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Over the past four editions of Best Practice Journal we have presented a series of articles outlining the challenges and issues faced by children and young people in New Zealand who have been abused and neglected, and the people that care for them. In this conclusion to the series, we revisit key messages and highlight actions that can be taken by primary care to address this significant problem.

Almost one quarter of children born in New Zealand come to the attention of Child, Youth and Family (CYF) before their 17th birthday. More than half of these children are Māori. More often than not, these children have a range of unmet health needs and usually lack an effective adult advocate to help ensure these issues are recognised and addressed. Sadly, half of completed youth suicides in New Zealand are in young people who have been known to CYF.

Although most of these vulnerable young people are unlikely to regularly visit a primary health care provider, every contact that takes place must be seen as an opportunity to identify needs and provide solutions, or ensure that the child is referred to someone who can help. It is important to look beyond the presenting condition and explore underlying emotional, behavioural and social issues, including the care they are receiving at home.

Detecting child abuse

Neglect is the most common form of abuse in children and young people. Neglect may be physical, emotional, medical or educational. Emotional abuse is a component of all abuse and neglect. Sleep problems, complaints of physical problems (real or imagined) and anxiety can all be signs of emotional abuse. Physical abuse may be more recognisable as unexplained bruises, abrasions, burns or other injuries. Signs of sexual abuse may be age inappropriate sexual play, knowledge or interest, fear of a certain person or place or physical signs such as itching, bleeding or bruising to the genitals. It is important to remain vigilant for any signs of abuse and to explore reasons given for injuries or illness.

Children who are more likely to be abused or neglected are those exposed in their home to violence, drug or alcohol use, financial stress, parents/caregivers with mental health issues, parents/caregivers with a history of abuse or a lack of parent/caregiver supervision.

It is sometimes very difficult to identify abuse and the child themselves will not always be forthcoming about what they have experienced. It is not necessary to define the type of abuse that you suspect and it is normal to feel uncertain. Trust your instincts, know the warning signs and listen to what the child and their family are saying. Talk to colleagues, talk to CYF and if the situation is life-threatening, talk to the police. The only action that is wrong is inaction.

Mental health issues in infants

Problematic care and traumatic home situations do not just affect older children. Early neglect, abuse and parental stress have significant long-term mental health effects for infants. Many infants in New Zealand are taken into state care each year.

Signs of mental health issues in infants may include; failure to achieve milestones, difficulty in regulating emotions and impulses, inappropriate play with other children, inability to problem solve and trust issues.

The factors that increase the risk of abuse or neglect in a child are the same as those which increase the risk of mental health problems in an infant. This includes young parents, parents who are socially isolated and those who have a criminal history. Poverty increases an infant’s exposure to multiple difficulties and this disproportionately affects Māori and Pacific peoples.

“Red flags” for mental health issues in an infant include:

  • Increased aggression and disruptive behaviour
  • Signs of anxiety – “on edge”, separation anxiety
  • Lack of emotional responsiveness, apathy
  • Sleeping or eating difficulties (in conjunction with other problems)
  • A parent who does not feel bonded to their infant, has overly negative feelings towards them or fears they may hurt them
  • A parent who intimidates or is hostile towards their infant (or vice versa)

Primary care plays a role in helping to identify those families with high needs who require an integrated care approach. This may include referral to specialised infant mental health services and parenting programmes where available. Interventions that decrease social isolation such as playcentres and community programmes are also often helpful.

If you are worried that a child is not safe or being well looked after, phone:

0508 FAMILY (0508 326 459).

If you think the situation may be life-threatening, phone the Police on 111.

Mental health issues in adolescents

The most common mental health issues in adolescents are depression (and suicide), conduct disorder and substance misuse. Receiving love is the most important mental health need for any child or adolescent. Also important are the need for safety from violence and abuse of all types and the need for positive development and encouragement.

Adolescent mental health needs that primary care can help to address include:

  • Advice and protection for sexual relationships and sexual identity
  • Advice and intervention for risky behaviours such as smoking, alcohol and drug misuse
  • Assessment of nutrition and activity
  • Assessment of specific health conditions or disabilities

It is important to understand that for many adolescents, mental health needs are intertwined with family or whānau, spiritual and physical health. Rather than recognising that they have a mental health issue, many young people will express their distress through criminal behaviour, withdrawal from society, self-harm or substance misuse. Primary care clinicians need to have a broad definition of mental health problems and the ways in which they may manifest.

Young people should be given appropriate treatment and support to address their mental health needs. This may involve referral to specialist services, mentors, community groups or culturally specific programmes.

It’s about taking action

Increasing reports of injuries and deaths of children at the hands of the adults that are supposed to be caring for them and the growing number of young people who require help make for alarming statistics.

Whānau Ora and the Government’s commitment to child health issues, such as the establishment of Gateway Assessments and more funding for child and adolescent mental health services, provides a stronger infrastructure for helping to address these issues. However, it starts with individuals. One person who listens, takes action and does not ignore the problem may be all it takes to change the course of a young person’s life for the better.