1. 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,

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

3. Consequences of Early Childhood Adversity

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

5. 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,

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

7. 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

8. Community Paediatric Clinics for vulnerable children in South Western Sydney

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. Research

18. 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

19. 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

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

21. 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%

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. References
Australian Institute of Health and Welfare. Child Protection Australia 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 ;
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), pp
Burke NJ etal (2011). The impact of adverse childhood experiences on an urban population. Child abuse and neglect, 35,

36. Thank you
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