It is typical of the discretion that Dr Kelly's profession demands, that he will use fairly benign terms to describe some of life's grimmest experiences. "Traumatic" and "disgusting" become "difficult". "Mother too drunk to care" may become "not particularly well-supported". You have to listen carefully.
LL: In fact you deal with kids much younger than 13, don't you?
PK: Our work is roughly 50/50 split between various forms of sexual assault, which nowadays tend to be largely in teenagers, and physical abuse and neglect, which tends to be largely in much younger kids. The seriously abused kids are the ones who end up in Starship. For them the mortality rate is quite high, 10 to 20 per cent. The children most likely to die are the ones who come in with head injuries from being shaken or slammed, or abdominal injuries from being stomped or punched.
LL: Are the impulses behind that similar to a shaken baby situation - the frustration with a child being ... well, a child?
PK: The factors are complex. In that situation, the person who injured the child typically doesn't volunteer exactly what they did or why, but when that information comes out it's often about a child who was crying or a toddler who was demanding - just doing what babies or toddlers normally do - with an adult who for some reason cannot cope or doesn't want to.
Sometimes it's where the adult, particularly the male, doesn't have any biological relationship to the kid, so this is a child whose behaviour he has no particular motivation to tolerate. But not infrequently it's the child's own parents ... In a lot of cases it's fairly ordinary people who just crack under the pressure. They shake that baby, often with the intention, not of hurting them, but of shutting them up.
LL: And even one shake can do it?
PK: If it's violent enough, one shake can do it. Violent to and fro movements cause subdural bleeding. The immediate outcome is that the baby is concussed, so she might stop crying, which is exactly what the caregiver was wanting. But they may not realise the only reason is that they've essentially knocked her out. Even if it never happens again, that child could still have some long-term neurological problems as a consequence of that event.
He tells of a case where he came in to treat a 15-year-old girl who had been raped. Although she was sociable and attractive, it became apparent during the assessment that she had a mental age of about 8. She was unaware of boundaries and often found herself in dangerous situations. Dr Kelly went back through her files and discovered that she had indeed been at the (then) Princess Mary hospital as a shaken baby, at the age of 9 months. Clearly, these children do not grow up and out of it.
PK: I meet young adult males with major learning and behavioural problems. Some are parents of babies who they now shake. And I wonder how many of them sustained injuries as babies. The lack of effective intervention early in their lives creates a miserable legacy.
Dr Kelly suggests it's been 20 years of missed opportunities. He says a commitment to research the interventions that worked (and didn't) in 1994 might have meant a lot fewer referrals in 2014.
SOCIAL INEQUITY
LL: Are we doing any better yet?
PK: There's been a huge increase in notifications and part of that's around public awareness, but I suspect there has also been a true increase.
LL: Why do you think that is?
PK: It's tempting to link our possibly increasing rates of child maltreatment to the huge increase in social inequality in New Zealand in the last 20 years.
LL: Do you?
PK: I'm reluctant to draw a direct relationship because if you do, it implies that because you are poor you are more likely to abuse your children and I don't think that's true. It's not as simple as that. But I think the more stress you put a family under - all other things being equal - the more likely it is that the family's going to crack. We know that during the recent economic crisis, rates of abusive head trauma in children went up in the US.
And if you look at countries like in Scandinavia, where rates of child maltreatment are much, much lower than ours, their rates of social inequity are also much, much lower.
SOCIAL DISINTEGRATION
LL: So the issue is money?
PK: Money is only part of the issue. It's also about social disintegration. For example, our own evidence at Starship would suggest that the rate of shaken baby syndrome in Pacific islanders is no higher than the general population in the first year of life, whereas it is in Maori. And I have wondered if that is because many urban Pacific Island babies are still much more in the bosom of their extended family.
LL: There's always someone to pass the baby off to?
PK: Well, exactly. If you've got 13 people living in the house, six of whom are female and many of whom have extensive experience with childcare, then you've got an insurance policy for when you lose it in the middle of the night. Whereas if you are a young Maori urban mother, cut off from your tribal roots and family, who's flatting somewhere with a whole bunch of unrelated people who are abusing drugs and alcohol, and you lose it in the night, you don't have much of a support network.
But it's important to note that the same stresses and factors can be seen in every ethnic group, and it's not just the people we usually perceive as "at risk". Being an upper-middle-class Pakeha with a tertiary degree doesn't prepare you for parenthood or ensure that you won't lose your temper with a crying baby in the middle of the night.
WHERE TO FROM HERE?
LL: What can we be doing better - apart from everything?
PK: I really like what Russell Wills, the Children's Commissioner, is proposing and his plan for the abolition of child poverty, which creates a level playing field for children in the first five years of life, which are so profoundly important.
The Vulnerable Children's Bill and the Children's Action Plan have some excellent ideas - for me, the most important is that the health system (for the first time) will have some responsibility under law for child protection. However, the Children's Action Plan proposes, for example, that all frontline professionals in health and education will be trained in appropriate response to child abuse and neglect by the end of 2015. Well, who is going to do it? It's the kind of training for which you don't want people running a slide show out of a book. You want people who know, from experience, the realities of child abuse and the realities of being a front-line professional in health or education.The ambition is laudable but it's a huge workforce development issue.
I don't think the people in Wellington and the upper echelons of decision-making realise the dearth of clinical resource at the front line. I think people assume that doctors and nurses know what to do, but in fact most of them don't because they've never been trained.
LL: What is it you want?
PK: I want the health system to think of child protection as a health responsibility. It is everyone's responsibility, but each part of the system has a responsibility to get its own house in order. Health professionals care about children, but often have little to do with child protection. To create a culture shift within the health system, there needs to be a funded nucleus of health professionals in every DHB, for whom child protection and associated system changes are key parts of their responsibility, just as we do for rheumatic fever, obesity, diabetes. We don't say to social workers "go and sort out diabetes". Social workers are a key part of the workforce, but they can't do this by themselves.
For kids who have been abused or experienced serious neglect, there should be positive discrimination in their favour. We should never allow that child to drop out of the system again. And if we have to go hunting for them and if that costs money ... [he shrugs.]
LL: Are you talking about a victim register?
PK: Well, I don't like the word "victim" and I don't like the word "register", which just sounds like another database. But I am talking about a concept and a commitment of no child being lost, the resource and the determination to do what's necessary to follow the children who have come to harm and to ensure that things are changing in their lives. We already have the means, if we had the motivation. We need a change of culture.
A child comes through this centre, we try to do a really good quality process in making the diagnosis, working with CYF, going to family group conference, being part of a court process, if that happens. But at some point, the case will be closed. The assumption is that if something bad is happening, someone will let us know. And that's a hugely dangerous assumption.
CYF's own data suggests that without concerted intervention, children who are notified in the first two years of life are likely to be repeatedly renotified because they are living in a toxic environment. They are like the canary in the mine, and by the time the system finally gets around to realising that, the child has suffered too much for too long, the consequences may be difficult or impossible to repair.
Dr Kelly stresses the social cost of that. The upfront cost of long-term follow up may seem prohibitive to bean counters, but getting in early is the right thing to do, morally, socially and economically.
He is tired of seeing hastily put together initiatives waste time and money while children keep coming into Puawaitahi tattered and torn.
PK: And I'm tired of people describing a place like this as "the ambulance at the bottom of the cliff". I feel there is this perception, at a policy level, that primary prevention is "good" and the kind of work that a team like ours does is just about putting the boot into people who have abused their children.
But I don't really care whether or not someone goes to prison for this. I care that this child is kept safe. From my perception, children who have already suffered harm are simply those who are at highest risk. If we cannot keep even them safe from further harm, how can we possibly say we know how to prevent it in the first place?
Lucy says:
Dr Kelly's fondest dream is that he should someday be put out of business. Until then he and his team will continue to stitch little girls back together and to redignify kids who've been polluted by the actions of grownups. He knows the issues only too well and has strong opinions on real solutions.Why on earth would we not listen to him?
On the web: starship.org.nz
