Child Abuse & Neglect, Vol. 1, pp. 245-254. Pergamon Press, 1977. Printed in Great Britain.

A MULTIDISCIPLINARY URBAN RESPONSE TO CHILD ABUSE AND NEGLECT

Peter Matthews, Child Psychiatrist Department of Psychiatry, University of Saskatchewan, Saskatoon

This paper outlines the methods adopted and the difficulties encountered by a multidisciplinary group.

Saskatchewan is a self-governing province of about 1 x lO 6 within the Federal system of Canada. The University city of Saskatoon has 150,000 population and a fair degree of political autonomy. Health and social programmes are provincially administered as are certain aspects of family law. The Federal Government contributes with money and advice in selected areas of all of these. In order to effect change, a number of individuals, groups and organizations must be approached, persuaded and asked for assistance.

The complexity of organization across the country has resulted in many similarities and differences in approaches to the problem of Child Abuse. Some of these are spelled out in the recent Report (1) of the Standing Committee on Health, Welfare and Social Affairs to the House of Commons. As always when many are involved, there is a tendency to leave the answers to s~neone else. There are no specific programmes in the area of Child Abuse in Canada which could be said to be national. Central government has funded research and pilot progra-,,es but has left management to the provinces. This policy continues in the Report (1) mentioned above.

On the other hand, several of the provinces have made excellent progress in providing services. Same are shown in Table 1. Most of these programmes will be familiar and will not be discussed.

Figures for Child Battering in Canada (2) approach those quoted by Helfer and Kempe ( in provinces with established recording systems). The management of these cases has largely been the responsibility of Children's Aid Societies.

The Province of Saskatchewan operates its Child Protection Programme through a Department of Social Services. Regular top level meetings are held with other government departments but there is limited liaison and cooperation in the matter of Child Abuse. Only recently has any commitment been made to a Provincial Programme including register, telephone emergency lines and adequate publicity.

Department of Social Services progra~nes focus on general issues such as family and income support. There is a mandate for the Department to intervene on behalf of children but it is not too often implemented to a significant extent. One has the impression that a child-centered progra~ne would be very useful.

To clarify the social setting a little further, Saskatoon, the group's base, is in the center of a farming and mining area. There is a mixed ethnic

245

TABLE i

PROG

MMES

i.

Mandatory Reporting

2.

Publicity

3.

Hospital Teams

4.

Register of Cases

5.

Preventive Progr~-..es

6.

Supportive Progr~-..es

7.

Research Support

POPULATION (Millions)

PROVINCES

B.C.

ALTA.

SASK.

MAN.

ONT.

QUE.

N.S.

NFLD.

N.B.

P.E.I.

N.W.T.

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

2.4

1

.7

1.0

1

.0

8.0

6

.0

0.8

0

.5

0.7

0

.i

0.0

6

~ARLE2

PARENTS ANONYMOUS

~iTI

ZEN

GROUP

UEAC

HERS

I

~UBLIC INFO

RMAT

ION

PROVISION

?HYS

ICIA

NS

ICTION

~OFESSIONAL

GROUP

HOSPITAL

CHILDREN AND CARETAKERS i

DEPA

RTME

NT OF

30CI

AL SERVICES

JIAISON

I

IESEARCH

PRIVATE AGENCIES I

I

Z "V

D.

d°

C ~r

O O C g)

~4

248 P. Mathews

population derived from Native Canadians, German, British and Ukrainian stock. A variety of language, religion and custom makes the establishment of cultural norms very difficult yet all are interested in agriculture, natural resources and higher education. There is little unemployment, wages are high and housing is good.

There has been real concern over Child Battering for about seven years but the early attempts to establish a register of cases foundered on the issues of confidentiality, case-losing, and the rights of parents. Newer approaches to the question started in 1974 from two main sources: first, a child was killed by its parents, and a number of professional workers were exposed to the issues. They decided that not enough was being done and formed a multidisciplinary group of paediatricians, social workers and psychiatrists. This group was especially involved with serious cases and with hospitals.

The second impetus came from responses to a letter written in our local newspaper expressing concern aver the treatment of children by adults in general. The letter noted that although excellent legislation for the protection of children existed in the province, many abuses were occurring such as violent punishment, exploitation in work, abandonment of children while parents had "fun" and a general lack of consideration of the needs of the young. The challenge was accepted by a mixed group of individuals from non-involved occupations as well as from the involved. They included lawyers, mothers, teachers and so on and became the nucleus of the Saskatoon Society for the Prevention of Cruelty to Children. This use of the familiar English Society's name reminds us of the history of Child Abuse in which animals are often given superior protection. It points the lesson that even when we think we have set up adequate machinery to deal with a problem, we must remain vigilant to stop any sign of reoccurrence.

From February 1975, the two groups worked steadily with regular meetings at monthly intervals and with good liaison. They defined different areas in which they would concentrate and areas in which they would cooperate.

In Table 2, certain functions were solely operated by the Citizen Group and others by the Professionals. The four functions Joined by lines from both were Jointly organized and operated. The Professional Group was connected more with treatment programming while the Citizen Group concerned itself with preventive or anticipatory aspects. Parents Anonymous is an example of the latter.

Links were forged with national and international groups involved in the same areas ; examples being the House of Commons Committee mentioned previously and colleagues in Calgary, Alberta. Here, a similar multidisciplinary group is working on a Canadian Newsletter and a film about abuse for distribution in Canada.

From the outset, co~aunications have been emphasized. Both major groups have met monthly and all meetings have been multidisciplinary. There was general agreement that present methods were unsatisfactory. The areas most in need of change were thought to be: information, preparedness, skills at case managing and the attitudes towards those involved by all concerned. The groups define problems, outline solutions and work with the people most closely involved assisting them educate themselves using advice, resource material and personnel from the groups.

A multidisciplinary urban response to child abuse and neglect. 249

For example, in dealing with the Emergency Roan Staff and identification of cases, a scheme (Appendix A) was devised based on the H~A.I.S. implemented in Hamilton, Ontario (4) and parallelled elsewhere. This scheme was presented to meetings of the nurses, doctors, and clerks of the three city hospitals and implementation left to them. Data from these sheets is being collected and is used for research and further programming suggestions. An important detail here is that two hospitals had no problems, but in the third, a series of administrative committees and some staff resistances prevented the survey from being effectively used.

On the other hand, all the hospitals have Child Abuse Teams set up at government direction. These teams function very well as:

Hospital Educators and Consultants Collectors of Data from Current Cases, and Liaison with the Local Department of Social Services

The teams work well because of previous motivation of the members who are ready to meet with each other and discuss plans.

The Saskatoon Dual Group has covered the following aspects of Child Abuse and Neglect:

RESOURCE MATERIAL

A basic library of books, papers and films can be used by anyone interested in the subject. Most of this has been duplicEted in the Public Library for reference. The list is advertised by S.S.P.C.C. in a newsletter to public and professionals. Speakers are available on a volunteer basis to accompany the resource material and a self-operated tape/slide presentation is being made. For physicians, who are often the first to see abuse, a special telephone tape is being made available. This is part of a series of tapes which a doctor can access free of charge for a brief resume on a variety of topics.

Public and professional booklets are either prepared or are in process. They explain responsibilities and where additional assistance may be obtained.

PUBLIC EDUCATION

Specific information on how to recognize Child Abuse and Neglect and what to do with the knowledge is given in training workshops for those coming closely in contact with the problem including parents, young mothers-to-be and u-~chers. These workshops are arranged and held at the request of the groups concerned on an ongoing basis.

Television, radio and newspaper publicity has been encouraged through cooperation with Journalists who undertook to emphasize the '~elping" nature of the response. However, in our attempts at publicity, we have found that violent and impulsive actions gain extra attention for the message. Our current television commercial shows a doll being thrown violently into a crib.

250 P. Mathews

CHECKS ON PROFESSIONAL AWARENESS AND PREPAREDNESS

At the outset, telephone calls were made to the various agencies in Saskatoon which might have Child Abuse and Neglect calls to deal with. Few police, nurses, emergency rooms or physicians' secretaries had a good idea of how to cope with such an emergency. A survey of Child Abuse and Neglect as part of the training of professionals also revealed scant attention being paid to the area. Packages of information have been sent to teachers, inservice workshops have been held and posters hung in most sites of presentation advising of the services available.

PARENTS ANONYMOUS

A Chapter of Parents Anonymous has been started in Saskatoon with a group convener supplied, also babysitting, transport and coffee. This has been most successful and is currently at a point where it will soon be independent and a second group started.

FUNDING AND POLITICS

Briefs have been prepared and given to various political bodies, increasing their knowledge of the problem, requesting money, legislative change and increased attention. As a result of this activity some monies are available to support various educational aspects.

LIAISON

The successful collaboration between the two main groups and the Department of Social Services has resulted in greater availability of skilled workers on telephone lines and easier public access to the services.

Difficulties have been encountered in trying to talk with people on Child Abuse. These difficulties may be called resistances since, in most cases, there are psychological reasons for the communication problem. The first group of resistances occurs in direct case management.

Anger is felt towards the adult who harms a child. This feeling has been discussed often in papers on Child Abuse (3) and in its full form prevents effective management of a case. It forms the basis also of much of the denial that is found amongst newcomers to the fact that hi, roans can behave in this fashion to children. Both the anger and denial are dealt with by discussion of the feelings with empathic listeners. Rational consideration of the possibility of acting on the feelings is followed by calming and improved ability to cope. This anger has been faced in medical meetings, sessions with the police and with such professionals as the clergy at the bedside.

Denial is more difficult to handle in the public since there is distance between oneself and the person who needs to be convinced. Steady exposure to factual information as a method of communication has been used.

A multidiscipllnary urban response to child abuse and neglect. 251

Fear of physical harm will stop reporting or confrontation of an adult in process of beating a child. The escalation of domestic violence is, of course, a common enough sequel to ill-advised intervention between husband and wife. The answer seems to be that the intervener should be as non- threatening as possible but an adequate reserve of ferce should be available to reassure all parties. Intervention should be quiet, supportive of beater and beaten and facts should be used.

Publicity has emphasized the helping nature of intervention in Child Abuse and Neglect and this kind of information carefully presented and discussed where possible allows those witnesses of Child Abuse in a neighbourhood to report this without the fear that they are getting someone else into trouble and that the neighbour will in turn attack them. Neighbourhood support is extremely important and there are hopes that a new 'Block Parent' programme will raise the level of concern for others.

"Don't confuse me with the facts" is the response of the emotional person. However, it is Just to confuse the emotions and to create reason that the facts are provided. Many people are quick to fall back on half-heard facts and myths and decide that no programme is needed or, worse, is interfering with other social needs. There are reactions such as:

"There are alreadY programmes for Child Abuse" "Children must be punished to learn" "This is not my task"

---which are examples of misinformation and need factual correction. The publicity committees have tended to anticipate a certain amount of mis- information in any group they talked to and, for this reason, supplied them with information before, during and after discussion. Written, visual and experiential materials were used.

"I alone can deal with this problem" is a sometime professional response either stated or implied. Interdisciplinary debate produces rivalry and disagreement on theory. An example would be the medical profession's individualistic approach with the non-sharing of confidential information. This has led to lack of follow-up over time and has only recently been changing. Hospital workers with their picture of serious abuse tend to be more cautious in their views, where legal experts consider questions of rights and the law.

From the beginning, those involved have worked as a multidisclplinary group, arguing, discussing and making steady progress because they keep most strongly in mind those suffering, namely, the children and the caretakers. The main objective has been to prevent violence and, secondarily, to deal with such violence as happens in a way which will not induce more violence. Professional differences have been aired and the group has become mutually dependent and friendly.

"Let's do it now" has been the watchword since there were problems in the group trying to do too much and losing the sense of immediate action. Now meetings are structured around short term objectives and the longer term ones are dealt with en passant. Many make the mistake of working from the social milieu back to the current difficulties. For an action group which works, objectives which are worthwhile and attainable soon are important as is a rapid news service.

252 P. Mat_hews

It is most important to be informed of the state of the information possessed by those who must he convinced. Then the needed facts may be provided at the time of presentations to all levels of bureaucracy. Steady improvements have been made in the services available to children and look to continuing well into the future.

Hopefully this paper has been helpful to those who will be trying the methods over the next few years and, with this kind of united attack on an age-old human weakness, perhaps there will be a new dawn for the children of the future.

REFERENCES

i. The Report of the Standing Committee on Health, Welfare and Social Affairs to the House of Commons on "Child Abuse and Neglect". Queen's Printer, Ottawa, Canada, 1976.

2. Van Stolk, Mary, The Battered Child in Canada, McClelland Stewart, Toronto, 1972.

3. Helfer, R. and Kempe, H., Helpin~ the Battered Child, Lippincott, Philadelphia, 1972.

h. Greenland, C. and Rosenblatt, E., Earl~ Identification of Child Abuse, Dimentions in Health Service, May, 1975.

5. Child and Family Services Act, 1973, Saskatchewan. Government Printer, Regina.

A multidisciplinary urban response to child abuse and neglect.

APPENDIX CHILD TRAUMA SURVEY

A survey of accidents, poisonings, assaults and miscellaneous injuries happening to children (under 16 years) in their homes.

Name of child: U.H. # Date: 19

Injuries: Name of Doctor

Names of Siblings:

253

A

PLEASE use this check list to evaluate your impressions of the clinical examination of a child with tranma. Four or more checks should be considered a reason for much close examination and thinking "child abuse".

Check i or

0 1.

0 2.

0 3.

0 4.

0 5.

0 6.

0 7.

0 8.

0 9.

0 lO.

0 ll.

0 12.

0 13.

o 12.

more boxes:

Child aged between birth and four (h) years.

Presence of physical (inc. sexual) or psychological trauma.

Specific injuries consistent with beating, burning, rape or cutting.

Indications of one or more previous accidents.

Story of the "cause" discordant from injuries.

History of another sibling dead or injured.

Poor social support for family.

Child appears frightened of adults and/or caretaker.

Caretaker disinterested in investigation or evasive.

Caretaker hostile or unsupporting to child.

Caretaker expects behaviour in advance of child's age.

Caretaker frankly depressed, "unreal" or intoxicated.

Caretaker minimizes injury and lacks interest in treatment.

Other reasons for suspicion.

Check i or more boxes:

1. SATISFIED INJURIES OCCURRED AS DESCRIBED BY INFORMANT

2. NOT SATISFIED INJURIES OCCURRED AS DESCRIBED BY INFORMANT

3. SUSPECTED CHILD ABUSE

h. CERTAIN CHILD ABUSE

5. REFERRED TO SOCIAL SERVICES (Necessary by law for all Child Abuse)

254 P. Mathews

0 6. REFERRED TO CHILD ABUSE TEAM

0 7. CHILD ADMITTED TO HOSPITAL

Please leave completed questionnaire at the hospital Social Services Office

GUIDELINES FOR THE PHYSICIAN

IN A SUSPECTED CASE OF CHILD ABUSE

i. Take careful and detailed history.

2. Measure and chart all injuries.

B. Colour photograph all injuries.

~. Exclude coagulation defect- Hb., Film, Platelets, Bleeding Time, 1 Stage Prothrombin Time, Partial Thromboplastin Time

5. Skeletal X-ray except spine & pelvic unless clinically indicated.

6. Decide whether to handle case yourself or call for help.

7. Decide whether to admit child for protection.

8. Report incident to the Department of Social Services or Child Abuse Team.

9. Discuss your suspicions with parents and explain the need for getting extra assistance in diagnosis and assistance to parents in handling angry/sexual feelings.