Children with complex health needs

Children and young people with complex medical needs (eg diabetes, severe obesity, chronic asthma and physical and neurodevelopmental disability) are a particularly vulnerable group within the child protection and the broader service system, particularly when there are compounding family factors, such as family violence, poverty, drug and alcohol or mental health issues.

The complex care needs of these children contributes to tremendous emotional and practical challenges that families are variably able to meet. There needs to be continuity of care and support for the family in management of the child’s condition.

A child’s condition can mask underlying child protection concerns such as medical neglect.  Treatment that is narrowly focussed on medical needs can miss identification of critical psycho-social risks and this can be life threatening for the child.

Parents / carers need a high level of support to effectively manage their child’s condition in the context of their family situation. Care of this vulnerable group of children and their parents is best achieved through a partnership approach between major stakeholders including disability and health services as well as child protection.

It is critical that various professionals responsible for a child’s care have an overall picture of the family situation, the child’s progress, family adherence to the child’s treatment plan and any signs of escalating risk.

These may include:

• repeated missed appointments
• school non-attendance
• parental mental health issues
• emergency department visits
• deteriorating condition of the child

This requires continuity of information, care, progress, and engagement with other services.

Useful Resources

Victorian Department of Human Services: Child protection work with children with complex medical needs and their families practice framework – more information

Pediatrics – December 2007, VOLUME 120 / ISSUE 6: Recognizing and Responding to Medical Neglect – more information

Concerns relating to parents or carers

Medical professionals, GPs in particular, are the front line of caring for Australian families, many of whom will at some time experience mental health issues, drug and alcohol issues, domestic and family violence, homelessness and poverty. Most families who experience mental health and / or drug and alcohol issues provide effective parenting.

However, for some families, these issues, particularly in the context of co-occurring domestic or family violence, homelessness or poverty, can increase children’s vulnerability to child abuse and neglect. It is important to remember that family situations are not fixed and that these issue do not define a family.

GPs are often aware of changes and pressures and the potential stress this places on families. This makes GPs well placed to monitor families for a potential situation that may give rise to child abuse or neglect.

Stressful events that can challenge family resilience include:

• family break up
• work stress
• additions to the family
• reduction in income
• homelessness
• incarceration
• moving to a new community

You have a pivotal role to play in working with the whole family in collaboration with other professionals who are helping them – from initiating a thorough assessment of parenting capacity and safety to planning an intervention which meets the individual and collective needs of the parents / carers as well as the children and young people in the family, and promotes child safety, welfare, and wellbeing.

Useful Resources

Child Family Community Australia: Issues for the safety and wellbeing of children in families with multiple and complex problems – more information

RACGP White Book: Clinical Guidelines Chapter 6, Child Abuse – more information

Parental drug and alcohol misuse

Significant harms can arise from the use of both licit and illicit substances. For example, there is a growing evidence base about the adverse impact on foetal development from drugs and alcohol use during pregnancy.

Alcohol or other drug misuse by parents may place children in highly chaotic and stressful environments with long-term adverse consequences on their health, development, and wellbeing. Medical professionals need to engage in non-judgmental, family sensitive conversations to facilitate a protective focus on children and build on the desire to be a good parent while acknowledging the difficulties that may hamper the fulfilment of that desire.

Listen to the needs of children and young people in the family.  Know what services and supports are available for families in your area and offer contact details for relevant supports.

Useful Resources

Child Family Community Australia: Improving outcomes for children living in families with parental substance misuse: What do we know and what should we do – more information

Parental mental health

Not all children of parents with a mental health issue will experience difficulties as a result. Many parents who have a mental health problem are capable parents and cope very well.

However, parents with mental health problems are at greater risk of relationship and parenting difficulties, social isolation, and poverty.  The child-parent interaction can be compromised by factors such as:

• the severity
• chronicity
• phase of the mental health issue / illness
• environmental factors such as the degree of support from the family and community

Each of these factors increases a child’s vulnerability to various physical, cognitive, social, behavioural, and mental health difficulties.

Medical professionals need to recognise and respond in a timely and appropriate way to the needs of families where parents have a mental illness. Providing family support and intervention at the earliest stage, from the antenatal period and throughout the course of development is important.

Early identification and intervention are likely to reduce the impact of mental illness on the family unit by building resilience and reducing risk factors.

Useful Resources

Children of Parents with a Mental Illness: Promoting better outcomes for children and families where a parent experiences mental illness – more information

Child Family Community Australia: Parental mental illness: Building understanding and resilience in children – more information

Child Family Community Australia: Focus on… Supporting families where a parent has a mental illness – more information

Domestic and family violence

Domestic and Family Violence is the repeated use or pattern of violent, threatening, coercive or controlling behaviour by an individual against someone with whom they have, or have had, an intimate relationship.

While domestic and family violence can be perpetuated by any member of a family against another, the evidence tells us that violence is more likely to be perpetrated by men (predominately by a woman’s current or ex-partner) against women and children.

Cultural background, age, sexual orientation, gender identity or gender history, disability, refugee status, or isolation may increase vulnerability to the risk and effects of domestic and family violence.

Domestic violence can include:

• physical abuse
• emotional abuse
• sexual absue
• economic abuse
• social abuse
• stalking
• deprivation of liberty
• damage to property
• causing injury or death to an animal

Domestic and family violence is about power and control,  the victim is never to blame for the violence and abuse, the responsibility of the violence rests solely with the perpetrator.

Domestic and family violence is a form of child abuse, whether children experience the violence directly, witness it or know it is happening. It affects the safety, stability, and development of unborn children, infants, children, and young people, and can cause them developmental, neurological, relational, physical, and emotional harm.

Women and children will be traumatised by the impact of domestic and family violence.

Medical professionals need to recognise and act when domestic and family violence is happening. If you suspect child abuse or neglect, you should consider if domestic and family violence is also occurring.  Similarly, when working with adult clients with mental health and /or drug and alcohol issues, you should consider the possible co-occurrence of domestic and family violence.

Ask patients do they feel safe at home and / or ask patients who are showing clinical and trauma indicators of the mental and physical effects of intimate partner abuse about their experiences of abuse.

You can call the NSW Health Child Wellbeing Unit to discuss your concerns. They will consider any additional information they may have at hand in order to provide guidance around the action you should take.

Medical professionals should assist patients to evaluate and plan for their immediate and future safety, and that of their children. Work closely with specialist services including Police, child protection and family violence services to enhance safety for women and children. Help to monitor the safety of parents/carers and children by asking about any escalation of violence.

Finally, consider that men who use domestic violence frequently consider themselves victims and will frequently have an excuse to justify their use of violence.

Provide women with:

• The 1800RESPECT (1800 737732) phone number for 24/7 for counselling, information and support.
• The 1800RESPECT website provides information and support for professionals as well as patients
• The NSW Domestic violence line on 1800 656 463 for information, support and referral 24/7.
• The NSW Government Domestic Violence website has useful information for patients and professionals.

Useful Resources

Women’s Legal Services NSW: When she talks to you about the violence – A toolkit for GPs in NSW – more information

AMA: Supporting Patients Experiencing Family Violence Resource – more information

RACGP White Book: Abuse and violence: Working with our patients in general practice – more information

Self-harm in young people

Child abuse, especially sexual abuse, is a strong and independent risk factor for self-harm and suicide in adolescents and adults.  Mental health issues (depression), loneliness, and low self-esteem and substance abuse may be related to suicide ideation and suicide attempts.

It is important to remember that though related, young people who self-harm may not wish to end their lives. Rather some young people report using self harm such as cutting or burning as a tool for managing their distress.

Useful Resources

NSW Centre for the Advancement of Adolescent Health: GP Resource Kit, 2nd edition – more information

Children and young people with sexually harmful behaviour

Harmful sexual behaviour in children and young people is a serious child protection concern. Around two thirds of children with harmful sexual behaviour have experienced some form of abuse or neglect. Exposure to domestic violence is strongly correlated to the development of harmful sexual behaviour in children and young people.

Defining harmful sexual behaviours, which involves differentiating between developmentally appropriate sexual behaviour and harmful behaviours, is not a straightforward task.

NSW Health has specialist therapeutic services called New Street for children and young people aged 10-17 who have engaged in harmful sexual behaviours towards others. Medical professionals can refer clients to NSW New Street Services provided through five local health districts at six sites across NSW:

• New Street Sydney and Central Coast (North Parramatta)
• Rural New Street Hunter New England (Tamworth and Newcastle)
• Rural New Street Western NSW (Dubbo)

New Street is currently being extended to the Illawarra Shoalhaven District.

Prior to referral to New Street services, a report to the Child Protection Helpline, and a subsequent investigation of the report, must be completed. In areas without a New Street, medical professionals can contact New Street for consultation and support in working with the family.

If this service is not available in a particular area, some private counsellors can undertake the work. The Office of the Children’s Guardian administers a scheme to help you find an accredited counsellor with the necessary knowledge and skills to work with people who sexually offend against children.

Again, if you become aware of a young person ten years and over who is exhibiting sexual behaviour that harms another person, a report must be made to the Helpline. If you are uncertain about whether the behaviour is harmful or within the range of normative, consult with the Child Wellbeing Unit.

Where a child is under ten, exhibits sexually inappropriate behaviour and is also a victim of sexual assault, Local Health Districts / Specialty Networks are responsible for ensuring that therapeutic services are available through Sexual Assault Services.

Where a child is under ten and is not a victim of sexual assault, therapeutic services for children exhibiting sexualised or sexually abusive behaviours are provided by trained counsellors in Child and Family teams, Child and Adolescent Mental Health Services, and Child Protection Counselling Services.

Useful Resources

Jannawi Family Centre: Wiley Park centre providing child protection and family support services  – more information

Rosie’s Place: Mt Druitt centre providing counselling and assistance for children affected by abuse – more information

NSW Office of the Children’s Guardian: finding a counsellor accredited to work with people who sexually offend against children – more information

UK National Institute for Health and Care Excellence: guidelines on harmful sexual behaviour among children and young people – more information

Brook: UK young people’s sexual health and wellbeing charity sexual behaviours traffic lights tool – more information

Child Family Community Australia: Young people who sexually abuse: Key issues – more information

Child abuse that has occurred within institutions

People who have been abused in an institution such as a school, health facility, out of home care, or sporting facility may seek medical attention from their doctor. It can take some people many years to disclose child abuse, particularly when sexual abuse was involved. Disclosures may occur well into adulthood, even decades later.

As a medical professional you may be the trusted person who hears such disclosures from the person for the first time.  A disclosure of childhood abuse by an adult survivor is a very significant event and if not taken seriously can be very detrimental.

If it happened in an institution and the perpetrator is still working in a role which includes contact with children, other children could still be at risk.

Steps to responding appropriately

• Show care and compassion
• Adopt a position of belief
• Offer your support (including linking the person to appropriate  health and other services)
• Consider whether other children may still be at risk today from the alleged perpetrator.

If you are a non-clinician, inform your manager or another health worker, if you are concerned.

If you are a clinician, consider reporting and other obligations to act.

Useful Resources

Australian Institute of Family Studies:more information Acknowledging complexity in the impacts of sexual victimisation trauma –