The health of children in refuges for women victims of domestic violence: cross sectional descriptive survey

Review of routine health records

Data from the child health system were available for 124 (84%) of the assessed children. Of these, 33 (27%) had either an incorrect address or no last address recorded, 80 (65%) had an incorrect or no general practitioner recorded, and 40 (32%) had both the incorrect address and incorrect general practitioner recorded. For those with a correct last address recorded (89), 48 mothers said they would not receive mail in the refuge as for their own safety they had not divulged their whereabouts. Consequently, 83 of 124 (67%) children would not receive any appointments sent by post.

Each refuge had a named health visitor who might visit once a fortnight and see any families who were present. These visits were ad hoc and unstructured. As no formal records were kept, no information was obtained from this source. The resources required for this work had never been estimated. All the named health visitors were attached to practices recognised to be under-resourced for health visiting, even without the refuge workload.

Table 2 summarises data on the uptake and outcome of health surveillance. The preschool and school age modules of the child health system were not added until 1988 and 1991 respectively. The totals reflect, therefore, those children who should have had each assessment by the time of the survey and whose age meant that they should have a record of that assessment on the child health system. In all, data on the birth visit was absent for 74/130 (57%) children and on the 18 month assessment for 40/105 (38%) children. Similarly, 37 of the 124 (30%) children for whom child health system data were available had failed to complete immunisations that were due by the date of assessment.

Developmental screening

Sixty eight of the 73 children aged 3-4 years were tested with the Denver developmental screen. Six (9%) of these children failed the screen, and a further seven (10%) had questionable results requiring review. These 13 children with problems were referred to appropriate agencies: three moved on to unknown destinations, three remained in a refuge (of which two were outside Cardiff), two returned home, and five were rehoused (though mostly not in their home area).

Behavioural assessment

Table 3 shows the results of the Rutter parents' scale administered to 101 children aged 3-15 years. Forty nine (49%) of the children scored >10. These results are presented in more detail elsewhere.11

Maternal concerns and referrals to health and social services

The mothers of 113 (76%) children identified at least one concern, and some identified several (table 4). Overall, 237 concerns were expressed, of which 67 related to the child's physical wellbeing, 129 to emotional and behavioural wellbeing, and 41 to management of the child (feeding, sleeping, and toileting).

Referrals were made only with consent (excepting child protection referrals). Seventy three referrals were made for 65 children. Thirty six children were referred to a health visitor; nine to a paediatrician; eight to social services; six to a school nurse; four to a family therapist; three each to child protection, audiology, and enuresis services; and one to a dietitian.

After leaving refuge

Only 37 of 148 (25%) assessed children were in permanent accommodation at the end of the study. Of the remaining 111 children, 37 returned home (36 to the perpetrator), 24 remained in a refuge in Cardiff, 12 moved to refuges outside Cardiff, 7 were in “second stage” refuge accommodation (half-way house), 9 were staying with friends or extended family, and 22 were untraceable (the mothers of 6 had been evicted for behaviour that put other residents at risk—for example, allowing a partner into the refuge).

Failings in the system

The child health system is designed to facilitate implementation of the immunisation and developmental surveillance programmes, as well as other health services for children—for example, school health services and services for children in need. In our study many children in refuges were not identifiable or accessible via the child health system. In effect, these children form a largely invisible population, outside the health system and poorly served by it. This may be blamed on the “chaotic” lifestyle of these families or on a current system that fails these and other highly mobile vulnerable families. We did not explore the reasons for the poor quality of data from the child health system. The poor quality may result from system failure (failure of transfer of registration details from the general practitioner to the health authority or from the health authority to the child health system) or failure by families either to register with a general practitioner or to provide information on change of status and address. Fear and experience of discrimination, as well as mobility, may be important factors. Although mothers are encouraged to register with local general practitioners, many reported being told by practices to return and register only if their child needed an appointment. Other mothers opted to remain with their previous practices but not to inform them of their change of address.

Children in refuges are at risk from preventable infections and the late diagnosis of remediable developmental and other abnormalities. Although our figures do not suggest an excess of children with developmental problems, as do American surveys,8 access to services for assessment and therapy is poor. Many mothers request, for their safety, that previous records are not sought. Families drift into other temporary accommodation, move to other refuges, or are rehoused far from their original address. We are concerned that, without dedicated services to which these families can be referred, many fall through the system. Nearly half of the assessed children required referral to another agency or health professional. In the absence of this project, few of these would have been identified.

Mental health

The prevalence of mental health difficulties in this population was 48% compared with estimates of 10-26% in the general school age population. 14 15 Although our findings may not accurately reflect the impact of domestic violence on the psychological wellbeing of children generally, they support the argument that domestic violence is harmful and thus should be seen as a form of child abuse.7 Indeed a 1999 report by the Department of Health encouraged Area Child Protection Committees to work with local domestic violence groups.16

New strategies needed

Child and adolescent mental health services need to work with refuge organisations to develop strategies to meet the needs of children whose mothers are victims of domestic violence. Currently families are supported by non-specialist refuge workers with extremely limited access to advice and referral. A tier 3 level of service—as defined in the Department of Health's report Together We Stand17—which provides training and support for staff in direct contact with mothers and children may offer a solution. Supported refuge staff may then be better able to provide tier 1 services to families in crisis. They are well placed to follow through referrals to tier 2 services if necessary, when children are settled into permanent accommodation.

The English primary care trusts and their equivalents in Wales and Scotland have a duty of care to families in their local refuges. The time that children spend in refuges provides a window of opportunity to review their health, identify problems, and begin the process of investigation, treatment, and care. The numbers passing through refuges are about half of those in care, on whom a large amount of money is currently being spent in England and Wales. 18 19 Children in refuges also deserve investment and targeted services. Appropriately trained and skilled specialist health visitors could provide support and advocacy and facilitate access to mainstream services.