Joanna Alexander, Shanti Raman, Terence Yoong, The health, developmental and service needs of vulnerable children in South Western Sydney Identifying the best fit model of assessment and care Thanks you and Good morning. This morning I would like to speak to you about the health developmental and service needs Joanna Alexander, Shanti Raman, Terence Yoong,

Overview Consequence of early childhood adversity Community paediatric clinics for vulnerable children Research from our clinics Best model of assessment and pathways to care

Consequences of Early Childhood Adversity

Early Childhood Adversities Child abuse and neglect Parental substance abuse Parental mental illness/intellectual disability Domestic/family violence/family dysfunction Placement into foster care

Early Childhood Adversity: effects Range of health, developmental and behavioural concerns Affect health and wellbeing through to adulthood Cumulative relationship of exposure and outcome Intervening early can make a difference Interventions most effective when commenced before significant health/ behavioural issues emerge There is a substantial body of literature world wide that clearly defines the effects of ECA including that there is a range of health developmental and behavioural concerns for children, and that the effects of these concerns affect health and well being well into adulthood. There is a cumulative relationship between exposure and outcome so that the greater the number of adversities a child is exposed to the greater the influence on outcome. WE know that intervening early can make a difference and tha interventions are most effective when commenced before significant health and behavioural issues emerge,

Substance Use 10% of children live in households where there is parental substance abuse or dependence 4.3% of pregnant women 15-44 years illicit drug use (US survey) 75% of clients with drug and alcohol problems also have a mental health concern

Out of Home care in Australia 12-13,000 children enter care every year 35, 895 children < 17 years in care in 2010 Indigenous children over-represented > 8 times New South Wales largest number of children in care

Community Paediatric Clinics for vulnerable children in South Western Sydney

South Western Sydney (SWS) Most populous/ethnically diverse health district: 20% of the NSW population 40% language other than English spoken at home Significant urban Aboriginal population Largest child population in NSW Second largest number of children in OOHC in NSW Rapidly growing area with poor communities: Large number of recent migrants High unemployment High proportion of families on welfare

Community Paediatric Clinics for vulnerable children The target group are children for whom significant child protection concerns have been identified Child has experienced abuse, domestic violence or neglect Child is in out-of-home care Parental mental health issues Parental substance misuse Parents with developmental disability

Community Paediatric Clinics - SWS KARI Clinic Comprehensive health assessments for Aboriginal children entering foster care Branches Clinic Targeting children with adverse perinatal risk/OOHC Substance using parents Parents with a mental illness Parents with intellectual delay Vulnerable Child Clinic Services children with child protection concerns

The KARI Clinic Commenced late 2003 partnership between KARI Aboriginal Resources Inc (NGO) South Western Sydney Area Health Service DoCS NSW Multidisciplinary Paediatrician, Psychologist, SP, OT, PT Culturally appropriate service delivery Standardised assessment tools used Monitoring and evaluation built into Clinic Quarterly management meetings of key stakeholders Follow up visits of clients

Branches and Vulnerable Child Clinics Branches commenced 10 years ago Service children identified as ‘at risk’ in perinatal period Provide out of home care assessment Vulnerable child clinic Acute assessment clinic for child identified as ‘at risk’ Comprehensive medical and psychosocial assessment Referrals from health workers, case workers (CS or NGOs) Single appointment Staffed by Community Paediatrician + Psychosocial worker Standardised assessment tools used rarely

Strengths-Based Model of Assessment Each child/ family has strengths supporting development acting as protective factors to reduce impact of adversity Aim to identify positive /negative influences on development considering individual, family and environmental factors Develop solutions which draw on the resources and protective factors around the child Recommendations building on existing strengths more likely to be effective in resolving any issues

Protective Factors Individual Factors Family Factors Community Factors Social skills, easy temperament Problem solving skills Attachment to family IQ and School achievement Family Factors Supportive, caring parents Parental employment Family harmony Access to support networks Community Factors Positive school climate Sense of belonging / bonding Opportunities for success at school and recognition of achievement Access to support networks, pro-social peer groups Participation in community groups Strong cultural identity

Risk Factors Individual Factors Family Factors Community Factors birth injury/disability/low birth weight Insecure attachment Poor social skills Low IQ, educational difficulties Family Factors Poor parental supervision and discipline Parental substance abuse Family conflict and domestic violence Social isolation / lack of support networks Community Factors School failure Negative peer group influences Bullying Poor attachment to school Neighbourhood violence and crime Lack of support services Social or cultural discrimination

Research

Research Audits of Community paediatric clinics Three separate studies looking at each clinic individually Different researchers Data looking at clients attending clinics 2003 – 2009 Summary of the data from the 3 studies

Aims To describe the health, psychosocial and developmental needs of children attending Community Paediatric clinics for vulnerable children in SWS To describe the referral pathways and functioning of these clinics To develop recommendations for a model of assessment that best suits the needs of the children

Methods Retrospective Analysis of clinical records Data collected Kari: First 100 patients attending (from 2003) Branches: 2006-2009 Vulnerable child clinic: 2007-2008 Data collected Demographics Referral source Risk exposure Health, developmental, behavioural concerns Recommendations KARI - Progress

Patient Profile Demographics KARI Branches Vulnerable Child Total Number 99 124 98 Age (years) Mean 4.7 3.95 4.6 Gender Male 54% 59% 56% Cultural Background Indigenous 100% 32% - NESB 21% Caucasian 47% Referrals Welfare 73% 79%

Parental History Kari % (n=99) Branches % (n=124) Vulnerable Child % Substance use 89 73 65 Intellectual Delay - 7 Mental Health Disorder 23 48 33 Mental health and drug concerns 37

Risk of Harm Concerns Kari % (n=99) Branches % (n=124) Vulnerable Child % (n=98) Neglect 100 92 57 Domestic Violence 35 72 Physical Abuse 30 - 19 Sexual abuse 2 OOHC 63

Health Issues Concerns Kari % (n=99) Branches % (n=124) Vulnerable Child % (n=98) Incomplete immunisation 50 29 34 Vision 35 25 26 Hearing 44 28 Dental 36 33 Nutritional concerns - 19 Referral to specialist 30 59

Developmental and Behavioural Issues Concerns Kari % (n=99) Branches % (n=124) Vulnerable Child % (n=98) Global Dev Delay 27 24 39 Speech Delay 54 36 45 Fine Motor 33 20 26 Gross Motor - 19 Behavioural 48 52 Educational 64

Discussion Specialised community paediatric clinics established in SWS for early identification and assessment of vulnerable children Significant rates of physical health problems and developmental concerns Encounter barriers in access to health services including access to preventative health

Discussion Patient Profile Children referred close to school age Mean age: 4.4 years Children referred close to school age Missing out on early intervention services The majority of children referred to the clinic by Community Services (>73%) Already exposed to significant adverse effects

Discussion Almost a third of the children were indigenous 1% of the total population of SWS is Indigenous Aboriginal children in OOHC have a similar range of concerns as other children in care Needs are exacerbated: immunisation rates Reflects disadvantage faced by urban Aboriginal population Children of non-English speaking backgrounds were under-represented May represent difficulty in accessing services

Discussion Close to half of children had behavioural concern 2/3 of had educational difficulties ¼ found to have developmental delay Majority had more than one health problem 1/3 needed specialist medical referral Over 90% of children were referred to health and early intervention services Most of the health and developmental problems identified were in the mild range

Discussion No difference in these needs between children in OOHC or parental care All have exposure to social adversities irrespective of present home setting The range of health and developmental problems identified in our cohort is similar to that identified in other studies

What about Strengths? (KARI Clinic) 16% of children were doing well at first visit 34% of children reviewed showed improvement Characteristics of children doing well or improving No significant differences on demographics Stable care Noted by clinicians to be positive, have pleasing temperament, good at recruiting adults

Limitation Retrospective cross-sectional design with highly selected clinic cases and lack of controls Largely welfare-based referral source A prospective cohort study following up vulnerable children proactively would be an ideal follow up study

Conclusion Children exposed to adversity have special needs Important to identify concerns early to facilitate intervention Better links between maternity, child health, hospital, community and welfare services are necessary Ideal to service community clinics with professionals trained in psychosocial assessment Strength based mode of care works well in identifying protective factors and vulnerabilities Although the model of care is important, good pathways to care between services are invaluable

Best-fit Model of Care An appropriately placed service pathway to assessment and care to help identify ‘at risk’ children early Model ideally staffed by Paediatric and Psychosocial workers with knowledge of early childhood adversities Pathway and model needs to link well with intervention and multi-disciplinary services Pathway needs to balance benefits of early identification versus ‘medicalisation’ of social problems

References Australian Institute of Health and Welfare. Child Protection Australia 2006-07. Child welfare series no 43. Cat no CWS 31 Canberra Australia AIHW. 2008 Health Series Profile (2006) Our Population: Demographic Profile of Sdney South West Area Health Service. Cashmore, J. (2011); The link between child maltreatment and adolescent offending: systems neglect of adolescents; Family Matters; Issue 89; pp 31-41; Australian Institute of Family Studies Daniel, B & Wassell, S (2002); Assessing and Promoting Resilience in Vulnerable Children, Vol 1 - The Early Years; Jessica Kingsley Publishers; UK Delima, J & Vimpani, G (2011); The neurobiological effects of childhood maltreatment; Family Matters; Issue 89; pp 42-52; Australian Institute of Family Studies Dubowitz, H., Kim, J., Black, M., Weisbart, C., Semiatin, J. & Magder, L., (2011a);Identifying children at high risk for a child maltreatment report; Child Abuse & Neglect; No 35; pp 96-104; Felitti, VJ., Anda, RF., Nordenberg, D., Williamson., DF., Spitz, AM., Edwards, V., Koss, MP. & Marks, JS. (1998), Relationship of childhood abuse and household dysfunction to may of the leading causes of death in adults: The Adverse Childhood Experience (ACE) study; American Journal of Preventative Medicine, Vol 14(4), pp354-364 Burke NJ etal (2011). The impact of adverse childhood experiences on an urban population. Child abuse and neglect, 35, 408-413.

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