Safeguarding is an international health priority

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Safeguarding is an international health
priority Prof Kevin Browne Professor of Forensic
Psychology Child HealthInstitute of Work,
Health and Organisations (I-WHO) University of
Nottingham
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Safeguarding Children is an International Health
Priority CPHVA Conference Southport, 16 Oct 2009
Professor Kevin Browne, PhD. Chair of Forensic
Psychology and Child Health Centre for Forensic
and Family Psychology, Institute of Work, Health
Organisations (I-WHO), University of
Nottingham, NG8 1BB, UK. Kevin.Browne_at_Nottingham.a
c.uk
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International Concern for Violence Against
Children, 2006
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Infanticide and child abuse in the European Region

• 1,500 (11) of 27,900 deaths in children under 15
  are due to violence
• The likelihood of child homicide in CIS is three
  times that in the EU
• The majority of these deaths are due to child
  abuse

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USA Child Fatalities by Age (N272)
Infants and toddlers are most at risk of fatal
maltreatment
(Bonner Crow, Child maltreatment fatalities in
Oklahoma 1987 t0 1996 Ten years report, 1997)
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Shaken Baby Syndrome (SBS)

• What is it? - It is a head or neck injury which
  can happen when an infant or a young child is
  shaken.
• What happens? - A babys head is large and heavy
  for its weak neck. Muscles tone in the neck, to
  maintain an upright head posture, is yet to fully
  develop and the weak neck can break. The
  developing brain can also bang against the hard
  shell of the skull and cause intracranial
  bleeding and haemorrhage. This can result in
• Brain damage
• Spinal Cord Injury
• Paralysis
• Retardation
• Blindness/Eye damage
• DEATH

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Extent of Child Maltreatment in High-Income
Countries

• Each year, approximately 4 to 16 of children
  experience physical abuse and 1 in 10 experience
  neglect or psychological abuse.
• During childhood, it is estimated that between 5
  and 10 of girls and up to 5 of boys experience
  penetrative sexual abuse and up to 3 times this
  number are exposed to any type of sexual abuse.
• Gilbert et al (Jan 2009) The Lancet Series on
  child maltreatment

•   

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Rate of child protection registration per 10,000
children by age for England at 31 March 2008
(DfES, 2007)
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Integrated Management of Child Abuse and Neglect
Does the Child have a condition associated with
child abuse and neglect? IF evidence of
physical injury or unusual genital discharge, OR
low weight and/or malnutrition, OR developmental
delay and/or disability, OR not immunized OR
delay in seeking health care. THEN CHECK FOR
SIGNS OF CHILD ABUSE AND NEGLECT

• OBSERVE AND CHECK
• Evidence of suspicious physical condition/injury
  from likely child abuse (e.g., multiple bruises
  of different ages, unusual discharge, lesions or
  scars on genitals or anus, whip marks, immersion
  scalds and fractures in children less than one
  year).
• Delay by parent/caregiver in seeking help for any
  injury with no valid reason.
• Lack of explanation or story inconsistent with
  injury or genital discharge.
• Inadequate physical care of child illness
  ignored, not-immunized, poor condition of skin,
  teeth, hair and nails, child unsupervised.
• Abnormal child behavior sexualized behavior,
  aggressive hyperactivity, frozen hypervigelance,
  avoids visual contact with caregiver.
• Abnormal parent/caregiver behavior careless,
  punishing, angry, defensive, insensitive,
  over-anxious, low self-esteem, depressed.
• Risky family circumstances history of family
  violence, alcohol/drug addiction, mental illness,
  social isolation, child disability,
  neglect/abandonment.

Classify signs of child abuse
Browne, K., Leth, I., Lynch, M., Mangiaterra, V.
and Ostergren, M. (2002)
NB LISTEN TO WHAT THE CHILD SAYS
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Extent of Recurrent Victimisation and the Failure
of Tertiary prevention

• In the UK and USA, referrals to child protection
  agencies have monitored the number of
  re-referrals, where another episode of abuse or
  neglect has been inflicted on a child who is
  already registered as a victim of maltreatment.
• Rates of Re-referral range from 5 to 24 within
  1-4 years follow up depending on the
  effectiveness of the social services
  intervention.
• Where a child has been referred on at least 2
  occasions, the risk of further victimisation
  significantly rises(Hamilton Browne, 1999).

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West Midlands police statisticsBrowne, K.D. and
Hamilton C.E. (1999). Police Recognition of Links
between Spouse Abuse and Child Abuse. Child
Maltreatment, 4 (2) 136-147.)

• Child maltreatment cases
• 13 offenders cautioned or charged.
• 17 offenders arrested.
• 64 no further action by police.
• 27 previously referred to the police
• Spouse abuse cases
• 16 offenders cautioned or charged
• 24 offenders arrested
• 72 no further action by police
• 47 previously referred to the police

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Consequences of Child Maltreatment
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Consequences of Child Maltreatment (contd).
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Effects on Brain Development(Schore, 1994
Perry, 1997, Glaser ,2000)

• Babies of depressed mothers 48 show reduced
  brain activity particularly in the left frontal
  cortex (which is associated with joy interest
  anger),
• Early experiences of persistent neglect and/or
  trauma result in neurophysiological changes in
  the brainstem and midbrain leading to anxiety
  impulsivity poor affect regulation, and
  hyperactivity.
• Deficits in cortical functions result in poorer
  problem-solving, and impoverished capacity for
  empathy. Such children become the delinquents and
  psychopaths of the future (Gerhardt et al.,
  2004).

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Evidence from Brain Scans
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Proportion of all children under 3 years who are
in institutional care, 2003 (blue estimates)
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Attachment theory and the Internal working model
(Bowlby, 1969 Ainsworth, 1978 Crittenden,
1988 Main 1989)

• Parenting Style Positive
  Positive model of self model of
  others
• Available co-operative Secure
  
• Rejecting controlling Avoidant -
• Neglecting, unreliable Ambivalent
  -
• Frightening unavailable Disorganised
  - -
• Importance of the first few years of life for the
  quality of the parent-infant relationship (i.e.
  secure attachment) for a range of outcomes. New
  relationships are developed based on the internal
  working model, defined from early relationships
  in childhood Sroufe et al., (2005).

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Link between Maltreatment and Delinquency(e.g.
Falshaw Browne, 1997, 2002)

• The childs first relationship, the one with
  the mother,
• acts as a template permanently moulds the
  individuals capacity to enter into all later
  emotional relationships Schore, 2001.
• Researchers have reported high rates
• (70 to 80) of delinquent children in local
  authority secure accommodation and young offender
  institutions have suffered some form of
  maltreatment in their childhood - 66 re-offend
  in 12 mnths.
• Young offenders redirected to specialist foster
  care do better 33 re-offend in 12 mnths.

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CRIME AND VIOLENCE
Percent
Source Widom, C.S. (1998) Childhood
Victimization Early adversity and subsequent
psychopathology. In Dohrenwend, B.P. (Ed.)
Adversity, stress, and psychopathology. (Pp.
81-95) NY Oxford Univ. Press.
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The Victims Potential for Violence

• Negative effects of childhood maltreatment are
  not inevitable with later childhood experience of
  positive relationships.
• 5 out of 6 child abuse victims do NOT progress
  onto offending behaviour (Widom, 1989, 1991).
• Protective factors, such as positive parenting
  and school experiences, may reduce propensity
  toward delinquency and antisocial behaviour.
• Pattern of abusive experiences important
  (Finkelhor, 1995) Maltreated by more than one
  person increases the potential for violence in
  the victim (Hamilton and Browne, 1998,1999, 2002).

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Cycle of Violence (Adapted from Patterson et al,
1989)
Middle childhood
Early childhood
Late childhood and Teenage years
Social isolation and Peer rejection
Child antisocial Behaviour and poor Self esteem
Poor parenting, Abuse, neglect and violence
Member of gang/ deviant peer group
Delinquency and crime
Early Adulthood
Truancy And Academic failure
Violent Thoughts And aggressive attitudes
Teenage pregnancy/parenthood reinforcing the
cycle of violence
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Implication for optimum investment
SourceJ Heckman D Masterov (2005) Ch 6, New
Wealth for Old Nations Scotlands Economic
Prospects
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Financial Costs of Child Maltreatment to Society

• Medical care for victims
• Mental health and substance abuse programmes for
  victims or offenders
• Criminal justice system expenditure on
  prosecution and treatment of offenders
• Legal costs for public child care and the
  rehabilitation of family break down
• Social welfare costs for social work provision
  and the prevention of delinquency
• Costs to the educational system in providing
  specialist educational provision for children who
  are developmentally delayed or who under perform
  at school (WHO, 1999, 2002, 2007)

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Cost of Child Maltreatment to UK Society per
Annum in 1996

• Total UK economic cost for child protection per
  annum estimated at 735 million pounds
• (The National Commission into the Prevention of
  Child Abuse, 1996)
• Social Services 71,
• Home Office 21,
• Health Service 6,
• Welfare Service 2 of expenditure
• Child Maltreatment is also responsible for at
  least 10 of the expenditure of mental health and
  prison services due to 1 in 5 victims becoming
  offenders. Plus 348 million pounds sterling could
  be added to the total cost of child maltreatment
  in England and Wales 1.1 Billion per year.

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Violence is a public health issue, WHO 2002
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World Report on Violence and Health (2002)

• Views child abuse and neglect in the broader
  context of child welfare, families and
  communities.
• From a health service perspective, this requires
  the integration of good practices across three
  areas of health service provision to families and
  children
• i) pregnancy and child birth
• ii) management of child health development
• iii) targeting services to families with a high
  number of risk factors associated with child
  abuse and neglect.

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The Public Health Approach

• Population-based
• Emphasis primary prevention
• Multidisciplinary and Multi-sectoral
• Evidence based

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The public health approach

• Focuses on populations rather than individuals
• The health and developmental needs of children
• The health and capacity of parents to meet the
  needs of children
• The social determinants of child maltreatment
• The cultural/environmental context of child
  maltreatment

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Levels of Prevention

• Primary Prevention with Universal Services
  offered to the whole population on a routine
  basis.
• Secondary Prevention with Targeted Services
  directed at high risk groups and offered
  intervention before maltreatment.
• Tertiary Prevention with Specialist Services for
  treatment of families/institutions where
  parents/caregivers are maltreating the children.
  Intervention is offered only after significant
  harm has occurred.

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The Build up of Health Services that Children and
their Families Receive

Hospital Teams
Specialist Services - 1/10 of targeted families
Targeted Services - 7 of population
Universal Services
To all
Primary Care Teams
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Primary care of children to prevent child abuse
and neglect

• Primary prevention
• services offered to everyone
• good practices in mother-baby/per-inatal care
• home visits by health workers
• education of parents and caregivers
• school programmes on parenting and child
  development
• day nursery places
• telephone help lines
• drop-in community centres

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Primary prevention by promoting positive
parenting skills and sensitivity

• HARSH WORDS
• HURT
• SHUT UP
• STOP IT
• GO AWAY
• YOURE STUPID
• YOURE BAD
• WISH YOU WERE NEVER BORN

• KIND WORDS
• HELP
• PLEASE
• THANK YOU
• WELL DONE
• YOURE CLEVER
• YOURE GOOD
• I LOVE YOU

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Does home visiting prevent childhood
injury?Roberts Kramer, BMJ 199631229-33
(6 January)

• Systematic review of 11 randomised controlled
  trials of home visiting programmes up to 1995.
  Four studies examined the effect of home visiting
  on injury in the first year of life. Conclusion
  Home visiting programmes have the potential to
  reduce significantly the rates of childhood
  injury.
• Later Systematic reviews show that antenatal and
  postnatal home visiting programmes can be
  effective in promoting a range of outcomes
  including parenting and child behaviour problems,
  child cognitive development, accidental injury,
  and the detection and management of PND. (Elkin
  et al, 2000 Bull et al, 2004)

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Does the public health approach work?

• Back to Sleep Campaign reduced infant mortality
  as a result of cot deaths, termed sudden infant
  death syndrome (SIDS) by 75 in 15 years
• Parents advised to place their babies to sleep on
  their backs and not let baby get too hot (or
  cold)
• Parents advised not to smoke in same room as baby

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Families in a Five Year HV Study

• Abuse No Abuse Risk Factors
• (N106) (N14146)
• 30.2 1.6 Violent Partners (RR 23x)
• 31.1 3.1 Indifferent Parents
• 48.1 6.9 Single Parents
• 70.8 12.9 Socio-Economic Problems
• 34.9 4.8 Mental Illness
• 19.8 1.8 Parent Abused as Child
• 21.7 6.9 Infant Premature
• 12.3 3.2 Separated at Birth
• 29.2 7.7 Teenage Parent
• 27.4 6.2 Step-Parent
• 16.0 7.5 Less than 18months between births
• 2.8 1.1 Disabled Child
• Significant difference between abusing and
  non-abusing families (PltO.05)

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Effects of Screening a Population to Predict
Child Maltreatment in Surrey, England.
From Browne Herbert (1997) Preventing Family
Violence p. 121
Screened Population 14,252 births
7 per 1000 Incidence
106 Abusing Families
14,146Non Abusing Families
68 Sensitivity at Birth
94 Specificity at Birth
34 false negatives(Misses)
72 abusers identified(Hits)
892 false positives(Alarms)
13 254non abusers identified
13 288 LOW RISK
964 HIGH RISK
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Parents who Abuse

• More negative, hostile and punitive than
  non-maltreating parents and react more negatively
  to ordinary parental challenges (e.g. infant
  crying)
• Unrealistic attitudes and expectations of young
  children and
• Poor perception and empathy for a childs needs
• Belief in the use of punishment to control the
  child (often inconsistent and impulsive)
• Puts own emotional needs first (often with role
  reversal - parentification)

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Secondary Prevention targeted services (Olds et
al, 1993, 1997)

• Home visits by community nurses to young
  first-time mothers with socio-economic problems
  in the first two years of the childs life
• RCT found differences both mothers and children
  on fifteen year follow-up after visits compared
  to young first-time mothers not visited
• Less child abuse and neglect.
• Fewer births after the first child for unmarried
  women.
• Less family aid received.
• Fewer problems with alcohol and drugs.
• Fewer arrests by Police.
• Net dividend of 180 (or Euros) per family when
  cost of service is compared to savings on Social
  Welfare provision in 1993

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NURSE FAMILY PARTNERSHIPSTHREE GOALS

• Improve pregnancy outcomes
• Improve child health and development
• Improve parents economic self-sufficiency
• Case load 25 first time mothers per Nurse Health
  Visitor.
• (4 HVs to 1 HV manager)
• 5HVs per 100 targeted families

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60min Visitation Schedule

• 1/week first month
• Every other week through pregnancy
• 1/week first 6 weeks after delivery
• Every other week until 21 months
• Once a month until age 2

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DfES 7 million project FAMILIES SERVED

• Low income pregnant women
• Usually teens
• Usually unmarried
• First-time mothers

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Accepted for NfP pilot programme in England
(Targeted programme)

• More than 3,500 names received
• 42 (1403) definitely eligible
• 87 enrolled (1217)
• 88 lt20 81 20-23
• Further 22 possibly eligible
• 7 not contactable
• 1 not enrolled, language issues
• 10 not enrolled, programme full
• 4 No details
• 34 not eligible

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Main ineligibility reasons

• Wrong geographical area
• gt28 week gestation
• Miscarriage/fetal death
• For 20-23s those employed or with qualifications
• NfP too expensive for capacity building to a
  universal national service

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Vulnerabilities of NfP Pilot sample

• 80 without 5 or more A-C GCSEs
• 78 not employed
• 67 not living with partner
• 75 below poverty line
• 24 report physical abuse in past 12 months, 11
  during pregnancy
• 50 BMI lt or gtrecommended range
• Claimed that simple selection system of young
  first time mothers will identify appropriate high
  risk group NOT TRUE!

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Analysis of NFP screeningfor economic problems
using Surrey Data.

• Of 603 mothers with economic problems, 31 (5)
  mothers were subject to child protection
  procedures within 5 years.
• Of these 31 mothers 9 (29) were first time
  mothers and 22 (71) had more than one child.
• Therefore, targeting first time mothers would
  miss 71 (the vast majority) of poor families who
  maltreat their child.

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Analysis of NFP screening for first time mothers
using Surrey Data.

• Of 409 single mothers under twenty one, 342 were
  first time mothers and 67 had more than one
  child.
• Within five years, 3.5 (n12) of the first time
  mothers were subject to child protection
  procedures in comparison to 12 (n8) of those
  with more than one child.
• Therefore, targeting only first time mothers
  would miss 40 of those young single mothers who
  are suspected of maltreating their child.

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Books that support the WHO training and
information pack on the prevention of child abuse
and neglect, Wiley 2006 2002.
Also see Craig, Browne, Beech (2008) Assessing
Sex Offenders, Wiley
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