2009-2010 Policy Paper on inflicted traumatic brain injury in children

Monday, 10 May 2010 09:46

Inflicted traumatic brain injury (ITBI) is the leading cause of death and disability in children who have been abused. Infants are at the greatest risk. The New South Wales Child Death Review Team's 10-year survey of 136 fatal assaults found that children less than 1 year old were 16 times more likely to die than those aged between 5 and 15, 6 times more likely than those aged between 2 and 4 and 4 times more likely than those aged between 1 and 2 years. Of those children who survive ITBI, as many as 2 in every 3 will live with profound and permanent disability.  Because it is their brain that is injured, children will experience a range of disabilities that will affect them not only physically but also in the way they think, feel and behave.

This paper details the outcomes for children who are abused in this way and the need for nationally consistent protocols for their rehabilitation and follow-up care.

Continue reading for the Executive Summary and Recommendations, or download the complete paper.   [Adobe Acrobat PDF - 454.69 KB]

Executive Summary

Inflicted traumatic brain injury (ITBI) is the leading cause of death and disability in children who have been abused. Infants are at the greatest risk. The New South Wales Child Death Review Team's 10-year survey of 136 fatal assaults found that children less than 1 year old were 16 times more likely to die than those aged between 5 and 15, 6 times more likely than those aged between 2 and 4 and 4 times more likely than those aged between 1 and 2 years. Of those children who survive ITBI, as many as 2 in every 3 will live with profound and permanent disability.  Because it is their brain that is injured, children will experience a range of disabilities that will affect them not only physically but also in the way they think, feel and behave. This paper details the outcomes for children who are abused in this way and the need for nationally consistent protocols for their rehabilitation and follow-up care.

In spite of the severity of such abuse and its consequences for the developing child, there is no reliable information - national, state or territory-based – on how often it occurs. Over the last 5 years, more than 50 children with ITBI have been admitted to two of New South Wales’ children’s hospitals alone, and their numbers are increasing. Their average age was 10 months.

This paper establishes the urgent need for research into the incidence and outcomes of this abuse, beginning with national agreement on terminology, and its incorporation into all hospital morbidity and mortality data collections.

As part of the paper’s preparation, Brain Injury Australia consulted widely with professionals engaged in child health, welfare and protection. There was universal agreement that children whose ITBI is detected and diagnosed in hospital represent only a small fraction of those abused in this way. A number of clinicians referred to ITBI hospitalisations as simply “the tip of the iceberg”. This paper cites Australian child protection agency data and parent survey evidence indicating that for every child hospitalised with ITBI as many as 150 others experience abusive head trauma from their caregivers.

Brain Injury Australia’s paper has attempted to estimate the size of the “iceberg”, citing the potential association between ITBI, post-natally acquired cerebral palsy (CP), developmental delay  and attention deficit hyperactivity disorder (ADHD).  And as many as 1 in every 3 cases of ITBI may be missed even if they reach hospital. Many of those children will go on to be re-abused, and some will experience fatal abuse.

While Brain Injury Australia’s paper acknowledges the difficulties in the detection and diagnosis of ITBI, it also reveals a clear and pressing need for education in ITBI for all professionals involved in child health, welfare and protection. Brain Injury Australia also strongly believes that where ITBI is suspected, children should receive a nationally consistent assessment protocol from health professionals trained in the detection of child abuse. This includes access to the technology necessary for accurate diagnosis, including computed tomography (CT) and magnetic resonance imaging (MRI) scans.

Like other forms of child abuse and neglect, ITBI is potentially preventable. Brain Injury Australia welcomes the Council of Australian Government’s “National Framework for Protecting Australia’s Children, 2009-2020” and the shift in policy from statutory child protection responses to abuse prevention. Brain Injury Australia expects that such a shift in policy will be reflected in changed spending priorities. This paper details programs of parent education and early intervention that have demonstrated their effectiveness at reducing child abuse, including ITBI. Brain Injury Australia also advocates a nationally consistent program of parent education, inclusive of information about child abuse and neglect, combined with secondary interventions targeting families “at risk” of child abuse. The costs of such programs are negligible when compared to the lifetime costs of a severe ITBI – more than $5 million – for just one child.

Recommendations

Recommendation 1:

Brain Injury Australia recommends the Department of Families, Housing, Community Services and Indigenous Affairs (FaHCSIA) provides funding to Brain Injury Australia to convene a short-term working group - comprising professionals involved in child health, welfare and protection - to produce a nationally agreed descriptor for trauma to a child’s head and brain as the result of abuse.

Recommendation 2:

Brain Injury Australia recommends that FaHCSIA, as part of the National Research Agenda for Child Protection, fund the first national incidence study of inflicted traumatic brain injury (ITBI).

Recommendation 3:

Brain Injury Australia recommends, as part of the National Research Agenda for Child Protection, that FaHCSIA and the Department of Health and Ageing (DOHA) direct all future Australian Modifications of the International Statistical Classification of Diseases and Related Health Problems (ICD-10-AM) to include classifications that will allow for the optimum identification of all child abuses, including ITBI.

Recommendation 4:

Brain Injury Australia recommends that FaHCSIA enjoin the Community and Disability Services Ministers’ Conference, in implementing Strategy 4.4 of the National Framework for Protecting Australia’s Children (“the Framework”) – “support enhanced national consistency and continuous improvement in child protection services” – to develop and provide professional education and training in child abuse (inclusive of ITBI) through bodies such as The Royal Australian College of General Practitioners, the Paediatrics and Child Health Division of The Royal Australasian College of Physicians, the Australian Medical Association and the Australian Nursing Federation.

Recommendation 5:

Best practice radiology is key to the diagnosis of ITBI. Brain Injury Australia recommends that FaHCSIA, in implementing Outcome 4.4 of the Framework - “support enhanced national consistency and continuous improvement in child protection services” – to direct production of national standards of practice for radiology relating to the detection of child abuse.  Brain Injury Australia also recommends that FaHCSIA, through DOHA, include the development of such national standards in the latter’s Diagnostic Imaging Quality Program.

Recommendation 6:

The majority of victim-survivors of inflicted traumatic brain injury are placed in Out Of Home Care. Brain Injury Australia recommends the “National Standards in Out of Home Care” being prepared by FaHCSIA should include regular and ongoing comprehensive assessments conducted only by medical and other professionals with relevant qualifications in child health and development.

Recommendation 7:

Brain Injury Australia recommends that FaHCSIA propose to the Community and Disability Services Ministers’ Conference, in its implementation of Strategy 2.4 of the Framework – to “enhance services and supports for children and families to target the most vulnerable and protect children ‘at risk’” – that both intensive (secondary) prevention and early intervention services receive dedicated education and training in child abuse and neglect inclusive of ITBI.

Recommendation 8:

Brain Injury Australia recommends that FaHCSIA urge the Community and Disability Services Ministers’ Conference, in implementing Strategy 1.2 of the Framework – “educate and engage the community about child abuse and neglect and strategies for protecting children” – to fund a universally available, evidence-based, child abuse and neglect prevention campaign inclusive of information relating to ITBI.

Recommendation 9:

Brain Injury Australia believes that parent education should be no different from any other – nationally consistent. Brain Injury Australia recommends that FaHCSIA propose to the Community and Disability Services Ministers’ Conference, in its implementation of  Outcome 1.2 of the National Framework – “educate and engage the community about child abuse and neglect and strategies for protecting children” – that a nationally consistent curriculum for parent education be developed and implemented, inclusive of information about child abuse and neglect.