Red Flags A Quick Reference Guide for Early Years Professionals in Middlesex-London
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Red Flags
A Quick Reference Guide for Early Years
Professionals in Middlesex-London
2014
A reference guide designed to assist Early Years ProfessionalsDisclaimer Notice Red Flags: a Quick Reference Guide for Early Years Professionals in Middlesex-London (Red Flags Guide) is a reference guide designed to assist Early Years Professionals in determining whether there is a need to refer families or caregivers to seek out additional advice, screening, assessment and/or treatment for their child. It is not an assessment or diagnostic tool. The information in the Red Flags Guide has been provided for professionals working with children up to the age of six years (Early Years Professionals). While every attempt has been made to ensure its accuracy, the information in this document is provided on an “as is” basis without warranty or condition. The Red Flags Guide cannot substitute for the advice, formal assessment and/or diagnosis from professionals trained to properly assess the growth and development of infants, toddlers and children. The intent of this document is to assist Early Years Professionals in determining when to discuss with a family the need to seek out advice and/or treatment. This document should not be used to diagnose or treat perceived growth or developmental limitations and/or other health care needs. The Red Flags Guide is not an assessment or diagnostic tool. It does not replace the responsibility of a parent/caregiver to consult their family physician and/or appropriate professionals. The Red Flags Guide refers to websites, resources and other documents that are created or used by independent organizations. These references and documents are provided as a public service and do not imply that they have been reviewed, verified and/or validated by the Community Early Years Partnership Specialized Services Committee. This document is being provided for the personal, non-commercial use of Early Years Professionals. This document and the information contained herein, shall not be modified; copied; distributed; reproduced; published; licensed; transferred or sold for a commercial purpose, in whole or in part, without the prior written consent of the Community Early Years Partnership Specialized Services Committee. Red Flags: a Quick Reference Guide for Early Years Professionals in Middlesex-London IS NOT TO BE USED TO DIAGNOSE OR LABEL A CHILD Middlesex-London Health Unit 3
Table of Contents
Introduction
Development of Red Flags Guide 5
Early Identification 6
What is Red Flags? 6
Who should use Red Flags 6
How to talk to parents about sensitive issues? 7
Sharing Sensitive Issues 7
Plan to set the stage for successful conversation 8
Sharing the information 9
Planning the next steps 10
Culturally Competent Care 11
Duty to Report 12
Sections
Abuse 13
Emotional 13
Neglect 15
Physical 16
Sexual 18
Witnessing Violence 19
Attachment 21
Autism Spectrum Disorder 26
Behaviour 29
Dental 33
Family and Environmental Stressors 36
Feeding and Swallowing 39
Fetal Alcohol Spectrum Disorder 45
Fine Motor 48
Gross Motor 52
Hearing 56
Learning Disabilities 59
Literacy 62
Mild Traumatic Brian Injury 65
Nutrition 66
Perinatal Mood and Anxiety Disorders 70
Sensory 74
Social Emotional 78
Speech and Language 83
Vision 86
Additional Contacts and Community Resources 89
Additional Resources 93
References 94
4 Middlesex-London Health UnitDevelopment of Red Flags Guide
The Simcoe County Early Intervention Council developed and distributed the original Red Flags document
in March 2003. The document was reviewed and revised by the York Region Early Identification Planning
Coalition and supported by York Region Health Services in April, 2004.
The Middlesex-London Health Unit’s Healthy Babies Healthy Children (HBHC) Early Identification Committee
adapted the initial Red Flags Guide with the assistance of many community agencies in April 2006, followed
by revisions in 2008 and 2010.
Review and revision was completed in 2014 by public health nurses on the Middlesex-London Health Unit’s
Early Years Team in collaboration with Community Early Years Partnership Specialized Services Committee.
Permission was obtained from the Ottawa Red Flags Task Group to adapt their version of the Red Flags
Guide. Previous permission from the York Region Health Services was also granted.
We would like to thank the many community partner organizations who took the time and effort to contribute
to the Middlesex-London version of the guide. Their expertise and knowledge were instrumental to the
completion of this document, ensuring the usefulness of this guide for professionals who work with infants,
children and their families.
Middlesex-London For further information, please contact Ruby Brewer, Manager of Early
Community Years Team at the Middlesex-London Health Unit at:
Early Years
519-663-5317, ext. 2253 or at ruby.brewer@mlhu.on.ca
Partnership
Middlesex-London Health Unit 5Early Identification Thanks to Dr. Fraser Mustard and other scientists, many professionals working with young children are aware of the considerable evidence about early brain development and how brief some of the “windows of opportunity” are for the optimal development of neural pathways. The early years of development from conception to age six, particularly the first three years, set the base for competence and coping skills that will affect learning, behaviour and health throughout life. (McCain, Mustard & Shanker, 2007). It follows, then, that children who may need additional services and supports to ensure healthy growth and development must be identified as quickly as possible and referred to the appropriate programs and services in Middlesex-London. Early intervention during the period of the greatest development of neural pathways, when alternative coping pathways are most easily built, is critical to ensure the best outcomes for the child. (McCain, Mustard & Shanker, 2007). A “wait and see” approach is no longer an acceptable option. What is Red Flags? Red Flags is a reference guide for use by professionals who work with young children and their families. Red Flags outlines a range of functional indicators that monitor healthy child development, as well as potential problem areas for child development. It is intended to assist in the determination of when and where to refer for additional services, formal assessment and/or treatment at the earliest possible sign. Who Should Use Red Flags Guide This reference guide is intended to be used by any professional working with young children and their families. We assume the reader has a basic knowledge of healthy child development. Red Flags will help professionals to identify when a child could be at risk of not meeting developmental milestones, triggering an alert for further investigation by the appropriate professional or discipline. Red Flags: • Can be used in conjunction with other screening tools, like the Nippissing District Development Screens or Ages and Stages Questionnaire to review developmental milestones and problem signs • Recognizes the importance of cultural competence in assessing child growth and development • Includes some indicators that focus on the parent/caregiver, or the interaction between the parent/caregiver and the child • Provides contact and referral information for the Middlesex-London Health Unit 6 Middlesex-London Health Unit
How to Talk to Parents/Caregivers About Sensitive Issues Sharing Sensitive Issues One of the most challenging issues to recognizing a potential concern in a child’s development is sharing these concerns with the parents/caregivers. It is important to be sensitive when suggesting there may be a reason for further assessment. You want parents/caregivers to feel capable and to be empowered to make decisions. The way in which sensitive news is shared has both immediate and long term effects on the family (and child) in terms of how parents perceive the situation and how ready or willing they are to access support (TeKolste, 2009; First Signs, 2009). Many parents are not aware, or may not recognize, that their child is at risk. Sharing sensitive news can be challenging both for the parents as well as for the person delivering the news. Upon receiving sensitive news about their child, some parents might react with a variety of emotions including shock, anger, disbelief, and fear. Parents hearing sensitive news might also feel overwhelmed and might need time to process, and then accept the information. For the professional, sharing sensitive news with families is often challenging and may sometimes result in a reluctance to initiate the discussion. Among barriers expressed by professionals are fears of the following: • Causing the parents/caregivers pain and negative emotional reactions • Parents being unready to discuss concerns • Parents rejecting this information • Being culturally inappropriate • Lack of knowledge of resources • Lack of time • Own discomfort at addressing some issues/subjects There is no one way that always works best but there are some things to keep in mind when addressing concerns. It is hoped that the following framework will be useful in preparing professionals for sharing concerns in a clear, informative, sensitive and supportive manner, acknowledging the parents’/caregivers’ perspectives and feelings. Presenting information in a professional manner lends credibility to your concerns (TeKolste, 2009; First Signs, 2009) and could be helpful to the parent. Make sure parents feel that they are not alone. Middlesex-London Health Unit 7
How to Talk to Parents/Caregivers About Sensitive Issues Plan to set the stage for a successful conversation: • It is extremely helpful if you have previously set the expectation that part of your professional role is to monitor the development of all children in your care to ensure they get support, if necessary, to optimize their potential • Set up the meeting in a private space • Allow for as much time as might be necessary without interruption • Develop a warm, trusting relationships with the parents/caregiver. It will help in easing the process of sharing concerns. It is most supportive if the staff member with the best relationship with the family is selected to share the information. • Make sure you properly document your meeting and that your concerns have been documented • Ensure there is a plan for follow-up action with respect to referrals and follow-up meetings (First Signs, 2009) • Begin with child’s strengths and positive attributes • Start by explaining that it is helpful to get as much information as possible regarding a child’s skills and areas to work on, so as to better support the child, and the earlier the intervention, the better Empathize: Put yourself in the parents’ and caregivers’ shoes. Empathy allows for the development of a trusting, collaborative relationship. It is important to acknowledge that the parents and caregivers are the experts in knowing their child, even though you have knowledge of child development. Ensure you listen carefully. Acknowledge and reflect their responses. When parents and caregivers have a chance to share feelings without feeling judged, they might be more receptive to hearing sensitive information. It is useful to begin the discussion with sensitive probing questions to find out what the parents already know and what their concerns are. Try to use open-ended questions (i.e. “Do you have any concerns?” “How do you feel about your child’s progress?”). It is also important to find out how much detail the family wants to know. If you give too much information when the parent is not ready, they may feel overwhelmed or inadequate. (First Signs, 2009) 8 Middlesex-London Health Unit
How to Talk to Parents/Caregivers About Sensitive Issues Sharing the information: Be sensitive to a parent’s/caregiver’s receptiveness to the information. You may want to offer the information you have by asking parents what they would like to know first or what they feel they need to know first, as they may not be sure where to start. Note that some cultural and language barriers may prevent the parents from asking their questions openly or directly. When you are more of a resource person than an authority figure, parents may feel less threatened. Give parents ample opportunity to ask questions. Having a parent use tools such as the Nipissing District Developmental Screen or Ages and Stages Questionnaire may help open the way for discussion. It may help to specify that the screening tool is something given to many parents to help them understand their child’s development and to learn about new activities that encourage growth and development. • Link what you are telling them with what they already know • Avoid the use of professional jargon • Make use of the written documentation you have gathered about their child’s strengths and needs from age-based screening tools • Present the information in a neutral matter • State facts, advantages and disadvantages without presenting your personal beliefs, convictions or undermining other approaches or practices • Encourage parents to explore all possibilities and options. Do not speak on behalf of a particular approach or agency • Approach the opportunity for accessing extra help in a positive manner - e.g. “you can get extra help for your child so he will be as ready as he can be for school”. • Try to balance the concerns you raise with genuine positive comments about the child (e.g., “Johnny is a real delight. He is so helpful when things need tidying up. I have noticed that he seems to have some trouble ... ”). Remember throughout the conversation that it is important to empathize with the parents/caregivers even if they are distressed, confrontational, angry or if they disagree with you (TeKolste, 2009; First Signs, 2009). Middlesex-London Health Unit 9
How to Talk to Parents/Caregivers About Sensitive Issues Planning the next steps: Have the family participate fully in the final decision about what to do next. Your role is to provide information, support and guidance. The final decision is theirs. It is important to summarize the discussion, the agreed upon next steps, as well as any questions for follow up. Finally, if the parents suggest a “wait and see” approach, explore why they feel this way. Allow them to express and explore their previous experiences. Acknowledge if concerns are related to the professionals’ agenda vs. the parents’ agenda. It may be important to offer reasons why it is not appropriate to “wait and see.” Explain that early intervention can dramatically improve a child’s development and may prevent additional concerns such as behaviour issues, and that the “wait and see” approach may delay addressing a medical or developmental concern. When possible, offer additional supports; perhaps suggesting to accompany the parents and introducing them to the professional who will offer the care. Early intervention helps parents/caregivers understand child behaviour and health issues, and will increase confidence that everything possible is being done to ensure that the child reaches his full potential. However, it is important that the parent is fully informed. If the parent is not ready, and needs more information, encourage further exploration of other approaches. If the parents refuse to provide care for their child and/ or refuse to give consent for intervention and you feel that the child may be in need of protection, your child protection concerns must be reported to the Children Aid Society (CAS). Be genuine and caring. You are raising concerns because you want the child to be the best they can, not because you want to point out “weaknesses” or “faults.” Your body language is important; parents may already be fearful of the information (TeKolste, 2009; First Signs, 2009). It is important to acknowledge their fears as well as your own concerns and limitations. Don’t entertain too many “what if” questions. A helpful response could be “Those are good questions. The professionals who will assess your child will be able to answer them. This is a first step to indicate if further assessment is needed.” 10 Middlesex-London Health Unit
Culturally Competent Care Early years professionals have the privilege of working with families from many cultural groups. These families come with their various beliefs, values, and knowledge which influence their childrearing practices. Childrearing is what caregivers do on a daily basis in response to children’s needs (Evans & Myers, 1994). This, in turn, impacts a child’s growth and development. To be able to provide the best care and service to the families they work with, it is important for early years professionals to become culturally aware and culturally competent. Culture is the pattern of beliefs, values, knowledge, traditions, and norms which are learned, shared, and may be handed down from generation to generation. A group of individuals is said to be of a specific culture if they share a historical, geographical, religious, racial, ethnic, or social context (Hate Crimes Community Working Group, 2006). To be culturally aware involves the ability to stand back and become aware of one’s own cultural values, beliefs, and perceptions (Quappe & Cantatore, 2005). Cultural competency means that the professional is aware that cultural differences and similarities exist and have an effect on your values, learning and behaviour. The components of cultural competency include valuing and recognizing the importance of one’s own culture, valuing diversity, and being willing to learn about the traditions and characteristics of other cultures (Stafford, Bowman, Eking, Hanna & Lopoes-DeFede as cited in Mavropoulos, 2000). While cultural patterns will guide a culture as a whole, these patterns may or may not be followed by individual parents/caregivers, creating individual variations in childrearing practices. Culture is constantly changing, and being reshaped by a variety of influences, including for some, life experiences in Canada. Professionals must remember that their client’s culture may be different than their own and must be aware of the significance of cultural behavior as it relates to parenting. Where there are concerns that cultural practices may be conflicting with Canadian child protection law, consultation with your CAS is the best route. The greatest resource for understanding each family’s unique culture is the family itself. By acknowledging the family’s origins and all the influences on their cultural expression and childrearing practices, the early years professional will be better able to provide culturally competent care. Suggestions for a successful conversation: • Try to learn more about the client’s specific culture to prepare for conference/meeting • Be respectful of customs (e.g. people from some cultures do not shake hands, so do not be offended if they do not extend their hand ) • Be respectful and open-minded and try to understand their perspective • Consider involving a professional translator (language interpreter) to help overcome any language barriers Middlesex-London Health Unit 11
Duty to Report We all share the responsibility to protect children from harm. As a professional working with children, you may encounter situations where you suspect child abuse or neglect. Ontario’s Child and Family Services Act (CFSA) states that anyone who has reasonable grounds to suspect that a child is, or may be, in need of protection must promptly report any suspicions to a CAS. The report must be made directly to a CAS by the person who has the reasonable grounds to suspect abuse or neglect. You have to report directly to a CAS and can not rely on anyone else to report on your behalf. “Reasonable grounds” refers to the information that an average person, exercising normal and honest judgment, would need in order to make a decision to report. It is important to remember your “ongoing duty to report”. This means that even if a report has already been made about a child, you must make a further report to the CAS if there are additional reasonable grounds to suspect that the child is or may be in need of protection. You must file an additional report if there are further reasonable grounds. The Act recognizes that people working closely with children have a special awareness of the signs of child abuse and neglect, and a particular responsibility to report their suspicions. Cultural practices of a particular group may sometimes conflict with Canadian law. In working with children of diverse cultures, early years professionals should be aware that families may include practices such as severe forms of corporal punishment. Professionals should remember that it is not their job to determine whether a suspicion of child abuse falls within a cultural context. Consultation with a CAS is the best route. (Rimer, 2002) Anyone who suspects that a child is or may be in need of protection should contact a CAS immediately. In Middlesex-London, call 519-455-9000 at any time of the day or week. To learn more, visit www.ontario.ca/children 12 Middlesex-London Health Unit
Abuse
ABUSE
There are four types of child abuse: neglect, physical abuse, emotional abuse and sexual abuse. Although
not conclusive, the presence of one or more of the following indicators of abuse and neglect should alert
parents and professionals to the possibility of child abuse. However, these indicators should not be taken
out of context or used individually to make unfounded generalizations.
ATTACHMENT
Pay special attention to duration, consistency, and pervasiveness of each characteristic.
AUTISM SPECTRUM
If you suspect child abuse or neglect, you are legally obligated to consult with or report to the
DISORDER
Children’s Aid Society (CAS) of London at 519-455-9000. (Also, see the Duty to Report section of this
document)
When in doubt always consult!
BEHAVIOUR
POSSIBLE INDICATORS OF EMOTIONAL ABUSE
Physical Indicators in Children Behavioural Indicators in Children
DENTAL
• The child does not develop as expected • Is unhappy, stressed out, withdrawn, aggressive
or angry for long periods of time
• Often complains of nausea, headaches, stomach aches
• Goes back to behaving like a young child
FAMILY AND ENVIRONMENTAL
without any obvious reason
(e.g. toileting problems, thumb-sucking,
• Wets or dirties pants
constant rocking)
STRESSORS
• Is not given food, clothing and care as good as what
• Tries too hard to be good and to get adults
the other children in the same family get
to approve
• May have unusual appearance (e.g. strange haircuts,
• Tries really hard to get attention
dress, decorations)
• Tries to hurt oneself
FEEDING AND
SWALLOWING
• Criticizes oneself a lot
• Does not participate because of fear of failing
• Is afraid of what the adult will do if he or she does
something the adult does not like
SPECTRUM DISORDER
• Runs away
• Has a lot of adult responsibility FETAL ALCOHOL
• Discloses abuse
FINE MOTOR
GROS MOTOR
Middlesex-London Health Unit 13Abuse
Behaviour Observed in Adults Who Abuse Children Emotionally
ABUSE
• Often rejects, insults or criticizes the child, even in front • Calls the child names, puts the child down, overly
of others critical of child and child’s behaviours
ATTACHMENT
• Does not touch or speak to the child with love • Lets the child be involved in activities that break
the law
• Talks about the child as being the cause for problems
and things not going as wished • Uses the child to make money
(e.g. child pornography)
AUTISM SPECTRUM
• Talks about, or treats, the child as being different from
DISORDER
other children and family members • Lets the child see sex and violence on TV, videos
and magazines
• Compares the child to someone who is not liked
• Terrorizes the child (e.g. threatens to hurt or kill
• Does not pay attention to the child and refuses to help
the child or threatens someone or something that
the child
is special to the child)
BEHAVIOUR
• Isolates the child, does not allow the child to see others
• Forces the child to watch someone special
both inside and outside the family (e.g. locks the child in
being hurt
a closet or room)
• Asks the child to do more than he/she can do
• Does not provide a good example for children on
DENTAL
how to behave with others (e.g. swears all the
time, hits others)
FAMILY AND ENVIRONMENTAL
STRESSORS
FEEDING AND
SWALLOWING
SPECTRUM DISORDER
FETAL ALCOHOL
FINE MOTOR
GROS MOTOR
14 Middlesex-London Health UnitAbuse
POSSIBLE INDICATORS OF NEGLECT
ABUSE
Physical Indicators in Children Behaviour Observed in Adults Who
ATTACHMENT
Neglect Children
• An infant or young child may:
◦ Not be growing as expected • Does not provide for child’s basic needs
◦ Be losing weight
◦ Have a “wrinkly old face” • Has a disorganized home life, with few regular
AUTISM SPECTRUM
◦ Look pale routines (e.g. always brings the child very early,
DISORDER
◦ Not be eating well picks up the child very late, meal times are
not predictable)
• Not dressed properly for the weather
• Does not supervise the child properly
• Dirty or unwashed (e.g. leaves the child alone, in a dangerous
• Bad diaper rash or other skin problems place, or with someone who cannot look after
BEHAVIOUR
the child safely)
• Always hungry
• May indicate that the child is hard to care for,
• Lack of medical and/or dental care
hard to feed, describes the child as demanding
• Signs of deprivation (e.g. hunger, diaper rash) which
• May attribute adult negative motivations to
DENTAL
improve with a more nurturing environment
actions of child- e.g. reports child out to get the
parent, child not like the parent
Behavioural Indicators in Children • May say the child was or is unwanted
FAMILY AND ENVIRONMENTAL
• Does not show skills as expected for child’s age • May ignore the child trying to be loving
and stage of development
STRESSORS
• Has difficulty dealing with own personal problems
• Appears to have little energy due to lack of sleep and puts own needs before care of the children
or lack of proper nutrition
• Is more concerned with own self than the child
• Cries very little
• Is not very interested in the child’s life (e.g. fails to
• Does not play with toys or notice people use services offered or to keep child’s
• Does not seem to care for anyone in particular appointments, does not do anything about
FEEDING AND
SWALLOWING
concerns that are discussed)
• May be very demanding of affection or attention
from others
* If you suspect child abuse or neglect, you are
• Older children may steal legally obligated to consult with or report to the
• Takes care of a lot of their needs on their own CAS of London at 519-455-9000.
SPECTRUM DISORDER
FETAL ALCOHOL
• Has a lot of adult responsibility at home; may be
required to look after younger siblings beyond
what is normal
• Hoards and hides food
• Discloses neglect (e.g. says there is no one
FINE MOTOR
at home)
GROS MOTOR
Middlesex-London Health Unit 15Abuse
POSSIBLE INDICATORS OF PHYSICAL ABUSE
ABUSE
Physical Indicators in Children Behavioural Indicators in Children
ATTACHMENT
• A lot of bruises in the same area of the body • Cannot remember how injuries happened
• Bruises in areas on the body that are not typical • The explanation of what happened does not
of childhood play (e.g. bruises on face, torso, match the injury
AUTISM SPECTRUM
upper back, head)
• Refuses or is afraid to talk about injuries
DISORDER
• Bruises in the shape of an object (e.g. spoon,
• Is afraid of adults or of a particular person
hand/fingerprints, belt)
• Does not want to be touched
• Burns:
◦ From a cigarette • May be very:
◦ In a pattern that looks like an object (e.g. iron) ◦ Aggressive
BEHAVIOUR
◦ Wears clothes to cover up injury, even in ◦ Unhappy
warm weather ◦ Withdrawn
◦ Obedient and wanting to please
• Patches of hair missing
◦ Uncooperative
• Signs of possible head injury:
DENTAL
• Is afraid to go home
◦ Swelling and pain
◦ Nausea or vomiting • Runs away
◦ Feeling dizzy • Is away a lot and when comes back there are signs
FAMILY AND ENVIRONMENTAL
◦ Bleeding from the scalp or nose of healing injury
• Signs of possible injury to arms and legs: • Does not show skills as expected
STRESSORS
◦ Pain
• Does not get along well with other children
◦ Sensitive to touch
◦ Cannot move properly • Tries to hurt themselves (e.g. cutting oneself, suicide)
◦ Limping • Discloses corporal punishment, hitting that results
• Breathing causes pain in injuries, abuse, or threats
• Difficulty raising arms
FEEDING AND
SWALLOWING
• Human bite marks
• Cuts and scrapes inconsistent with normal play
• Signs of female genital mutilation
SPECTRUM DISORDER
(e.g. trouble going to the bathroom)
FETAL ALCOHOL
FINE MOTOR
GROS MOTOR
16 Middlesex-London Health UnitAbuse
Behaviour Observed in Adults Who Abuse Children Physically
ABUSE
• Does not tell the same story as the child about how • Talks about having problems dealing with the child
the injury happened
ATTACHMENT
• Talks about the child as being bad, different or
• May say that the child seems to have a lot of accidents “the cause of my problems”
and/or is clumsy • Does not show love toward the child
• Severely punishes the child • Delays seeking medical attention for injuries
AUTISM SPECTRUM
• Cannot control anger and frustration or illnesses
DISORDER
• Expects too much from the child • Has little or no help caring for the child and
reports feeling overwhelmed, isolated, fatigued
* If you suspect child abuse or neglect, you are legally obligated to consult with or report to the CAS of London
BEHAVIOUR
at 519-455-9000.
DENTAL
FAMILY AND ENVIRONMENTAL
STRESSORS
FEEDING AND
SWALLOWING
SPECTRUM DISORDER
FETAL ALCOHOL
FINE MOTOR
GROS MOTOR
Middlesex-London Health Unit 17Abuse
POSSIBLE INDICATORS OF SEXUAL ABUSE
ABUSE
Physical Indicators in Children Behaviour Observed in Adults Who
ATTACHMENT
Abuse Children Sexually
• A lot of itching or pain in the throat, genital or anal area
• Underwear that is bloody • May be very protective of the child that results in
the child being isolated from adults and peers
• Injury to the breasts or genital area:
AUTISM SPECTRUM
◦ Redness • May be jealous of the child’s relationships with others
DISORDER
◦ Bruising • Does not like the child to be with friends unless
◦ Cuts the parent is present
◦ Swelling
• Talks about the child being “sexy”
• Touches the child in a sexual way
BEHAVIOUR
Behavioural Indicators in Children • May use drugs or alcohol to feel freer
to sexually abuse
• Withdrawn or aggressive behavior
• Allows or tries to get the child to participate
• Problems in school
in sexual behaviour
DENTAL
• Engages in sexual behaviours that are beyond
the child’s age and stage of development * If you suspect child abuse or neglect, you are legally
• Knowing more about sex than expected obligated to consult with or report to the CAS of
London at 519-455-9000.
FAMILY AND ENVIRONMENTAL
• Details of sex in the child’s drawings/writing
• Sexual actions with other children or adults that
STRESSORS
are inappropriate
• Very demanding of affection or attention, or clinging
• Refuses to be undressed, or when undressing shows fear
• Tries to hurt oneself (e.g. uses drugs or alcohol,
eating disorder, suicide)
FEEDING AND
SWALLOWING
• Discloses sexual abuse, exposure to pornography, or
inappropriate touching from adult or older caregiver
SPECTRUM DISORDER
FETAL ALCOHOL
FINE MOTOR
GROS MOTOR
18 Middlesex-London Health UnitAbuse
INDICATORS OF WITNESSING FAMILY VIOLENCE
ABUSE
Physical Indicators in Children Behaviour Observed in Adults
ATTACHMENT
• The child does not develop as expected • Abuser is aggressive with others, uses aggression
• Often complains of nausea, headaches, stomach aches to get own way
without any obvious reason • May harm pets
AUTISM SPECTRUM
• Fatigued due to lack of sleep or disrupted sleep • Abuser has trouble talking and getting along
DISORDER
• Physical harm, whether deliberate or accidental, during with others
or after a violent episode, including: • Abuser uses threats and violence (e.g. threatens
◦ While trying to protect others to hurt, kill or destroy someone or something that
◦ Are a result of objects thrown is special; cruel to animals)
BEHAVIOUR
• Is physically, emotionally and economically
controlling of his/her partner
Behavioural Indicators in Children
• Forces the child to watch a parent/partner
• May be aggressive and have temper tantrums – uses being hurt
DENTAL
aggression with peers and siblings • Abuser is always watching what the partner
• May appear withdrawn, depressed, and may demonstrate is doing
nervous behaviours (e.g. clinging, whining, a lot of crying) • Abuser insults, blames, and criticizes partner
in front of others
FAMILY AND ENVIRONMENTAL
• Acts out what has been seen or heard between parents;
discloses family violence; may act out sexually • Jealous of partner talking or being with others
STRESSORS
• Tries too hard to be good and to get adults to approve • Abuser does not allow the child or family to
• Afraid of: talk with or see others – isolates the family from
◦ Someone’s anger extended family and friends
◦ One’s own anger (e.g. killing the abuser) • The abused person is not able to care properly
◦ Self or other loved ones being hurt or killed for the children because of isolation, depression,
◦ Being left alone and not cared for trying to survive, or because the abuser does not
FEEDING AND
SWALLOWING
• Problems sleeping (e.g. cannot fall asleep, afraid of the give enough money
dark, does not want to go to bed, nightmares) • Holds the belief that men have the power
• Bed-wetting; food-hoarding and women have to obey
• Tries to hurt oneself; cruel to animals • Misuses drugs or alcohol
SPECTRUM DISORDER
FETAL ALCOHOL
• Stays around the house to keep watch, or tries not to • Discloses family violence
spend much time at home; runs away from home • Discloses that the abuser assaulted or threw
• Problems with school objects at someone holding a child
• Expects a lot of oneself and is afraid to fail and so works
very hard * If you suspect child abuse or neglect, you are
FINE MOTOR
• Takes the job of protecting and helping the legally obligated to consult with or report to the
mother, siblings CAS of London at 519-455-9000.
• Does not get along well with other children
GROS MOTOR
Middlesex-London Health Unit 19Abuse - Where to go for help?
Children’s Aid Society (CAS)
ABUSE
1680 Oxford St E, London, ON N5V 4X7
519-455-9000
519-858-5998
ATTACHMENT
For emergency services after hours
www.caslondon.on.ca
Description of Service
AUTISM SPECTRUM
DISORDER
The CAS is mandated under the Child and Family Services Act, (CFSA RSO 2000 as amended) to ensure
the protection, safety, and wellbeing of every child under the age of 16 and any child over the age of 16,
subject to a court order. The Act sets out for the Society the definition of child in need of protection under
Sec 37 (1). The Society is also accountable to its funder the Ministry of Children and Youth which sets out
standards and guidelines which must be followed.
BEHAVIOUR
Hours of Operation
Monday to Friday 8:30 am – 4:30 pm
Emergency Services are available after hours
DENTAL
What should the client expect at the first appointment?
Once the phone screening is complete and eligibility has been determined, an intake worker will be
FAMILY AND ENVIRONMENTAL
assigned, who then makes a home visit(s) to complete an assessment. If a determination is made that
ongoing services are warranted then a service plan will be developed with the family.
STRESSORS
How long will the appointment take?
The length of the home visit will vary depending on the situation but, generally, visits last between
1 and 2 hours.
FEEDING AND
SWALLOWING
What does the client need to bring to the first appointment?
The family usually does not need to bring anything specific to the appointment. During the assessment
interview(s), the family will be asked about their background and family history, areas of concern/stress and
areas of strength, family and child functioning, and other areas more specifically related to the presenting
SPECTRUM DISORDER
issues. Observations of the home environment and parent-child interactions may be helpful as well.
FETAL ALCOHOL
Interpretation Services
Interpreters are available at no cost when needed. Services need to be requested in advance so they can
be arranged.
FINE MOTOR
GROS MOTOR
20 Middlesex-London Health UnitAttachment
ABUSE
ATTACHMENT
AUTISM SPECTRUM
DISORDER
BEHAVIOUR
...identify and respond quickly
and sensitively to a child’s
emotional needs...
DENTAL
FAMILY AND ENVIRONMENTAL
Research Shows Clinical Practice
STRESSORS
Research in children’s mental health demonstrates Good clinical practice within children’s
that the quality of the early infant-caregiver mental health is to screen for the quality of
relationship influences a child’s development and the parent-child relationship. A child who
his/her ability to form secure attachments. A child experiences their caregiver as rejecting,
who has a secure attachment with a caregiver trusts intrusive, absent, unpredictable, inconsistent
in the relationship and feels confident that he or or frightening is at greater risk for developing
FEEDING AND
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she can rely on the security of the caregiver for insecure attachment patterns with associated
protection during periods of distress. In turn, the emotional and behavioural challenges
caregiver’s ability to accurately identify, and respond (Hoffman, Marvin, Cooper & Powell, 2007).
quickly and sensitively to a child’s emotional needs, Difficulties within the parent-child relationship
SPECTRUM DISORDER
promotes within the child feelings of safety from that can be primarily accounted for by other
FETAL ALCOHOL
which he/she can explore their environment mental health, developmental or neurological
with competence. problems, including but not limited to Pervasive
Developmental Disorder, Bipolar Disorder,
Alcohol Related Neurodevelopment Disorder
need to be ruled out and distinguished from
FINE MOTOR
insecure attachment.
GROS MOTOR
Middlesex-London Health Unit 21Attachment
ABUSE
The following items are considered from the parent’s perspective, rather than the child’s or could be
an observation of the child interacting with their parent. If a parent states that one or more of these
statements describes their child, it may indicate a disruption within the attachment relationship;
consider it a red flag:
ATTACHMENT
• Is difficult to comfort or soothe when distressed • Is fearful, inhibited and hyper vigilant when
(e.g. rocking or holding)* observed with caregiver*
• Minimally seeks comfort from caregiver when hurt • Is flat in affect*
AUTISM SPECTRUM
or distressed*
DISORDER
• Difficulty regulating emotion*
• Rarely checks back with caregiver after venturing • Withdraws and/or appears angry upon reunion*
away in unfamiliar settings* (older baby/toddler included)
• Self-infantilizing – “fakey” tone to the cry* • Rarely exhibits reticence with unfamiliar adults*
• Is controlling or demonstrates behaviour suggesting
BEHAVIOUR
• Engages in a pattern of self-endangering
excessive preoccupation with caregiver’s emotional
behaviour that is more pronounced with a
well-being/ attempts to care for the caregiver(s)*
particular caregiver
• Is defiant
• Excessive clinging to caregiver in unfamiliar
• Is resistant/ argumentative settings or with unfamiliar people*
DENTAL
• Is overly compliant*
*Red flags that also apply to ages 10 months to 2 years
FAMILY AND ENVIRONMENTAL
NOTE: If a mother or other primary caregiver is frequently displaying any of the
STRESSORS
following, consider it a red flag:
• Being insensitive to a child’s emotional needs or cues • Is rejecting or neglecting of child’s needs
• Often unable to recognize child’s cues • Is intrusive with child
• Provides inconsistent patterns of responses • Is demonstrating role distortion (peer to peer)
to the child’s cues “Let’s be little together, be my companion,
FEEDING AND
SWALLOWING
don’t need me’
• Frequently ignores or rejects the child
• Is demonstrating role reversal: parent controlled
• Speaks about the child in negative terms
by child’s caregiving, child’s aggression
• Often appears to be angry with the child
• Dissociates
SPECTRUM DISORDER
• Often expresses emotions in a fearful or intense way
FETAL ALCOHOL
• Demonstrates helplessness, fearfulness
• Is distracted
• Is aggressive or shows threat of aggression
• Is anxious/ hyper vigilant
• Demonstrates abandonment or threat
• Demonstrates pressure to achieve of abandonment
FINE MOTOR
GROS MOTOR
22 Middlesex-London Health UnitAttachment
ABUSE
Other red flags for potential attachment disruptions based on parents’ histories:
• Unresolved history of physical, emotional, • Multiple hospitalizations and/or
ATTACHMENT
or sexual abuse medical procedures
• Exposure to domestic violence • Traumatic separation from primary caregiver
(e.g. illness, death)
• Unresolved history of physical or emotional neglect
• Caregiver mental health problems
• Environmental disruptions –‘the chaotic home”
AUTISM SPECTRUM
(e.g., trauma, depression, psychosis)
DISORDER
• Multiple moves (i.e., foster homes, adoption breakdown)
Many children under these unfortunate circumstances, as infants and toddlers, appear to lack a clear
strategy for how to obtain the needed comfort and safety when fearful or distressed. At these times,
BEHAVIOUR
such children may respond in an odd or contradictory way (e.g. approaching the caregiver and veering
away, huddling on the floor and not seeking comfort while crying, appearing “frozen” or “dazed”). This
may be indicative of a disorganized attachment relationship which is a risk factor for later child pathology.
DENTAL
FAMILY AND ENVIRONMENTAL
STRESSORS
FEEDING AND
SWALLOWING
SPECTRUM DISORDER
FETAL ALCOHOL
FINE MOTOR
GROS MOTOR
Middlesex-London Health Unit 23Attachment - Where to go for help?
Vanier Children’s Services
ABUSE
871 Trafalgar Street, London, Ontario N5Z 1E6
519-433-0334
(Crisis intake is available 24/7)
ATTACHMENT
www.vanier.com
Description of Service
AUTISM SPECTRUM
Vanier is a children’s mental health centre serving children ages 0 to 14 with emotional, behavioural and
DISORDER
attachment difficulties. Vanier offers Crisis and Intake Service 24/7, assessment, in home counselling,
treatment, early years programming and various attachment interventions, day and overnight respite,
residential treatment as well as a range of services for children who cannot cope in childcare, kindergarten
or in school settings. Vanier also offers services in French. French speaking families and youth can
complete an intake in French as well as access brief counselling services. Vanier is an accredited
BEHAVIOUR
Children’s Mental Health Centre primarily funded by the Ontario Ministry of Children and Youth Services.
Hours of Operation
Crisis Intake (C-IT) is available 24/7
DENTAL
Accueil en français en composant le 519-433-3101 poste 228
Monday to Thursday 8:30 am – 8:30 pm
Friday 8:30 am – 4:30 pm
FAMILY AND ENVIRONMENTAL
What should the client expect at the first appointment?
STRESSORS
When clients call C-IT, they will receive immediate response when in crisis, they will be informed about
services for which they are eligible and receive support while waiting for other services to begin. Clients
will meet with an Intake Worker who will go through the report comprised of information provided during
the initial phone interview. Consents to share information along with consents for service can be signed if
the client wishes to proceed with service.
FEEDING AND
SWALLOWING
How long will the appointment take?
The first appointment will be about 1 - 1.5 hours.
What does the client need to bring to the first appointment?
SPECTRUM DISORDER
FETAL ALCOHOL
The client needs to bring previous reports completed by other service providers, their Ontario Health
Insurance Program card (OHIP), and physician contact information.
Interpretation Services
Interpreters are available at no cost when needed. Services need to be requested in advance so they can
FINE MOTOR
be arranged.
GROS MOTOR
24 Middlesex-London Health UnitAttachment - Where to go for help?
Child and Parent Resource Institute (CPRI)
ABUSE
600 Sanatorium Road, London, Ontario N6H 3W7
519 858-2774 x 2024
www.cpri.ca
ATTACHMENT
Description of Service
CPRI serves children and youth (and families) on a short term community and residential basis. The
AUTISM SPECTRUM
services provided are highly specialized and include assessment, consultation, treatment, research and
DISORDER
education. CPRI also provides programs and clinics for children and youth, their families and caregivers.
Generally, children and youth come to CPRI after using other community services.
Hours of Operation
Monday to Friday 8:30 am – 4:30 pm
BEHAVIOUR
What should the client expect at the first appointment?
The first contact will be a telephone assessment interview with an intake worker, who will be gathering
information to better understand the needs of the child and family. From this assessment, the information
DENTAL
collected will be directed to the appropriate programs and clinics where services will be offered.
How long will the appointment take?
FAMILY AND ENVIRONMENTAL
The telephone interview will be approximately 1 hour.
STRESSORS
Interpretation Services
Interpreters are available at no cost when needed. Services need to be requested in advance so they can
be arranged.
FEEDING AND
SWALLOWING
SPECTRUM DISORDER
FETAL ALCOHOL
FINE MOTOR
GROS MOTOR
Middlesex-London Health Unit 25Autism Spectrum Disorder
ABUSE
Autism Spectrum Disorder is typically considered to be a lifelong neuro-developmental disorder
characterized by impairments in all of the following areas of development: communication, social
interaction, repertoire of activities and interests and behaviours. Each child has a unique presentation.
Some other behaviours which are also common include difficulties in eating, sleeping, unusual fears,
ATTACHMENT
repetitive behaviours, self-injury and peculiar responses to sensory input.
Typically, Autism Spectrum Disorder therefore represents a pattern of behaviours. As there is no one
specific behaviour which identifies an autism spectrum disorder, it is important to look at a child’s overall
AUTISM SPECTRUM
developmental pattern and history to ensure that the behaviours are not better accounted for by other
DISORDER
developmental conditions or syndromes (for example, intellectual disability, speech and language
disorders, fetal alcohol spectrum disorders, mental health or behavioural issues).
A diagnosis of Autism Spectrum Disorder is provided when the difficulties are not better accounted
BEHAVIOUR
for by one of these other developmental or medical conditions.
If the child presents any of the following behaviours, consider it a red flag:
DENTAL
Social Concerns Communication Concerns
• Doesn’t smile in response to another person • Language is often delayed but is characterized
FAMILY AND ENVIRONMENTAL
by abnormal communication features, as below
• Delayed or abnormal imaginative play – lack of varied,
(language delays often occur without Autism
spontaneous make-believe play relative to the child’s
STRESSORS
Spectrum Disorder being present)
developmental age
• Unusual pattern of language or communication
• Plays alone, decreased interest in other children
- repeating phrases from movies, echoing other
• Little or no interactive play with children of a similar age people (echolalia), repetitive use of phrases not
(skills depend on the developmental and chronological due to developing language, odd intonation, lack
age of the child) of pronoun use, reading skills above functional
FEEDING AND
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• Inconsistent, poor or fleeting eye contact or unusual communication abilities (hyperlexia)
visual interests - this does not mean eye contact • Poorly developed pointing response, i.e. child
is absent. may point only for things he wants, may have a
• Less showing, giving, sharing and directing others’ vague point or no point at all
SPECTRUM DISORDER
attention than usual for a child of that age. • Poor comprehension of both verbal and nonverbal
FETAL ALCOHOL
• Any loss of social or other skills at any age communications (words and gestures)
(skill regression) • Any loss of functional or developed language
• Prefers to do things for themselves rather than skills at any age (regression), but particularly
ask for help between 15 and 24 months; (this does not refer
to words which are ‘outgrown’)
FINE MOTOR
• Awkward or absent greeting of others and/or difficulties
understanding normal social exchanges • Inability to carry on a conversation (relative to
(relative to developmental level) the child’s age as well as developmental level
of ability)
GROS MOTOR
26 Middlesex-London Health UnitAutism Spectrum Disorder
Behavioural Concerns
ABUSE
• Excessive behaviours, such as tantrums or self-injury, • Repetitive hand and/or body movements: for
due to lack of ability to communicate, interruption example, finger wiggling, hand and arm flapping,
ATTACHMENT
of routine, or interruption of repetitive behaviours tensing of fingers, complex body movements,
spinning, jumping, etc.
• Narrow or restricted range of interests that he/she
engages in repetitively that interfere significantly with • Unusual sensory interests - visually squinting or
day to day functioning looking at things out of the corner of eye; smelling,
AUTISM SPECTRUM
licking, mouthing objects; hypersensitive hearing
DISORDER
• High pain tolerance
• Unusual preoccupation or fascination with objects
• Lack of safety awareness (i.e. climbs on high objects,
or their movement (e.g. light switches, fans, spinning
runs on the road, walks over objects or people in
objects, vertical blinds, wheels, balls)
the room)
• Insistence on maintaining sameness in routine,
BEHAVIOUR
activities, clothing, etc.
DENTAL
FAMILY AND ENVIRONMENTAL
STRESSORS
FEEDING AND
SWALLOWING
SPECTRUM DISORDER
FETAL ALCOHOL
FINE MOTOR
GROS MOTOR
Middlesex-London Health Unit 27Autism Spectrum Disorder - Where to go for help?
Child and Parent Resource Institute (CPRI)
ABUSE
600 Sanatorium Road, London, Ontario N6H 3W7
519 858-2774 x 2024
www.cpri.ca
ATTACHMENT
Description of Service
CPRI serves children and youth (and families) on a short term community and residential basis. The
AUTISM SPECTRUM
services provided are highly specialized and include assessment, consultation, treatment, research and
DISORDER
education. CPRI also provides programs and clinics for children and youth, their families and caregivers.
Generally, children and youth come to CPRI after using other community services.
Hours of Operation
Monday to Friday 8:30 am – 4:30 pm
BEHAVIOUR
What should the client expect at the first appointment?
The first contact will be a telephone assessment interview with an intake worker, who
will be gathering information to better understand the needs of the child and family.
DENTAL
How long will the appointment take?
The telephone interview will be approximately 1 hour.
FAMILY AND ENVIRONMENTAL
STRESSORS
Interpretation Services
Interpreters are available at no cost when needed. Services need to be requested in advance so they can
be arranged.
For more information on Autism Spectrum Disorder, please see:
FEEDING AND
SWALLOWING
www.autismspeaks.ca
Children who have a “red flag” for Communication Concerns as indicated below should
also be referred to tykeTALK.
SPECTRUM DISORDER
FETAL ALCOHOL
FINE MOTOR
GROS MOTOR
28 Middlesex-London Health UnitBehaviour
ABUSE
Children may engage in one or more problem behaviours from time to time. Some factors should
be considered in determining whether the behaviour is truly of concern.
These include:
ATTACHMENT
• Injuring themselves or others
• Behaving in a manner that presents immediate risk to themselves or others
• Frequency and severity of the behaviour
AUTISM SPECTRUM
DISORDER
• Number of problematic behaviours that are occurring at one time
• Significant change in the child’s behaviour
If the child presents any of the following behaviours, consider it a red flag:
BEHAVIOUR
Self-Injurious Behaviour Aggression
• Bites self; slaps self; grabs at self • Temper tantrums; excessive anger, threats
DENTAL
• Picks at skin; sucks excessively on skin, bangs head • Hits; kicks; bites; scratches others; pulls hair
on surfaces • Bangs, slams objects; causes property damage
• Eats inedibles • Cruelty to animals
FAMILY AND ENVIRONMENTAL
• Intentional vomiting (when not ill) • Hurting those less able/bullies others
• Potentially harmful risk taking (e.g. running into traffic,
STRESSORS
setting fires)
Social Behaviour Noncompliance
• Difficulty paying attention/hyperactive; overly impulsive • Oppositional behaviour
• Screams; cries excessively; swears • Running away
FEEDING AND
SWALLOWING
• Hoarding; stealing • Resisting assistance that is inappropriate to age
• No friends; socially isolated; will not make eye or other
contact; withdrawn Life Skills
SPECTRUM DISORDER
• Anxious; fearful/extreme shyness; agitated
FETAL ALCOHOL
• Deficits in expected functional behaviours
• Compulsive behaviour; obsessive thoughts; bizarre talk
(e.g. eating, toileting, dressing, poor play skills)
• Embarrassing behaviour in public; undressing in public
• Regression; loss of skills; refusal to eat;
• Touches self or others in inappropriate ways; sleep disturbances
precocious knowledge of a sexual nature
• Difficulty managing transitions/routine changes
FINE MOTOR
• Flat affect, inappropriate emotions, unpredictable
angry outburst, disrespect or striking female teachers
are examples of post trauma red flags for children who
Self-Stimulatory Behaviour
have witnessed violence
• Hand-flapping; hand wringing; rocking; swaying
GROS MOTOR
• Repetitious twirling; repetitive object manipulation
Middlesex-London Health Unit 29Behaviour - Where to go for help?
Parents can self-refer for:
ABUSE
BEHAVIOURAL CONCERNS:
ATTACHMENT
Vanier Children’s Services
871 Trafalgar Street, London, Ontario N5Z 1E6
519-433-0334
AUTISM SPECTRUM
(Crisis intake is available 24/7)
DISORDER
www.vanier.com
Description of Service
Vanier is a children’s mental health centre serving children ages 0 to 14 with emotional, behavioural and
BEHAVIOUR
attachment difficulties. Vanier offers Crisis and Intake Service 24/7, assessment, in home counselling,
treatment, early years programming and various attachment interventions, day and overnight respite,
residential treatment as well as a range of services for children who cannot cope in childcare, kindergarten
or in school settings. Vanier also offers services in French. French speaking families and youth can
complete an intake in French as well as access brief counselling services. Vanier is an accredited
DENTAL
Children’s Mental Health Centre primarily funded by the Ontario Ministry of Children and Youth Services.
Hours of Operation
FAMILY AND ENVIRONMENTAL
Crisis Intake (C-IT) is available 24/7
Accueil en français en composant le 519-433-3101 poste 228
STRESSORS
Monday to Thursday 8:30 am – 8:30 pm
Friday 8:30 am – 4:30 pm
What should the client expect at the first appointment?
When clients call C-IT, they will receive immediate response when in crisis, they will be informed about
FEEDING AND
SWALLOWING
services for which they are eligible and receive support while waiting for other services to begin. Clients
will meet with an Intake Worker who will go through the report comprised of information provided during
the initial phone interview. Consents to share information along with consents for service can be signed if
the client wishes to proceed with service.
SPECTRUM DISORDER
FETAL ALCOHOL
How long will the appointment take?
The first appointment will be about 1 - 1.5 hours.
What does the client need to bring to the first appointment?
FINE MOTOR
The client needs to bring previous reports completed by other service providers, their Ontario Health
Insurance Program card (OHIP), and physician contact information.
Interpretation Services
GROS MOTOR
Interpreters are available at no cost when needed. Services need to be requested in advance so they can
be arranged.
30 Middlesex-London Health UnitYou can also read
