Healthcare of Vulnerable Persons; a Study among Children Living Under Domestic Violence

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Introduction Vulnerability as a concept in nursing can be defined as susceptibility to change which is adverse to the wellbeing of the subject due to threat or inadequacy (Chesnay et al, 2008). Vulnerable people are often presumed as at risk considering their health, economic, social or living conditions. Abuse may consist of single or repeated acts. It may be physical, verbal or psychological, it may be an act of neglect or an omission to act, or it may occur when a vulnerable person is persuaded to enter into a financial or sexual transaction to which he or she has not consented, or cannot consent. Abuse can occur in any relationship and may result in significant harm to, or exploitation of, the person subjected to it (No Secrets, DoH March, 2000)

One of the most vulnerable groups is children living under different circumstances. According to the National Resource Centre Report on Child Maltreatment (2008), child vulnerability denotes the capacity of a child for protecting himself. The group of children identified for the purpose of this study is children living under circumstances of domestic violence studying in school in East London. These children live with their families where there are frequent instances of domestic violence by the father. The study of the risk factors among vulnerable children under domestic violence would help in formulating strategies to prevent the risk of vulnerability and plan appropriate treatment methods.

Risk factors associated with vulnerable children in domestic violence: There are several risk factors that are associated with vulnerable children living under the circumstances of domestic violence. Children who are previously abused have the tendency to become vulnerable in an environment where domestic violence prevails (Humphreys and Stanley, 2006).The lower age of the child is another risk factor of vulnerability. Other risk factors of vulnerability among children are low weight at the time of birth, chronic diseases, delay in growth and mental development, separation from parents especially from mother, criticism and punishment of parents, frequent cries, feeding difficulties and adoption or foster care (Cawson, 2002). Apart from these risk factors, several factors related to parents and family circumstances act as risk factors for vulnerability among children. These are mental health problems and drug abuse of parents, domestic violence, parents who are adult survivors of child abuse, unemployment and poor financial conditions, low self esteem and illness of parents (Humphreys and Stanley, 2006). Social factors like caste system and ethnicity also act as risk factors for vulnerability among children.

Several studies have been conducted on the vulnerability among children related to the risk factors, types of vulnerability among children, preventive measures etc. Assessing the risk of vulnerability among children living under domestic violence circumstances In order to understand or judge child vulnerability, there must be constant interaction with the child and understand the family conditions of the child through observation. If the ability to protect oneself is taken as the sole criteria for judging child vulnerability, it can be said that children are always under somebody`s care and protection and they are not able to protect themselves (www.barnet.gov.uk). Then arise, the question; how a child who is always supposed to be under somebody`s care can be judged as vulnerable or under what circumstances a child can be said to be vulnerable? A single factor cannot be taken as a factor for vulnerability; instead vulnerability can be judged on the basis of several factors which are explained below:

Age: Children are vulnerable to harm injury or abuse depending upon their age (Cleaver et al, 2007). Younger children because of their ignorance, reason, financial dependency etc. are more vulnerable to injury, harm or abuse than older children. Young children who live under domestic violence situation are often helpless to prevent the harm of domestic violence because of their tender age.

Physical disability: Children who are physically disabled are vulnerable because of their physical immobility and limitations they depend on others even for fulfilling their basic needs. Physically disabled children are helpless to avoid any physical attack due to domestic violence (Cleaver et al, 2007).

Mental disability: Mental disability is another factor for vulnerability among children. Children because of their ignorance and lack of reason may be vulnerable but this vulnerability is reduced over years when they attain reasoning and knowledge. This does not happen in the case mentally disabled children whose mental capacity is limited forever. Thus mentally disabled children who are unable to sense anything are vulnerable. Mentally disabled children are also helpless to protect themselves from domestic violence (Brown, 2007).

Provocative: The mental, physical and behavioural aspects of the child irritate others and invite them to harm the child. Thus the provocative nature of children makes them vulnerable (Brown, 2007).

Powerless: Children are powerless in so many aspects, financially, legally, physically and mentally, hence they are vulnerable. The provocative nature of children makes their fathers more aggressive towards them (Braye et al, 1995).

Defenceless: The lack of capacity of children to defend them makes them vulnerable. They lack physical, mental and moral capacity to defend themselves by force or by argument. Due to the defenceless position of children, their fathers physically and mentally harm them. (Braye et al, 1995). Non assertiveness: Children who are non-assertive cannot make demands, deny, or refuse something which they do not like. Hence, they are vulnerable to abuse and exploitation. Domestic violence from father make the children suffer from low self esteem and fear and depressed which in turn make them non assertive and unable to claim their personal rights. (Kennison and Goodman, 2008).

Illness: Illness and other medical problems make children vulnerable. Sick children are sometimes deprived of medical help by fathers who cause domestic violence (Kennison and Goodman, 2008).

Invisible: Invisibility of a child or the isolated condition of a child makes him vulnerable. Children are sometimes isolated by the father not allowing them to communicate with other people or relatives note even with their mother. This makes them more vulnerable to abuse and harm by disallowing them to ask for help (Bourlet, 1990).

Helplessness of mothers: In most cases of domestic violence, women especially the wife is the victim. They are deprived which make them unable to protect their own children. Children who live in condition of domestic violence are in constant danger of being abused and the above factors add or reduce the extent of their vulnerability (Baxter et al, 2001). Methods and strategies for assessing risk among vulnerable children: There are several methods developed to assess the risk factors of vulnerability among children under domestic violence. The Domestic Violence Risk Assessment Model (DVRAM) developed by Barnardos (2000) is a popular measure to assess the risk of vulnerability among vulnerable children. This measure was later modified and adapted by Maddie Bell and Joan McGovern. DVRAM was started with several objectives to protect children from domestic violence. These are:

To provide assistance to staff in identifying the risk factors of vulnerability among children living under domestic violence To examine the need of the child regarding whether he need support of the family To provide assistance to the staff to help them to protect the vulnerable child from his abusing parents To assist the social workers to assess the risk factors of vulnerability among children living under domestic violence (Calder, 2007).

It is the DVRAM model that provides a comprehensive plan for assessing the risk factors and management strategies for rescuing vulnerable children (Calder, 2007). This model is based on the given below principles: The first priority should be to protect the child and then the non abusing parent who is usually the mother which help in protecting the children Provide support and help to the non-abusing parent Preventing the abusing parent from perpetrating the abuse against the child and the non abusing parent

The DVRAM risk assessment model provides for nine areas for risk assessment among children living under domestic violence (Calder, 2007). These assist social workers to take decisions on preventing and protecting vulnerable children under domestic violence. They are: 1. Nature of abuse: The social workers should assess the risk of vulnerability by examining the nature of abuse 2. Risk to the child posed by the abusing family member: The social workers should assess the nature of risk posed by the family member against the child. 3. Risk of lethality 4. The pattern of violence and assault 5. Impact of the abuse on female members of the family 6. Effect of the abuse on children 7. Effect of the abuse on parenting roles 8. Protective factors 9. The nature of the women`s reaction to the abuse in the past

These nine aspects are helpful for social workers to assess the rate of risk of vulnerability among children living under the threat of domestic violence. This risk assessment tool is suitable in assessing the risk of vulnerability among children living under domestic violence as it take into account all aspect of family life and domestic violence and make separate

analysis of the nature of response of the non abusing parent. The benefits of the DVRAM assessment model are such that even courts have started to appreciate and comment on the importance of this model in domestic violence cases. The DVRAM model is suitable not only in assessing the risk of vulnerability, but also in planning strategies for prevention, protection, empowering the children and helping other family members who are vulnerable, assisting and supporting the workers in their practice and the community as a whole indirectly (Calder, 2007).

Multi-agency working model: Strategies to prevent and protect children under the risk of vulnerability must be aimed at preventing further domestic violence as well. This should also include rescuing other adult members of the family who are also under the risk of vulnerability. Hence the help of other agencies apart from the child protection agencies are required. This may include police, domestic violence prevention unit, healthcare workers and other agencies for protecting adults and mentally disabled from domestic violence (Pascal et al, 2002).. In short, a multiagency approach is most suitable in risk assessment and prevention of vulnerability among children in domestic violence cases. This requires the assessment of resources for the agency activities, the external environment and internal environment of the agencies and their organisational culture etc have to be taken into account. Staff training, resource material development and updated knowledge on the dynamics of domestic violence are necessary to formulate a better strategy to combat the event (Pascal et al, 2002).

Studies of Bourlet (1990) reiterate the importance of multiagency working model in dealing with vulnerable children. According to Pascal et al (2002), the working of multi-agencies model is of four types; unified, coordinated, hybrid and coalition models. Among these models, the coalition model of management is the popular one as it consists of the merits of federal partnership of both the management and staff in working with vulnerable children. This study recommends the coalition model of management strategy to prevent vulnerability among children. The Caring Dad programme (www.caringdadsprograme.com) also recommends the support of fathers in rescuing children under vulnerability.

A publication of Department of Health (2000) named Framework for the Assessment of Children in Need and their Families provided a framework for gathering information about families where domestic violence prevails that contains children in need. This is a multiagency single assessment model that is primarily designed for Northern Ireland. This model assesses the parental capacity of fathers and mothers and concludes that the

children of those incapable parents or those fathers and mothers who are not up to the mark in parenting are vulnerable. This assessment model has its defects because, parental capacity alone cannot be deemed as criteria for assessing risk of vulnerability in family settings. This is because even if the parents are capable for parenting, the domestic flights between the parents and the violence between them may cause mental harm and personality disorder in the children. Hence, this assessment model cannot be deemed as foolproof.

Apart from the above framework, several other risk assessment models were developed by the local councils and agencies. The policies and procedures suggested by these framework models recommend that social workers are responsible for assessing risk among children living under domestic violence but these policies do not mention how to assess the risk. Managing vulnerability among children living under domestic violence Managing the risk assessment and prevention strategies for vulnerable children living under domestic violence requires best practice methods of management, including human resources management, financial management and care management. There must be an all-inclusive plan for preventing vulnerability among children, living under domestic violence (Kennison et al, 2008).

The Green Paper by the Parliamentary Committee on Every Child Matters (2003) suggests four types of methods for managing child vulnerability issues. These are focussed on providing support to family members and social carers, providing early support to vulnerable children before they face a dangerous situation, examine the roles and responsibilities of agencies in supporting vulnerable children and ensuring the safety, esteem and reward of the social workers who work for vulnerable children. Evidence based practice and managing child vulnerability Another important aspect that should be taken into account in managing child vulnerability is to manage the communication between medical practitioners and the social workers on the findings and analysis that the former learnt and observed during the treatment of abused children under domestic violence. This exchange of information is a part of evidence based practice and would help the social workers who work among vulnerable children under domestic violence as these children can give a better idea on the risk factors and nature of vulnerability and abuse meted out against them (Shlonsky, 2008). This information would help social workers to update their knowledge database and formulate new strategies that would aid them in their practice (Shlonsky, 2008). Thus, there must be a clinical and field

level communication in managing the risk of vulnerability among children under domestic violence.

Resource allocation is another issue in the management of vulnerable children because all the above suggestions and functions require financial resources as lack of financial resources would hinder the implementation of the above strategies (Shlonsky, 2008). Adhering to the Code of Conduct in care policy is another major issue in working with vulnerable children. Empowering children; power and powerlessness The studies of Kennison (2008) mention the importance of power as a factor in vulnerability. According to him, children are vulnerable due to their powerlessness. The powerlessness of the children makes the risk assessment a difficult process. According to the Code of Ethics (2002) of the British Association of Social Workers, the social workers are responsible to empower the children to disclose the issues that they face in homes. The studies of Mullendar et al (1985) suggest that empowerment denotes equipping the victim to combat and challenge oppression. The concept of empowerment according to Braye et al (1995) refers to taking control of oneself and enabling one to exercise their power. All these studies simply urge the importance of empowering children to protect themselves from vulnerability and abuse. Record keeping Managing the child vulnerability under circumstances of domestic violence requires the implementation and practice of proper recording and reporting. Beresford (2003) suggested that reporting and proper recording of incidences of child vulnerability and intervention are helpful for social workers and researchers to conduct further research. Recommendations The Department of Health should conduct sufficient research in assessing the risk factors of vulnerable children living under domestic violence. It should also formulate strategies to prevent and protect such children. There must be strategies to rescue the vulnerable non abusing parent as well from such abuse. There must be specific training programmes for social workers and practitioners to assess the risk for vulnerability among children in domestic violence circumstances. They should be trained in understanding the dynamics of domestic violence. There must be multi-disciplinary agencies for risk assessment and such agencies should be trained to implement `safety work` and threshold scales. Children should be participated in decision making and should be provided adequate counselling. Adequate counselling sessions following the pattern of Seasons of Growth should be provided to

children who are vulnerable. There must be a national level coordination and policy making to save children from domestic violence. Conclusion Vulnerable children who live in a situation of domestic violence need special attention and protection because of the nature of the vulnerability. Since the persons who are supposed to be their protectors are the perpetrators of vulnerability, the seriousness of vulnerability is high among such children. Further, the age, mental incapacity, lack of decision making power, psychological attachment to the abusing family member or perpetrator of domestic violence; make it impossible for children to seek help from outside. The isolated nature of domestic violence and the helplessness of the non abusing parent usually the mother make the risk assessment difficult.

The theories and risk assessment models as mentioned above have their own merits and defects. Among them the DVRAM model is the most suitable and developed strategy to assess risk and prevent and protect vulnerability among children under domestic violence. The management of risk of vulnerability among children living under domestic violence requires multi-agency cooperation, the cooperation of the school and other family members. Providing proper training to the social workers who work with vulnerable children is very important. There should be more intense research on the assessment of risk of vulnerability and its psychological impacts at the academic level. Moreover, there must be coordination between the clinicians and social workers who work with vulnerable children in sharing knowledge on child vulnerability. UN and vulnerable children living under domestic violence According to the study report by UNICEF (2006) on the children living under domestic violence, the following findings have been made: Children deserve a safe home environment Children should know that there are adults who are ready to listen them and assist them Children need a sense of routine and normalcy Children need support services to meet their needs Children need to know that domestic violence is wrong and they should know the non-violent methods for resolving conflicts The study report makes the following urges to the policymakers in this regard: Raise awareness on the effect of domestic violence on children Make laws and policies to protect vulnerable children

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