Introduction

In this module, we will be discussing the specific needs of children who receive home care services. We will discuss why children may need home care and how the Home Health Aide/Personal Care Aide can best help meet the physical and psychological needs of children and their families. We will explore children’s growth and development starting from infancy and ending with adolescence. We will examine how children may react to stress and the various problems that may affect families such as domestic violence, substance abuse, and mental illness. Finally, we will discuss how to help children cope with stress and to strengthen families.

Why Children May Need Home Care

Children may face a number of situations in which home care is helpful to provide temporary care to recover from a medical illness or injury, or even long-term care if the child has a chronic illness or disability. Children who have sustained wounds, burns, or injury from a trauma such as a motor vehicle or sporting accident may benefit from receiving home care services. The child may need special medical care to treat wounds, perform dressing changes and to receive medications such as intravenous (IV) antibiotics (medications that are administered through a catheter into a vein). The child is able to receive the medical attention they need within their own home, while also reducing the financial burden on parents. Hospitalizations are very expensive.

Children who are mentally or physically disabled will also benefit from services provided by a home health care team. Just as in caring for an adult with a disability, children with mental or physical disabilities can receive care from a team of physicians, nurses, social workers, respiratory therapists, nutritionists, and a home health aide/personal care aide. By receiving home care services, the child may remain in the comfort of their own home, surrounded by the people and things they love, while also receiving necessary medical care and assistance with their activities of daily living (ADLs). Home care services for children with disabilities allows them to live as normal a life as possible with their family rather than living in a long-term care facility.

Children can have chronic illnesses just as adults do. Muscular dystrophy is a progressive disease in which there is a gradual wasting away of muscle. Cerebral palsy is a neurological disorder which affects motor development. Children with these disorders have difficulty with using their muscles and may need assistance with self-care such as feeding, toileting, and bathing. Children who have suffered from a head or spinal cord injury that has caused permanent brain damage and/or loss of function may also need assistance with self-care. A person with paraplegia (inability to use the lower part of the body) or quadriplegia (inability to use both the upper and lower body) is not able to fully care for themselves. Children also suffer from chronic health conditions such as diabetes, heart disorders, respiratory disorders such as cystic fibrosis and various types of cancer, such as leukemia. Vision and hearing disorders also affect children. Congenital disorders such as Down‘s Syndrome, a genetic disorder that can result in cognitive and physical disabilities, may also affect children. Receiving home care services allows the child to receive the medical attention they need within their own home so they may be close to family and what is familiar to them. It also helps to reduce costs of hospitalizations and long-term care facilities.

Home care services may also be used to help families who have recently given birth to a child who is premature (born before they are fully mature in the womb), or who has a physical disability due to a birth defect. Mothers and fathers may be overwhelmed by the care the new baby needs and may benefit from a Home Health Aide/Personal Care Aide providing them assistance as they adjust to the care of their newborn. A new parent may need assistance with providing care for the baby such as feeding, bathing, and diapering. They may also need assistance with providing self-care to the new mother, and with basic household tasks such as laundry, cleaning, meal planning, preparation, and shopping.

Premature babies are babies who are born before 37 weeks of gestation (Leahy, Fuzy & Grafe, 2013). These babies are born too early and are not yet fully developed. Premature babies may need special care once they are released from the hospital. Special attention must be paid to helping these babies meet their nutritional needs, monitoring intake and output, weight gain and vital signs to ensure they develop in the way they should. Sometimes, mothers who have not yet given birth may be put on bed rest to prevent complications of pregnancy. They may benefit from assistance from a home health aide/personal care aide in meeting their self-care needs and in preparing for the coming baby.

When a child has suffered from the death of a parent, they may also benefit from receiving home care services. The remaining parent or family members may be overwhelmed emotionally and unable to meet the physical and emotional needs of the child. Home Health Aides/Personal Care Aides can provide housekeeping, meal planning and preparation, and completion of activities of daily living assistance for children and families in these types of situations. Finally, there are situations in which children face domestic violence, abuse, neglect, or substance abuse by a parent within the home. The home health care team can assist the child with meeting his or her physical and emotional needs, while monitoring the safety of the child within the home, and providing care for the entire family.

Maslow’s Hierarchy of Needs Applied to Children

Just as adults, children go through stages of physical and psychological growth.In Module Two, we discussed Maslow’s Hierarchy of Needs. Here, we will discuss the specific needs of children according to this hierarchy and how to best meet those needs as a Home Health Aide/Personal Care Aide.

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Physical Needs

Children have the same basic physical needs as adults do. They need oxygen, food, activity, sleep, and must eliminate in order to survive. Home Health Aides/Personal Care Aides will work to help children meet their basic physical needs, just as they do with adults. They will assist them to complete Activities of Daily Living (ADLs) such as eating, drinking, toileting, bathing, and grooming. Taking vital signs, shopping for and preparing food for their patient, and measuring intake and output are other important tasks Home Health Aides/Personal Care Aides do to help patients meet their physical needs.

Safety and Security Needs

After meeting basic physical needs, children must have their safety and security needs met. This includes having a safe place to live and not feeling afraid within our homes, or of the people around us. Home Health Aides/Personal Care Aides work within the child’s environment to make their home safe so that the child feels safe. This means they will need to ensure that there are no hazards in the patient’s home such as clutter or loose rugs that could cause a patient to slip, trip, or fall.Special safety precautions for children also includes to make sure medications in the home are locked up, cleaning equipment is kept out of reach, and electrical outlets are kept covered to avoid children sticking their fingers or objects into them and risk getting electrocuted.Performing light housekeeping duties such as laundry, vacuuming, and cleaning, maintains a safe environment for the child.

Children who are sick often feel afraid. The job of a HHA/PCA is to help them feel secure by reassuring them, being patient when they try to complete tasks on their own, and being competent (good) in the tasks they complete. Home Health Aides/Personal Care Aides must also always be on the lookout for signs of abuse or domestic violence. Children need to grow in a safe environment. Home Health Aides/Personal Care Aides should document and report any signs of abuse or neglect to a supervisor immediately.

Need for Love and Belonging

Once children have met their physical and safety/security needs, the need for love and belonging is the next important level in order for a child to grow and flourish. This need includes feeling that they are loved and cared for. Children need to feel important to other people and to feel that they are a part of something, such as a family or community. Children need to feel special and loved, and that they are a valued part of their family and community. For Home Health Aides/Personal Care Aides, the way they care for the children they work with demonstrates to them that they care for and about them. This means being patient, kind, compassionate, understanding, trustworthy and accepting their patient’s thoughts, feelings, and uniqueness, even if they do not agree with them.

Family is an important part of a child’s life and helps them to meet their need for love and belonging. We all have different views of what “family” means to us. Home Health Aides/Personal Care Aides should be careful not to judge their patient’s family or the ways they think care should be provided to the child. Include the patient’s family in their care whenever possible. HHA/PCAs may also be educating parents and other caretakers in how to care for the child. The need to socialize with other children is also very strong. Children with disabilities may not have as many opportunities to socialize with other children. Home Health Aides/Personal Care Aides should provide opportunities for the child to play with other children their same age whenever possible.

Need for Self-Esteem

The need for self-esteem is the next level in Maslow’s Hierarchy of Needs. Self–esteem involves valuing and respecting oneself and learning that you are a good and worthy person. Self-esteem comes from within us, and from interactions and feedback from other people. When people become sick, injured, or disabled, their self-esteem may be affected. Young children and adolescents are especially vulnerable when it comes to developing positive self-esteem. Being sick may affect the way they see themselves. They may have many emotions about their appearance or physical disability.Home Health Aides/Personal Care Aides can help patients to accept physical changes by demonstrating their acceptance. Showing that they are okay with their physical or mental disability will tell the child that they accept them the way they are.

It is also important for HHAs/PCAs to encourage the child to perform as many activities as they can independently. This will help their self-esteem to grow. Treat each child as unique with special talents and strengths. Find out what the child’s interests and talents are and work to encourage their development. Young children need opportunities to play make believe. Home Health Aides/Personal Care Aides should provide lots of opportunities for the child to play and explore the world.This helps them to try on roles, such as learning to care for a baby by playing with a doll or cooking with their pretend food.

Children can also develop self-esteem by assisting with household chores and being given responsibilities. This helps them to feel that they are contributing to their family. While parents may have the final say in what is best for their child, it is important to remember that the child also has a voice. Allow the child to express their thoughts and feelings and give them choices whenever possible. Home Health Aides/Personal Care Aides can ask children what outfit they would prefer to wear that day or what toy or activity they would like to play with. Remember to provide lots of praise and encouragement for children as this will help their self-esteem to flourish (grow).

Need for Self-Actualization

The need for self-actualization is the highest level of Maslow’s Hierarchy of Needs. Self-actualization means that we try to be the best person that we can be and try to reach our full potential. The goals that we each set often change throughout our lives and may change as a result of experiencing an injury, illness, or disability. Remember that it is important to accept others the way they are.If a child has a physical or mental disability, the goals they set may need to be broken down into smaller ones so that they are able to achieve them. An important part of development for children is that they learn to set and work towards goals. Home Health Aides/Personal Care Aides should help the children with whom they work set goals to achieve things such as learning to dress or feed themselves, completing a jigsaw puzzle, learning to read a book, or even learning to tie their shoes. Provide lots of encouragement and praise as children work towards new goals.

Child Growth and Development

As children grow and develop, they go through many physical, cognitive, and emotional changes. These changes are known as human growth and development. All children will go through these stages, but they may not go through them in the same manner or rate as other children. It is important to remember that all children are unique.

Jean Piaget, a famous developmental psychologist developed a theory called the Cognitive Development Theory. It is widely used today to understand the cognitive development of children. He believed that children go through four stages as they construct (make and understand) meaning of the world.

Sensorimotor Stage (birth to 2 years)

Infants construct an understanding of the world as they interact with it using their senses. Infants use the sense of sight, hearing, touch, smell, and even taste to learn about the world around them. Their senses are combined with physical actions and muscle movements such as pushing, pulling, and kicking to make sense of objects around them. For example, a baby kicks a brightly colored ball and learns to understand that they can make the ball move by using their muscles. However, if the ball is out of their sight, they will no longer think about it until they develop object permanence, which occurs at the end of this stage. Object permanence is the understanding that something exists even though it is no longer in sight.

Preoperational Stage (2 to 7 years)

During this stage, children learn about their world beyond just senses and using motor actions. They also learn to understand the meaning of words and images. They learn about the world by looking at pictures, symbols, and books. Piaget believed that children at this stage cannot perform operations or solve problems mentally, but still focus on the physical understanding of the world. For example, a child in this stage could not say if there was the same amount of liquid in two glasses even if they saw you pouring equal amounts of liquid in two cups, with one cup tall and the other short. To a child in this stage, there appears to be more liquid in the short glass because the glass appears to be fuller. Children in this stage also believe that inanimate objects such as toys and trees have human like qualities.

Concrete Operational Stage (7 to 11 years)

In this stage, children learn to perform operations such as math and to reason logically. However, Piaget believed that children at this age can only do this with concrete things (things that are right in front of them). He felt they are unable to reason about abstract things (things we can only think about or imagine). If a child in this stage was shown the same two glasses in the example as discussed above, they would have an understanding that there was an equal amount of liquid, even though one glass is taller than the other.

Formal Operational Stage (11 years to adulthood)

At this stage, Piaget believed that people can move beyond what is concrete (or right in front of them) and think in abstract ways about things that are not right in front of them or which they can only imagine. They are able to reason and perform logical thinking about abstract things. People at this stage begin to think about the possibilities of what could be in the future.

Self-Check Activity m4-3

Physical, Cognitive, and Social Development in Childhood

Infancy: Birth to 12 months

Physically, infants grow very quickly. Infant growth occurs from the head down (Leahy, Fuzy & Grafe, 2013). This is the reason why an infant’s head may appear bigger than their body. Infants gain control over the head and neck muscles before they gain control over their arms and legs (Santrock, 2009). It is very important to remember to always provide support for an infant’s head and neck as they do not have the ability to provide this support for themselves. Never rush a baby to perform any skills they are unable to do before they are physically ready. For example, people should not rush an infant to walk if they are not yet able to stand. Infants typically crawl before they sit and sit before they stand or walk. Infants require a lot of sleep during this time period and may sleep between 10 and 21 hours per day (Santrock). Home Health Aides/Personal Care Aides should provide the baby with a safe environment in which to sleep, such as a crib. Do not put stuffed animals or too many blankets in the crib as this could potentially lead to suffocation.

Language development is also very fast at this stage. Babies move from saying a word or two at around 12 to 13 months to having a vocabulary of about 200 words by 2 years of age (Santrock, 2009)! It is important that children have plenty of interaction with others who speak with them in order to develop their language skills. Infancy is also an important time for children to begin to develop trust in others. Home Health Aides/Personal Care Aides should ensure that the baby they are working with has all their needs met such as being fed, bathed, changed when diapers are soiled, and comforted when they are crying. This helps to support positive development and trusting relationships in caretakers.

According to Piaget, a child at this stage would be in the sensorimotor stage. To support cognitive development of children at this age, Home Health Aides/Personal Care Aides should provide lots of stimulation with safe toys they can touch and move with a variety of colors and shapes. Allow babies to explore their environment in safe ways. Babies are very interested in putting things into their mouths to explore their world. Provide safe toys for a baby to do this.

Toddler: 1-3 years

Toddlers continue to grow and develop physically. This is also a time of great growth cognitively and socially. Children at this stage advance with their ability to use gross motor skills (activities using large muscles such as kicking a ball or walking) as well as fine motor skills (activities using smaller muscles such as picking up paper or drawing) (Santrock, 2009).

Toddlers have a desire to become independent as they now see themselves as separate from their parents or caretakers. Independence should be encouraged in a safe manner. For example, infants who want to climb the stairs themselves should not be allowed to do so. However, with support and careful assistance from a HHA/PCA standing behind them and providing assistance, toddlers can learn to go up the stairs one at a time safely.

Toddlers also learn to gain control over their bowel and bladders during this time. Praise should always be provided during toilet training and children should not be scolded if they have “accidents” or wet the bed. This will only damage their self-esteem.

Since this is a time of great exploration, care should always be taken to provide for a safe environment. Medications, cleaning supplies, and other hazardous chemicals and objects should be locked up and away from a toddler’s reach.

Home Health Aides/Personal Care Aides should provide encouragement for a toddler to explore their environment and to play games such as make-believe. This is also an important time to develop routines and rules to follow. Toddlers may have temper tantrums when they do not get their way and scream, kick, or throw things. Home Health Aides/Personal Care Aides should remain calm and be firm yet gentle as they redirect them toward another activity.

According to Piaget, children at this stage are in the Sensorimotor to Preoperational Stages, depending on their age. Children at this age begin to represent the world using symbols, and inanimate objects can take on lifelike qualities. There is a great deal of imagination at use. Puppets, coloring, drawing, and make-believe play are good opportunities to help a child develop cognitively at this stage.Exploration of the environment around them is important. Home Health Aides/Personal Care Aides should provide lots of play opportunities for the child. Allow them to learn what they are capable of doing, such as building towers with blocks. Home Health Aides/Personal Care Aides should assist with development of language by reading to the child and pointing to objects in books as they name them.

Preschool: 3-6 years

Physical development continues during the preschool years. Gross and fine motor skills continue to develop. Physical activity is important to help children develop motor skills and to maintain healthy weight. During the preschool years, children continue to gain independence and begin to form social relationships.

Vocabulary and language development is very fast. Home Health Aides/Personal Care Aides should continue to read to the child but allow them to read if they are able.Provide lots of encouragement and praise during reading to help build self-confidence. Encourage children to develop language and fine motor skills through writing and drawing activities. This is also a good time to begin to teach children right from wrong and to take on small responsibilities within the home such as cleaning up their toys or helping to set the table. This will encourage self-esteem to flourish. According to Piaget, the child continues to be in the Preoperational Stage of cognitive development. Home Health Aides/Personal Care Aides should continue to provide play opportunities and encourage imagination and exploration of the world around them.

School Age: 6-11 or 12 years

School age children continue to grow but at a more consistent and steady rate than in earlier childhood (Santrock, 2009). Children at this age become involved in many physical activities which continue to help improve their muscle coordination and balance. Children often become involved in activities such as running, bike riding, skating, and swimming. These are good activities for children and will help them to maintain a healthy weight.

The school age years are a time of great cognitive and social growth. Children enter school often for the first time and begin to develop social connections and friendships. They begin to learn gender behaviors (how females and males act) (Santrock, 2009). Their sense of self-esteem is developing and opportunities to encourage and praise should be sought.

School age children may need assistance with completing their homework and studying for exams. Home Health Aides/Personal Care Aides should provide opportunities for children to read by allowing them to read to them or their loved ones and to practice writing skills. Provide lots of encouragement and praise during reading to help build self-confidence. Provide assistance when the child struggles with a word but do not take over or make them feel badly for not being able to recognize a word. Help them to sound it out. This is the time period when learning disabilities may become apparent. If Home Health Aides/Personal Care Aides notice the child appears to struggle with keeping attention, reading, writing, or with math, they should inform their supervisor. There are many support systems in place within schools to help children who struggle with learning. Specialists such as speech therapists and social workers may be added to the team to work with children who struggle with speech problems or emotional issues.

According to Piaget, children at this stage are in the Concrete Operational Stage and are better able to reason logically if there are specific and concrete situations. Support their cognitive development by working with them with games such as memory and using math and language workbooks.

Adolescence: 11 years to 19 years

The adolescent years are when puberty occurs. Puberty is a stage of development when hormones change and secondary sex characteristics such as body hair, breast and testicular growth occurs (Leahy, Fuzy & Grafe, 2013). Teens may begin to shave for the first time. Self-care is important and opportunities to provide assistance and encouragement to maintain personal hygiene should be provided. Teenagers may suffer from oily skin and acne and care should be taken to keep the face and body cleaned. Most teens become very focused on their appearance during this time and may need encouragement and support to deal with changing moods and worries about how they look or if peers like them.

This is also a time where peer pressure (pressure from other children of the same age) can become intense (Santrock, 2009). Teens may experiment with romantic or sexual relationships, drugs, alcohol, or smoking. This is a good time to provide education about these topics. If Home Health Aides/Personal Care Aides have any concerns about a teen they work with using substances such as alcohol, drugs, cigarettes, or engaging in sexual activity, they should inform their supervisor.

Some teens may experience eating disorders because of concerns about their physical appearance. Anorexia is a disorder in which a person does not eat or exercises excessively (Leahy, Fuzy & Grafe, 2013). Bulimia nervosa is a disorder in which the person eats very large amounts of food and then purges (vomits) or uses laxatives to have bowel movements in order to eliminate the food. Both disorders have very serious physical and emotional consequences, and could result in malnourishment, serious physical problems such as heart disorders, and psychological problems such as depression or suicidal thoughts. Home Health Aides/Personal Care Aides should immediately inform their supervisor if they suspect the teen with whom they are working has an eating disorder or an emotional issue such as depression or thoughts of suicide. Medical and psychological intervention, and sometimes hospitalizations and medications may be necessary to help a teen with these disorders.

According to Piaget, adolescents begin to enter the Formal Operations Stage in which they can think in abstract ways about things that are not in front of them. Adolescents begin to wonder about their future lives. Home Health Aides/Personal Care Aides should support this development by discussing with them thoughts about what they would like to do in the future and support their interests and dreams.

Problems Affecting the Family and How Children React to Stress

Types of Families

We have discussed throughout these modules that families can mean different things to different people. Support the patient’s view of who constitutes their family. Some children come from homes with a single-parent, while others may have parents who are divorced, or a parent who has died. Some children live in blended families where a parent has remarried. There may or may not be children from the new parent’s previous relationship or even new children from the new marriage. These adjustments may be difficult for the child to deal with. Divorce may be particularly difficult for children and they may express emotions such as anxiety, depression, sadness, and anger. Some children may even act out and have temper tantrums, start fights, and get into trouble in school. Home Health Aides/Personal Care Aides should provide support to the child by allowing them room to express their thoughts and feelings. If they have concerns about the adjustment of the child, these should be discussed with their supervisor. A social worker may be able to work with the child to assist them to adjust during stressful time periods of family change.

Guidelines for Communicating with Children about Divorce:

• Explain that the separation is not the child’s fault and that they are loved by both parents and the entire family.
• Ensure the child understands that they will still be taken care of by their parents and others who love them.
• Give the child room to express their thoughts and feelings. Some children may prefer to talk about and others to draw about their feelings.
• Encourage the family to maintain routines in the home and to keep rules and traditions as consistent as possible for the child.
• Encourage the parents to explain to the child reasons for the separation in a way they will understand.

Styles of Parenting

There are different styles of parenting. Diana Baumrind is a developmental psychologist who described four types of parenting styles:

• Authoritarian parenting: In this style of parenting, firm limits are placed on children and parents expect children to do as told without question (Santrock, 2009). Parents may spank the child, be threatening, and enforce rules without explaining why they are in place. A typical statement by an authoritarian parent may be, “Do it because I said so or else.” Children from these types of parents may be fearful, unhappy, and have poor communication skills (Santrock).
• Authoritative parenting: In this style of parenting, limits are placed on children but there is a verbal give and take between parent and child (Santrock, 2009). Children are encouraged to be independent within limits. Parents are nurturing and demonstrate warmth toward their children. A typical statement by an authoritative parent may be, “Let’s talk about why I want you to follow this rule.” Children from these types of parents often learn self-control, tend to be cooperative with others and positive (Santrock).
• Neglectful parenting: In this style of parenting, parents are uninvolved with the child (Santrock, 2009). The child is allowed to do whatever they want. A typical statement by a neglectful parent may be, “I don’t care. Do what you want. I am busy.” Children from these types of parents tend to have low self-esteem and may end up in risky situations in which they get into trouble (Santrock).
• Indulgent parenting: In this style of parenting, parents are very involved with their child but do not place enough limits on their children (Santrock, 2009). Children are allowed to do whatever they want, although the parent cares and is involved. A typical statement by an indulgent parent may be, “It’s okay. You can do what you want. I want you to be able to control your own life.” Children from these types of parents tend not to learn self-control and expect to get whatever they want (Santrock).

Authoritative parenting tends to be associated with the most positive outcomes for children (Santrock, 2009). If Home Health Aides/Personal Care Aides have concerns about parenting styles they see in the home, they should be discussed with their supervisor. She can help them develop a plan for educating parents about other ways to communicate with and set limits with children. Remember that there may be cultural differences in parenting. For example, Asian American parents tend to be authoritarian but in a less dominating way. Latino families also tend to use a more authoritarian approach but in a way that emphasizes respect and is not threatening. African American parents also tend to be more authoritarian and may use spanking. However, the use of physical punishment within this culture has been shown to have more positive outcomes within African American families (Santrock). While it is important to promote the most positive parenting style, it is also important to be aware of cultural differences and what may work best within one culture versus another.

Socioeconomic Status

Socioeconomic status means the social and financial level of the family. Families who have low incomes may have less access to resources than families from higher incomes. They may need more support from a HHA/PCA and more assistance to find resources available to them. It is important to ensure the family has access to resources such as food, clothing, and healthcare. There are resources within communities to help families who may be struggling. Federal and state financial assistance may also be available for these families. Home Health Aides/Personal Care Aides should discuss their concerns with their supervisor and how they can best help these families.

Children from low income families may struggle in school. They may feel embarrassed if their family is unable to afford the latest trends in clothing or technology. They may struggle with schoolwork and may not be getting the help they need at home. Share any concerns with a supervisor so that these issues may be addressed within the Care Plan.

Domestic Violence

Domestic violence is abuse that occurs by spouses, intimate partners, or family members. It can include any type of abuse such as physical abuse, emotional abuse, financial abuse, or sexual abuse. Domestic violence and the different types of abuse were discussed in Module Two.

Child neglect or maltreatment is when a child is harmed by a caregiver, (whether it is a family member or a healthcare worker), when the caregiver fails to provide necessary care. This includes failing to provide for the basic needs of a child such as food, shelter, and clothing. Neglect can mean abandoning the child, being inattentive to the child’s emotional needs, and neglecting the child’s education. For example, allowing a child to miss school so they do not get an adequate education is neglect.Neglect can be just as harmful as abuse. In fact, child neglect occurs more often than child abuse.

Children who come from homes where domestic violence occurs may have adjustment problems. They may suffer from anxiety, depression, have trouble forming positive relationships with others, have low self-esteem, and may get into trouble or engage in risky behaviors. Children who come from abusive homes are at risk for later becoming abusive themselves, particularly for sons. Daughters are more likely to end up in an abusive relationship themselves. Problems with alcohol and drug abuse, depression, and anxiety can also occur in later life.

If Home Health Aides/Personal Care Aides ever notice any signs of domestic violence, child abuse, or neglect, they should immediately report these to their supervisor. All health care workers are required by the law and have an ethical obligation to report incidents of child abuse. Refer to the agency’s policy on guidelines for reporting observed or suspected abuse to agencies, such as the local Child Protective Services. Laws may differ from state to state and country to country about how to report child abuse and neglect. Always follow your agency’s rules and state/country law for reporting suspected child abuse/neglect.

In families where domestic violence is actively occurring, the abusive person may likely need to be removed from the home. In some instances, the abused family members may need to enter a domestic violence shelter or be placed in a secure and confidential location, away from the abuser. Families where domestic violence occurs may benefit from parenting classes and in or out of the home counseling.

Self-Check Activity m4-10

Special Issues of Families: Substance Abuse and Mental Health Issues

Some children may have parents that abuse alcohol or other substances or who have mental health illnesses. Substance abuse is a major factor in child abuse. According to the National Council on Child Abuse and Family Violence, more than 8 million children live with a parent who abuses substances, and between 40-80% of homes where there is substance abuse, there is also child abuse. The long-term effects of a parent abusing a substance on children include: depression, anxiety, an increased risk of the child eventually becoming a substance abuser, low self-esteem, and acting-out behaviors (National Council on Child Abuse and Family Violence).

Home Health Aides/Personal Care Aides may be the first to recognize that a parent is abusing a substance or has mental health issues. They should always report their observations to their supervisor and seek direction from them about what to do. They should also remember that if they ever feel unsafe in the home, leave immediately and call their supervisor.

Signs of Substance Abuse:

• An odor of alcohol on the breath
• The parent appears unkempt in appearance or the home is unkempt
• Children needs are not met and they may be neglected (e.g. no food, clothing, not going to school)
• The parent appears to be intoxicated (e.g. stumbling, slurring of words, abusive language)
• Blood shot eyes
• Shaky hands and irritability
• You find bottles or drugs hidden around the home
• The parent or caregiver seems forgetful, moody, or you observe sudden changes in behavior
• You notice the caregiver has insomnia or they report not sleeping for a couple of days
• You observe bizarre behaviors
• The children report they see their parent drink or use drugs
• The children seem afraid of the caregiver

Signs of Mental Illness:

• Children needs are not met and they may be neglected (e.g. no food, clothing, not going to school)
• You notice the caregiver has insomnia or they report not sleeping for a couple of days
• You observe bizarre behaviors
• The caregiver reports seeing or hearing things that are not there
• You notice the caregiver talking to themselves or what appears to be another person even though no one else is there
• The parent appears unkempt in appearance or the home is unkempt
• The children report strange behaviors of the parent
• You notice a change in behavior or mood
• You notice the parent seems withdrawn or apathetic (does not seem to care) about what is going on around them
• The children seem afraid of the caregiver

Stress

An important aspect of child development is to learn how to cope effectively with stress. Younger children are less able to understand stressful or traumatic events. They may think that they have caused the stressful event to happen. They may become unhappy, listless, not want to play as usual, forget to do homework, get poor test scores in school, or even become aggressive and act out, getting into trouble at home or in school. Older children and adolescents are better able to understand the causes of stress and to use cognitive coping skills to deal with the stressors in their lives. They too, however, may become anxious, depressed, and hopeless, make statements of wanting to hurt themselves or die, become aggressive, and get into trouble in the home or at school. Sometimes adolescents who have stress may engage in risky behaviors such as driving recklessly, engaging in unsafe sexual activity, or beginning to use drugs or alcohol.

How to Help Children Cope with Stress

• Provide reassurance that the child is safe and protected.
• Allow the child room to talk or draw about their thoughts and feelings.
• Reassure children that it is okay to feel stress, anxiety, or depression.
• Reassure children that traumatic events are not their fault.
• Protect children from stressful situations as much as possible and avoid discussing stressful or traumatic events in front of them.
• Correct any misconceptions about the stressful or traumatic event. Explain the situation in words the child understands.
• Teach children coping techniques to use when feeling stressed such as engaging in relaxing activities. These may include listening to music, dancing, coloring, and engaging in physical activities such as running and bike riding.
• For families that practice religious or spiritual beliefs, encourage children to turn to these practices in times of stress. Provide support and be respectful of these practices. Encourage children to talk to religious leaders.
• For older children and adolescents, talk to them about the cause of their stressors and help them plan ways to overcome the stressors. Children in these age groups are able to have a better understanding of stress and can think about how the future may be different without the stress. They are also able to think about what they could do to make changes to better deal with their stress. This helps to give them hope that things can change.

Working Effectively to Strengthen Families

As Home Health Aides/Personal Care Aides work with children and their families, they should always keep in mind that all families are different. Families have different religious and spiritual beliefs, customs, cultures, traditions, and values. Always be respectful of the uniqueness of each family and look for the family’s strengths. Even in families where substance abuse or domestic violence has been an issue, there are strengths. It is important to help the family recognize these strengths and build upon them.

Learn what family member sets the rules and is considered to be the head of the household. Be respectful of parenting rules and styles, yet be aware of any possible issues of abuse or neglect. Home Health Aides/Personal Care Aides should model positive parenting techniques with the children they work with to show parents and caregivers other methods of working with children. Keep in mind that many situations which require home care are stressful for the family and children involved. Practice good communication skills and act as a role model for how to positively communicate and handle stress.

Remember that families will all have different resources, financial situations, education levels, and lifestyles. It is not up to a HHA/PCA to change a family‘s lifestyle. It is up to the HHA/PCA to find the strengths and positives in each family and to treat each family and family member with respect. At the beginning of each home care visit, Home Health Aides/Personal Care Aides should meet with the parent or primary care provider to discuss what concerns they have and what needs they have for the day. If they demonstrate that they care about the family’s needs being met, the family will be more willing to work with them and the experience will be more positive for everyone involved.

Home Health Aides/Personal Care Aides should always remember to report any incidents where they suspect a child is being maltreated or abused or if domestic violence is occurring in the home. They should report any observations they make about changes in parent or children behaviors and suspicions of alcohol or substance abuse to their supervisor, and they should inform their supervisor if they think the family could benefit from extra assistance such as parenting classes, a social worker, or community resources such as referrals to food banks, social service agencies, and healthcare facilities.

Post-test

1. True or False: Meeting a baby’s physical and emotional needs, such as feeding them when hungry, changing them when soiled, and consoling them when they cry helps babies to develop a sense of trust in their caregivers and environment.
2. Which of the following is the correct way to pick up an infant?
   1. Pick the infant up by one arm.
   2. Pick the infant up by her waist and allow the head to roll backwards.
   3. Pick the infant up using one hand to support the head and neck and the other to hold her bottom.
   4. Pick the infant up by grabbing both arms and allowing the head to freely tilt back so the baby can see you.
3. Which of the following are the best ways to provide a safe environment for a child? Select all that apply.
   1. Allow children to use the stairs unsupervised so they can explore their environment.
   2. Allow children to ride bikes, skateboard and roller skate without helmets or supervision.
   3. Lock up medications, cleaning supplies, and hazardous chemicals.
   4. Keep sharp objects such as knives and scissors out of reach of children.
   5. Teach children to hold your hand and look both ways while crossing the street.
   6. Allow children to leave shoelaces untied.
4. True or False: In order to promote a sense of independence and encourage exploration, children should be allowed to play with anything they want, including cleaning supplies, medications, sharp objects, and electrical outlets.
5. Which of the following are ways a HHA/PCA can support the development of self-esteem in a child? Select all that apply.
   1. Find out what the child’s strengths and talents are and encourage growth in these areas.
   2. Allow children to explore their environment while providing supervision and ensuring safety.
   3. Encourage children to play make believe and to use their imagination during pretend play activities.
   4. Allow children to choose toys and activities during play time.
   5. Give children small responsibilities such as picking up toys and helping with household chores.
6. Which of the following are possible issues teens may face during the adolescent period of development? Select all that apply.
   1. Concerns about their appearance
   2. Peer pressure
   3. Experimentation with drugs, alcohol, and cigarette smoking.
   4. Eating disorders such as anorexia and bulimia
   5. Thoughts of depression or suicidality
7. Which of the following are signs of abuse or neglect that a HHA/PCA should immediately report to a supervisor? Select all that apply.
   1. Unexplained bruises
   2. Burn or teeth marks on the child
   3. Inadequate clothing for the weather (e.g. child has no coat in the winter)
   4. Child is left home alone for two days
   5. A caretaker is observed shaking an infant to stop him from crying
   6. The child reports their uncle touched them “down there”
   7. A father strikes the mother across the face and pushes her against a wall
   8. An inadequate supply of food is in the home and the children are often hungry
   9. A parent or caregiver is intoxicated
8. True or False: Homes where substance abuse occurs also have higher rates of child abuse and neglect.
9. True or False: You should immediately report signs of substance abuse or mental health issues from children or their parents to your supervisor.
10. Which is the best way to help children cope with life and family stresses?
    1. Change routines and rules frequently.
    2. Point out the child’s flaws and how they contribute to their family problems.
    3. Teach children positive coping skills and provide reassurance when they are upset.
    4. Don’t allow children to express their thoughts and feelings. Children should be seen and not heard.

References

Leahy, W., Fuzy, J., & Grafe, J. (2013). Providing home care: A textbook for home health aides (4th ed.). Albuquerque, NM: Hartman.

National Council on Child Abuse and Family Violence. (2015, May 1). Parental substance abuse: A major factor in child abuse and neglect. Retrieved from http://www.nccafv.org/parentalsubstanceabuse.htm

Santrock, J. W. (2009). Life–span development (12th ed.). New York, NY: McGraw Hill.