Recognition and Response

Further

P4

Children's health,including mental health

1

Learning OutcomesTo recognise signs and symptoms of children and young people who are, or may be, being neglected.

Learning Outcomes

2

3

Indicators -

begging for or stealing foodfrequently hungry rummaging through rubbish bins for food gorging self, eating in large gulps hoarding food obesityovereating junk food.

Nutritional neglect

4

Denial of health care.Delay in health care.Indicators of poor health:

drowsiness, easily fatigued puffiness under the eyes frequent untreated upper respiratory infections itching, scratching, long existing skin eruptions frequent diarrhoea bruises, lacerations or cuts that are infected untreated illnesses physical complaints not responded to by

parent.

Medicalneglect

5

Neglected children have an increased risk of developing PTSD.

BUT other variables also play a part.

Neglected children are at increased risk for early behavioural problems and conduct disorder.

Effects on lifestyle and behaviour may expose individuals to higher risks.

Mental Health

6

Exposure to hazards such as -

safety hazardssmokingweaponsunsanitary household conditionslack of car safety restraints.

Environment and hazards

7

International research shows that disabled children are more likely to be maltreated than others.

Disabled children are 3.8 times more likely to be neglected.

Parenting capacity may be diminished.

(Sullivan and Knutson 2000)

Disability and neglect

8

There is a lack of general awareness of disabled children’s vulnerability.

Growth, behaviour and other problems may be seen to be the result of the disability.

Professionals need to be vigilant about feeding regimes.

(Sullivan and Knutson 2000)

Disability and neglect

9

Organic/nonorganic debates. Failure to meet expected weight and growth norms

or developmental milestones. 5% of all children have faltering growth; 25% of

children who are abused or neglected have faltering growth.

Routine growth monitoring is important: height, weight, BMI and head circumference.

Health visitors are the crucial first link. Dietetic and paediatric assessment next.

Previously known as Failure to thrive (FTT)

Weightfaltering

Lack of supervision (most deaths occur from this category).

Malnutrition or poor care can lower resistance to infection.

Failure to respond to illness in child - sudden infant death.

Failure to use preventive health care; for example, immunisation.

Parental use of drugs - intoxicated adult/lack of supervision, accidental ingestion.

(Brandon, Bauley and Belderson 2010)

10

Child death related to neglect

NB under-reporting and under-recognition of neglect in child death are both common.

11

Severe and persistent infestations (for example, scabies or lice).

Consistently inappropriate clothing.

Persistently dirty and smelly.

Faltering growth because of inadequate or inappropriate diet.

(NICE 2009)

Clinicalpresentation

Home reports which indicate a poor standard of hygiene which affects the child’s health; inadequate provision of food and living environment unsafe for child’s developmental age.

Parent/carers fail to seek medical advice for their child to the extent health and wellbeing are compromised, including if the child has ongoing pain.

(NICE 2009)

12

Clinicalpresentation

If explanation of injury suggests a lack of appropriate supervision (for example, sunburn, ingestion of harmful substance).

Repeated failure by parents/carers to administer essential prescribed treatment.

Repeated failure by parents/carers to attend essential follow-up appointments.

13

Clinicalpresentation

Repeated failure by parents/carers to engage with relevant health promotion programmes; for example, immunisation, screening and health and development reviews.

If parents/carers have access to, but persistently fail to obtain NHS treatment to their child for dental tooth decay.

14

Clinicalpresentation

15

Adverse Childhood Experiences and their relationship to Adult Health and Wellbeing.

Child abuse and neglect.

Growing up with domestic violence, substance abuse, mental illness, crime.

18,000 participants.

10 years.(Anda et al. 2008)

Adverse Childhood Experiences

The ACE study

Scientific Gaps

16

Death

Conception

Who

le L

ife P

ersp

ectiv

e

Early Death

Disease, Disabilityand Social Problems

Adoption of Health risk Behaviours

Social, Emotional and Cognitive Impairment

Adverse Childhood Experiences

The ACE pyramid

17

Some findings so far...

Increased risk of: lung cancer

auto immune disease

prescription drug use

chronic obstructive airways disease

poor health related quality of life.

18

An introduction to brain development and neglect

Brain plasticity

Neurobiology

The Romanian orphanage studies

Perry and the Child Trauma Academy

At birth 6 years old 14 years old

Illustration based on Seeman (1999)

19

During the development of the brain, there are critical periods during which certain experiences are expected in order to consolidate pathways – for example, the sensitivity and regularity of the interaction which underpins attachment with the caregiver.

Negative experiences such as trauma and abuse also influence the brain’s final structure.

In cases of severe emotional neglect some pathways will die back.

The child’s brain will be smaller.

Brainplasticity

20

The ‘new neurobiology’: traumatology (especially PTSD) and developmental neuroscience.

Neurobiological treatment goals.

Brain plasticity.

Differences between neglect and abuse.

Genetic and environmental modifications.

Neglect and the brain

21

Developments in neuroscience have given us a greater understanding of the developing brain and the impact of abuse and neglect.

Neglect and the brain

Our brains are experience dependant

Our brains expect to have

experiences

Genetic and environmental modifications

22

Neurobiology

Structures tend to be fixed by birth, but the connections and functions carry on being sorted until early adulthood.

Frontal lobe

Motor speecharea of Broca

Parietal lobe

Reading comprehension area

Occipital lobe

Sensory speech area of Wernicke

Cerebellum

Pons

Neglect and the brain

23

Chugani et al. (2001)

Romanian Orphans.

Persistent specific behavioural and cognitive deficits.

Brain glucose metabolism.

Significantly decreased metabolism.

Neglect and the brain

24

Front

Back

Front

Back

Temporal lobes Temporal lobes

Most activity Least activity

Illustration based on actual PET scan images - Center for Disease Control and Prevention

Healthy brain An abused brain

25

The Child Trauma Academy (Perry et al.).

The Child who was Reared as a Dog (Perry and Szalavitz 2007).

Neglect: the absence of critical organising experiences at key times during development.

Non-human animal studies.

Institutional deprivation.

Recovery after safe placement.

Corroboration: Romanian orphans.

Brain scans.

see www.childtrauma.org

Child Trauma Academy

26

Perry (2002)

Cumulative Impact

Early trauma and abuse

Environment and parenting

Sequelae

Risk taking behaviours

Downstreamtertiary intervention

Midstreamsecondary prevention

• Lobbying

• Educational initiatives

27

Possible points of intervention

• Risk reduction programmes

• Community based primary prevention

• Poverty, housing •Trauma recovery programmes• Parenting support

Social inequalities

Institutional power Neighbourhood

Riskindicators

Morbidityand injury Mortality

Upstreamprimary protection

A public health approach?

Further Reading

Breslau, N. and Davis, G.C. (1987) ‘Posttraumatic stress disorder: the etiologic specificity of wartime stressors’. American Journal of Psychiatry 144, 578-583. Glaser, D. (2000) ‘Child abuse and neglect and the brain - a review.’ Journal of Child Psychology and Psychiatry 41(1): 97-116. Perry, B. (2002) “Childhood experience and the expression of genetic potential: What childhood neglect tells us about nature and nurture” Brain and Mind 3, 79-100. Perry, B. and Szalavitz, M. (2006) The Boy who was Raised as a Dog. New York, NY: Basic Books. Widom, C.S. (1999) ‘Post-traumatic Stress Disorder in abused and neglected children grown up’. American Journal of Psychiatry 156(8) 1223-1229.