Treatment of abused children

Assessment of the child

 Appearance, growth, personality

 General health
 General functioning: emotions, behaviour, self care

 Development including language, communication and social

relationships

 Intelligence, cognitive and academic functioning

 Mental health: diagnosis of specific disorders

 Attachment and significant relationships

 Wishes and feelings

 Information from records and interviews

 Geneogram including  Separations

biological and other
 Relationships
relationships
 Pregnancy, birth and  Abuse and neglect
development, especially  Life events, trauma
language domestic violence,
 Medical history including  Changes of carers and
growth, injuries, placements
 Education, learning  Changes in child’s behaviour
problems, attendance in relation to contact with
Statement
parents, separations,
 Family history (education,
trauma
work, physical and mental
health, substance misuse)  Attachment interview
 Assessment of the child: Issues to be
considered
 Nature / Nurture
 Attachment and relationships
 Abuse and/or neglect
 Effects of abuse, neglect, adversity
 Effects of separations, life events
 Child’s needs- short and long term
 Risk- short and long term
 Child’s views
 Maintenance of child’s relationships in relation to
attachment and continuity (extended family, school)
 Multi-factorial Developmental Model

Predisposing Perpetuating Precipitating

Genetic Early
endowment infantile Life Events
experience
Temperament

Gender Development Problem

or
IQ
Disorder
Pre/perinatal
adversity Current
Familial family
Socio-cultural
Physical factors psychopathology
Factors
attributes

Predisposing Perpetuating
Genetic endowment:
Affective disorders, ADD
Temperament:
Sociability vs. poor
adaptability, difficult
temperament,
Gender
Boys-conduct, early
Girls-emotional, late
IQ: high- protective
Pre/peri-natal adversity
20% cf. 2% premature
Physical illness, deformity
Multi-factorial Aetiology
Precipitating
Early infantile experience
Healthy parent, attachment,
failure to thrive, separations,
Quality of alternative care
Socio-cultural factors
Education, poverty
extended family, social
support, racism
Familial factors
Family communication,
organisation, warmth,
limit setting, consistency,
conflict resolution,
closeness, sensitivity
Life Events
More adverse life
events: separation,
marital breakdown,
bereavement,
violence & murder
Long term effects on
self esteem & mental
health
Current family
psychopathology
Domestic violence &
conflict, quality of
parenting under stress
 Developmental issues:
nature or nurture?
 Growth and motor development
Failure to thrive, obesity, changes in growth, diet, voracious appetite,
clumsiness
 Habits: feeding, sleep, toilet training, enuresis
 Language and communication
Delay, disorder, eye contact, non verbal communication, fluency,
comprehension, mute
 Cognitive development
General delay, specific learning difficulty, developmental disorder, academic
underachievement, school attendance, concentration,
parental IQ
 Social and emotional development
Separation and stranger anxiety, ability to relate, express affection and
feelings, empathy, peer relationships and play: imaginative, cooperative,
 Mental health
Specific disorders and functioning

 Definite or possible developmental disorder

ASD, ADHD, specific language delay, sensory impairment, general or specific learning
difficulty, dyspraxia, specific syndrome, (genetic/acquired, ante-natal/peri-natal/infancy)

 Other psychiatric disorder

Nature, severity, prognosis

 Emotions
Emotional maturity, affection, trust, attention seeking, frozen, fears, nightmares,
tantrums, reaction to separation, ability to verbalise feelings, need to control, child carer

 Behaviour
Aggression, destructiveness, self harm, lying, stealing, fire setting, regression,
hyperactivity, soiling, smearing, wetting, sexualised behaviour, indiscriminate
inappropriate relationships, cruelty, self neglect, lack of pain
 Attachment and significant relationships
Secure, anxious, avoidant, disorganised

 History of relationships and attachment behaviour-

changes with changes of carer, response to contact, response to lack of
contact

 Observation of relationships with parents and other carers- affection,

regression, clinging, capacity for independent purposeful play,
communication, anger, hyperactivity, chaos, indifference, fear, loyalty,
parental behaviour and child’s response, arrivals and departures

 Eliciting attachment behaviour:

Brief separations from current carer, parent

 What child says : consistency / to different people

loyalty and display of affection do not reflect quality of attachment
 Child’s wishes and feelings

• What child tells you

• Direct questions
• What child says/has said to different people
• 3 wishes
• Observations of child’s reactions to:
– what parent says or does
– to issues raised
 Separations and life events

 Duration, frequency
 Child’s age and ability to verbalise
 Quality of attachment beforehand
 Reason: illness, abandonment, imprisonment
 What child is told
 Maintenance of contact
 Alternative caretaker
 Continuity of relationships with sibs, school
 Nature of event, timing and impact, bereavement,
violence, ?witnessed by child
 Associated disruption: moves, change of school
 Child’s needs:
immediate and longer term
 Safety and protection

 Containment: staff ratio, secure placement

 Need to develop/maintain secure attachment

 Quality of care: warmth, consistency, stimulation,

limit setting, sensitivity and continuity
 Consider child’s needs for
 Further assessment:
forensic, educational/cognitive, medical
(in placement with parent or in alternative setting)

 Contact, with whom?

 Temporary or permanent placement

 Education: special education, day or residential, stability

 Treatment : medication, individual, behavioural or family

therapy, CATT
 Conclusions of the Assessment (formulation)
• What was child’s potential? Nature
• Was the child abused or neglected?
• What were the effects of abuse, neglect and other
adversity? Nurture
• Is the child still at risk of abuse or neglect?
• What were or will be the effects of change of carer?
• What is the child’s potential now?
• What will improve or reduce this?
• What is in the child’s best interests?
 Attachment
 The relationship the child develops with his main carer in infancy

 To seek nurture and a response to physical and emotional needs, relief of
anxiety and distress

 PARENTAL LOVE IS NOT SUFFICIENT

 Affects capacity to relate and quality of subsequent relationships

 What are the child’s significant attachment relationships now and in the
past?

Classification

 Secure 65% of one year olds

 Insecure
Anxious
Avoidant
Disorganised
 Attachment Assessed by
 Behaviour- changes with changes of carer, response to
contact, response to lack of contact

 Observation of relationships with parents and other carers-

affection, regression, clinging, capacity for independent
purposeful play, communication, anger, hyperactivity, chaos,
indifference, fear, loyalty, parental behaviour and child’s
response, arrivals and departures

 Eliciting attachment behaviour: Ainsworth Strange Situation

Brief separations from current carer, parent

 What child says

 Attachment interviews
 Consider Separations

 Duration, frequency
 Child’s age and ability to verbalise
 Quality of attachment beforehand
 Reason: death, divorce/separation, illness, abandonment,
imprisonment
 What child is told/ witnessed
 Maintenance of contact
 Alternative caretaker
 Continuity of relationships with sibs, school
 Associated disruption: moves, change of school
 Physical and Sexual Abuse

 Physical abuse
 history of injuries and physical findings,
 what child has said, emotions (frozen watchfulness, lack
of response to conflict and aggression)
 behaviour (inhibited, aggression)

 Sexual abuse
 history and physical findings, what child has said,
 symptoms (sleep problems, enuresis, encopresis),
 emotions (low self esteem, depression, specific fears)
 behaviour (sexualised or inappropriate behaviour with adults or children,
promiscuity/prostitution, masturbation, insertion of foreign bodies, running
away, eating disorders, substance misuse, self harm, suicide attempts),
 family history of sexual abuse