their carer for comfort and reassurance before they turn to the stranger in the room. And then of course there is the suggestion that there is self-stimulation, and that has flattened the life out of Kate because she is now worried about sexual abuse. So I think here, going back to what we were talking about originally, I think it is really important for the GP not to be seduced into, not to be infected by Kate’s anxiety. So the reality is, that once young children learn to masturbate, they are not going to stop masturbating this side of the grave and we could in that situation where we are just getting to know them, perhaps just role model, look Kate what you do when you see Jane masturbating in public, is you say, darling that is okay but it is for in the bedroom. Come with me. Some non-judgemental, non-anxious, non-punishing way of setting limits to say that there is nothing terribly wrong with this behaviour but it is not appropriate in a public space. And that does not sort out Kate’s anxiety, but quite clearly of the issues we need to be helping this little family with, sexual abuse in the past for Jane is not one of them. Not one of those pressing issues. The pressing issue is that Kate develops confidence and competence and she is going to need some support for that before we get around to therapy for the 8-year-old. And in fact, as the family functioning improves, that is therapy for the 8-year-old.
Michael: So, Linda do you think that is helpful?
Linda: I am just wondering, it is nice that you tell me I do not have to worry about sexual assault right now. My sane intelligence agrees with you. My bureaucratically anxious general practice person worries about my mandatory reporting and all that kind of stuff. You are telling me I can wait to sort that out.
Michael: Well remember we are dealing here with a child who is in the care, who has been notified, is in the care of DOCS and has a case worker who is supervising her.
Linda: Fair enough.
Michael: So this is quite different from a situation where you might see that behaviour completely separately from out of home care. I mean the notification to get into out of home care, you have to have a notification which has been made and established.
Linda: Okay. I feel more calm about now.
Michael: If I was to see that behaviour alone in an otherwise appropriate 8-year-old, I would behave just as I have described. I mean, once people have learnt that self-stimulation is pleasurable, you are not going to ever stop them again. So the thing about, the reason that it may well reflect toxic stress for Jane, is the other behaviours that go with it, and the fact that she is in out of home care. So this kid has been traumatised. So even if we cannot easily unpick and reverse and provide therapy for the trauma, we can be very careful we are not increasing the trauma.
Linda: Thank you.
Michael: So, that brings us on to Billy. Are there any questions arising from the audience from Jane? They are a very quiet lot.
Kat: So, case study 2 is Billy. Billy is a 12-year-old child who is currently living in a residential care setting with an NGO. His annual health check is due and he has been brought in by his youth worker, Sam who met him for the first time yesterday.
Michael: So let us pause there for a moment, because that, how common is it to have a young person brought in by an NGO employed care worker who does not know the child. When I am asked to refer, prescribe, develop plans. I do not see any way around that other than gradually saying to the NGO, this is not appropriate. I need you to go back to your manager and your manager has to send someone who actually knows young Billy and we are going to work out what general practice stability actually is.
Linda: Yes. That is so common.
Michael: So well it goes back to being given a form. Being given a form does not mean you have to fill it in. Nor does it mean you have to be disruptive to the system. It is just saying the system is no longer standing my role. And it needs to be, just so that I can cooperate.
Linda: And some people do just want a box ticked so that they can move on to the next box.
Kat: Okay. So the worker hands you a form and asks you to complete it for their records.
Michael: So I am going to do what I just said. I let, there has to be discussion about I do not serve Billy well by making this NGO happy that I have ticked the boxes that they can show to the people who fund them. In fact I am doing Billy a big disservice. So I am not going to do that. But I am going to be positive and say this is what has to happen, so that I can fill in the form.
Kat: On your examination of Billy, you notice that he does not make eye contact with you or Sam.
Michael: So that there, could make us think, could Billy possibly be autistic, having difficulty with social relationships. But of course there are a myriad of other causes and other reasons for him not making eye contact, which may be absolutely normal and not a sign of being damaged. He may be shy. He may come from an indigenous culture in which eye contact with strangers is not what you do. That is why it is there, just to keep in the back of your mind, we do not have to sort that out today, but it does make you a little more primed to watch how young Billy is responding to you, how he is responding to the care worker who he does not really know. But over time, you are going to take an interest in Billy’s social skills.
Kat: Billy is underweight. He has small stature and shrugs when you ask him questions.
Michael: Well the shrugging goes with the social skills and the, again the temptation for people, it is all very well in my old age, but as a young doctor, young people who shrug and are dismissive, I mean that can make you quite angry. But they cannot make me angry anymore, and that is a good thing because getting angry with this behaviour is failing to see where it is coming from. It is not personal. It is not, I hate you, Dr Fasher and I am not going to cooperate with you. It is years of toxic stress. And of course the issue of underweight and small stature again comes to this fragmentation of records. To make any sense of a single weight or measure of height, I need growth charts because 3% of the normal population actually have a weight that is on the third centile and height that is on the third centile. So you cannot make any sense of single numbers. Though if you saw someone who was really down there you might be looking elsewhere in the physical exam for other signs of chronic problems, clubbing, any other abnormality on physical exam. But of themselves they mean nothing. You need growth charts. And then the last bit of this is that he is getting good grades at school which tells you great, at least we are not dealing with intellectual disability here which is so often a complicating factor in children who have experienced toxic stress. But the difficulty with young Billy is that he often acts out when frustrated. If you have lived a life in which you cannot predict danger, you cannot predict when the next punishment is coming, you cannot predict when the next put-down, the next low is coming from. Well if you survive, you become hyperactive and you get the blow in first. And then of course, you start punching when there is no actual thing, when there is no threat. We see that across the whole of the anxiety spectrum don’t we? The thing about anxiety is that if it is a problem you’re very normal responses to a dangerous responses to a dangerous situation are continually aroused when there is no danger. So it is a very similar situation. And it leads me to say that it is really important that when you hear that the school will often ask you to make a diagnosis, what is wrong with this boy? And I counsel all of us to keep remembering to ask the question, what has happened to this boy before you even consider the question of what is wrong with this boy?
I recently had a fascinating case conference with a local primary school about an 8-year-old, and I am encouraging the teacher, a really fabulous primary school, really, headmistress, principal, teacher, school counsellor, all wanting the very best for this boy. But finding his behaviour very difficult. Keeping other children in the environment safe, very difficult. So I began the talk about let us keep remembering to ask what has happened to this boy, rather than the gossiping in the staff room about what is wrong with him. When you hear that gossip, let us ask, but what has happened to this boy? Anyway, that all worked very well but at the end of the day, the principal said to me, I need a diagnosis if I am going to get the funding. Because what this boy actually had the potential to have was an older young person in his twenties who was a footballer to be a mentor in the playground, helping with his social skills, keeping the other children safe. But for the principal to do that, she needed funding. To get the funding, she needed a diagnosis. So as long as everybody in this conference is clear, including the mother, that oppositional defiant disorder means very little to me other than what we are watching, then I am happy to say that this is what he has got. But remember that we are saying this so that we can get the funding for what he needs. So that is Billy.
Kat: So that is Billy.
Michael: Does that raise any discussion from the audience?
Linda: There has been a little bit actually. There was some question about what could we do for Kate? What kind of support can we provide for Kate?
Michael: So before I started this webinar, I went to the Western Sydney Health Pathways, and remember we are not confusing the Health Pathways with the OOC Health Pathway Program. They are different. Ultimately of course, they should be melded. I went to the Western Sydney Health Pathways, and there is fantastic stuff there for families, children, adults, parents in distress, and it leads you to a service called the Family Referral Service. And the Family Referral Service needs to know about Kate and they are funded now to wrap services around Kate in the social care environment.
Linda: Thanks, Michael.
Michael: The Family Referral Service, a good mob to remember.
Linda: They are good.
Kat: The other thing I would be looking at is finding out if there is something already in place. Kate may have not mentioned that the case worker has already assisted with some other support. And some of the FACS case workers and some of the NGOs do fund parenting programs, parenting support, respite, counselling for the carers as well.
Linda: Okay Michael, we have more things to talk about. Let us be moving on.
Michael: So we are up to consent. You ought to take this, Kat.
Kat: So, under the Pathways program, for the children and young people, the parental responsibility is with FACS, so Family and Community Services have the parental responsibility for these children and young people. So once they get older, depending on their capacity and understanding, after 14 we need their consent to enrol them on this program. So that is part of the referral process. So if they are happy to be part of this program when they are over 14, we need their signature. So it will be, that is part of the referral process and part of the assessing of that referral process.
Michael: I must admit for me in the context of this program, the issue of the mature minor, so if I have a mature minor - and I have a case in which it was decided that although young people under 18 are minors by law, a doctor or a health professional may form the opinion that this young person under 18 is a mature minor. And the most vivid one that comes to mind for me is a 16-year-old who has been out of home, is living on the street and the question of asking a parent to consent about anything that is going to be done is, assuming she does not need notification, is obviously not an issue. Once they are on the program, it used to be called in the care of the Minister, the Minister has to decide, and usually I guess for most of us that will come mostly in the psychotropic drugs, probably will not arise in other situations.
Linda: In most basic medical the carer or the young person themselves can provide consent. General dental check-up is okay. The consent does not need to be sort from that information.
Kat: I can imagine stroppy teenagers who refuse Gardasil thank you very much.
Linda: Vaccinations, I know…
Michael: So if you have got a teenager who will not consent to vaccination, then you cannot vaccinate them on that day. The old, I mean thirty years ago I might have wrestled them done and done it, but I mean that will not do. So a teenager is mature enough to give consent. Now we are a bit off out of home care, Linda, but those young people who are hardest to vaccinate are those that are highly anxious and have needle phobia. That needs to be negotiated in its own right.
Linda: Yes, and that is the education for these young people.
Michael: And for children who are younger and the parents want them vaccinated, then I would be enveloping them in the warm, loving, constraining arms of the parent and doing it as quickly as possible.
Linda: And sometimes that is the carer, sometimes it is, depending on where it is, the nurse or…
Michael: You need to judge the relationships in the room.
Kat: Though if the child needs more, I cannot think of the right word, more involved treatment, so if they needed general anaesthetic. If they need dental treatment…
Michael: So that is all going to be sorted out at the hospital. I mean, the kind of treatments that are going to need the nurses consent are those that are given in hospital or prescribing of psychotropic drugs probably.
Linda: Okay, we have not got long.
Michael: Before we leave the mature minor. Again if you go to Health Pathways people, under child health, go to consent in mature minors. This whole thing is beautifully discussed and there is some excellent advice there with a couple of papers from GP journals. So anyone with an interest in mature minors I recommend you go to a local Health Pathway under child health and then consent in mature minors.
Kat: And from that follow consent in information sharing. So, the chapter 16A of the Children’s and Young Person’s Protection Act allows for sharing and requesting of information for the ongoing health and safety of young people. So, as part of that referral that we receive that Health receive from FACs, that 16A is complicit in that. So, as a GP you are able to provide that information to Out of Home Care Health Pathways.
Michael: So because we are coming rapidly to an end and hopefully we will have some questions, I think the issue of the GP providing the material that he has got or she has got, is not a big issue. The issue is gleaning the other material and my thinking as a result of this conversation, is my first phone call should be to you.
Michael: Excellent. One stop shop.
Kat: And that helps navigate the information that is potentially out there.
Michael: Okay, well I think that brings us pretty much Linda to the end of our discussion.
Linda: Excellent. Are there any questions from people who are listening? We did have a question earlier on that I just need to mention since we have a minute, which was asking whether Billy could be depressed? My response was if you lived his life, you would be depressed too. And I saw another one earlier about the Aboriginal Health Assessment. It is very similar. That would be a conversation I would have with your local Out of Home Care Pathways coordinator, because sometimes that can be enough information in that form, but maybe there is more that we would like.
Michael: The question of depression in teenagers is another webinar, but of course it is possible that he may be, but we do not have anywhere near enough information. Nor do we have anywhere near a good enough relationship with Billy to make that judgement.
Linda: One of the other questions was about how to get access to the forms. These links will be sent by email to everyone who was part of this webinar, so these can be accessed. And as mentioned before, in fact we who are presenting this webinar have been talking about making sure that this program does have a presence on the various Health Pathways projects of all the people listening. Look for this in weeks to come.
Kat: The other time that you might receive those forms is if they have been provided to the carer, to the case worker by Out of Home Care Health Pathways. So that may be provided to the carer or case worker who then brings those forms to you.
Michael: That is the commonest way I get them. In fact it is the only way I get them.
Linda: The other questions that were written here were in relation to the need to notify or inform parents and when the child does not want that to occur. Because many of these children do have of course connection to their parents. Does the child have the ability to say do not tell my parents if the child is a mature minor?
Kat: If they are under the care of the Minister, nobody needs to know. Because it is not a normal child-parent relationship.
Linda: The question was, a decision has been made and the child is saying that is fine, but do not tell my parents. So the child has the ability to keep that knowledge from an enquiring parent if the child is a mature minor.
Kat: If that child is on that Out of Home Care Health Pathway, then it would be a conversation with the case worker as to what amount of disclosure is allowed to be given to that birth parent, because there may be zero. And a 16-year-old would know.
Linda: Thank you very much. So I hope you have managed to achieve your learning objectives. I will just mention them to you all again. They were, that you be aware of the principals of trauma informed care for children and young people in out of home, that you would understand how to share information to assist in clinical assessment and care of children and young people in out of home care, and you know how to access information and resources about the Out of Home Care Health Pathway Program, some of which is coming to you by email.
Sammi: Fantastic. That brings us to the end of the session. I would just like to say a big thank you to our presenters, Michael and Kat, and also to our facilitator, Linda. And thank you to everybody online.