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Dealing to child neglect: some things have to change, if New Zealand's appalling rates of child abuse and neglect are to improve.

The statistics on child abuse and neglect in New Zealand are appalling. This country is the fifth worst country in the Organisation of Economic Co-operation and Development (OECD) for child deaths due to maltreatment, and we are 25th of 35 for the health and safety of children. (1)

Between 1991 and 2000 there were 91 child homicides, of which only two did not involve excessive physical abuse. (2) While child murders grab the headlines, child neglect is a far more prevalent and pervasive iniquity in our society and one from which we are signally failing to protect our most vulnerable.

According to Child Youth and Family (CYF) data, approximately three quarters of all substantiated cases of child abuse involve emotional abuse and neglect. CYF has reported that Maori and Pacific children are 4.5 and 1.6 times, respectively, to have a finding of neglect, compared to European children or those of other ethnicities. (3)

Neglect is not defined in the Children, Young Persons and their Families Act, 1989. (3) The British Government, however, defines neglect as: "The persistent failure to meet a child's basic physical and/or psychological needs, likely to result in the serious impairment of the child's health or development. It may involve a parent or carer failing to provide adequate food, shelter or clothing, failing to protect a child from physical harm or danger, or the failure to ensure access to appropriate medical care or treatment. It may also include neglect of, or unresponsiveness to, a child's basic emotional needs." (4)

Neglect has been referred to as the "Cinderella" of child welfare issues because it attracts relatively little attention, compared to child physical and sexual abuse. (5) Neglect has multifactorial causes. (6) One large 2002 review identified a list of characteristics associated with neglect. (7) These included young, single or isolated mothers, unplanned/unwanted babies, prematurity or low birth weight, low income, unemployment, poor educational achievement, family violence, substance abuse, mental health problems, caregiver history of childhood maltreatment and poor attachment, low maternal self-esteem, poorly organised families with Little positive carer-child interaction, and insensitive and unresponsive caregivers. (7)

The effects of child abuse and neglect on the developing brain are measurable (neuroimaging, animal studies, post-mortems and blood analysis), real and possibly life-long. Neglect has a significant negative effect on all the developmental needs of a child. (8) Research has examined the mechanisms by which neglect affects the developing brain. While genes determine the basic neuroanatomic organisation of the brain, the internal model that categorises experience develops gradually as the child grows. (9) Researchers have demonstrated that alterations in maternal care affect the expression of genes that regulate endocrine and behavioural responses to stress.. Moreover, there are sensitive periods when the brain cannot develop without the right environmental and stimulatory input. (10)

The more children live in a disorganised physiologic state, the less they are able to deal with stressful situations, and the more likely their development is to be damaged by exposure to traumatic situations. The brain memory areas (including the frontal cortex, amygdala and hippocampus), areas for executive function, and areas for regulation of homeostasis (brain stem and locus coeruleus) are all disrupted by trauma. (11) Trauma also affects every aspect of the neuroendocrine and neurotransmitter systems. (12) The long-term effects of such neurobiologic dysregulation include loss of self-regulation, learning and memory problems, social problems and physical illness. Abused and neglected children are far more likely to experience delinquency, teen pregnancy, mental health problems, drug use and poor academic achievement. (13)

Identifying and reporting neglect

In a review of international literature investigating barriers to nurse reporting of suspected child abuse, three themes emerged in relation to nurses' recognition and reporting of suspected child abuse. (14)

1) Factors influencing identification: Nurses reported their training was inadequate, particularly in techniques of soliciting information while maintaining a therapeutic relationship. They also reported their knowledge, particularly of emotional abuse and neglect, was limited. Nurses have sound theoretical knowledge on identifying physical abuse but nurses felt they had limited ability to gain information when abuse was suspected in the absence of physical injuries. (14)

2) The role of experience in recognition and reporting: Nurses who have had training and experience with children who have been abused have better skills in recognising and reporting it. While several studies found nurses used intuition, the nurses believed this intuition was informed by previous experience, which prompted them to look for evidence once suspicion was aroused. Nurses' perceptions on their role in reporting differed according to their particular field: Australian community health nurses felt it more important to support families in exploring strategies that assisted them, than to report abuse. Some community child nurses described difficulty discerning between deliberate neglect and "failure to measure up to middle-class standards", and often saw the issue as a social problem that was impossible to change. (14)

3) Factors that deter reporting: A commonly cited reason was nurses' fear for themselves and their families. Reporting was viewed as especially difficult in small communities, where it might be deduced who had made the report. Negative experiences with child welfare agencies also affected the decision to report. Lack of documentation was also a barrier--nurses were more comfortable reporting, if there was previous documentation of abuse. (14)

Other barriers to action include underfunding of, and inconsistency within, the agencies charged with protecting young children. CYF is underfunded for the job it is meant to do. Social workers are not immune to funding pressures and that, I believe, can compromise their care and protection role.

The Privacy Act has been cited as a reason for not developing a national register of "at risk" children. The Accident Compensation Corporation may be the only agency with a full list of a child's non-accidental injuries but there appears to be no way of using this information to identify children who are suffering abuse and neglect.

And I understand there are no systems in place in maternity units to identify women giving birth, who have had previous children removed for abuse and neglect. This means CYFS has no way of automatically knowing if other children have been born to such women.

Neglect prevention

Preventing neglect effectively is hindered by the difficulty in identifying those children and families at risk. There is also a lack of evidence on what constitutes effective interventions. (15) Targeted interventions of proven benefit are parenting education, multi-component programmes and home visiting by nurses. (3)

The response to the Safeguarding Children Initiative (SCI) has revealed a keen desire on the part of health and education professionals, lawyers and community workers to be better informed and educated on child protection issues. Thousands have already attended these free seminars in the upper South Island. The initiative was developed by three Nelson-based nurses, prompted by their identification of "yawning gaps in child protection services" (16) The initiative has been so successful, there are plans to provide these services in other parts of the country.

Well-child nurses are often better placed than other agencies to provide or facilitate appropriate interventions, as they may be the only health professionals with regular access to these homes. Home visits are essential to fully assess a child's physical and emotional environment and the potential for abuse and neglect. Seeing a mother and her child/ren in a clinic does not provide that same opportunity. Intensive nurse home visits were demonstrated by the United Kingdom Child Development Programme to reduce rates of child abuse by 50 per cent and placement on the Child Protection Register by 40 per cent. (17)

More resources need to be targeted to the most vulnerable families, particularly in areas such as South Auckland. Ironically, one of the barriers to achieving this is the Ministry of Health's funding mechanisms. (18)

The strategies employed by district health boards and other entities, eg well-child services, to meet their contracts with the ministry create inequities in health care. I suspect it is the same in CYF. Meeting "key performance indicators" (KPIs) is incompatible with providing an equitable service. This KPI-based method of funding has been demonstrated to have significant failings. (19) It requires more government regulation and monitoring, and this increases, rather than decreases costs. (20) It has also led to underfunding, rivalries between groups competing for limited funds, a focus on outputs rather than outcomes, pressure to achieve contracted numbers and fragmentation of services. Such pressures can decrease the likelihood of effective identification of, and intervention for child neglect, particularly when combined with high staff turnover and many inexperienced staff working in these services.

The 2009 Young People's Reference Group asked that communication between professionals working with children and their families be improved. (3) But an ongoing frustration for some of those working in this field is that, once they have made notification of concern to CYF, they often get no feedback from CYF on any action taken as a result of the notification. This is despite the "legislative responsibility to inform referrers of the referral outcome" (3)

The issue of child abuse and neglect is inextricably linked to wider, more complex issues like poverty, unemployment and high imprisonment rates, particularly for Maori. But it is out of proportion, compared to other OECD countries. Australia has only slightly lower child poverty rates (22) but almost half the incidence of child maltreatment deaths. (23)

Our child abuse and neglect statistics remain unchanged, despite much political hand-wringing, endless report-commissioning, working papers and working groups. The Vulnerable Children's Act and the development of Children's Teams are the latest attempts to grapple with child abuse and neglect. It is hoped these are the first steps in a practical approach to address this gaping need. All that seems to have been achieved thus far is rhetoric and "paralysis by analysis" by top-heavy ministry bureaucracies.

The health and welfare of New Zealand children must be given the priority, structure and funding needed to begin to address these inequities. Nurses have a vital role in helping do so. An increasing body of evidence on the life-long impact neglect has on physical and mental health, learning and behaviour indicates there needs to be more effective interventions. Some positive interventions, eg the provision of 20 hours of free early childhood education, have been implemented. But there are many other evidence-based interventions that deserve attention. These include: prioritising a central register of children at risk of any form of abuse; funding for well-child services that focuses on outcomes rather than outputs; better collaboration between well-child providers and CYF; specialised training in identifying and reporting abuse and neglect for well-child nurses and health workers; a multidisciplinary approach to vulnerable children; and media campaigns such as It's not okay to include issues of neglect, rather than just a focus on physical family violence alone.

If New Zealand wants to improve its woeful record on child abuse and neglect, then many of the changes need to start from the bottom up, rather than the top down, an approach that clearly isn't working. Programmes like the SCI need appropriate support and resources, and need to be nationwide. Funding and support for well-child services needs to reflect the real problems facing our youngest and most vulnerable, rather than the outdated and unrealistic notion that a finite number of visits satisfies the "universal" needs for the healthy development and growth of atl our children. There needs to be a will to "do the right thing", rather than the current patch protection and deflection of responsibility that plagues too many of the services and institutions with responsibilities for child protection. So my plea to the government is--Stop fiddling while Rome burns and start properly funding the fire extinguishers.

* References for this article are at: resources/kaijiaki/recentjssues.

Catherine van Miert, RN, BN, PGCert, works with high-needs families in South Auckland. She has extensive primary health care nursing experience, including working in Corrections, environmental health and as a case manager and medical case reviewer with the Accident Compensation Corporation.
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Title Annotation:viewpoint
Author:van Miert, Catherine
Publication:Kai Tiaki: Nursing New Zealand
Geographic Code:8NEWZ
Date:Mar 1, 2015
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