Improving the clinical assessment of acute presentations of child maltreatment using a quality and child rights framework

Transcription

1 Improving the clinical assessment of acute presentations of child maltreatment using a quality and child rights framework Dr Paul Hotton Vulnerable Child Fellow at Liverpool Hospital South Western Sydney Local Health District Dual Trainee in Community Child Health and General Paediatrics Dr Shanti Raman Community Paediatrician: Child Protection South Western Sydney Local Health District

2 Child Maltreatment (CM) Major public health & social-welfare problem CM associated with: Child health/developmental problems Adult mortality and morbidity (cf ACE) Strong evidence-base for medical examination in the assessment of CM. Little known about the health & social outcomes for children following assessment for acute CM.

3 Why Clinical Assessments for CM are Important Children at risk of abuse/neglect: utilize health services +++ Frontline health services (Emergency Dept. & Paediatrics) Not ideal venues for acute CM assessments Screening tools for ED poor evidence base Good evidence for comprehensive clinical assessment Clinical guidelines exist for acute CM assessment Identifies health & supports for vulnerable children

4 South Western Sydney Local Health District (SWSLHD) Area of 6,243 square km Population 919,787 rapidly growing Culturally & Linguistically diverse Many sub-populations with social risk: Small & disadvantaged Aboriginal population Newly arriving migrants/refugees

5 Acute CM Assessments in SWS Unique service Population & Community responsive Community Paediatrics Sexual Assault (SA) Services Not a tertiary Paediatric Hospital Service Joint Work Collaboration Committed to Child & Family focussed assessment / management Hospital Social Work General Paediatrics

6 Previous Study Addressing Clinical Assessments for CM CM in 2 5 % of Paediatric ED presentations Gaps & good local practice Identified minimum standards for clinical assessment

7 Minimum Standards

8 Aims of the Study 1. Describe acute presentations of CM in SWS, to one unique hospital service, during Identify health & social outcomes for children following medical assessment Support or Refute Allegations of CM Identify support and intervention needs 3. Determine if the cases fulfil established minimal standards for clinical assessment of CM. 4. Identify if acute assessments supports a child rights framework

9 Methods Gathered data from Acute Child Protection Database (Community Paediatrics & SA) For all referrals for acute assessment <16 yrs, between 1st January st December Performed simple descriptive analysis on clinical data. To identify Health / Social Outcomes To identify if MS attained and children s rights upheld

10 What Minimum Standards?

11 Findings Types of CM 204 cases referred 187 assessed 17 were phone consultations (4 SA & 13 PA) TYPE OF CM NUMBER PERCENTAGE Physical Assault (PA) 18 9 % PA + Other CM (excluding SA) 17 8 % Sexual Assault (SA) % SA + other CM including PA % Neglect 2 1 % Review of Sibling of Index case 6 3 %

12 Demographics Age & Gender AGE GENDER Type Mean Age Range SA yrs. NON SA 4.7 3wk 13yr TYPE FEMALE MALE SA 85% 15% NON SA 36% 64%

13 Demographics Ethnicity TOTAL % SA % NON SA % Area Indigenous Born Overseas Middle East Europe Asian SWS 1.7 % 32.7% 15% 8% 12% NSW 2.5 % 34.2% - 8% - Census Date 2011

14 Who Referred? 9% 8% 2% Joint Investigation Response Team (JIRT) Police Emergency 10% Community Services (CS) 12% 59% Paediatricians Other

15 Who Assessed? 2% 3% 7% 16% Community Paediatrics (CP) Joint Assessment (CP/SA) Sexual Assault (SA) 26% Phone consultation SA 46% General Paediatricians + Comm Paeds advice Phone consultation CP

16 Types of Examination Done SA : n 148 NON SA : n 39 Forensic Medical Refused Forensic Medical 6% 47% 46% 47% 54%

17 Outcome of SA Assessments OUTCOME Number (n = 148) No SA issues No SA, other CM concerns 10 7 SA - no injury, CM concerns SA - no injury SA injury documented 10 7 SA - confirmed Refused Medical assessment 9 6 %

18 Outcome of Non SA Assessments OUTCOME Number (n = 39) No Injury 3 8 Accident 8 20 Unclear 4 10 Inflicted injury Other CM 3 8 %

19 Outcomes Social & Family 51 % home with no Child Protection agency involvement 17 % home with Child Protection agency involvement 28 % were placed into Out of Home Care (OOHC) Some already removed before assessment 46% of Non SA were placed into OOCH Large proportion had JIRT (Forensic) Investigation Majority unknown outcome 15 % of case Person of Interest charged

20 More Than Just a CM Assessment 58 % of CM assessments lead to other health concerns: Chronic Medical Conditions Developmental Delays Dental Cavities Hearing and Vision concerns Behavioural issues School Difficulties Mental Health concerns Joint assessments: Better identification of health concerns

21 Minimum Standards Achieved? MINIMAL STANDARDS (MS) Results % Trained Doctors 187 / Social Worker present 179 / Protocol used 186 / Report generated 170 / Report Counter signed 170 / Report in the Medical Records 170 / Medical follow up assessment 82 / Psychosocial follow up 80 /

22 Is the Child in Mind? Timing : Mean length 1.6 days (longest 22 SA; 27 - PA) After hours 72% 28% 96 % of Out of Hours: SA OUT of HOURS IN HOURS Child accompanied by: 54% 10% 32% 4% No Carer Support person Long Term Carer Relative

23 Discussion Types of CM 70% Acute referral SA related 42% had >2 or more CM issues 17% of cases referred had no CM concerns Largely due to overcalling SA cases Neglect 1% of cases Other pathways for referrals and assessments Hard to determine Mounting evidence that Neglect can be most damaging

24 Discussion Girls higher risk of CM 75% compare to 25% Majority are SA Reflects published data Ethnicity breakdown Incompletely documented for SA only Aboriginal over representation Siblings 3% of siblings reviewed as a result of CM in another sibling SWS has alternative pathways/clinics

25 Discussion Health concerns identified in many Reflects growing international evidence Identification improved with joint / collaborative assessment Social Outcomes Unsure if acute assessments make a difference Minimum Standards Overwhelmingly achieved but Only 44 % had medical follow up Child Rights 28 % occurred out of hours Forensic need 32 % occurred with no carer/support person

26 Conclusion First study of its kind describing acute CM presentations Minimum standards for CM assessment fulfilled in most Improvements needed in follow up after acute assessment Better identification of neglect essential Difficult to determine how child rights promoting this service is

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29 Acknowledgement Cath Dunn Acting Manager of Sexual Assault Services, South Western Sydney Local Health District Rosemary Isaac Director of Sexual Assault Services, South Western Sydney Local Health District Chris Holstein Administrator of Sexual Assault Services, South Western Sydney Local Health District