Upgrading CAN cases' surveillance capacity among

crisis era at national and European level: the

experience from GreeceATHANASIOS NTINAPOGIAS, CHARA TOMPRA, MARIANNA TSANA, FOTEINI

ZAROKOSTA, GEORGE NIKOLAIDIS

INSTITUTE OF CHILD HEALTH, DEPARTMENT OF MENTAL HEALTH AND SOCIAL WELFARE, CENTER FOR THE STUDY AND PREVENTION OF CHILD ABUSE AND NEGLECT

PART OF THE PROGRAM: “HOLISTIC APPROACH FOR THE INQUIRY, DIAGNOSIS AND MANAGEMENT OF CASES OF CHILD ABUSE AND NEGLECT”, RUN BY THE INSTITUTE OF CHILD HEALTH, DEPARTMENT OF MENTAL HEALTH & SOCIAL WELFARE (CODE: MIS 372071)CO-FUNDED BY THE EUROPEAN SOCIAL FUND AND THE MINISTRY OF HEALTH & SOCIAL SOLIDARITY IN THE CONTEXT OF THE OPERATIONAL PROGRAMME “HUMAN RESOURCES DEVELOPMENT”, PRIORITY AXIS 5.1: “ESTABLISHMENT OF REFORM IN THE MENTAL HEALTH SECTOR – DEVELOPMENT OF PRIMARY HEALTH CARE AND PROMOTION OF PUBLIC HEALTH IN THE 8 REGIONS OF CONVERGENCE”

Milestones of development for CAN research and interventions

• Initially Medical-centered model• In turn, influenced by Women’s and Human Rights’ Movements, research often

dominated by victimological studies• Sometimes over-charged with values, beliefs, ideologies or even preoccupation of

pioneers• Gradually fine-grained through understanding of relative autonomy of scientific

evidence and rightful human rights’ agenda

• During the last couple of decades entering the evidence-based practice paradigm• Augmented by the necessary practice-based evidence

A public health approach to child A public health approach to child maltreatmentmaltreatment

A multi-sectoral approach:

4 steps:1. surveillance to define the magnitude of the problem2. analysis to highlight the risk factors and risk groups3. evaluative research to identify effective interventions 4. implementation of what works at a broader level

(WHO 2007, Preventing child maltreatment in Europe, Violence and Injury Prevention Programme, WHO Regional Office for Europe)

Empirical grounding of the necessity for CAN

surveillance

Starting point – Empirical Initiation: Starting point – Empirical Initiation: the BECAN project and its resultsthe BECAN project and its results

Contract Number: HEALTH-F2-2009-223478

Type of Project: Collaborative ◦ Call: FP7-HEALTH-2007-B

• Co-funding:Research Directorate General EC & 9 Balkan Participating Organizations

• Duration: 40 months• October 2009 - January 2013

• Participating countries• Albania• Bosnia & Herzegovina• Bulgaria• Croatia• Former Yugoslav Republic of

Macedonia• Greece• Romania• Serbia• Turkey

BECAN ConsortiumBECAN Consortium

Overall rates of self-reported children’s exposure to violence Overall rates of self-reported children’s exposure to violence in Greecein Greece

Case-based Surveillance BECAN Study (CBSS)Case-based Surveillance BECAN Study (CBSS)Administrative Data Collection Research’s outcome:

Child maltreatment incidence rates (per 1000 children) for 2010 according to authoritative organizations’ records and files

Total Attica Cretemale femal

etotal male femal

etotal male female Total

Children population (National Statistical Service, 2001)

Age group 0-4 106.605

100.789

207.394 89.362 84.392

173.754 17.243 16.397 33.640

5-9 107.755

101.719

209.474 90.454 85.706

176.160 17.301 16.013 33.314

10-14 115.330

107.145

222.475 96.872 90.582

187.454 18.458 16.563 35.021

Subtotal 329.690309.65

3639.3

43 276.688260.68

0537.36

8 53.002 48.973 101.97515-19 144.51

2136.81

0281.3

22 122.598117.28

2239.88

0 21.914 19.528 41.442Total 329.69

0309.65

3639.3

43 276.688260.68

0537.36

8 53.002 48.973 101.975CAN cases extracted for 2010 (141 agencies; Attica=127, Crete=14)

Age group 0-4 474 420 929 409 363 804 65 57 125 5-9 799 583 1.405 666 469 1157 133 114 24810-14 733 615 1.355 591 490 1088 142 125 267

Subtotal 2006 1618 3689 1666 1322 3049 340 296 64015-18 358 386 750 279 327 612 79 59 138

Total (for 84 cases sex is unknown) 2.364 2.004 4.439 1945 1649 3661 419 355 778CAN annual incidence (2010) per 1000 childrenAge group 0-4 4,45 4,17 4,48 4,58 4,30 4,63 3,77 3,48 3,72

5-9 7,41 5,73 6,71 7,36 5,47 6,57 7,69 7,12 7,4410-14 6,36 5,74 6,09 6,10 5,41 5,80 7,69 7,55 7,62

Total 6,08 5,23 5,77 6,02 5,07 5,67 6,41 6,04 6,2815-18* *the comparison is not feasible due to different age range (15-19 vs. 15-18)

Child maltreatment as an “Iceberg” Child maltreatment as an “Iceberg” ((CHILDONEUROPE, 2009)CHILDONEUROPE, 2009)

However, if someone compares what is found by children’s However, if someone compares what is found by children’s reports and recorded cases, figures – however inaccurate – reports and recorded cases, figures – however inaccurate – speak for themselves…speak for themselves…

Results presented are concerning prefectures of Attica and Crete referring to calendar year 2010 (field survey vs. case-based surveillance study’s results). Extrapolation was calculated for CBSS’s results based on national statistics on children’s population and the ration of participation of agencies to the study in respect to the totality of agencies dealing with CAN cases.

Even if one doubles first row’s figures (in virtue of non-collaborating agencies), even if one divides by 10 second row’s figures (for counting only more severe cases of children’s adverse experiences), conclusion still remains the same in terms of social policy deficits:

In Greece some professional assistance is provided to less than 1 in 10 children experiencing some short of violence, victimization or in any case adverse experience

It is the first time that the “iceberg” phenomenon on CAN cases was quantitatively documented

Furthermore the necessity for building up a permanent CAN-data collection surveillance system in Greece was empirically grounded

Psychological Physical SexualContact Sexual Neglect

Self-reported Syrvey 70,02 47,38 9,54 4,45 26,41Reported Cases Study 0,53 0,18 0,46Ratio 0,76 0,38 0,73 1,57 1,74

0,07

Type of exposure to violence

Incidence Rates

Developing a CAN surveillance system in Greece

Steps in designing and implementing a CAN surveillance system in Greece

1. Conducting an extended literature review on procedures and variables of other countries’ CAN registering or surveillance systems

2. Conducting a similar review on available data by national research (one-off) resources

3. Drafting accordingly a first set of potential variables to be included in the Hellenic system

4. Conducting a first round of consultation with 5 top experts (consensus panel) of various sectors and professional background and consequently concluding to a smaller variables’ list

5. Conducting a second round of public consultation with 50 experts by various sectors and professions involved as well as leading national scientific associations and consequently concluding to the list of variables for the pilot phase

6. Developing software application for implementation of the registering system

7. Piloting the registry with 5 major volunteering organization by governmental and NGO sectors and consequent readjustment based on that experience

8. Continuing recruitment of organizations and agencies for adopting the usage of the registry (bottom-up process)

9. Concluding final variables and procedures’ set and begin normal operational mode

10.Ongoing regular re-assessment of the registry's main features

An overview of CAN Surveillance Systems (Europe, USA, Canada and Australia)1. Mandatory reporting

2. Child abuse & neglect systematic record keeping

3. Type of information most commonly included in department records and central registries

Conclusions

1. The main source of data should optimally be the child protective services as they are more frequently the ones that come into contact with a wider variety of cases.

2. Data should better meet the needs of both professionals and policy makers being at the same time in full respect of the rights to privacy of involved parties.

3. Data collection is not a cost-free activity, as not only the infrastructures (database and software), but also training, maintenance, monitoring and analysis require financial investments.

4. Technical aspects of CAN data collection are directly linked to purposes of the process and its tacit or explicit preconditions and moral values.

5. Finally, even if the most efficient system was designed, a wider societal change is required from adult to child centered services in order to have reliable data that serve better the purpose of child protection

Final Outcome: the system in short

• An electronic database in which professionals will register all reported cases of child abuse and neglect.

• Data from various sources (social services, healthcare settings, law enforcement, justice).

• Variables regarding the victim, the incident of maltreatment, the alleged perpetrator, the investigation status and possible risk factors.

Variables (1)b. Child 1. ID number of the child

2. Gender

3. Age

4. Citizenship

5. Availability of address

6. Residence

7. Working status

9. Permanent residence

10. School attendance

a. User 1. Username 2. Password 3. Region 4. Regional Unit 5. Municipality 6. Name of the agency/service 7. Access date

11. Social Insurance

12. Biological parents

13. Roommates ID

14. Report of CAN regarding another child

Variables (2)c. Maltreatment

15. Type

16. Referral source

16. Date of the 1st referral

17. Name of the agency/service that received the 1st report

18. Date of the first report

19. Duration or multiplicity of the abuse

20. Date of the 1st incident of abuse

d. Case Investigation

21. Investigation result

22. Police involvement

23. Justice involvement

24. Agencies/services involved

Variables (3)g. Risk factors

34. Of the child

35. Of the family

36. Of the alleged perpetrator

e. Alleged perpetrator

25. Relationship to the child

26. Gender

27. Age group

28. Confirmation of the perpetrator

29.Referral to the court

30. Jurisdiction

f. Clinical intervention31. Therapeutic intervention on the child32. Therapeutic intervention on the family33. Therapeutic intervention on the perpetrator

Greece’s National CAN registry's

comprehensive goals and objectives

Register all reported cases of child maltreatment Measure the scope and magnitude of child maltreatment Develop a network for the effective collaboration and coordination of all professionals involved in child abuse and neglect cases Inform and guide professional practice Unifying criteria for detecting and classifying child abuse cases Inform and guide policy makers of possible risks and trends affecting health and safety Prevent multiple victimization Set priorities for prevention and intervention

The process is currently ongoing moving through expert's panels and public consultation’s rounds towards pilot phase…

anticipated to be completed by mid 2015

Developing a pan-European CAN-related data collection’s surveillance system

Project’s Identity

The Project aims at creating the scientific basis, necessary tools and synergies for establishing compatible and effective national CAN-MDS

Surveillance systems

Project’s Consortium

Steps in designing and implementing a CAN surveillance system in Europe

1. Conducting an extended literature review on systems, operators, procedures and variables of existing national CAN registering or surveillance systems as well as respectful recommendations by international organizations; including also available relevant research data

2. Defining the appropriate optimum set of variables

3. Defining the appropriate type of operators (sectors, services, professionals)

4. Defining the appropriate procedures for regular data collection including ethical requirements

5. Providing operational definitions and developing a respectful toolkit for usage

6. Doing all aforementioned (2) to (5) tasks in a publicly visible manner, inviting more organizations, researchers, countries, participants to join in and provide feedback at any stage

7. Submitting drafted preliminary outcome to public consultation by a large number of international top experts on the field of CAN data collection

8. Concluding final variables and procedures’ set, publishing toolkit, conducting training seminars for their application

9. Building a strong supportive base for the potential of the application of the MDS into the largest number of countries or regions possible by intensive dissemination and lobbying efforts

10.Ongoing re adjustment of the entire model systm according to implementation’s feedback monitoring

On example on the methods of work on defining the appropriate optimum operators/data sources:How the eligibility criteria were defined

Identification of potential sources of data for a CAN-MDS Surveillance System

A 4-step methodology was developed to define the eligibility criteria for CAN-MDS Core & Expanded Groups of Operators:

DEFINING ELIGIBILITY CRITERIA FOR CAN-MDS DATA SOURCES & GROUPS OF OPERATORS

Step A Identification of relevant fields to be involved in a future CAN-MDS system as data sources

Step B Identification of eligible professionals to be invited as potential operators of a CAN-MDS system per working field

Step C Identification of responsibilities of each eligible professionals' group

Step D Decision for level of access of eligible professionals to be included in the expanded groups of operators in a future CAN-MDS according to their responsibilities for the administration of CAN cases and the field they are working

Step C

Step B

Step A

Step D

more informationwww.can-via-mds.eu

Eligible fields relevant to CAN cases to be used as data sources for a CAN-MDS Surveillance system

Fields related to CAN-cases administration Eligible field Non-eligible field

CPS/ Social Welfare Services BE-BG-CH-DE-ES-FR-GR-IT-ROPhysical Health Care Services (primary, secondary & tertiary) BE-BG-CH-DE-ES-FR-GR-IT-ROJudicial Services BE-BG-CH-DE-ES-FR-GR-IT-ROAccredited NGOs/ Community Organizations BE-BG-CH-DE-FR-GR-IT-RO ESMental Health Services BE-BG-DE-FR-GR-IT-RO-ES CHLaw Enforcement related Services BE-BG-CH-ES-FR-GR-IT-RO DEEducational Services (preschool, primary & secondary) BE-BG-DE-ES-FR-GR-RO CH- ITAlready existing registries/monitoring mechanisms BE-BG-DE-ES-FR-RO CH-GR-ITResearch Organizations/ Institutions BE-BG-DE-FR CH-ES-GR-IT-ROIndependent Authorities (such as Child Ombudsman) BE-FR-GR BG-CH-DE-ES-IT-ROOther BE-ES-RO BG-CH-DE-FR-GR-IT

Core data sources (applicable in all countries)

Expanded data sources (recommended where applicable)

To be considered (based on country specifics)

resu

lts

Data sources for a potential CAN-MDS Surveillance System(a) applicable in all countries, (b) recommended-where applicable, (c) according to country specifics

Fields should be represented in national core groups

Core data sources for a CAN-MDS Surveillance System◦ CPS/ Social Welfare Services◦ Health Care Services (primary, secondary & tertiary)◦ Judicial Services

Sectors that could also be among the main data sources (common in at least 7 out of the 9 countries) ◦ Mental Health Services◦ Accredited NGOs/ Community Organizations◦ Law Enforcement related Services◦ Educational Services (preschool, primary & secondary)◦ Already existing registries/monitoring mechanisms (not available in all countries)

Sectors that would probably be difficult to be included as data sources because their involvement seems to be more as a country specific attribute rather than a common practice among countries

◦ Independent Authorities (such as Child Ombudsman)◦ Research Organizations/ Institutions◦ Other fields

Sample table (Step 2 Results)

Number of countries where professions’ groups currently work

in CAN administration fields

Social Services/CPS

Judicial Services

Health Services

Mental Health Services

Law enforcement

Other Services (Registries, Research, etc)Other Services (Registries, Research, etc)

Educational services

NGOsNGOs

Welfare professionals

Justice Professionals

Health professionals

Mental Health Professionals

Law enforcement Professionals

Education professionals

Other Professionals

Sample table (Step 3 results)

Levels of access to CAN-MDS

Gradation

Definition of operations per level of access

Responsibilities

System Management (National Administrator)

- Making decision on whether sufficient evidence exists to prosecute (alleged) offenders

- Conducting initial assessments for suspected CAN cases - Providing services to CAN victims (diagnostic/ treatment/ consultation/ care) - Providing services to CAN victims’ families (supporting)- Following-up of CAN cases

- Notifying (optionally) authorities of (suspected) CAN cases - Reporting mandatorily (suspected) CAN cases- Applying screening in the general child population for CAN- Providing emergency protective measures to CAN victims- Providing legal advice/ consultation/ advocacy for CAN cases

“rights” of the level of access

enters data WITH access to ALL data, aggregated AND disaggregated (at case-level) (view/ edit/ delete) and to users’ accounts create/edit/ delete)

enters data WITH view access to ALL data, aggregated AND disaggregated (at case-level) (view/ edit/ delete) and to users’ accounts (view)

enters data WITH access to data entered by the same user (view/ edit/delete) AND to data entered by other users for the same case (view)

enters data WITH access ONLY to data entered by the specific user (view/edit/delete)]

Level of access

Full Access

Full View access

(level 1)

Limited access

(level 2)

Limited access

(level 3)

Sample table (Step 4 results)

Full View Access (Level 1)(with the responsibility “making decision on whether sufficient evidence exists to prosecute alleged offenders”)

Data sources & Eligible Professionals

Recommended for all countries Where applicable

Public Prosecutors working in Judicial Services Social Workers working in Child Protection System

Limited Access (Level 2)(with at least one responsibility corresponding in level 2)

Data sources & Eligible Professionals

Recommended for all countries Where applicable

Social Workers working in Child Protection System/Social Welfare Services Accredited NGOs/ Community Organizations

Child Psychiatrists working in Health Care Services Mental Health Services

Psychologists working in Child Protection/Social Welfare Services Health Care Services Mental Health Services

Pediatricians working in Health Care ServicesMedical Doctors (different specialties, e.g. gynecologists, orthopedists,

radiologists) working in Health Care ServicesPolice Officers working in Law Enforcement-related Services

Mental Health Professionals (psychologists, psychiatrists) working in Law Enforcement related services

Licensed Counselors working in CPS/Social Welfare ServicesMental Health ServicesJudges working in Judicial ServicesNurses working in CPS/Social Welfare ServicesMidwives working in CPS/Social Welfare ServicesData administrators working in available related registries

Limited Access (Level 3)(with at least one responsibility corresponding in level 3)

Data sources & Eligible Professionals

Recommended for all countries Where applicable

Social Workers working in Health Care Services

Mental Health Professionals (psychologists, psychiatrists, licensed counselors) working in Accredited NGOs/Community Organizations

Social Workers working in Education ServicesMental Health ServicesCare Providers in Institutions working in Child Protection System/ Social Welfare

ServicesPsychologists working in Educational ServicesLicensed Counselors working in Educational ServicesProbation Officers working in Judicial ServicesOther Justice-related professions working in Judicial ServicesNurses working in Accredited NGOs/Community OrganizationsTeachers/educators (pre-school, kindergarten, primary and secondary education, for

children with special needs, school principals) working in Educational servicesOther personnel working in antitrafficking, directorate for disability, Child Ombudsman,

etc.) working in Independent Authorities

The process is currently ongoing moving concluding expert's panel and public consultation towards the phase of publicizing toolkit and organizing training activities…

anticipated to be completed by early to mid 2015

“Coordinated Response to Child Abuse and Neglect (CAN) via Minimum Data Set (MDS)”http://www.can-via-mds.eu

/

Website of the Department of Mental Health and Social Welfare, ICH: http://ich-mhsw.gr/

Thank you for your patience!!!