ࡱ> %` Jbjbjٕ 2RBBBB***>fCfCfC8C,Dl>RBE(jEEEEFv G$-G,......$hg.R*]FF]]RB`EEg7`7`7`]^*E*E,7`],7`7`<D**E6E R4ǥfCE^^&}0^6L*hAGN|7`kTdXAGAGAGRR_^AGAGAG]]]]>>>")>>>)>>>BBB*** THE CHILDREN, YOUNG PERSONS, AND THEIR FAMILIES AMENDMENT BILL (NO 6) A submission to the Select Committee Paediatric Society of New Zealand April 24 2008 Introduction This submission is made on behalf of the Paediatric Society of New Zealand. This submission is largely identical to the submission we made to the CYPF Act Update Team on June 1 2007. Unfortunately, none of the fundamental points raised in that submission have been adequately addressed in the Amendment Bill which is now before the Select Committee. In our view, the Amendment Bill as it now stands will not only fail to address these issues, but may make some of them worse. We wish to make a verbal submission to the Select Committee. Background The Paediatric Society of New Zealand is an independent society of health professionals throughout New Zealand, who are committed in their daily work to the delivery of health care services to children and young people. The Society includes almost all practising paediatricians in New Zealand, and also includes paediatric surgeons, general practitioners, paediatric dentists, child health nurses, midwives, allied health professionals (such as dietitians, physiotherapists, occupational therapists, speech language therapists, play specialists and pharmacists), child mental health professionals from several disciplines and social workers. The current membership of the Society is 426. The Child Protection Special Interest Group is a sub-group of Paediatric Society members who have a special interest in the provision of services to children and young people affected by abuse and neglect. It also includes, by virtue of their appointments, most child protection and family violence co-ordinators in the 21 New Zealand District Health Boards. Current membership of the SIG is 79. The Paediatric Society and its Child Protection SIG therefore represents the largest national inter-disciplinary group of frontline health professionals working specifically with abuse and neglect. The need for a submission, and the broad principles of this submission, has been supported by the following processes to date: Paper developed by Dr Dawn Elder and the Child Abuse Sub-Committee of the Paediatric Society of New Zealand in 1998 as part of the development of a proposal for equitable provision of child health services throughout New Zealand. This process was known as Through the Eyes of a Child. Paper presented to the Minister of Health by Dr Nick Baker and Dr Dawn Elder in November 2006, concerning the need for proper development of health-based services to children and young people in need of care and protection. Papers presented by Dr Dawn Elder and Dr Patrick Kelly to a workshop convened jointly by the Office of the Childrens Commissioner and the Ministry of Social Development in December 2006. This workshop was entitled Developing the Path Forward, and the papers presented by Drs Elder and Kelly were circulated within the PSNZ SIG for comment and feedback. Dr Kelly also presented his paper at the Inaugural Women and Childrens Health Social Work Conference in Auckland in March 2007, at the National Meeting of Family Violence Co-ordinators in May 2007, in several different multi-disciplinary forums in Auckland in 2007, and at the Keeping Kids Safe conference hosted by Presbyterian Support Northern in Auckland in March 2008. Several meetings within the Paediatric Society of New Zealand. These included a national videoconference in May 2007, involving representatives of the Paediatric Society of New Zealand from 17 District Health Boards. Participants came from the following District Health Board areas: Auckland, Bay of Plenty, Canterbury, Capital & Coast, Counties Manukau, Hawkes Bay, Hutt Valley, Lakes, Midcentral, Nelson Marlborough, Otago, South Canterbury, Southland, Tairawhiti, Taranaki, Waikato and Whanganui. In the 11 months since that videoconference, the submission has been available on the website of the Paediatric Society of New Zealand and has been widely circulated, meeting with a uniformly positive response from health care providers. This was confirmed at the annual national face-to-face meeting of the Special Interest Group with Family Violence Co-ordinators and Child Protection Co-ordinators in Christchurch in November 2007. General Comments In our view, the process of developing this Amendment Bill has reflected some of the fundamental flaws within the legislation itself. That is, the Amendment Bill has been developed essentially in-house within the Ministry of Social Development, rather than in a collaborative process attempting to give equal weight to the voices of all those who must live with its effects. The Paediatric Society entirely supports the general principles of the current Act contained in Sections 5 and 6. Both these sections contain principles that are fundamental to good paediatric practice. The family decision-making model (the Family Group Conference), supported by the Act, is a good model provided that: It is actually used Those attending are fully representative of the wider family, whanau, hapu, iwi and family group All relevant information is presented by those qualified to present it Decisions are made that are in the best interests of the child and protect the child from further harm. Decisions made are followed up to ensure implementation The Act, however, is weak in its provisions for interdisciplinary practice, and fails to ensure that children and young people in the care of the Department receive necessary health care. These two weaknesses expose a significant number of children and young people to the risk of further harm. These two deficiencies were the focus of this submission when it was first addressed to the CYPF Act Update Team in June 2007. Since then, there has been considerable progress within the Department of Child Youth and Family Services in regard to the health care needs of children in care. However, the fundamental deficiencies in child protection practice outlined in our submission are not addressed in the Amendment Bill (no 6) that is now before the Select Committee. The authors of the Amendment Bill have commented on those aspects of the 1989 Act which have been emulated overseas (such as the Family Group Conference). However, they have failed to note that by the standards of international practice in child protection, the focus on multi-disciplinary decision-making processes in our child protection legislation is extraordinarily weak. In our view, the Amendment Bill as it now stands is driven primarily by the overwhelming increase in notifications to the Department seen in recent years. It will strengthen the ability of Departmental Social Workers to adopt a differential response model, but will have no effect at all on the practice issues outlined in our submission. This will continue to place children and young people at significant ongoing risk of harm. We will frame this submission under the four themes suggested in the Ministry of Social Development 2007 discussion document entitled Safeguarding Our Children. Theme One: Technical Amendment and Drafting We made no specific suggestions under this heading, except that in June 2007 we agreed that the Act was wordy and needed to be simpler. In our view, the Amendment Bill has not addressed this issue. Clearly, the suggestions we make under Theme Two would require significant re-drafting of parts of the Amendment Bill currently before the Select Committee, Theme Two: Care and Protection Meeting the support needs of children and families. The discussion document placed this issue under the heading of interagency collaboration, focusing largely on possibilities for collaboration with community social services in assessing and meeting the support needs of children and families referred to Child, Youth and Family. The focus of the discussion document was clearly to invite comment on the merits of the differential response model. However, in our view, there is a critical deficiency of current practise which is completely separate from the issue of interagency collaboration. This deficiency is the lack of support for those (within the whanau or outside it) who are asked to care for children and young people once care and protection needs have been confirmed. We suggest the following provision: The CEO of CYFS shall be required to provide reasonable support for carers this shall not be limited to non-kin carers, but shall also include kin carers(e.g. grandparents) this support shall include (but not be limited to) education regarding the likely psychological consequences of the abuse or neglect the child has experienced appropriately skilled support from qualified professionals experienced in the psychological consequences of abuse and neglect appropriate skilled support from qualified medical professionals where a child has problems requiring such support (common examples would be disabilities, soiling, wetting etc ) financial support (benchmarked against an agreed measure and increased annually against that benchmark) The CEO of CYFS shall annually include in his/her report to Cabinet a survey of carers' satisfaction with this support and ideas for improvement, and shall include a plan to address the issues identified in the CYFS Annual Plan for the following year We also draw your attention to our related recommendation on the experiences of children and young people in care, in part 4 of our submission under this theme (see below). Interagency Collaboration and Information Sharing Information Sharing. The discussion document focuses largely on possibilities for collaboration in meeting the support needs of children and families in the care and protection system, and on provisions in Australian legislation which allow child protection services to request or require other agencies to provide services or information. This focus in the discussion document is mirrored in the Amendment Bill, where it is identified as an issue with information sharing. Put bluntly, it is identified as an issue with agencies providing information to the Department. Decision making However, in our view the problems with the Act under this heading are far more fundamental, and begin with the manner in which a social worker decides that a need for care and protection exists. While the Department may perceive health services as unwilling to collaborate or provide them with information, health services widely perceive the Department as often unwilling to participate transparently and collaboratively in making decisions around care and protection. The Amendment Bill does not address this issue at all. In fact, it is likely to make the practice issues worse. The only multi-disciplinary forum in the Act (the Care and Protection Panel), is even less likely to become involved in many notifications, because all those that are streamed into an alternative agency will be below the threshold at which consultation with the Panel is required. We strongly support the Common Assessment Framework, used in the United Kingdom, as a structure of working together, and of shared language that builds understanding between different disciplines. One article has described the use of this framework as follows: Key findings were that most CAF work was being undertaken by practitioners in the health and education sectors; assessing children holistically requires many practitioners to adapt their skills and way of thinking; CAF is well accepted where multi-agency processes are working well and an environment of professional trust exists  The unfortunate fact is that in many parts of New Zealand, no such environment of professional trust exists between service providers in District Health Boards and Child Youth and Family service centres. This is despite accumulating evidence that inter-disciplinary investigation is the safest way to practise in child protection. The concept of substantiation is fraught with difficulty , and it is vitally important to follow a safe process. This process should be followed not only at intake, but at critical points in the progress of any intervention. Unfortunately, the way our Act is currently structured, there is no mandatory requirement for such practice. The 2007 discussion document (Safeguarding Our Children) made no reference to any international models of legislation containing such requirements, although such models exist . The Amendment Bill (No. 6) does not even attempt to address the issue. Care and Protection Resource Panels The current Section 17 (2) specifies that where, after an investigation under subsection (1) of this section into the matters contained in a report under Section 15 of this Act, the social worker or member of the Police to whom the report was made reasonably believes that the child or young person to whom the report relates is in need of care or protection, that Social Worker or member of the Police shall, as soon as practicable, notify a Care and Protection Co-ordinator. The Amendment Bill as it now stands (particularly the revised Section 17), obviously provides a social worker with much wider discretion not to investigate, but to pass on a notification to alternative agencies for assessment or intervention. That is, far fewer of the decisions made by a social worker will be (even potentially) subject to multi-disciplinary review. The only provision in the current Act for multi-disciplinary input to the process by which a social worker forms their belief, is found in Section 17(1), requiring them to consult with a Care and Protection Resource Panel, as soon as practicable after the investigation has commenced. The Section does not stipulate whether the investigating officer is required to act on the opinion provide by the Panel, nor does it give the Panel any authority formally to review or challenge social work practise. This omission is maintained in the Amendment Bill. Outside Section 17, the only provision for the participation of other professional disciplines in the forming of an opinion as to a need for care and protection is at the discretion of the Court once a matter has been brought before it. In July 2005, the Chief Social Worker commented on a survey of Care and Protection Co-ordinators regarding the usefulness of the Care and Protection Resource Panels (CPRP). Her discussion did not address the experience of frontline social workers or Resource Panel members. In preparing this submission, we have been unable to find any good quality published research on the efficacy of the Care and Protection Panel in embedding inter-disciplinary practice into the investigation process. There is one document available on the MSD website, dated September 2003, on an assessment of CPRP conducted in the wake of the report by Judge Mick Brown . The published summary document does not adequately address the issue we have raised, and it appears that no changes in practice have taken place in this regard. In July 2005, Dr Connolly argued that the re-establishment of some form of inter-disciplinary Child Protection Team (as first proposed in the 1986 Children and Young Persons Bill) would be unnecessary and unhelpful, as the CPRP (despite its deficiencies) still provided a potentially viable mechanism for inter-disciplinary practise. In this respect, Dr Connolly dismissed the arguments advanced by Ann Caton in 2000 . With due respect to the Chief Social Worker, the Paediatric Society does not agree. The experience of members of the Society has been: CPRP function to rubber-stamp decisions already made by social workers. Recommendations made at CPRP to social workers are often ignored. When CPRP are seen to be functioning well, it is usually as providers of ideas about community resources that may be accessible to the social worker. They seldom participate meaningfully in decisions about investigation. The Social Worker can present a case at any time through the investigation process. Presentation just prior to closure of the case is common and limits the usefulness of panel feedback. For these reasons, many Paediatricians and other experienced medical practitioners have resigned from CPRP. In most parts of New Zealand, they no longer sit on them. In our view, the ambiguous status of Care and Protection Resource Panels in the legislation is a key factor in their failure, over the last 18 years, to create a meaningful interdisciplinary investigative process. At their very best, Care and Protection Resource Panels may sometimes function as a forum for multi-disciplinary review. They do not provide an effective model of multi-disciplinary practise. In this respect, the New Zealand legislation is clearly deficient. Child Youth and Family, in general, operates on a model by which a single professional discipline makes the decision as to whether a child or young person is in need of care or protection. In our view, the Amendment Bill perpetuates and indeed strengthens this model of practice, which is in fact one of the fatal flaws of current child protection legislation in New Zealand. Three examples of the results of this deficiency are provided here. The vulnerable infant. New Zealand  and international  data is very clear that most children who suffer death or serious injury from child abuse are pre-verbal that is, under the age of 3 years. In this age-group, the signs and symptoms of abuse and neglect may be subtle or confusing. Head injury, in particular, may be missed without careful attention to detail in the assessment process . Furthermore, a growing body of data has emphasised the crucial importance of the first 3 years of life in brain development and emotional attachment . Proper assessment of any infant in this age group requires review by persons skilled in the assessment of growth, development, infant behaviour and the significance of apparently minor injuries in different age groups. In the year from July 1 2005 to June 30 2006, 6700 notifications to the Department of Child Youth and Family Services were made for concerns about possible abuse or neglect in children under the age of 2 years. Although the Department has not published the data, it is our impression that many if not most of these notifications did not receive a formal health assessment. We understand that internal research conducted for the Department on vulnerable infants suggested that a structured program of inter-disciplinary management of such cases (analogous to the successful Youth Suicide Prevention program) may well be successful in reducing the risk of further harm. We understand that the Department chose not to pursue this suggestion. In 2007, the Department began an extensive internal process to review and develop an approach to the needs of vulnerable infants. An invitation from the Paediatric Society to develop this as a collaborative, inter-agency model of assessment, was declined. The Amendment Bill as it now stands, makes no attempt to mandate an inter-disciplinary assessment process in any context, no matter how high the potential risk to a child or young person. Sexual abuse. Good quality longitudinal research suggests that 17% of New Zealand women have experienced some form of sexual abuse by the age of 16 5.6% will have been raped . In the year from July 1 2005 to June 30 2006, we estimate that approximately 1500 cases of sexual abuse were regarded as substantiated by the Department, based on rates of notification, further action required and substantiation cited by James Mansell in 2006 . Considerably more may have been notified for concern about sexual abuse, but not substantiated. Despite recent local literature on the necessity for inter-sectoral collaboration in the assessment of alleged child sexual abuse , there is no commitment to a medical examination as part of the process. Yet even if we take only those cases which were substantiated by the Department, according to our estimates, less than 20% of these children and young people received a medical examination (the evidence for this is presented in Appendix A, Sheet One. Note that Sheet One has a second page with notes explaining the method used). New Zealand data has shown quite clearly that only a minority of victims of sexual abuse are referred for an examination , and that this rate is falling over time . There are many myths about sexual abuse and medical findings, most of which are false  NOTEREF _Ref168375394 \* MERGEFORMAT 15. However, it is our experience that many children and young people are deprived of the reassurance of a medical examination, often on the decision of a social worker. Although this point has been made to the Department on a number of occasions (see for example, Chapter 7, Interagency Work in Judge Mick Browns review), practice has not changed. Children and young people placed in care. There is abundant evidence that children and young people taken into care have exceptional rates of developmental, physical and mental disorders ,. These disorders are treatable and without treatment have profound implications for the child's future wellbeing. There is also evidence that a comprehensive assessment can improve sustainability (permanency) of care. A paediatric social worker with extensive experience in the United Kingdom comments as follows: I have many years of working with children in care. I was fortunate to come from a statutory agency who recognised that this group of children were amongst the most vulnerable children in society a great deal of emphasis is placed on Looked After Children in care medicals are very much part of the placement process and the ongoing reviewing process- this process in some Authorities is being undertaken by Independent Reviewing Officers to ensure all the child/young persons needs are met and continue to be met. I am not attempting in any way to say that the UK is without fault in this area. It has taken them many years and several tragedies to recognise this. My experience was of one authority (albeit the largest in the UK) where they were making strides in the right direction. The service for Looked After Children, and more recently Privately Fostered Children is no longer being seen as a Cinderella service. In New Zealand, the need for a health assessment (if addressed at all) is addressed in a token fashion only in most parts of the country. It is usually provided in the form of a brief examination by a General Practitioner who has no history to go on. It is not uncommon to receive an urgent request for a medical assessment prior to a Family Group Conference, months after a child has been taken into care, and when the ability to provide a meaningful opinion to the FGC has largely been lost. Furthermore, many children and young people are lost to health follow-up as they move between multiple placements. This lack of health assessment and follow-up for children in care is unconscionable given the current evidence. The Paediatric Society wishes to acknowledge that there has been considerable progress on this issue in the last 12 months, and the Ministries of Social Development and Health are working to address this problem. However, in our view, the requirement for such assessments should be embodied in the law. With regard to children in care, the Act should state that The CEO of CYFS shall request a comprehensive medical, developmental and psychological assessment by appropriately trained paediatric health professionals for children taken into care. Where this is not available through the public system it shall be paid for through the private system.This assessment shall also be available for children whose placement fails. The CEO shall work with the sector to develop the skills required for such assessments, including providing such educational opportunities as shall be deemed necessary. The CEO's annual report to Cabinet shall include mention of trends in health issues identified for children in care, access to such assessments and progress in workforce development as above In our view, the Act should mandate assessment by an appropriately qualified multi-disciplinary team as part of the investigation process for at least some specified categories or age-groups of suspected abuse or neglect, and audit of these figures also should become part of the CEOs annual report. The two categories mentioned above are those of infants under the age of 2 years, and allegations of sexual abuse. There are other categories where similar arguments could be made. These categories could be defined in further discussion between the Ministry of Social Development, the Paediatric Society and other stakeholders. One example of mandated categories of referral from statutory authorities to health services is provided in the Florida legislation (Appendix B). We would be the first to acknowledge that Child Youth and Family also often find it difficult to find health professionals who are prepared to devote the time to interagency practice. The purpose of Sheet Two, Appendix A, is to provide one illustration of the sheer volume of cases where (in one scenario) health care assessment might be required. Requirements such as the ones we have suggested (for categories of investigation, and for children in care) would of course entail that District Health Boards develop services capable of working alongside Child Youth and Family to provide timely and appropriate assessments. The question would arise how these are structured and funded, and that would require further development. The issue would also arise as to who would take responsibility for ensuring that District Health Boards provided these services. One option may be to amend the Act to empower the Childrens Commissioner to audit the structure and quality of such services. It should be pointed out that structures such as those proposed for National Family Violence Death Review make no sense if they are not built on an infrastructure of collaborative inter-agency practise including joint case management and case review. That is the way such reviews are structured in the United Kingdom  NOTEREF _Ref168389452 \h  \* MERGEFORMAT 3. We note that the Amendment Bill continues the practice of internal case reviews within the Department of Child Youth and Family Services, which in our view is unsafe. Variations on the theme of multi-disciplinary practice could include co-location in multi-agency centres (such as Puawaitahi in Auckland), Child Youth and Family Social Workers based within health teams, and more explicit support of the role of Consultation Liaison Social Worker. Multi-Agency Centres (Child Advocacy Centres). This model is widely used in the United States, where some positive evaluative research is now beginning to appear . Statutory Social Workers embedded in District Health Boards. In Auckland, there is a dedicated Liaison Social Worker who is part of Te Puaruruhau (the child protection team affiliated to Starship Childrens Hospital). This position also has been of enormous value, and such positions would be of equal value in the larger District Health Boards around New Zealand. Embedding statutory social workers in hospitals is a model followed successfully in some parts of the United Kingdom. Consultation Liaison Social Worker. These positions have drifted back into frontline work in many service centres. These positions came about following the decision not to have mandatory reporting, but to educate and work with community organisations to improve collaboration in child protection. Where it still exists, members of the Paediatric Society have found this role to be invaluable. One possibility would be to amend the Act to include something like: "The CEO shall ensure that each CYFS Service Centre shall have a dedicated social worker in the role of Consultation Liaison Social Worker". Another possibility for multi-disciplinary practise would be for health clinicians (such as well child nurses, health visitors or clinical psychologists) to be embedded in child protective services, with joint appointments between their base services and child protective services. This model is used in some jurisdictions in the United States. The whole issue of joint management of cases between Child, Youth and Family and Health also raises the issue of a shared information database. The lack of such shared data has been a key issue identified in such earlier reports as the Commissioners Report into the death of Riri-O-Te-Rangi Whakaruru . The Paediatric Society of New Zealand supports the development of a national child protection alert system across the District Health Boards, the key criterion for which would be notification to the Department of Child, Youth and Family Services. It may be that a shared national Child Protection Register should be developed, and this might require amendment of the legislation. Permanency We have been surprised how difficult it is to obtain basic data on permanency. Such data includes the average number of placements in 5 years, or the average duration of placements over time. It appears to be very difficult to ascertain if permanency is getting better or worse, and the factors that affect it (such as whether it differs by ethnicity, geographical location or age). We suggest that: The CEO shall include in his/her report to Cabinet each year reliable measures of permanency, together with an analysis of reasons for any differences by ethnicity, age and service centre. The Annual Plan shall address any issues identified in this report Children and Young Peoples Participation We strongly support the development of a systematic mechanism through which children and young people in care can voice their experiences in care, and have that voice heard at the highest level within the Department. That is, the Act should require the CEO to work with the children and young people themselves. Associations of children in care Australia and the United Kingdom have been able to effect some change in caregiving services, and such associations should be supported by the Act. They could be supported or co-ordinated by the Office of the Childrens Commissioner. Theme Three: Disabled Children Minor changes only have been made to Section 141 in this Amendment Bill. If anything, these amendments would appear to make it even more difficult to achieve appropriate care for disabled children under Section 141. This is a direction of change which is the precise opposite of the suggestions made by the Paediatric Society. A paediatric social worker with extensive experience in the United Kingdom commented as follows: These children are extremely vulnerable and need the skills of competent practitioners with good knowledge and skills to advocate on their behalf and to be able to assess risk. My experience of working with children with disabilities is one where there is a specialist team. Such a team is dedicated to acquiring the skill base which enables them to provide services, resources and protection to which this group of children are entitled, yet must rely on others to provide. Section 141 Dr Russell Wills commented as follows: I find this section problematic, though I'm not sure whether the problem lies within disability or CYFS. I suspect the former. Children with disabilities who need to come into care are rare. In Hawkes Bay I see this most commonly for children with intellectual disability and autism whose families can't cope with their behaviour (usually in mid-to-late puberty) and want them in a residential setting. While I agree that it should not be "easy" to put your child into care and every step should be made to find alternatives to out of home care first (like parent education, respite and good medical and psychological care), in practice this has meant (for instance) that a very difficult young person living on a remote farm is forced to fail taxis or buses to get to a special school in town, or to fail weekly "boarding" in town, before a S141 can be granted and she can get funding to attend the residential school, which was always her parents' wish. High and Complex Needs (while very welcome) will make it almost impossible to demonstrate that "all other avenues have been exhausted" before a S141 can be granted. S141 needs to be clarified so that young people with intellectual disabilities and challenging behaviour are able to access appropriate residential care and education away from home at little or no cost to parents. This should not be the default and the onus should still be on local services to attempt to meet these needs first, but it should not be made nearly impossible, as it now is. This may not need a change in legislation but maybe in the guidance issued/ interpretation. With regard to Section 141, Dr Rosemary Marks, who heads the Developmental Paediatric service in Auckland and is the current President of the Paediatric Society, comments as follows: In relation to disabled children, I too have some concerns in relation to Section 141. I think it would be useful to note that Section 141 needs to be reviewed in some detail in conjunction with other disability legislation and interests. For example, the gap between the ending of Child Youth and Family responsibility and the start of the Protection of Personal Property Rights Act, which is particularly relevant to young people who are not competent to make decisions for themselves and are very vulnerable to abuse. Dr Marks also comments that there needs to be further discussion on this issue within the Paediatric Society, between the Special Interest Groups on children and young people with disability, and child protection. Theme Four: Child Offenders and Youth Justice The Paediatric Society supports the raising of the age covered by the Act to include 17 year olds. We also support any initiatives which ease the mutual flow of information between the Department of Child Youth and Family Services, who should be working together for the welfare of young people. However, we note that the Amendment Bill makes it no easier for health professionals to obtain information from the child welfare system which may be necessary for the provision of appropriate health care. For example, reports made under Section 333 of the Act often contain information that would be of great value to health care providers, but are currently sequestered to the Judge. The Amendment Bill does not address this issue. We are also concerned about the use of provisions under S238 1(d), in which a young offender who has not yet been tried may be incarcerated for a period substantially longer than the 3-6 month period which appears to be the norm for other sections related to Youth Justice. Other Comments In our view, Section 139 of the Act (Temporary Care Agreement) has been widely misused. As it stands in the Act, it is a provision by which families who are unable or unwilling to care for their child, request the Department to take care of the child for 28 days, with the ability to extend it for a further 28 days. We have often seen this Section used by social workers as an easy alternative to more formal applications for custody, in cases of significant injuries in young infants where the family do not accept that a family member may have caused the injury. Not uncommonly, there has been an implied or overt threat that if the family do not consent to a TCA, the Department will go to court. The 2006 Practice Note from the Office of the Chief Social Worker has somewhat improved practice in this regard . However, some social workers have suggested that this practice note has not always been supported by the Court. Social Workers continue to use S139 Temporary Care Agreements as a preferential method of obtaining custody where there are suspected serious non accidental injuries. It may be that the Act needs to be further amended to make clear the proper use of Section 139, and to ensure that the Practice Note is supported more fully in law. Conclusion It is important to make it clear that there are serious deficiencies in inter-agency child protection practise between health services and the statutory authorities in New Zealand, and some of the responsibility for this rests with the Children, Young Persons and Their Families Act itself. It is difficult to insist on a quality of practise for which no clear legal mandate exists. It is clear to health professionals that the Ministry of Social Development does not understand the depth of feeling within the health care community about the practice issues we have raised here. However, it is our view that, if these issues are not addressed, care and protection practice in New Zealand will continue to be, for those most at risk, seriously unsafe. In the words of the discussion document, we believe that the changes we suggest will: better achieve the objectives and fulfil the principles of the Act strengthen the family decision making model at the heart of the Act assist best practice in promoting the wellbeing of children, young persons and their families. Dr Patrick Kelly FRACP Paediatrician, Clinical Director, Te Puaruruhau, Starship Honorary Clinical Senior Lecturer in Paediatrics, University of Auckland Faculty of Medicine and Health Sciences Chair, Special Interest Group on Child Protection, Paediatric Society of New Zealand     Paediatric Society of New Zealand Page  PAGE 1 The Children, Young Persons, and Their Families Amendment Bill (no 6) Submission from the Paediatric Society of New Zealand Child Protection Special Interest Group  Brandon, M., Howe, A., Dagley, V., Salter, C., Warren, C., & Black, J. (2006). Evaluating the Common Assessment Framework and Lead Professional Guidance and Implementation in 2005. Research Report RR740. Nottingham, United Kingdom: Department for Education and Skills Publications.  Hussey et al. Defining maltreatment according to substantiation: Distinction without a difference? Child Abuse and Neglect 2005;29:479-492  For example, see Walter H. 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UNICEF Innocenti Research Centre, Florence.  Jenny C et al. Analysis of missed cases of abusive head trauma. JAMA 1999; 281:621 - 626  For a readable summary of relevant literature, see the Brainwave trust website (http://www.brainwave.org.nz, accessed May 31 2007)  Fergusson DM, Horwood LJ, Lynskey MT. Childhood sexual abuse, adolescent sexual behaviours and sexual revictimization. Child Abuse & Neglect 1997;21:789-803.  Mansell J. The underlying instability in statutory child protection: understanding the system dynamics driving risk assurance levels. Social Policy Journal of New Zealand 2006;28: 97 - 132  Several articles in the July 2006 volume of the Te Awatea Review. Accessed at http://www.vrc.canterbury.ac.nz, May 31 2007.  Halsted S, Elder D. Delays in the investigation of allegations of child sexual abuse in the Wellington city district 19951996: a retrospective study. N. Z. Med. J 2001; 114: 335.  Kelly P, Koh J, Thompson J. Diagnostic findings in alleged sexual abuse: symptoms have no predictive value. J. Paediatr. Child Health 2006; 42: 11419.  Brown M. Care and protection is about adult behaviour: the ministerial review of the department of Child, Youth and Family Services. Accessed at http://www.msd.govt.nz/documents/publications/sector-policy  Health of children in out- of- home care. Sydney: RACP 2006. Accessed at http://www.racp.edu.au, 31 May 2007  Clarkson J, Kenny G, Taylor N. The health of children in state care. Advocating systematic medical assessment and treatment for children who enter state care. Social Work Now 2000;17: 14-20  Finkelhor D. Multi-Site Evaluation of Children's Advocacy Centers (CACs). Crimes Against Children Research Center, University of New Hampshire 126 Horton Social Science Center, Durham, NH 03824 . Accessed at http://www.unh.edu/ccrc/multi-site_evaluation_children.html, May 30 2007.  Webb L, Kelly P. Communicating with the Starship. 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The Paediatric Society believes all children and youth should, by right, attain optimal physical, mental and social health and wellbeing.  By working as a coordinated national network of health professionals the Society dedicates its efforts and resources to making official submissions to both Government and Non-Government organisations on issues that will impact on the health and wellbeing of children and young people.

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