Primary Prevention:
The Health Sector: An Essential Partner in
Preventing Child Abuse/Neglect and
Enhancing Young Child Wellbeing
Bettina Schwethelm
Inter-Sectoral Consultant
CEECIS Regional Office
Outline
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Two case scenarios
Important considerations
Young child needs
Opportunities and challenges in the health
sector
• Regional priorities for action
Two Hypothetical Cases
• Case 1
• Case 2
Important Considerations
• Less than 10% of abused children come in contact
with child protection services
• Domestic violence occurs more frequently in
families of younger children (WHO, 2002)
• Most abuse and related death in the earliest years
• Caregivers most often involved
• Impact severe, lifelong, and very costly
• The health system is in frequent contact with
almost all caregivers during the early years
Basic Building Blocks for “Normal”
Development during the Early Years
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A healthy start (from conception and before)
Health & good nutrition
Contingent responding by caregiver
Warm and nurturing caregiver
Secure attachment
Stimulating environment
Safe environment
Equity Gaps Begin Early and Widen Progressively
Biological risks
Chronic under-nutrition
Iron and iodine deficiency
IUGR
HIV infection
Psycho-social risks
Poor caregiver-child
interaction
Maternal depression
Institutional rearing
Exposure to violence
Poor learning environment
Protective factors
Good nutrition
Responsive & nurturing
parenting
Safe and stimulating
environment
Health care (prenatal,
maternity, new born, infant)
Adequate family income
Lancet, 2011
Variables related to Neglect and Abuse
Child
Parent
Environment
Demanding infant
Special health care
needs
Developmental,
emotional or behavioral
disability
Premature
Unplanned, unwanted
Poor parenting
experience, abused,
neglected…
Stressors
Low self esteem
Poor impulse control
Substance/alcohol abuse
Young age
Low maternal education
Mental illness/maternal
depression
Lack of knowledge about
child rearing, developmentally inappropriate
expectations of child
Lack of social support
Poverty
Unemployment
Single parent family
Living with nonbiologically related male
Intimate partner violence
Did you know?
Research suggests that:
• For many parents, crying is the most distressing aspect of baby care. On
average, up until the age of three months babies cry for two hours a day
(more in the case of the 20% of infants who are diagnosed with colic).
• Feeding can be a challenge: short-term feeding problems are common,
and chronic feeding problems affect between a quarter and a third of all
babies.
• The tasks of caring for a baby add up to approximately 35–40 hours of
work per week for the average couple household.
• In the early months, most of the work is done by mothers; since few
fathers take care of newborns on their own, the ‘skills gap’ between
mothers and fathers often increases rapidly.
(from: UK Department of Health
http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/prod_consum_d
h/groups/dh_digitalassets/documents/digitalasset/dh_131090.pdf)
Common Child Triggers
• “7 deadly sins” (colic, awaken at night,
separation anxiety, normal exploratory
behavior, normal negativism, normal poor
appetite, toilet training resistance)
Why the Health Sector?
• Is in most frequent contact with families
• Can prevent many risk factors – primary prevention
• Can draw on extensive evidence of what promotes lifelong
wellbeing
• Interacts/accompanies families during periods of
vulnerability (pregnancy, birth, newborn period…)
• Health workers’ advice trusted
• Health workers can build relationship with families over
time
• More likely to reach excluded groups
• Can link with other community services
• Active role in case management
Child-Friendly Health Care System : Integration of Development and Child Protection
PREGNANCY and CHILDBIRTH CARE
Outreach/outpatient
Clinical
REPRODUCTIVE
– Post-abortion
counseling to prevent
unwanted pregnancies
– Post-abortion
assessment for abuse
and neglect
REPRODUCTIVE
HEALTH CARE
–YFHS
– Prevention of
unwanted pregnancies,
VAW/ girls, and PMTCT
– Harm reduction
services
Family/community
Intersectoral
Pre-pregnancy
– Early detection and treatment of disabilities and other risk
factors
– Inter-disciplinary and cross-sectoral approach to deal with
disabilities, psychosocial risks, and other conditions
– Case-management approach with periodic review involving
children in formal care and their families
–Child and family-centered hospital care
– Kangaroo Care for LBW
– Psychosocial support to women and families
– Birth Registration
– Referral and discharge information to PHC system
– Screening/treatment for syphilis, PKU and iodine
deficiency
ANTENATAL CARE
POSTNATAL CARE
NEWBORN, CHILD, and ADOLESCENT CARE
– Birth planning and
parenting education
–Assessment of risk for
abandonment/relinquishment (social networks,
economic needs…)
– Prevention of VAW
– Comprehensive support
for women with HIV
– Support to BF, bonding,
attachment
– Early detection of
parenting difficulties
– Treatment of maternal
depression
– C4D & parenting
education
– Parenting education & support
– Rehabilitation support
– Inter-disciplinary case management of children with disabilities
and/or delays
– Placement in the least-restrictive environment
– Detection and treatment of abuse and neglect and referral
– Monitoring of growth and nutrition status and treatment
– Healthy life style education for children and youth in coordination
with education sector
– Injury prevention education
FAMILY AND COMMUNITY
– Healthy lifestyles
– Promotion of delayed
marriage/union
–Community-based
harm reduction
– Peer counseling
NEWBORN, CHILD, and ADOLESCENT CARE
– Birth preparedness
– Risk assessment for abandonment and relinquishment
– BFHI (Plus)
– Home visitation for birth
preparation and parenting
education
–Assessment of risk for A/R
(social support network,
financial, VAW…)
– Referral of domestic violence
–Transport &
accommodation of
women from
dispersed
communities/
pregnant
adolescents with
no support
Healthy home care, supported by home visitation
– Home and community safety
– Healthy life styles, responsive feeding and positive parenting
– Early childhood stimulation/education
– Detection of abuse and neglect and coordination of multi-sectoral support
at the household level
– Prevention of substance abuse
– Family- and community-based rehabilitation of children with special needs
– Promotion of school completion and vocational education
Health sector coordination with Social Justice, Social Welfare, Education, and other sectors for the health and wellbeing of mothers and children
Pregnancy
Birth
Newborn - infant - child - adolescent
Common Barriers and Bottlenecks
• Weak policy environment
• Lack of clear system responsibilities and
accountabilities
• Provider accountability systems
• Provider training in young child development
and needs
• Provider support systems
• Information systems, M&E
Provider level
• Focus on acute medical needs
• Many myths, lack of correct information
– Harsh discipline builds character
– Infants and young children will forget pain
– Newborns with problems are better cared for
by professionals in a sterile or special
environment
• And fears and concerns
– Interfering in the private sphere of the family
– If a referral is made, what will happen in the
other sector?
Opportunities
HOME BASED
(In patient)
FACILITY BASED
Child birth, illness
Almost universal hospital
deliveries, pediatric care
Opportunities:
Significant contact, support
mother-child dyad, link with
other sectors (social workers)
Promote good parenting
(Out patient)
FACILITY BASED
Ante- & postnatal visits, well and
sick-child services
Opportunities:
Relatively regular, brief
contact
Can be used for information,
guidance, screening, testing,
and linking with other sectors
and services
Prenatal, post-partum,
child/mother/father/family
By community/patronage nurses,
Roma Health Mediators,…
Opportunities:
On family territory (all stressors
visible)
Non-stigmatizing, when universal
See caregiver-infant relationship
unfold
Continuum of care within and
across sectors
UNICEF Health Sector Activities to
Promote Child Wellbeing
• Hospital level: Improve perinatal care (BFHI,
quality of care during delivery, SW,
communications and counseling withbirth
registration, shelters)
• Hospital Level: Council of Europe ChildFriendly Hospital Policy
• PHC: Integrated Care for Child Development
• Home visiting
Home Visiting – the Global Evidence
HV can contribute to improved:
• Parental wellbeing
(spaced pregnancies,
maternal depression,
substance abuse)
• Parenting skills and
behaviours
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(breastfeeding/ responsive
feeding, nurturing
responsiveness to infant, less
harsh discipline, stimulating
and safer home
environments…)
Child outcomes (health,
nutrition, and vaccination;
infant sociability, exploration,
and cognitive growth…)
A FEW
Alert
Link/refer
Identify
Screen
Monitor
Support
Counsel
Advise
Inform
INTENSE
services facilitated through multidisciplinary case management
SOME
ENHANCED
Services counselling, work with caregiverinfant dyad
ALL
UNIVERSAL
health promotion, healthy life styles,
common childhood problems (feeding,
discipline), detection of difficulties,
delays and problems in caregiver-infant
relationship, access to information,
access to benefits
“Tool” for Identifying Caregivers At-Risk
for Abuse/Neglect
Difficult area for research
• Relationship of trust
• Observations over time
• Interactions with caregivers
• Community/cultural comparisons
• Experience
• Intuition
• “Tools”
Sample Tool (NL, 2004)
• Maternal isolation
– Mother intimates that she is alone, has few contacts outside
family, dissatisfied with contacts, not much support from partner,
gloomy expectation…)
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Maternal Psychological condition
– Expects baby to give abundant love, mother speaks mainly
about herself, in stress mother turns helpless, little selfconfidence, felt not loved by parents
• Maternal style of communication
– HV has feeling that info about dealing with baby does not tally.
Mother does not keep appointments, atmosphere of secrecy,
feels uncomfortable in family, mother does not take advice,
mother sets few limits for baby
Home Visiting Implementation Plan
Assist countries in strengthening community
outreach systems/home visiting (HV) to enable
caregivers and families
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Regional reference and expert groups on HV
Contribute to country assessments of HV systems
Develop policy guidance for a blended HV model
Special focus on reaching vulnerable and excluded
groups
– Build capacities of home visitors through evidencebased training package (focus: equity and inclusion)
– Identify evidence-based tools and approaches
– Promote regional exchange (Regional Conference,
Ankara)
Role of Child Protection in HV
• Shared understanding of early child
development and long-term impact of ACEs
• Shared understanding of the role of child
rights and protection within health sector
• Shared knowledge of both sectors and referral
and collaboration pathways
• Joint work on a seamless transition from
health to multi-disciplinary case management
Useful References
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U.K. Health Child Programme
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_107563
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The Pediatrician’s Role in Child Maltreatment Prevention (2010)
http://pediatrics.aappublications.org/content/126/4/833.full.pdf+html
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American Academy of Pediatrics (Jan 2012). Early childhood adversity, toxic stress, and
the role of the pediatrician: Translating developmental science into lifelong health.
http://pediatrics.aappublications.org/content/129/1/e224
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Browne, KD, Douglas, J., Hamilton-Giachritsis, C, & Hegarty, J. (2006). A community
health approach to the assessment of infants and their parents: The C.A.R.E.
Programme. Wiley-Blackwell.
•
Grietens, H. et al. (2004). A scale for home visiting nurses to identify risks of physical
abuse and neglect among mothers with newborn infants. Child Abuse & Neglect, 28,
321-337.
•
Center on the Developing Child – Harvard University
http://developingchild.harvard.edu/
Thanks You!