1. Aaron J. Miller, MD, MPA, FAAP
Multidisciplinary Team Identification and Evaluation of Child Maltreatment
Aaron J. Miller, MD, MPA, FAAP

2. Learning Objectives The participant will be able to:
Explain the different roles and responsibilities of medical and other health professionals, social services, law enforcement, education/schools, NGOs and other agencies.
Discuss the medical, psychosocial and safety benefits of interagency coordination.
List common barriers to interagency coordination and consider effective steps to create lasting improvements in coordination.
Recognize the signs and symptoms of compassion fatigue/secondary trauma.
If the participants are from different agencies, this module provides a great opportunity for them to educate each other on the different mandates that each agency has, which can thus bring to light various barriers and opportunities.
“With the last two objectives – improving interagency coordination/teamwork, and compassion fatigue – this module serves as an introduction to these topics, it does not provide the same level of detail as the other modules. These topics each require hours of training on their own, but this module helps address the important issues to know.”

3. Disclaimer
What should happen: Medical, social, and law enforcement professionals know all the laws and policies and follow them always. What often happens: Professionals don’t know the laws, or don’t care, or have numerous barriers to doing the right thing.
Read the slide, then quickly give examples of barriers like lack of time, lack of resources (ie. no money for gas to do home visit), and state that there are additional barriers that will be helpful for them as a team to identify in order to help move forward. The main point of this slide is the disclaimer: even where we have multidisciplinary teams that are well-developed and trained, we still do not always do everything the way we should. We are not perfect, nor do we claim to be. In order for us to improve how we care for children, we must allow each other to admit our imperfections to each other in a supportive way that does not lay blame. So I hope that each of us here can be open – not just about the problems in the system – but about our own limitations and challenges.

4. Hospital Emergency Department
Common Practice
Hospital Emergency Department
Inexperienced Doctor
District Attorney
The purpose of this slide is two-fold:
List all the different issues and problems that occur from lack of coordination and training in order to highlight the benefits of MDT coordination
Help the participants feel more comfortable knowing that dysfunction occurs in all countries so that they might feel more comfortable in the next slide/case discussion to say “Yes, that happens with us, too.”
Note: Feel free to give your own details and explanations for this slide. The examples below include things that happen in all countries, but also includes details that are more unique to low-income countries.
Common Practice: Children first come to our attention through any of our agencies, but let’s just use the example of a child first being brought by mother to the police after the girl said her uncle touched her:
-Police often do not have someone trained in how to perform forensic interviews of children, and they do not understand why children do not give them a clear history of what happened to them.
-If the child was touched on her genitalia, but not penetrated, then the police may not send the child to the hospital. If they do send them to the hospital, they may request money from the family to pay for the police to come along with them. Or the hospital may be far away on foot. The police often don’t know about the 72hr window for HIV PEP, so they don’t know to inform the family of the urgency of getting to the hospital as soon as possible – and thus many children can miss the opportunity to take life-saving PEP.
-When children get to the hospital, they may have to weight for hours to be seen; they may be interviewed several times by different hospital staff – again with people who have not been trained to ask children about abuse – and these interviews may happen where there is little/no privacy. There might not be a private room for the genital exam, and the medical professionals have little/no training on how to perform genital exams and to correctly know if they are seeing injuries to the genitalia or not. Sometimes girls are told they have a tear to their hymen, when in fact they do not, which can cause significant emotional stress for the girl and her family. When the medical exam is done, the doctor fills out the form for police and then tells the family to take the form back to the police. But the doctors may not call police to explain the significance of the physical exam findings. If the sexual abuser lives in the home, the doctor does not necessarily know who to contact to ensure that the alleged perpetrator is removed from the home; doctors may not have contact numbers for social services – or social services may not be able to make a home visit if they do not have gas for their vehicle.
-Police, Social Services, and hospitals each of different mandates, which sometimes lead to differences of opinion, which can lead to poor relationships and poor communication.
-And with sending the child to all these different places, the child can get lost in the middle.
Police
Social Services

5. Case Discussion
5-year-old girl told mom that her father touched her vagina and is then brought to one of our agencies.
Case Discussion (20-30min):
“In the previous slide, I listed many of the issues that are common in countries across the world, but now I want to use a hypothetical case to discuss what policies you already have in place here so that each of your agencies can begin to think about what ways you may be interested in improving what you do.
I can start with any agency – hospital, police, social services – and then go to the other agencies. What I’m most interested in learning is the policies and practices for each step of what you do when a child like this is brought to you. Do you have certain mandates that affect why you have these policies?
If you feel comfortable explaining the limitations and challenges that you face within your agency – great, we’d love to hear those – but if you don’t have limitations you need or want to discuss today, that’s totally fine, too. The one rule we have for this discussion is that you list a problem – it must be a problems within your own agency needs to do better – do not list your frustrations for what the other agencies here do not do well. Even if one of the agencies here says they take certain steps – but you know they actually do NOT do that the way they should – this is not the forum right now to discuss that. The main purpose of this case discussion is to:
Help each other learn more about the mandates and policies that guide our every-day decisions,
Which may bring to light simple steps for improving how your agencies work together.”
Note: Start with one agency and then go through each of the questions listed in the Baseline Survey. This may be repetitive to a certain extent, because you already asked these questions of your host partner when first setting up the trainings, but these questions are also very helpful for this case discussion and may help illuminate new issues that were not yet identified.

6. Children’s Advocacy Centers
Medical
District Attorney
Social Services
Police
“Children’s Advocacy Centers are one model for bringing all the agencies together. When all the agencies come together in one place, it becomes much easier for the child to remain the center of focus and not get lost between all the agencies.
Children get referred for sexual abuse, physical abuse or severe neglect.
This is not the only model, and we fully recognize that there are many limitations that can prevent all the groups from coming together.
Note: these centers may have different names - in several countries, UNICEF call these One-Stop Centres and they also treat adult survivors of domestic violence.”
In preparing the Baseline Survey, if you learned that the host community does not have the capacity to have any type of colocation of agencies, then you can delete this slide and focus on the following slides which show the benefits of interagency coordination (regardless of whether there is colocation).

7. Medical, Psychosocial and Safety Benefits of Interagency Coordination
Bring medical, legal, and social services to one centre to prevent secondary victimization of children
Helps ensure that more of the child victims brought to police also receive a medical evaluation
Two-way mirror for forensic interviews
Fewer interviews = less traumatic and fewer inconsistencies
Experienced interviewer = greater ability to get the truth
Experienced health provider
Administers HIV post-exposure prophylaxis if <72 hours
Can testify in court that a normal exam is expected
Bring medical, legal, and social services to one centre to prevent secondary victimization of children

8. Medical, Psychosocial and Safety Benefits of Interagency Coordination
Experienced social worker
Performs assessments and follows through on safety plan
Experienced police and prosecutors
Conduct thorough investigations in a child-friendly manner
Provide therapy for children or have established referral networks
Full standards for Children’s Advocacy Center established by National Children’s Alliance, Washington, D.C., USA
“If the center is not able to have professionals from all the different agencies on site, then they at least have relationships established with the service providers in the community. For example, some center might have therapists on site, but they have a close relationship with an organization nearby where the children can be referred.”

9. Working Jointly With Others
Understand and respect the child protection roles, responsibilities, policies and practices of other agencies and professionals, and cooperate with them.
Be clear about your own role and responsibilities in protecting children and young people, and be ready to explain this to colleagues and other professionals.
Source: Protecting Children and Young People: The Responsibility of All Doctors. General Medical Council, United Kingdom: 2012.

10. Working Jointly With Others
Make sure you have effective systems for communicating with health visitors, child protection leads and other statutory agencies, either on a regular basis or as the need arises. You must know who to contact and how to contact them.
If you are asked to take part in child protection procedures, you must cooperate fully. This should include going to child protection conferences, strategy meetings and case reviews to provide information and give your opinion.
(General Medical Council, 2012)
You may be able to make a contribution, even if you have no specific concerns (for example, general practitioners are sometimes able to share unique insights into a child’s or young person’s family).

11. Working Jointly With Others
If meetings are called at short notice or at inconvenient times, you should still try to go. If this is not possible, you must try to provide relevant information about the child or young person and their family to the meeting, via a written report or phone call.
(General Medical Council, 2012)

12. How do you do this work?

13. Same question asked differently:
How can we open ourselves to the children - show as much care and support as a close friend or family member, yet not feel as much anguish, so that we have energy to care for the next family?

14. Compassion Fatigue
Compassion Fatigue: a physical, emotional and spiritual fatigue or exhaustion that takes over a person and causes decline in his/her ability to experience joy or to feel and care for others. (Figley, 1995; Friedman, 2002)
Also referred to as secondary trauma, vicarious trauma and burnout.

15. Compassion Fatigue
Prolonged occurrence of the natural behaviors and emotions that arise from knowing about a traumatizing event experienced by another.
a one-way street in which individuals are giving out a great deal of energy and compassion to others over a period of time, yet aren’t able to get enough personal support to reassure themselves that the world is a hopeful place.

16. Compassion Fatigue: Signs & Symptoms
Biological
Psychological
Social

17. Compassion Fatigue: Biological Signs & Symptoms
Increased use of drugs and alcohol
Sweating, Rapid breathing
Increased blood sugar levels
Increased illnesses
Hypertension/high blood pressure
Gastrointestinal complaints
Brittle nails, dull hair, hot flashes

18. Compassion Fatigue: Biological Signs & Symptoms
Weight changes: over- or under-eating
Migraine headaches
Fatigue/chronically tired
Cracked teeth/grinding teeth
Panic attacks
Physical appearance change
Sleep Disturbances

19. Compassion Fatigue: Psychological Signs & Symptoms
Feelings of dread
Anguished “survivor” guilt
Feelings of having given up
Feelings of evilness and impending doom
Anger, less ability to feel joy
Increased irritability
Horror, inescapable shock

20. Compassion Fatigue: Psychological Signs & Symptoms
Decreased concentration/unable to focus
Depression, sleep disturbances
Low self-esteem, exhaustion
Crying for no apparent reason
Apathy or use of dark humor
Poor impulse control
Relapse to addictions

21. Compassion Fatigue: Social Signs & Symptoms
Terrorization and elimination
Burnout, Chronic lateness
Workaholism
Inability to maintain balance and objectivity
Blaming, Cast out
Learned-helplessness

22. Compassion Fatigue: Social Signs & Symptoms
Vulnerability
Isolation
Stuck in negativity, Cynical
Divorce/interpersonal problems
Withdrawal from activities
Promiscuity

23. Compassion Fatigue: Prevention
Maintain balance between personal life and work
Activities, ways to relax, getting enough sleep
Strong relationships with family/friends
Organizational culture
Should allow us to feel comfortable to admit we need help
Monitor caseload
Working on a team: having colleagues to talk with
Education on compassion fatigue helps us recognize the signs early in ourselves and our colleagues
Most of these bullets are self-explanatory. Here are a few extra points:
Organizational culture:
--Compassion fatigue can happen with even the strongest of people. And it may just last a few days – it doesn’t necessarily last weeks or months in many cases. So if someone is experiencing compassion fatigue, they should not be viewed as “weak” and they should not be punished or feel afraid to admit to their boss they are experiencing this stress. If the leadership of your organization views this as weakness, then no one will come to them to explain they need help, and one day they will just no longer come to this job – they will leave and go for a new job. But if the leaders sit with their staff, explain compassion fatigue and explain that it is fine for the staff to come to them when they have this problem, then these staff can have a chance to work through the stress and get better.
Working on a Team: working with multiple people on a given case of child abuse can be helpful (1) to discuss your fears and frustrations in a way they might be able to give basic support, and (2) it allows your colleagues to know how you are doing so that you all can keep in touch and recognize the symptoms of compassion fatigue early on.

24. Compassion Fatigue: Treatment
If you are experiencing the symptoms and you are deprived of sleep, take a day off, rest, and make sure to eat normally.
Consider meeting for a few sessions with a therapist who is experienced in treating trauma.

25. References
Protecting Children and Young People: The Responsibility of All Doctors. General Medical Council, United Kingdom: available at: uk.org/static/documents/content/Child_protection _-_English_0712.pdf
Osofsky, J.D., Putnam, F.W., Lederman, C.S. (2008). How to maintain emotional health when working with trauma. Juvenile and Family Court Journal. 59, 4:

26. References
A complete list studies that demonstrate the efficacy of Children’s Advocacy Centers is available from the National Children’s Advocacy Center: online/evid-based-prac.html