Child abuse and neglect: Response and management in general practice

Sue Gedeon (She/Her) - on Wurundjeri Country:

Okay, Hi! Everyone welcome to this evening's child abuse and neglect, response and management in general practice. Webinar. My name is Sue Gedeon, and I'll be your host for the evening before we get started. I would like to make an acknowledgment of country.

We recognize and acknowledge the traditional custodians of the land and sea on which we live, and work and pay our respects to elders, past, present, and future, just a few housekeeping notes. This Webinar is being recorded and will be uploaded on the RACGP website. Everyone is on mute to ensure the learning will not be disrupted by any background. Noise.

If you have questions during the Webinar, please add these, using the Q & A box at the bottom of the screen. You can also interact with the panellists and other attendees using the chat function.
We will address all questions at the end of the presentation, and if we don't, get to your question, we'll review these and provide a response offline.

If you're not asking if you're not comfortable asking a question during the Webinar, please don't hesitate to email your question through, and it will answer it offline. I'll put my email in the chat box.
I'd like to introduce Dr. Bianca Forrester, Dr. James Best, and Jacqueline Kuruppu
Dr. Bianca is a regional GP, specializing in adolescent health and systems change facilitation
As a senior lecturer at the Department of General Practice University of Melbourne. She leads the clinical learning network for the Victorian government's, doctors and secondary Schools program, and teaches adolescent health in the postgraduate medical program.
Bianca has worked as a GP. Across mainstream Primary care, community health and in health service settings. She produces the maze phase podcast for primary care professionals working with teens and is the GP For North Geelong's secondary school.

Dr. James is a GP, on the south coast of New South Wales. His practice has a specific interest in child health, particularly children with disability, and those who have experienced early childhood trauma. He is the chair of the child and young Person Health group within the RACGP GP faculty of specific interest.
Jacqueline is a fourth year PhD. Candidate at the University of Melbourne. Her research focuses on exploring the response to child abuse and neglect in general practice. Thanks.  

Bianca Forrester:
Thank you. And um before I get off, I'm just going to embarrass Jackie soon to be Doctor. She's doing her completion seminar to worry for her. PhD, So good luck with that, and I’m so pleased to be working with you on this webinar to you also, James. So, I mean. I think it's nice to start with um understanding the underpinning of this, and that is, I think we don't look great with it, whether it not united in our laws or legislation. I think this is a value. We share this right for children, the young people to live free from violence.

It's a fundamental element in policy and practice. So, with a young people and children experience um, but they experience the same negative effects with. They directly experience our exposed to all witness family violence, or it's affecting other family members. So, I think that's first place to share. And while we'll be focusing this web on in this Webinar on the impact to them directly. I think it's worth thinking about. Um their experience and the witnessing of um family balance as well. They must see risks and need that should be assessed independently.
Uh, in the context of their needs and risks of families and carers.

Um, who are not using family violence, and they can suffer that range of physical, emotional, mental, and developmental effects, including to cumulative harm and trauma, the impact of trauma experience by children needs to be understood in relation to how it impacts the development of behaviour. And so, this is this: Um, you know, underpinning for the work that we'll be presenting tonight. Um, and that any intervention is to consider that existing trauma, and how to um prevent feature uh ritual
Thank you.

So what are our learning uh outcomes for this evening? We're going to discuss the nature and prevalence and impact of child abuse and neglect. Describe early childhood needs, and how these can impact upon development, describe best practice, approach to recognizing and responding to child abuse and neglect, identify key challenges in responding um within the general practice setting and describe adverse childhood experiences and the impacts across the lifespan. Thank you.

Um, to start, I guess. Thinking about this, I’m going to position your um right where you uh most sit in general practice. Um, and that presentation a mother brings in a twelve-year-old. So, this is um based on a patient that came a client diet that came to me.

Um! Mya presents with the Mother, Teresa, of course, of change times. The reason is asking for you to write a mental health care plan for Mya. She's been struggling with struggling to settle into her new school after moving from Queensland and a recent separation, Mum and Dad separated. Dad was described as having recurrent issues with drugs and alcohol, and I can no longer live with him. My has been very quiet about it, but he's having a episodes of shaking in class.

She settles when she leaves class and has some chill out time in well being um and on history. Let's just say that this uh is not consistent with seizures. Theresa describes household difficulties with a new partner, and his kids described as chaotic. And upon review with Mya you're concerned by her descriptions of him being not a very nice man of the words she uses.

So just to put you in the picture, and we'll go into the next slide. Thanks over to you, Jackie.

Jacqueline Kuruppu:
Thanks, Bianca, and to take a bit of a segway from the case Bianca has just presented. I'm going to go through some quick by background just to introduce the theory behind the topic of child abuse and neglect so child, at least neglect or child to be, as I will call it, from here on, is considered as any intentional or unintentional act or a mission of care that results in harm, the potential for harm or the threat of harm to a child.
And there are five recognized types of child abuse, physical, sexual, and emotional abuse and neglect and exposure to domestic violence and experiencing any of these types of abuses classified as an adverse childhood experience or ace which James will speak to in a few minutes.

Um, and some risk. Factors associated with child abuse uh socioeconomic adversity and parents with mental health problems, intellectual disabilities, or a previous um history of child abuse themselves, and the WHO estimates that nearly seventy five percent of children between the ages of two and four have experienced physical and emotional abuse, and it's quite common, and the most commonly reported forms of abuse are neglect and emotional abuse and exposure to domestic violence, and these forms seem to be experienced equally by boys and girls.

uh physical and sexual, be, on the other hand, uh less common and agenda with girls experiencing unsurprisingly sexual, be more commonly than boys and boys experiencing physical abuse more commonly than girls.

And, of course, child abuse, as we heard briefly before, has devastating consequences. It's associated with learning, difficulties, behaviour problems, and mental health issues in children and adult survivors are more likely than the general population to experience physical health, complications, serious depression, and twelve times more likely to suicide.

And of course, death is an outcome that is relatively rare. Um compared to these health impacts. But it is more common that we'd like with about twelve percent of homicide victims in Australia being under the age of seventeen and next slide, and we've included some further information about the background of child abuse in our child abuse, neglect. Chapter that Bianca and I wrote with Professor Lenni, Lena Sanchi, and she um, and a lot of the presentation that we give today is based on the information that we present in that chapter. So please feel free to refer back to it next slide, and I’ll head over to James.

James Best:
Thank you, Jackie. Um, the um Your system. Now a little bit of the theory as well as I'm depending on all this. Yeah, um about parenting and early childhood needs just next slide, please.
So what does a baby your young child need people talk about The first thousand days is where you really set up a lot of this sort of stuff which is from your conception to your second birthday, and it's the two thousand days from consent to your fifth birthday is where it's most malleable in terms of uh being able to remedy if it if they had those childhood experiences happen which I’ll talk about, is it?

And also, though very importantly, they have to have loving, secure relationships. Now, that sounds like fairly self-evident, obviously, but it's not always there, of course, and this is where we can run into trouble. Um! So uh, parents will often get the first one but the second one they may. They might the well that yes, I agree with that. But their interpretation of what that means, and what that looks like can be very, quite variable. Um, in terms of what they, what's normal for them? What's happened to them when they were growing up, what happened in their community. So, um next slide

I have a tree as a symbol on the right here, where I’m talking about attachment, because I like to use this analogy of a tree is the trunk of the tree is kind of like our attachment to emotional attachment to our primary carer and other people as well in our world; but most importantly, that we have a primary care. But other people as well can be involved in the attachment.

So if you have a loving, secure relationship, then that that leads to what is referred to as much, or many of you are just kind of secure attachment. Now, the way you get a secure attachment is to have prompt, consistent and appropriate response to the stress. So when we're talking about babies, and if you're talking about response to crying, but it also keeps going on the cash, and it's not something that stops at the second birthday or the first birthday it keeps going, and it can change uh, in terms of how secure it is, and how many people are being a are attaching to so so um and also evening utero. We talk about that for a thousand days, you know. The mother being distressed and not having quarters all going through a system. If, for example, if she is a victim of violence, or is having mental health problems, so it's all part of that epigenetics that are going on in neutral. So there's a whole lot of stuff going into secure attachment, and it's an evolving process.

But what happens when it's not working that. Well, when it's insecure. Well, there's a basically three ways that it can become secure. You can have uh the care and office on.
So neglect to basically um. And we saw the extreme example, you know, fifty years ago with the Romanian orphans, uh, where they look at extreme neglect, and they had what is referred to as learnt unresponsiveness where they've learned to not be able to respond to a lot of people in an emotional connection, and which is pretty awful, and it is pretty awful uh the um.

But of course, there are degrees that that happens to, and this can lead to what is referred to as an avoided dismissive attachment. So you, you basically have trouble engaging with others, and it can also be hereditary, so it can go through it a DE generational uh, so that when they have children that they make the same way. The second way is where the care response inconsistently, and this can often be seen whether the parent or the primary carer has mental health issues, or it has uh or has drug and alcohol issues. Um, and that can lead to actually detection.

It also depends on the temperament of the child, as well as to how much these issues uh affect them, and how much it affects their attachment with their so um! Someone has a very uh a um difficult challenging temperament in their genes may be affected more than others.

And the third way we've got is a carer responding inappropriately, like we like to think about violence and aggression, and at least this term with what's called an unsolvable paradox, where the person who is actually meant to be your carer, and looking after you and giving you security, is actually a threat which obviously is incredibly destructive.

Um, So and that can lead to an avoidant – fearful attachment.
This is a slide. This is the image I get up in my screen in my practice so many times. Um, probably four or five times a week at least, I would think uh where I’m talking to parents about how the parent um. Most parents want to do the right thing. Most parents want to be, you know, connect with their kids and loving their kids and being a good parent or a good mother or good father. Um, but sometimes they just don't know how to do it, and um, and sometimes they don't even know that they're not doing it the right way and um, and so I go through this, and I just talk about the different parenting styles the four main parenting styles.

We talk about the two on the left quite uncommon uh, but quite damaging. Uh, it's not quite um unhealthy. Uh so. Um, we have to be see parenting, and you can do whatever you want. Um, You have an uninvolved which is obviously once again getting back to that neglect sort of aspect where they're not remotely connecting. And I and but those are the two compounds I deal with in terms of parenting. So it's a two on the right. And um I thought it you versus authoritarian.

Now see the X and Y axis the um x-axis is how what we expect I mean uh expectation having control. Um, uh, and I think demands in terms of behaviour. And then you have the Y Axis, which is how warm and loving and feeling how you feel. You are about to agree that that message so authoritarian people, which are often once again inherited in this style of their parents, often had an authority in some. So basically cause I said so. And you know don't you speak back, and um, and this sort of message I’m in charge. I'm your father. You do what I tell you to do uh all, mother and um, and an authoritarian parent. Once again, they've got from their own their own parents. I will look at authoritative parenting which they might not be that familiar with as permissive. They'll see you can't let them get away with it. Um and um, and so authoritative is what we want.  What do you still have expectations? You still have rules. You still have consequences, for unwanted behaviour at the appropriate age, which is usually over five um and the consequences and stuff are still delivered without losing your long time, that you Still, most of things are coming out of your mouth are in a positive sense of the negative. And if you've had a lot of the unnecessary negative stuff, that's a really good way to get that ratio done.
Excellent!

So why do we need to have expectations delivered before? Well, we, as you can see on the right here. This guy is not delivering it as well. He's an authoritative parent, that because they need that, we, we do need to have those expectations to the guidance. Because we are guiding our children. We are controlling actually the guiding, and we are teaching them um, and it's interesting. I think the words of um punishment and um and discipline. Who this is from the Latin of the harm and um uh, the discipline is from the Latin discipline which is uh to teach into the word disciple.

Um. So we want to teach our children. We need to show them the way to go. What's right, what's wrong, what, what, what doesn't work! But we need to have that wall in our once again getting back to the secure attachment stuff that we, you know, if you're having that all running time, then you'll see it as a place of safety it when things are up, that's where you could always retreat to Mom's lap and um, if you have that secure attachment. Some of you may have seen this model of the brain where we have what you purchase the flip brain with using. If this is a model where you've got the bottom of the brain being it Yeah, your brain stem your reptile brain is sometimes referred to where it's plot, right and also sensory and all that sort of stuff it's. It's real primitive sort of stuff.

And then the next part of the brain is your emotional part, your mammal brain, where you're talking about emotions and mostly connected with other people or other animals in, and that your other mammals, or and also nurturing the and that sort of stuff. So that's the next part of our brain came along evolutionary, and then we have the prefrontal cortex um, which is very much the big part of our brain. It's a lot of energy, a lot of blood supply um, and but it enables us to do this amazing stuff where we can think and we can reason, and we can. We can think together in teams, and we can problem solving.

And we can put space shuttles in a space and right symphonies. So do all these amazing things but what happens when stress comes along, we'll just deal with that the second, next slide to me. This brain development stuff. It does so over the first year or so roughly.
So when you’re an infant all of the stuff that's going on, and a little born by the It's all very brain stem. It's sensory. You see there the red, the red pathway, and it's really peaking in that first half of the first year, and then the language centres start working with. It's always up to the understanding language, and that's happening more towards the second half of first year, and that thinking bit. The blue line is really twelve months is, you know, it takes a while to get going. So we ship from Brainstem to prefrontal cortex over that year or two, if things go well, but not when things don’t go very well.

So then we get to adverse childhood experiences, first talked about with by a large study. There was bought out by the CDC. And there are a gazillion studies on this now uh lots and lots of evidence uh, just these two girls in these photos. They're actually a bit older than I would have like. I would like to have more babies and small infants, because that's where I since really have a profound effect.

Of course you can have an effect of any age, but um younger is worse, and because we are wanting to get that transition of brain stem to prefrontal cortex, and I ACE’s get in the way of that.
And this is the one that uh from uh, you'll see they have the reference from disease control. We have the abuse one that we're talking about tonight, physical, emotional, sexual. We have the neglect one we're also talking about, but physical and emotional with the household challenges like mental illness in the house incarceration of a relative mother being treated violently or exposed to domestic violence the substance abuse parental separation or divorce. So, there are other ones that have been mentioned uh in, and Some people talk about displacement and being refugees and other things that have come along as well. But these are the ones that most commonly refer to the big thing about ACE’s is the combination of them, and um.
And so, if you get, and we know we talk about ACE scores, the number of ACEs you have in your I would also like to acknowledge that it may be people in had ACES themselves in our audience. It may have had as it themselves, and that doesn't mean, you know you're stuffed up, or anything like that. It's a lot of us have had at least one or two, and a significant proportion of had three or four more, and the combination of them can be very damaging. But it could also be something that can deal from.

So we get back to this brain
So ACEs come along, boom, hypothalamus, pituitary, adrenal cortisol everywhere happening with currently. That's the point, and it's when those is happening, combination that it really affects and we get brains stem dominance assisting, and this leads to all sorts of really crappy outcomes, often and in terms of health, mental health, like expectancy, all sorts of stuff. Um. So when you think about, what does the trauma tell it in behalf of the they have a kinetic before that big um. And as to the adults, and so you know, they punch as the big second, and they on brain stem. Still, they're not thinking, and um, and this is part of the reason why.
So next lot. Look at this stuff. This is horrific stuff. I school is greater than or equal to four.

Once again, the combination. You can read them yourself. I won't read them out, but they are massive steps. Um uh real quickly to the last one, twenty times more likely to go to prison.
So uh, these are big, big, risk factors in combination. So And this is being recognized around the world in the of the world of being such an important thing into how children progress through life, and why we should be getting in and trying to rectify the score into, obviously in terms of identifying. Hey, this is our situation, and she think there's something we can do about it, even if it's just simply talking to the parents about parenting style
Exactly more bad stuff that we're talking cancers. We're all in diabetes, but it will liver a disease, and  strokes. And these graphs are all independent of other respects, like smoking and drinking, so chronic, profound odds ratio.

I love this picture of um actually was um Penny Brown, one of my our RACGP colleagues. Um uh showed me this picture, and I thought it was such so illustrated. The mother's going through trauma. She's just had something horrible happen to her. Look what the children do! Look at how they look at they’re horrified, only knowing that she's horrified.
So that that that's the stress that stress on at a maternal level, both in neutro and after child birth is so profoundly affect, the so for family affects small children, and of course, um and child abuse is leading onto. I sort of gave you all that theory about ACEs and trauma and everything like that it, which is a risk factor leading onto, because what is what is clearly positive parenting uh secure attachment.
And then what is clearly child abuse? And then there's this whole grey area in the middle. About what you know. Is it just a shouting household and a chaotic house that's in the example that Bianca gave us, for example. Um. So you know. So there is this this dynamic down on the spectrum going on

Bianca Forrester:
And it's over to me, James

James Best:
 Yes it is

Bianca Forrester:
Thank you. Um:

Bianca Forrester:
Yeah. And I think that I love the way you present that. Um, it's really interesting to kind of um put together the cortical development, and the ACEs together, and I think that makes my job really easy here. Um, you know, I think when I present ACEs is and I do this a lot with the medical students we kind of talk about how it's like the injury occurs in the first decade of life. The cracks start to show, you know, in the next decade. Um. And really, by the time you get into your third, fourth, fifth decade, that's where you're a biological impact to happen. And you see those non-communicable diseases. Um, you know that's an oversimplification but I think it really is illustrated in in what you just described. So, if we think about presentations now to primary care, and we think about well, what's walking in outdoor? Um, we're looking at um, really the fix of balance across the lifespan. So an infancy. We, you know, a tune to those headline stories of in injury, and I know that um, you know, when we went through medical school that was often the focus. So I think now, with this contemporary viewpoint, Um, you know, while we are thinking about, of course, that very pointy and um of physical and of course, sexual abuse. I'm looking out for that as part of a presentation more commonly, and as Jackie described with the statistics. It it's really being attuned to um, you know, if affect regulation. Um, you know, thinking about it as a as James described it might be the behaviour seeing in the room, or what's being presenting um, you know, by parents, and keeping it as a differential diagnosis in mind.

Um, when you see those um delays presenting, uh, of course, in childhood, as in adolescents. Um, maybe more commonly it might be um the secondary mental health problems that present um and uh, and I think as we could see uh, you know, laid out in that anxious attachment style, you start to say that mental health come out as a very much a relational pace. Um! That anxiety PTSD mood disorders um the disruptive behaviours. Um, and and I think really um another one I think of, and I didn't reference this. But um, I don't know if you're familiar with the poly Bagel, or if you think about that flat right response. So when we are in that flat, flat response, Um! And we go into our kind of active defence mechanisms. Um, you know it's not where our best learning takes place, or our best relationships um can occur. We're often um often thinking about. How do we maintain safety? So it's no wonder that um in childhood and adolescents. Um, you know kids who are um, perhaps either in a chronic re traumatization state, or perhaps um isn’t settling post a history of trauma is finding it hard to um progress academically. Um, I think it's interesting. I work in a school setting now, and I know that, as you know, that even with the way speech therapist works they can evaluate the type of speech and language delays that might be more suggestive of trauma. So, Um really a huge impact, of course, on that type of um, you know functional performance like I said, the cracks come out in that second decade, and you know I'm really an adolescent specializing GP really, what I say is that's where the risk taking stuff takes place. So always with risk taking behaviours in particular long that extreme end I'm also always thinking about what are the feelings behind those behaviours? What's happening? What's the history of this young person, and why they acting out in this way. And then, I think, into adult as James described? And Jackie described um unfortunately that not to use the word legacy, that burden of um child abuse and a history of child abuse um over one's lifetime, and that it can really take shape into um hardening of personality disorders, relationship problems that intergenerational impact of the way they provide caregiving um to their own children. And of course, in your biological impact of what we're not recognizing is that chronic arch exposure.
So next slide. Thanks. Sue

So in a in the chapter, on child abuse in the White Book, we've created a list of things to look for and many of these things I guess we've previously described and so tuning into physical abuse, emotional abuse and neglect through these lens, sexual abuse or family violence, and of course, again, like we mentioned, and in the previous slide tuning into those behavioural signs, And I think maybe at this point in time I’m happy to throw again back to Jackie and James, because thinking about well for me, what this walks in, as is, it often is. Can I have a mental health care plan, please, and its always part of my uh comprehensive assessment to think about.
Could this be part of a formulation? Could this be part of a predisposing or precipitating factor as part of the mental business Mental health needs disruptive behaviour. Sleep issues self, harm and suicidal behaviour, eating disorder, school refusal school, poor attendance and decline. Um, you know, for me again often, and I do see a pointy end through um, seeing a lot of young people independently through school-based clinics, um and over time often what I’ll find is where some of these things present, it's not uncommon for me to find there has been other historic child abuse, or some ongoing conditions of abuse, or ACEs, James yourself I mean again, I think, probably just reflecting. Some of those really can be kind of um, you know descriptions of what kind of walks into the room in primary care that you later find is lots of this stuff, um, you know.

James Best:
So um so, but with which may have something underlying it or not. So, you know, if you have someone who's got school refusal, or have a behavioural issue
What's going on? You know I have things that still happen to home. Let's just go back to the so. So, because we're seeing it the other way around, we're seeing it, I’ll tell you, is collected this stuff. But if you come in with this stuff, maybe we need to think about it and just make a few people questions. From a GP point of view that's where it's coming from.

Bianca Forrester:
Okay, Great thanks. I think we move on to the next slide. I guess magical neglect one for me is one that you know it’s one of that evolves over time, you know for me it's that over time I'll make multiple recommendations, I keep seeing them but it seems like the parents are kind of keen to engage in service, but there's not a lot of follow through or again, I don't know how this picks up for you, James, but it's not uncommon. I see this, and in my mind when you're putting up when you put up the slide of the different types of parents, I often find it's that uninvolved parent um that perhaps leaves the young person to do this all on their own, and it's that go hard to kind of tell. Am I calling this medical neglect? Is it just very uninvolved? And for me it's really where we are actually cares needed, and it's recommended. That's where I might stop thinking about medical neglect. Um, you know it It's been out of them by then, but the um, the maybe certainly they need to be like lots of attention. But but yeah, so it yeah, it's something to think about as well. Well, so let's now create this formal approach to recognizing it. Respond to child abuse and neglect so a step to approach that we suggest. So, we're working with children and families some of the key steps in vacation and response are as we describe having that awareness, the possibility of family violence and trauma, recognizing vulnerability and risk. And we'll go into this in a bit more detail. But I think James has all grounded this, and what types of things we might be looking at and looking for one hundred and one um we need to make a ha assessment of harm and make a risk assessment and provide that initial response that, in a sense I think it's important to think about that. The way we respond is part of our therapeutic intervention, and we put forward um the lives um tools something that you might reflect upon um, and in practice safety planning is important to think about. Um. Really, our position and the difficulty with this work is Jackie will describe, and when we might want to. Um consult with colleagues or professionals. Um, notifying the appropriate child protection service in your State and territory, where relevant, and then, considering that, of course, this is not one of those static things, this is dynamic. And over time, or how do we provide ongoing care? Thank you.

So, recognizing vulnerability and risk. And, as mentioned, this is possibly um repeating things a little bit. But if you think about that person in front of us when we're when we're seeing um when we are um creating that formulation, we are wondering about vulnerability or factors that make someone vulnerable and think about risk factors. Um. So, I guess the key pieces that families my experience vulnerability at some stage is dynamic, and that it may be time limited, or it could be significant and long lasting, and its effects could last through our childhood.

In considering our intervention, we need to begin with understanding the family context and making that assessment of risk and protective factors and thinking about how they balance one another out.
Um! Again, I was thinking to, and James was describing um attachment styles and thinking about um. You know that type of parenting or the type of attachment? Um, you know some of these things are things that we will tune into. But let's look at some of those um kinds of factors we think about, I guess, in my mind I tend to think about um you know the relationship with the parent. Think about the household. Think about vulnerability factors in the children, and then think about those changing circumstances over time. So for caregivers. It's that parent with substance abuse, mental illness. Um, I think it's important to you know. Think about um kids with intellectual disability, um and uh, you know sensitively, and think about um. You know what that might mean. Um in regulation to parenting um risky social or family context. So it is household family violence. That's the risk factor um positive poverty or poor housing. Um again, not as a static um, not as a static factor, But the dynamics of this financial stress or um insecure um housing and moving and transitions being difficult for families. So, thinking about those dynamic factors.

Um, where there's into generation trauma. And I think, James provides that that that kind of theoretical ration. Now, um! As to understanding um what impact that might have gone forward, and that and families that really lack social support and a very isolated I can be very vulnerable.
Um. Children with medical needs or the disability are particularly vulnerable, and of course, as we described, and as we've seen through the pandemic changing circumstances, um can tip the balance. So really, at the moment being really tuned to financial um pressures on families where there's been bereavement or illness that I’m really, I guess um might raise the threshold, or, if you like, lower the threshold um, through which people might find that tip the balance, and then thinking about what are those things that really buff up families, or mitigate risk. Those protective factors in include extended family support. It might be that person's temperament or coping style. Um, you know, I think things that are really important to recognize in in communities like um, you know, connection to cultural groups or um. You know, religious institutions where there's support, provided, of course, some of those factors can also provide discrimination or um, you know. So, it's thinking about the balance where we're. That's a positive factor within a community having a sense of uh, you know, an order or a spiritual faith can sometimes be protective as well. So, we are those protective factors in families where, despite the vulnerability and risk that you recognize, seems to be holding everything together. So, it's always important to not only look for those risk factors, but also think about those protective factors, and I think what we can recognize. Protective practice, I guess, is something we can work on building. Um, so it's kind of creating that strength-based approach to work on building.

We go to the next slide

So, um again, I think, and this is probably another way to say similar thing. This is a pyramid. I've taken this from a Victorian um framework where we think about um at the bottom of the Pyramid you know, this is the majority of people. Families in this group might have known risk factors due to significant stress in their life, and you just mindful of the fact that mal treatment or neglect might emerge in this group. And so you'll think about this group as a group that needs to be supported to reduce vulnerability and prevent harm. This group is a group we want to really engage in primary care and provide supportive interventions in the groups that are vulnerable families who are vulnerable. They might have risk factors present, and we might start to try and combat those risk factors or build those protective factors, if you like. So that's where you might start involving um community services, social services, families that are vulnerable. But and there's children who are at risk of harm. This is where we start to kind of home in on risk of harm.

This might be um, that this uh the vulnerability and risk factors. And there's those tipping points. So we start to see um stresses or tipping points. This might be where we might start to have that high threshold suspicion, and we might want investigation. And then, finally, those who we actually see. And this is where you know in my mind we talk about the grey, and we think about what's black and white. This is that black and white. We suspect this the child abuse and or neglect requires urging um attention, and sometimes um intervention by child protection. These might be the ones that we might report, and I tend to be that pointy end
Next slide. Thanks.

So if I reflect back on the case of Mya and Teresa and I've changed the picture. We're kind of thinking about um different cultures, different um presentations. Mya describes Mum's partner as being an alcoholic, and he says rude things to her. She says he and Mum always fight. It could break out of something small like Theresa being to save to favour her own children over his. He stays in bed all day, according to my, and demands to Teresa, drives his children to school on her way to work.
This means Mya doesn't have much time with the mother anymore they don’t get to really talk anymore. She worries about Mum because Mum is always crying and Mya doesn't feel like she can talk to other family members about this, because a Mum will get cross.
Okay, we'll go to the next slide.

Jacqueline Kuruppu:
Thank you. So I’m going to now really focus on um assessing harm in terms of how you would, might ask about it.
And the occasion to ask about child. We might spontaneously happen within a consult. But most of the time it might just be a bit of a gut feeling that you have um, and this is when you can do some planning around asking about abuse and assessing harm.
And so, when you're preparing to ask about child abuse, there a few important things to consider and remember, and so to move from that um level of consideration that it might be within your um set of differential diagnosis to that level of suspicion. You often do need to inquire further.
Uh, but you're only sort of asking questions. To really work out is actually a reason to be suspicious. Um, it's not your role to investigate where the child is actually happening.
It might be quite obvious, like Bianca said, you know it could be really black and white, and it's really obvious that you have to report. But in other sort of cases you only need to get up to that point where you feel that there is a suspicion that something is going on, and then it's up to child protection to really determine if that abuse is happening, and I’m sure many of you know that asking about child abuse can be extremely uncomfortable at best. So, if you do feel that, you know, asking is, is quite daunting. You know us go through some concerns with the trusted colleague.

Um, maybe do a bit of a role play if you feel that that help you. And if you are intending to ask about child abuse of course, creating that private and safe space is obviously important. And this might mean that you book a longer consult. Um. It might also mean that you have to separate the young person from their caregiver.
Um, and of course you know seeing a young person alone depends on the developmental stage and the age of their at, and some child experts say that you could sort of do this from about eight years old, but it, of course, depends on the individual circumstances.

Um, but when you are getting the young person alone it's really important to be sort of practice to know how to say it to the caregiver. So, for example, you could say something like, you know it’s part of my practice to see young people alone. Um, you know, for part of the consult. Um, just to get that, so I can provide the best care that I can for you and you’re in your child. Um, and of course you know it's really important not to imply to the caregiver you have a suspicion of abuse, because, of course, this could lead to the caregiver, you know, leaving prematurely, and can increase the risk of the child a platform away from your practice.
Um! And when having a conversation about child abuse, it's really important to discuss the limits of confidentiality, you might already have a spiel that you give new patients about confidentiality, and of course maintaining that sensitive non-judgmental open-ended approach goes without saying, and I’m sure you know you're all very familiar with providing this to next slide. Thank you.

So when you're asking a young person about child abuse, it's really important to conduct a phase in phased inquiries. So to move from? What broader questions to more specific questions?

Um! And you can begin with the presenting concern. And then for you to ask a bit more about the child's well-being um, and then finally sort of get on to safety at home. We could even sandwich it between, you know, like at home and like school and hobbies, and just general things about the child's life and The Heads Assessment can be a really good way to do this as well. I know a lot of the GP and nurses I interviewed came across a lot of abuse situations by going through the Heads assessment. I've got an example of a fee, a phase inquiry Um! For when you do get on to that topic of home life, Um! And of course some of you might have questions. Um, that work really well for you in your practice, so feel free to person in chat if you'd like to share um. But in general you can sort of begin with a general question about how things going home, and then you might probe some sort of difficulties that could be going on. So you might say, you know, growing up can be a really tough time. And so, as parents and kids don't really get along, or don't see how to eye on things, and how are your things with having things with your parents? And do you have any concerns or frustrations.

Um. And then the next question is a really good question to ask. Maybe older children, or even adolescents. So do you ever compare how your parents treat you with how your friend gets treated by their parents. And what do you think about that again? Do you have any concerns?
Um! And then you might sort of want to get into some more specific questions about. You know what happens when things were wrong at home, or when your parents were angry at you, and depending on the answer, you might. They want to flow into some more direct questions, And at this point it might be a really good idea to bring up um, you know, confidentially out the limits of confidentiality again, and sort of reintroduce manage for recording in an age appropriate manner. And of course, this space inquiry can be modified for a predicted caregiver as well. So, instead of you know, sort of saying it from it. A child would be you might say. Raising kids is really hard, you know. How does everyone get along at home? And so on and so forth.
Um, next slide. Thank you

Some more specific questions that you might want to ask could follow um this axe framework here uh, and it's just a bunch of questions. Um. So first one is, you know, has parental care done something that's made you feel afraid?
Um! And has a parent Care controlled your day to day activities or put you down now with controlling acts. Um, you want to be looking for some more extreme examples, because it is appropriate for caregivers to it. A certain amount of control over their children's um activities to provide that safe environment as they learn and grow.
So you want to be looking for things that are a bit more extreme, like being locked in their bedroom for extensive periods of time, or controlling and monitoring. If central activities like going to the bathroom um, or if they're being made to look after siblings or help their parents in another capacity that seems really excessive.
Um. And compromises their, you know, alone time, or you know time to themselves.

That's sort of the thing that you'd want to be looking for. And then the last two questions, you know, has a parental care threatened to hurt you in any way, or hits left kick to touch your private parts, or otherwise physically hurt you. Generally, those two questions depend on me as you get would require a report.
Um next slide. Thanks.

Now, as I said before, the questions that I talk through can be modified and applied to caregivers. Um, but some other questions that you might ask uh a protective caregiver could be. Have you noticed patterns in what or who triggers worrying behaviour in your child?
Or do you ever see your child safety, or do you see them fear for their safety, and those questions are just designed to open up a bit of a discussion about potential Um, child, abuse but again, if you have your own questions that work well, um!

You might like to share um, and then you know, of course you are in general practice, and you often, seeing the entire family and Family Violence Guidelines recommend that if you are seeing both a victims survivor and a perpetrator, that you continue care with only one part of the family.
Um. And, if possible, it could be best to hand over the other part to another GP in your clinical area.
And if you are supporting okay, give it. That is using a basic behaviour, or, you know, is tending towards maybe, that that authoritarian style that James was talking about, and into that spectrum of more of use. Um some questions that you might ask then would be, you know children can be really frustrating. Talk me through what happens when your child behaves, and when you start to feel that um frustration. And how do you think your child reacts when they see you frustrated or angry? And if appropriate, you might, ask reflective questions like, What sort of parent did you want when you were little? Um, what some parental caregiver do you see yourself being? And do you think that your kids actually see you that way?
Um! And next slide? Thank you. And that's Bianca.

Bianca Forrester:
So I had to go back to you. Great Thanks, Jackie. All right. So at this point we now need to um put together our assessment. We need to balance our assessment I guess, as you know, the is the ACEs vulnerability risk factors, protective factors within those um, you know actions and behaviours described or observed.
Um, the child of care givers self-assessment really important here? Um, as the type of actions, and the highest taking place is Jackie described. If we, hearing about threats or actual physical abuse. Um, then, that um generally mandates a report in, I think every state um so. Um, of course, bearing in mind um we will go into that in a moment. You'll go with that in in terms of different state legislation. But um! Our response is kind of governed by the um severity of the of the um abuse um our the person self-assessment of fear and self-assessment safety and uh, and where we see about red flags. Um, for uh um, child, abuse um. Of course we need to think about that, too, so we'll think about that high risk. Um, and that generally requires protective intervention.

I guess right down the bottom, and I know we've kind of covered this through the pyramid. But let’s just kind of reiterate again where there's vulnerability present, and maltreatment might emerge, we might think about trying to increase our enhance family support.
Um! And then we sit in those middle groups that moderate risk. Perhaps there's further um uh investigation required. Um in this one. I think you think about it as high level risk factors and vulnerability. Um! You might think that without intervention that could cause a tipping point or stress risk. A palm is not um. You know high. By that I mean, you know, severe or imminent.

And we might just kind of think, Okay, maybe this does require a bit of further investigation, and that probably does depend on which state you read, and what services are available as to what you do with this piece, and perhaps that might be something we think about in our discussion. Um, and it could also relate to our kind of threshold, if you like, of reporting which I would talk about in a little while, and then we think about that risk. So there's some risk. Factors. Um, but support and coping in to be present. Um! Self-assessment of fear is low and feeling of safety is high, and that might be both caregiver and child, if it didn't the child, if it's appropriate to assess. But it might be that you're thinking well his family really would benefit from supportive interventions. And the types of interventions. I guess we're thinking about more cover in a moment is, you know, how can we build up the strength and capacity. How can we build attachments in this um family unit. How can we perhaps help modify us adapt parenting practices.

So that might be the reason why we might refer to supportive services. Um, you know. Yeah, thank you. So we'll move on to the next slide. Thanks.
Now I think kind of want to just pop this in here. Of course, we have urgent and acute care priority. So if we, if in our assessment there's immediate safety and risk issues um, that's why we need to kind of really um work. Um with our repeat services. So where is physical issues? And maybe that person needs to go to ED, or we might need to do um specific investigations. We might need to consider the need for forensic investigation. Um! And where this severe neglect it might be that an in-patient stay is important particularly in babies, I think just to wanted to sign post um that where there's immediate high risk and safety issues Um, we would need to um access kind of emergency care, triple zero, admission that type of thing. Um! But outside of that we'll go to the next slide, where there's not that immediate we have time now, I think I wanted to really say with this slide with lives, it's almost like we could just slow things down a little and consider the importance of our response. Now as part of the beginning of our therapeutic intervention. If we suspect abuse or neglect so LIVES is a useful guide. Um! It helps us to be therapeutic in our approach. It helps us to prioritize the well being and safety of the person with us, as well as maintain, I think, a calm and restorative practice.

So it's an acronym um LIVES um starts for listen closely with the Empathy and no judgment so really creating that space for that person. It may be um, and we know from I guess, the literature, that it may be um that if that a family, or a carer or a young person, it might be the you know, eight full night time that they seek help and assistance that they decide to disclose. Um. So, taking the time to um, not rush things. This is really important consultation.
Um, and really try to listen to that person, inquire about their needs and concerns. So while we're kind of primed in form, we can often spring into action, probably the most important thing to slow down and consider is, What is it that you feel you need at the time at this time so position them as an expert um in their own lives, and what their needs and concerns are, and listen carefully to that.  Often people have been through a family and experience. Family violence uh have often made many um many interventions up until this point to achieve safety and to kind of, you know, create strategies for themselves. Um! And they will know um. So think about what they need at this time, and how you can respond to that.

Um, because it might not, maybe slightly different to your own. So I think it's a really useful starting place. Validate their experiences. So at the time when someone does disclose it's really important to validate whatever it is that they do share. So you believe and understand, and that's probably the most crucial thing that you could do. Um is to um believe, them enhance their safety, and we'll go into um a little bit more like declining. But I think this is where you need to think. Okay at this point in time. What would help um to help bring about safety for this person? Uh, physically, emotionally, psychologically, within this consult.
Um. You know what are the types of safety interventions we might start to construct?
And then how do we support them to connect with additional services It may be information. It may be social support, maybe a refuge. Um, maybe um, you know thinking about um, you know personal or professional services. Um, that could help them in at this time well go to the next slide. Thanks.
 So when we think about safety planning some really practical things to think about, so communication a safe place to go transport items to take support of someone close by. So here's some kind of really practical things. Now, um! This is kind of designed really for teens. But I guess you could really relate this to parents as well. So who has access to phone and social media? Is there a code word you could use to let people know you need help.

And of course this is something we talked a lot about during the pandemic. Um, because often um you know, in lockdown um to see Victoria, I guess. But I'm speaking from Victoria. We were thinking about how it must be for people who are locked down with perpetrators and having kind of maybe being surveyed  by perpetrators. Is there a way that could create signals or um code words, or even use of certain emojis that might let people know they need help. Um, if you had to leave home in a hurry, or if you need to finish you as a way. Where would you go? Is there a friend or relative place that you feel safe at to creating that kind of backup?
Um accommodation plan um, or is a refuge if that's not an option, how would you get there?
Um! So thinking about um, you know who's available to transport that person? Do they have a car? We have access to the car. Is there any issues around control of that type of transport or the providers that could um, you know, transport that person? Or if you're talking about teams, how is the team going to get around items to take with you? So thinking about a bag that's prepared with safe, close to toothbrush things that make you feel safe. I'm thinking about those kind of comfort items. One thing that really struck me. There was this charity that was providing um, you know, set up for um families playing from domestic violence, and one of the things that they recognized was um. The hardest time is often in those um days and weeks where, you know the kids don't have their toys a lot and have comfort items. Um! And the temptation is to go back to where it does feel safe. So thinking about pre-empting that and support someone close by, or a neighbour parent or a friend, you can help when things get scary at home. That might be the child, or it might be for the family thinking about neighbours um, and safe houses. Thanks.

So Um. So I guess it's thinking about that pointy end of safety, and how to enhance safety when we hear a disclosure of abuse.
Um. Now, if we think about um, I guess that other end of the risk assessment where we may actually be thinking about those um strength, building interventions, those people with vulnerability and risk um all history where there's been um abuse that you know they deescalated what next? So what do we do now? That's therapeutic? Um, what’s evidence based to work? And so when we um review the chapter Um, we based uh this is based on an evidence review that you can find in the chapter um, and referencing the chapter of intervention that are showing to work to help children, parents and carers. Um with um, I guess. Restorative practice. So this relates a lot to what James is describing about how the uh you know the importance of attachment to thrive and um caregiving. So where perhaps maybe families might not have um loan to those skills? Um, or whether there's something getting in the way of those skills. How can we regroup?
So under five, it's that attachment-based intervention, child, parent, psychotherapy, and perhaps even home visiting programs that have been shown to work. Um, I think it's important to be in mind in one area that it'd be nice to explore um, you know, perhaps in future white books is, What about those kids in out of home care or kids in kinship care? Um who've experienced? Probably the most pointy end version. Um! By the time they um move into kinship or foster care. Um, this group has often gone through child protection, there's been an investigation, and they are the group have been deemed to not be safe to live with families. So what type of prevent? You know interventions are we providing those for those children, and how can we help support Foster and Kinship care is to provide, you know, attachment and kind parenting. Similar things with five to twelve year old’s. Um, parenting programs, meditation programs might engage in group work. I'm like thinking about what else might help with that caregiver you're going to address as underlying issues. If there's mental health issues, AHD issues where we might start thinking about therapeutic interventions for the caregiver, and we might engage child in psychological therapy or family based therapy. Um, and also thinking about school education programs have been um shown to work. So, you know. Does the school there add off to that?

And I think it's then um one part that you know doesn't relate to is there ongoing needs of children as they develop and grow. And so one thing that I’ll often say is someone who probably works more with that second decade of life. Um is that when you get into the team stuff um often they're revisiting. Now, I’m an experience family violence when they were younger. Um! That they want to now process. So with thinking about um, Perhaps when we're looking at um later on in life. Um! And still thinking about that experience of child abuse um! How can we make sure that um therapeutic interventions for mental health are safe and appropriate for processing? Um, Those past dramatic experiences.
That's just a reflective question, I think. Thank you. You'll go for the next slide

Bianca Forrester:
uh over to you, Jackie. Thanks.

Jacqueline Kuruppu:
Okay. So now let's tackle the curly issue of mandatory reporting. Now I know there's a lot of information on this slide. Um, but I've put it up so I can show you some of the differences across States. So if we look at that um second column state of mind, you can see either reasonable belief or reasonable suspicion being listed and reasonable means basically that someone else's sound mind would come to the same conclusion as you have based on the information at hand.

And this is why secondary consultation can be a really useful step in the decision Um! To report and suspicion requires slightly more certainty than belief. But the research does acknowledge that this is still really vague and confusing terms for GP and nurses, and in that third column um abuse and neglect types that must be reported, we can see a lot of variation. So in New South Wales and Tasmania that they require all forms of child abuse to be reported, whereas places like Northern territory, WA and Victoria, a lot more narrow, and this leads me to the next slide.

Um, that you know, when making the decision to report it's really important to consider whether reporting is actually needed for the situation at hand. And this is where, being really familiar with the laws in your State and Territory, um can be useful, because,  know if you're seeing exposure to domestic violence in WA, you wouldn't really be obligated to report that, like you would in New South Wales or Tasmania, so there might be a bit of wiggle room,with  the law, where, if you can't see an immediate risk, you might just like to follow up with the family for a while, and just get more information and really build up that live response. Um! Over a couple of couple of consults, if that felt good to you.

But of course this depends on the risk um the risk level that you're saying. You might really see the potential for significant harm. Or you might feel that you don't really have the resources to respond. So you might make a report to access those resources. And of course, if the situation really isn't mandated to be recorded. You can still make that voluntary um report if you feel that the situation is serious.
And again, this is where secondary consultation comes in handy. Um, if you're sort of determining whether a situation warrants a report. But you can also seek advice from your from child Protection um service, and You can also bring your medical defence organization, and they, seeing um from me to be with um GP and nurses. They seem to be um more likely to advise you to report to be on the safe side, which, of course, is very good advice.

Um! And there might be an alternative service that you can um call as well. So in Victoria. Um. There was a service called Child first, which is now being um absorbed into the orange door.
Um, and we have equivalent services in other States and territories listed in the child of these neglect chapter. But you can ring the services to also get further advice. Um,
And another important consideration could be any potential biases. And we've talked a little bit about, you know, seeing um the whole family in general practice. But beyond this um is a concept that I've developed in my PhD. From the existing literature, and that's the personal threshold. Suspicion. So next slide, thanks to so I found um in my PhD. That each clinicians seem to have their own threshold suspicion that would activate their reporting duty. So some clinicians seem to have a really high threshold of suspicion, so they would need a lot of evidence, or really um by severity of abuse, before they thought it was appropriate to report whether, whereas others um it had a really low threshold of suspicion, and would report with less evidence or a less severity of abuse, and the personal threshold suspicion is influenced by these other three factors that we can see um in the diagram. So, for example, if we look at um, the red factor having little faith in the child protection system that raises the personal threshold of the literature because it's perceived that the that you know Clinicians suspicions were ignored by child protection, and that meant that in the future clinicians felt that they had to gather more evidence um before they thought it was appropriate to report. So then, of course, the reporting is a bit more delayed.

So it might be important to reflect on your personal threshold suspicion, and how that might compare with um colleagues in your practice or with the law when making the decision to report child abuse.
next slide. Thank you.
And in making that decision to report um. My research found that obviously the biggest concern for GPs and nurses is maintaining that therapeutic relationship.
And so some GP and nurses choose to tell their patients that they are reporting in an effort to maintain a transparent relationship. But you definitely do not have to do this child protection aren't allowed to give any identifying details about who's made a report.
But if you are the only person that your patient has told um about this situation, then you can't really get guaranteed anonymity I did explore the ways in which GP and nurses maintain the therapeutic relationship with my PhD.
Um. And some of those strategies included really emphasizing that it's illegal responsibilities to sort of saying. You know my hands are tied. I can't do anything about it, but I still like to work with you to sort of formulate a bit of a response that you and I can do on I right so really bringing in um the parent and care about, or the young person into that whole um decision about what to do next.
 
Um! Other participants um really framed reporting as an avenue to help seeking uh with the family. So in these sort of cases that sort of say, talking to a parent, you know, things seem really tough for you right now, and I don't think anyone can really do it on their own, and I think it's a good idea to let child protection know what's going on, so that we can get some access to services to help you cope with that situation. And doesn't mean, I think you're a bad parent. It just means that you're in a situation where I think we might not be the best parent that you could be.
Um, even so, sort of saying all this stuff, and going to one's actions. The decision to report can bring a lot of guilt and a lot of other emotions for GPs and nurses. So if that option is available if the option is available to you trying to make that decision in a team setting where you can really reduce the burden of responsibility.
And even if a colleague has already made a report, it's still really important for you to do your own um independent report, because this can add white um or evidence um, and contribute additional information to child protections. Um knowledge of the situation, and on the orange tile there on the slide I've got make a report. But um, I go into that. This can be really practically difficult to do for GPs and nurses. You might be waiting a long time with the phone, or you might not have answers to all the questions that child protection ask.
So it is important, if you can, to that adequate time and know that you don't have to have all the answers. Remember, child, protection is the agency that's meant to be doing the investigating um, and it's really important to be aware of the emotional labour that you're undertaking during the response to charities it can be quite emotionally exhausting, and this can lead to burnout. So putting in some limits, or bringing in some variety in it type of work that you're doing or putting in more self care, practices can really help to manage all of this um. Thank you.

So um really what my research sort of came out with was um. There was some situations where GPs and nurses will make a report, but they weren't any um there wasn't a response from child protection, and this was because um the threshold of suspicion for GPs and nurses was crossed, but it didn't reach this sort of threshold of action for child protection, which basically meant that the response to child abuse and neglect was sort of situated in the gap between these two thresholds. And I've called this gap the grey space which also speaks to that um spectrum that James is talking about where you just sort of what's grey area that you are practicing in. And you know he talked a lot about some of the strategies of attachment building or something that you can do within the grey space, but I’ll hand back over to you the anchor he's going to take you through a bit of a framework that can also be useful.

Bianca Forrester:
Thank you, Jackie. So um!
I think this is a really helpful um approach that draw more. Inform practice. Um, I think it's gaining. This idea is gaining momentum, particularly in social services. I think it's something that's really useful for us in primary care, because um, it is taking uh an approach to this type of presentation, so an approach to family violence. So um child abuse where we start with this awareness of um, this individual in front of us has experienced trauma, and we have the awareness that really has James Really, yeah, beautifully described just what's been going on for this person in the Brighton stem their emotional brain centres and in the development. And they're really holding a compassion for that and saying that, uh, you know, they really haven't got the best of things, and that we need to be very careful in our approach going forward, and where someone has experienced trauma, we think about. Okay, first step is safety. How do I kind of create the conditions for this person in this console? So not kind of going back to forward on what safety planning. Now we just think about within this consult. How can I ensure the conditions of safety and this consult, and in my practice, and going back to that underpinning that we discussed it that kind of freedom from threat or harm. Um that everyone should have the right to, and that idea that um, when working with victims, survivor’s um things that we do might inadvertently um trigger, I guess, if you like trauma. So, for example, you know, you might not, in in a circumstance, want to go back over the memories of what happened, because that might trigger that person to experience that, or we traumatize it, or if we have an awareness of someone having experience trauma, we might just be very careful with certain things like when we say um do a procedure or send them in for investigations, or, you know, refer them on um, that some of those experiences might we traumatize or trigger. So we just thinking about safety as some kind of our, you know um key principle.

And I think that in a way it also helps, because sometimes, when you uh recognize. And these presentations are complex. And as Jackie described, there is this burden: Um! By actually pivoting from um the trauma, and actually thinking, well, what can I do um for me if I kind of just think, how can I create safety? Um! And if that's all I do today. Um, I’m doing something therapeutic. I think that also frees us up as well to think about. You know what we're seeking to do therapeutically in that exchange for safety, transparency, and build trust, so that trustworthiness people have experienced trauma have had been betrayed by caregivers or being betrayed by loved ones, or had had their trust broken, perhaps time and time again. So how can we be a person in their life? Um, that builds trust, and we can do that by creating transparency, you know. Um explain the reason for our questions to find the reason for our referrals. Um being quite transparent about what we're doing,
Choice and voice so people have experienced from my have maybe been silence haven't had a choice or a voice, or being controlled, and they might not have um had that ability. Um. I mentioned before asking them, what are your needs at this time really starting with that and starting your management, planning, helping them to have the choice. Now it's difficult, I guess, where mandatory reporting might take place, or we might kind of have things that we might need to do. But it's a matter of saying within this confine of our medical, legal, and ethical responsibilities.

So what can we do that keeps this person choices um and voice, and as it says that development, of course it's appropriate to the developmental that context side to go from the children and young people collaboration. How can we work with other support services? And I think we're now increasingly talking about warm transfers. And how can we help streamline. Okay, where we are referring out um without kind of an understanding what that person's been through. There is that kind of risk of not engaging, or that person being maybe treated in the way that some kind, How can we work with other support services to streamline that um referral process or warm transfer.

Um! And how can we create that idea of empowerment for that person? I guess it's similar to choice of voice. But with someone's had their trust broken, or they being disempowered by a family violence. Um. Or you know, abusive experience, How can we help them?
I'm correct. There are conditions of empowerment. Um! There's this classic thing called the um, the drama of a victimhood um, where we can often be drawn into this either rescuer or um perpetrator role, or we can Perpetuate that victimhood. How can we, step back as a coach and help them start making choices that help them step out of victimhood into survivorship. So empowerment being done with the not to is a really small but very significant shift in our approach. So I think of this um practice, and I know we referenced Blue Not foundation. I think, James, you with Blue Not, I don't think this is kind of blue not foundation. It's been some of our Australian crew that adapted the trial of guidelines to Australian context. Is that right? Yeah. So I’m sure there's a lot more. You could, you know, find? Look into, I think, for me. The reason we wanted to put it here is that I think for me this in practice. And again, I don't know about you, James, but this actually combats some of that emotional burden that I think Jackie describes one

James Best:
um. But providing a kind of this type of approach. I think what you're describing me about this problem. These principles of chronic form practice that's really useful, because it's so turning it's going around, and I think a lot of people have come in. They hit around what it actually means. And um! That that that aspect of you being a safe place, and just being acutely aware of where this person has gone and what it might be doing to them, and just saying, look. How can I help you, And um, and not underestimating that you know. So I think all that you know the choice of voice stuff and the collaboration and doing it with them rather than to them and all that. So it's not cool just really about showing um.

I get it, I appreciate it, I I've got it, and patient centred care and therapeutic relationship and in the trauma with the trauma.

Bianca Forrester:
That's it. Safety and trust the importance of rebuilding that with someone's um been hurt by relationships in the past. Okay, thanks. So much of this much left. Um, um. We put together some. I guess resources. Um! Now some of these actually will be um Victorian resources. Um. So perhaps referencing that the um the child abuse neglect um chapters more relevant to state wide. But um, I guess I’ll probably help networks across the nation will have um referral pathways, and of course, thinking about what are the um relevant child services in your region if you want secondary consult, and of course, being familiar with your reporting um bodies in your region,
Thanks. We might move on to the next. Jackie, did you want to reference the resources? These are some of our published resources?

Jacqueline Kuruppu:
Uh, yeah, So I will draw your attention to. Of course we've got the White Book. But um! There's also the VEGA resource which was developed by um a team of researchers in Canada, and it is a really good training program. Of course it is more specific to Canadian mandatory reporting. Well, but there's still plenty of things in there that are very useful. So I highly recommend that, and then um
I and another GP. Dr. DeAya um did a similar uh, even module specific to Australia. Um, on uh identifying and responding to child abuse, neglect in practice so available um to go through as well.
Oh, um! And that's basically the training program that I just talked about um that we did is part of a suite of training modules that were developed um in in in as part of the readiness program. Um, and it looks at a whole bunch of um different. So it looks at, you know. Domestic violence. Um, I think it's the elder abuse there  a lot of suite of um, you know modules in there as well, so be sure to check that out if you're looking for more information and training

Bianca Forrester:
Yes, so sometimes we do, and from a care I guess we get to see multiple members of the family, and sometimes with one piece, you know, might said about understanding the conditions of the context. Maybe another presentation tips the balance. So my sibling presented an acute to stress as a recent discharge from emergency department. The um young person had made a attempted um suicide by overdosing on Panadol. Um, of course, a child not a less mental health services or aware, but they hadn't get followed up here. It refused to engage with family services in the past, but agrees to ring cams to engage in care upon review with the young person one hundred and fifty.

There's still no contact. I was unsure if mother had called them, I’d run mother on multiple occasions, and Mum wasn't answering the phone so um in my mind it was a sense of really we needed if they weren't going to engage in family services, we at least needed to engage um tertiary mental health services. Um, but it was difficult, because um in this situation it was difficult to reengage the mother so. Um that, you know, put me in a difficult situation. So Um, I guess It's kind of throwing over now to questions and discussion.

Bianca Forrester: Thank you.

James Best:
If anyone wants to put any questions in the chat, please feel free to do so, or anything, or even things they just want to raise or discuss while we're waiting for people to do that.
With your work in um in schools where you've got you're doing, I imagine, with high risk people that sort of thing. How do you think that differs is to what you might do within a general practice setting, and how it does it change what you do?
So I think that? Um, we will, I I've noticed, and I don't know whether things have kind of changed,

Bianca Forrester:
You know, I don’t know whether this is because of this accessible model of primary care. I mean seeing a lot of disclosures, family violence, both historic and current. So where the young people coming in by themselves, I feel more able to disclose. Um. So I don't know if that's just generally increased in mainstream primary care, or whether this is something to do with the service that we provide being a youth, friendly and accessible model in terms of resources available to us. Uh, you know It's part of the collaboration and building of trust. It's thinking about, you know who in the young person's life. Um So for the I was thinking about adolescents so twelve to eighteen year old’s, who did they trust? Who are they kind of people that are they kind of caregivers that might not be the primary care, but people that they might trust when they are in crisis or need support. And sometimes those people are school team, you know, people in in schools. Um, sometimes it's hard. I think you probably care to navigate social services. So I really enjoy the colleagues that I work with Again, if I can gain permission from the young person to um, you know, do secondary consults or talk to um student Well being, we might actually puzzle a plan in that grey space. Um, that might um work to um build the family's engagement with family services, or perhaps um yeah, engage family services, or even think about what are some of the social prescribing interventions that might work. Um, you know. So I think that schools have a with schools as a platform for health and social services uh are daily placed. Um typically often is resourcing. Um, we're lucky in Victoria to have the funded program and um I and a group. Actually, I might just give a quick plug for the Australasian School by Health Association or a new association that are trying to bring together clinicians who are interested in um building school based on services. So there is a growing movement in Australia. Um!
What else? I think we do also see kids in out of home care. I think a lot of kids in out of home care, presenting again. I think it's kind of like second decade. But second chance so often they're reaching out and hoping to access services. Maybe um mental health care services. Um whether to co that ongoing stresses, or perhaps um think about processing their experiences that you know, coming up from the past. Um! So that's certainly been an interesting space

James Best:
very enormously in jurisdiction to jurisdiction. Doesn't end from rural remote to urban. And you know just how well resource and I put people is kind of get used to knowing what's around and what's available Um, and you know, using help pathways and things like that to know that that that that knowledge um. And so please jump in. If we do. Anyone wants to any questions or something we want to write. Please check now's the time to do it. Yes, I would say across jurisdictions, you know. Again, it is hard, often isn't it to pick up the phone. But one thing I would say is

Bianca Forrester:
Especially now I don't know what it's like in other States, or whether it's, you know, Victoria, we we're having a bit of a um crisis of access in mental health services. Um! And often what's coming into primary care is that the teams are in distress, and we can't access services. Um don't forget student Well, paying might be a resource. Um, so it's not to do that we necessarily often think of in primary care. Um. But if you've got

James Best:
yeah, it is a big one. Yeah. So in my mind, I think sometimes I was never quite sure what to call the vice principal, but if they put it in well, being team often just us to speak to the latest student will be, with the family's permission. Of course I want to do. Ask you a question, James. Um, You know, when we're working with young people we'll often talk about confidentiality and privacy and safety, and we'll. We'll provide this three exceptions, and we'll say, you know, if your risk of harming yourself harming others or someone's harming you, and we've got a duty of care to report. Um, We're working with children uh and families. Um, you know how much are you signed? Posting that your responsibility

Bianca Forrester: as a mandatory reporter.

James Best:
Um, I must admit that doesn't it. It really is more an adolescent young person conversation that that um you know the setup of the privacy being where? Because it is a transition from childhood to adult food for you to say you, you need to know your what your r are, and I, and in terms of cause often they don't and um, so that clarification will be at less, and I think it's really cable with young children. I think it's different. Kettle of fish. Um, you are really seeing the young child fuelling through the prism of the parents relaying the story. Now I don't think that you I can't see how you can say to five year old or an eight year old Um, if you've got anything you want to tell me you wait for mom and Dad? You haven't? Asked him. Step outside. I think that it work. I know. So with the non perpetrator Um

Bianca Forrester:
 uh non perpetrator care keeper.
You know how much as part of letting them know about what's going to happen with disclosure. Um! You know do you set that up so that when they really I mean to me most of the stuff we're talking about tonight is a um

James Best:
from a GP level. It's not that that commonly we come across that crisis situation of someone who's disclosing uh, that's even in my practice. It's That's not that common. And um. And I think that we're more dealing with what happens before and what happens after all, the risks before that risk environments and trying to mediate that. And also someone has had a history. You know something just those in a more acute, more dramatic to a setting out I was that the Jackie would you have some knowledge on that? It What happens in terms of where,

Jacqueline Kuruppu:
 in terms of who's presenting? And
I don't know, I sort of say um, I mean Chinese is quite common, and if you are seeing the effects of you know, before I get to that point of child which is why you know, GP. And this is so ideally place because you are seeing that that period before it gets to. You know the crisis situations, or even if you're saying it, you know. Afterwards you still got that period. It's like It's difficult to believe that you wouldn't be seeing it somehow, you know, across the board a little bit um, and you know, with the whole idea of you know, speaking even twenty-eight year old. It is difficult, because he sort of think you know. How would you sort of say that? But I know that the Vega training does have scenarios with kids about that age. Um, where they talk about confidentiality manager, reporting in a really age, appropriate manner. So it is possible.

Um. But yeah, I do agree with you that most of the cheap, like the GP, cause I interview GP from regular general practice, but also about half of them came from doctors and secondary schools, and I asked them to compare their experience in both um both settings, and they did sort of say Yes, you know we're seeing a lot more disclosures in do in in secretary schools than we would be in general practice, and it's not something I’d be thinking about as much in general practice than I am in doctors and secretary schools. So I think you're right there, James. It's difficult

James Best:
to see that. And you would be saying less of it rather than you in that sort of setting of. If you're working directly with adolescents, it's a confronting. So what actually could see all the steps you were talking about with Project, and where we know that these it's really common stuff and hidden stuff, and um, and you know it is. I just don't see it being something that will pop into my head if I’m seeing it from the unless it was something that triggered it in my head, like you know, obviously both behaviours or physical signs, or anything else of something concerning

um. But some of the things you're talking about before the anger. Pardon me in terms of things like school for us all. And um, you know all those other behaviours you had on that slide. They might make it true that well, we need to maybe make some inquiries in there, but I think routinely it's. It's just from the adolescent one where you're saying upfront, because you know the three reasons why you know company, because I think that they sort of taking control of their own.

Sue Gedeon (She/Her) - on Wurundjeri Country:
Oh, sorry we got a question. We do have one question. Um. Sorry, since you're. Up At this we got a comment here. I want to appreciate the panellists for the in-depth discussion. I am a nurse from and in Nigeria My concern is the silence surrounding the occurrence of family violence In homes.
This is associated with the belief that such issues are not disclosed to health care Workers perceived to be strangers.

James Best:
Yeah. And I think that that's really important. And I'm: I think a book about what the ankle is saying. We have to have those site that's like environment, that Yes, West, this is a place you can talk about this stuff.
at least also, Tom, I want to ask you? I asked Jacqueline. Um! What is happening with the comfort of disclosure? I mean um!
Is it getting like I mean? I'm sure it's getting better over a generation but that but um! It used to be. This is the sort of thing that no one was. Believe you know it. They have. They say that about my your uncle that you know, and then and then double blind, and um and all that, and I imagine that's happening that But how could we getting it? Is what what's happening?

Jacqueline Kuruppu:
Well, I mean, it still happens. So I did have one. That GP: You sort of talked about um the case of really severe sexual abuse, and um you know it wasn't a GP: Sorry it was a nurse, and she had to report it, and of course she did. But then the family reacted in the way that you're saying um, and there was complete um disassociation um of the family with that young person, so I think, in family settings that could be happening a bit more. But I think in terms of um, how geez! And this is responding, and even the way in which you know um parents, or uh, or young people are disclosing. I think they are more comfortable about that, because I mean you have this whole dialogue in the media. Now it's a lot more accepted to talk about. Um, at least, you know domestic violence especially, and family violence a little bit more broadly, and I think you know there's a bit more of it. An idea that um, if you are in this are a little bit more. Um, Well prepared to deal with it a bit more sensitively. So you know they have that training to respond where they would, you know. Validate. Um, you know. Listen and believe, and inquire, and all that sort of thing. So I think I think it is getting better.

Um, but you know I do know that there's still there's still issues out there, and it's like you say it's super confronting um, and that's where I think the therapeutic relationship.
Um, and sort of developing. That is so important, because that's when you can sort of elicit a disclosure even without having to do too much. Because if that young personal family trusts you.
Um! They are going to say something, because, especially if they don't feel like they can do something about the situation themselves. It comes into that whole plan. Disclosure like Bianca was talking about where you know young people will make It will sort of sort of stuff out a clinician over a couple of you know, or many different consults, and even, you know a parent will do that, too.

Bianca Forrester:
Um! And that's where I think that the therapy relationship is so important, and I guess it's why I purpose it with that Um, this maybe sign posting, you know, if I am really getting into pointy end of it. I just want to remind you about your confidentiality and let you know that I’m someone mandated to report.
You know. Did you have any questions about that when that young person discloses? I've removed or conflict if I if I sign post, and I remind them, and then they disclose. I say, great, Okay. Thank you for telling me that. You know we go into lives, and now we need to enhance your safety. Remember I told you I’d need to report how we're going to do this. What do you want to be here when I make the report? Do you want to me to do separately. So choice. I'm going to report. How do you want? Where do you want to be?

You know, because it's really important. And again, that's the thing. When we actually are reporting child abuse, and we've got that non perpetrating caregiver in place again. Um, I don't know it's going to be different in every State. But in Victoria there is this idea of um, you know, working with that that caregiver um to help them have some choice about how this is handled, because they're going to know We'll listen, you know. Don't do it tonight. I'm going to pack my bag, and then I’m going to like maybe could do it in a couple of you know, in a day, or you know what I mean. Like It's going to be a little bit of stuff. Um, what we have to use a little bit of safety Discretion? Um, you know.

I want to yeah uh, but I just want to Also, just quickly before we finish off, and we're almost at time. I just do want to relate back to that um question and thank you for putting all that comment, and they keep putting it in the chat. I just had a little look at the child. Abuse some book, and of course there is a chapter on Aboriginal and Torres Strait Island violence, and also migrant refugee communities. I think it's really important.
Um to make sure we do shine a lot on culture and think about um. You know what might be the experience of someone from a community different to ours, and what impact my culture have on disclosure also thinking about James. Your parenting styles, you know, in my mind sometimes it's difficult. You think well about certain cultures. All is that. How does that see in your culture, you know, is that. And being very careful about how we understand other cultures. And I think, kind of from my practice it's um positioning. That person is expert in their own culture. Um! But thinking about, how can we support them in a in a culturally inclusive way? Um, I don't know if either of you have it. It's a treaty balances in it. You, of course you can't forget the rights of the trial that we you had in first slide. Yeah, but we do have to do.

Sue Gedeon (She/Her) - on Wurundjeri Country:
Alright, I don't think we got any more questions. Um, so just wrap it up. Um. Thank you, everyone for attending, and we hope you enjoyed the Webinar and thank you so much to our presenters. Bianca, James, and Jackie for sharing your knowledge and time this evening.
Uh please feel free to get in touch with me if you do have any further questions. Um, I did put my email in the chat box. Thank you. Have a good night.

Bianca Forrester:
Thanks a lot.