multidisciplinary curriculum on child maltreatment international society for the prevention of child...
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Multidisciplinary Multidisciplinary Curriculum onCurriculum on
Child Child MaltreatmentMaltreatment
International Society for the
Prevention of Child Abuse
and Neglect
Multidisciplinary Curriculum Committee Members
Robert Morris (Chair) Jingqi Chen
Hiroaki Ishikawa (Co-Chair) Anne Hollows
Wambui Njuguna Elena Volkova
Clemencia Ramirez
Editors:Editors:
Howard DubowitzHoward Dubowitz
Wendy G. LaneWendy G. Lane
What is Child Maltreatment?What is Child Maltreatment?
Child Maltreatment Definition
All forms of physical and/or emotional ill treatment, sexual abuse, neglect or negligent treatment, or commercial or other exploitation, resulting in actual or potential harm to a child’s health, survival, development or dignity in the context of a relationship of responsibility, trust or power.
(World Health Organization 1999)
Why is child maltreatment Why is child maltreatment a concern?a concern?
Incidence of Child Maltreatment
43
11
31
40
0
10
20
30
40
50
PhysicalAbuse
SexualAbuse
Neglect Total
NCANDS NIS-4 Harm NIS-4 Endanger Self report
R
ate
per
100
0R
ate
per
100
0
Incidence of Child Maltreatment
6.6
250
2.3
150
0
25
50
75
100
125
150
175
200
225
250
Physical Abuse Sexual Abuse
NCANDS NIS-4 Harm NIS-4 Endanger Canada WHO Estimates
R
ate
per
100
0R
ate
per
100
0
Known cases of
child abuse and neglect are just the
tip of the iceberg.
Rates of Harsh Physical Punishment
0
10
20
30
40
50
60
Hit onbuttocks
with object
Hitelsewherewith object
Kicked Burned
Chile
Egypt
India
Phillipines
US
Source: WHO WorldSAFE studyRunyan, D. Pediatrics. 2010;126:e701-11
Rates of Psychological Punishment
0
10
20
30
40
50
60
Called names Cursed at Threatenedabandonment
Locked out ofhouse
Chile Egypt India Phillipines US
Source: WHO WorldSAFE study
Abusive Head Trauma
17
2600
0
1000
2000
3000
Rat
e p
er 1
00,0
00
Keenan Theodore
• Shaking of children < 2 years
• Keenan: ICU admissions & deaths
• Theodore: parental report
Keenan, et al. JAMA. 2003;290:621-6Theodore, et al. Pediatrics. 2005;115:e331-7
Rates of child maltreatment are higher than what most “official” statistics suggest
But is child maltreatment more common than
other childhood conditions?
Comparison to Other Childhood Conditions
5450
10
0.20
10
20
30
40
50
60
rate per 1,000
ChildAbuse
Asthma Autism* Cancer
* Denotes prevalence. All others are incidence rates
UN Convention of the Rights of the Child (UNCRC)
• A child: under age 18
• CRC has been signed by almost all members of the United Nations
UN Convention on the Rights of the Child - Selected Rights
1. You have the right to grow up and to develop physically and spiritually in a healthy and normal way, free and with dignity.
2. You have a right to special care and protection and to good food, housing and medical services.
3. You have the right to special care if handicapped in any way.
UN CRC
4. You have the right to love and understanding, preferably from parents and family, but from the government where these cannot help.
5. You have the right to go to school for free, to play, to develop, and to learn to be responsible and useful.
6. You have the right to be protected against cruel acts or exploitation. This includes work which may hinder physical and/or mental development.
Why is child maltreatment so common?
Child
ParentsFamily
Community
Society
Contributors to Child Maltreatment
Belsky, Psychological Bulletin. 1993;114:413
Professionals
Child Risk Factors
• Age - younger children
• Gender -
- girls: higher risk for infanticide, sexual abuse, educational and nutritional neglect
- boys: higher risk for physical abuse
• Special Characteristics – twins, children with handicaps, prematurity, unwanted pregnancy
Parent/Caregiver Risk Factors
• Young age
• Single parent
• Unwanted pregnancy
• Poor parenting skills
• Substance abuse
• Physical or mental illness
Family Risk Factors• Overcrowded living circumstances
• Poverty
• Social isolation
• Major stress
• Domestic violence
Community/Societal Factors
• No or poorly enforced child protection laws
• Limited value of children
• Social acceptance of violence (family, community or society – including war)
• Cultural norms
• Social inequities - poverty
Professional Factors
Failing to:• Acknowledge that child
maltreatment exists• Identify and address child
maltreatment• Offer necessary services to
children and families• Help prevent maltreatment
– By promoting health, development and safety– By addressing major risk factors
Impact of Maltreatment on Children• Every child is affected – extent varies
• Several factors determine the impact:– Nature of maltreatment– Child’s personality– Protective factors
• Consequences can be:– Physical – Psychological– Behavioral– Societal
Physical Consequences• Injuries
(such as fractures, burns, injury to internal organs, lacerations, head injuries)
• Impaired brain development
• Short and long-term disability
• Death
Odds of Ischemic Heart Disease By Number of Adverse
Childhood Experiences (ACE)
0
0.5
1
1.5
2
2.5
3
3.5
Control MedRisk
ControlPsychosocial
Risk
Control Both
1
2
3
4
5-6
7-8
Psychological Consequences
• Common• May include:
– Immediate issues of isolation, fear and lack of trust
– lifelong problems of depression, low self-esteem, relationship difficulties
– Impaired cognitive development
Short-term Emotional Effects
• Infants/Toddlers– Sleep disturbance– Irritability– Separation anxiety– Language, toileting regression
• School age– Difficulty regulating emotion– Trouble getting along with peers – hostile intent– Difficulty concentrating
Short term Emotional Effects
• Teenagers– Anxiety
– Aggression
– Risk taking (run away, drug use, sex)
– Participate in family violence
– Depression
– School failure
Suicide Risk by ACE Score
1 1.8
3
6.6
12.2
0
2
4
6
8
10
12
14
Adjusted Odds
0 1 2 3 4 or more
Number of Adverse Childhood Experiences
Behavioral Consequences
• Increased rates of delinquency, drug use, and criminal acts involving violence
• Intergenerational abuse. It is estimated that 1/3 of maltreated children will abuse their own children.
US$ 104 billion annuallyUS$ 104 billion annually
Prevent Child Abuse America, 2008
Cost of abuse
Can we afford NOT to provide funds for prevention?
Identifying Maltreated Children
Types of Child Maltreatment• Physical abuse• Neglect• Sexual abuse• Emotional abuse
and neglect• Labor• Trafficking• Others
Physical Abuse
The use of force against a child that results in harm for the child’s health, survival, development or dignity
Modified from ISPCAN & WHO in, “Preventing Child Maltreatment” 2006.
Indicators of Physical Abuse• Injury inconsistent with history or child’s
development
• Shape of lesions (for example, hand prints or cigarette burns)
• Multiple injuries in various stages of healing
• Family history of abuse
• Child’s report
Physical Abuse
Physical findings may include:
• Bruises • Cuts
• Fractures • Welts
• Burns • Abdominal trauma
• Abusive head trauma (includes inflicted injury to brain and/or skull)
Case 1Case 1
• 3 month old baby
• Bruises on her face and arms
• Mother: “I saw the bruises when I fed her this morning. They were not there when she was put to bed last night. She must have fallen from the crib!”
Case 1Case 1
3 month old with bruises
Source: AAP
Case 2Case 2
• An 11 year old boy
• Uncomfortable in his seat at school
• Tells the teacher, “I was beaten by my father. I was rude to him.”
• He shows her his back.
Case 2Case 2
11 year old with bruises
Source: AAP
Case 3Case 3• A grandmother notices that her 2 month
old grandson is crying a lot and not consolable
• She says, “he is not moving his left arm and cries harder when I try to move it.”
• She brings him to be examined.
• X-ray shows:
Case 3Case 3
2 month oldNot moving arm
Case 4Case 4
• A young, single mother complains that her 3 month old son is “a difficult child”, always fussy, crying, difficult to feed and irritable
• A week later the boy is brought to the hospital unconscious and breathing poorly
Case 4Case 4
3 month old with excessive crying
Source: AAP
Case 5Case 5
• A 22 month old brought to hospital with burns to her buttocks.
• Her mother says, “she got into a hot bath when I was out of the room.”
Immersion BurnCharacteristics
Sparing of flexoral creases
Donut hole – Skin in contact with
Bottom of tub
“High tide” mark
From: Stratman. Arch Dermatol. 2002;138:318-320.
Effect of Skin Thickness on Time Effect of Skin Thickness on Time to Full Thickness Burnto Full Thickness Burn
Adult 2.5 mm Child 0.56 mmAdult 2.5 mm Child 0.56 mm60
35
60
16
3 2 110
4
0
10
20
30
40
50
60
127 130 135 140 150 160temperature
seco
nds Adult
Child
Data from National Burn Victim Foundation
Corporal Punishment vs. Abuse
Physical Discipline“Corporal Punishment”
• Controversial and ingrained: “Spare the rod, spoil the child”
• Widespread: “a parent’s right”
Questions:
• Is it effective?• Is it a form of abuse? • What are the possible outcomes?• What forms of discipline are preferable?
WHO (1999) Definition of Neglect
• Inattention or omission by the caregiver to provide for the child: health, education, emotional development, nutrition, shelter and safe living conditions
• In the context of resources reasonably available to the family or caretakers
• And causes, or has a high probability of causing, harm to the child’s health or physical, mental, spiritual, moral or social development
• Includes the failure to properly supervise and protect children from harm
Child-Centered Definition of Neglect
• Neglect occurs when a child’s basic needs are not met, resulting in potential or actual harm.
• Basic needs include adequate:– Food - Clothing– Supervision - Protection– Health care - Education– Love and nurturance - Home
Case 6Case 6
• A 10 year old boy with diabetes
• Brought to an emergency department - dehydrated, lethargic
• He has not taken his insulin for 2 days.
• His mother explains “We ran out.”
Case 7Case 7
A 9 year old girl is seen for repeated injuries over a 6 month period, including
-fell from a tree causing minor head injury
-major laceration on forearm when climbing through a broken window
-burns to her hands from handling hot fat
Case 8Case 8• A 10 month old girl was noted by a public health
nurse to be thin
• Her weight is less than 5th percentile; height is in the 10th
• Her mother describes an adequate diet and the child feeds well in front of the nurse
• A month later she is has not gained weight and is very irritable
• The child is admitted to hospital, investigations for diseases are negative. She eats well, puts on weight and is more active
Child Sexual Abuse• Involvement of a child in sexual activity
that he/she:
– does not fully comprehend,– is unable to give informed consent to,– is not developmentally prepared for,– violates laws and taboos of society.
• Children can be sexually exploited by an adult or other child who by virtue of age or development is in a position of responsibility, power or trust. (From ISPCAN & WHO in, “Preventing Child Maltreatment”, 2006)
Child Sexual Abuse
• Often a ‘hidden’ assault
• All forms of sexual activity are included, not just intercourse and other physical types
• Includes child prostitution and exposure to pornography
Case 9Case 9
• A 6 month old girl is brought to a local nurse because her mother found blood in her diaper. She is happy and healthy looking, with no obvious medical findings upon examination.
• Mom says only she and her 17 year old sister care for the baby. The sister babysat the previous evening.
Case 10Case 10
A 7 year old girl tells her mother that a boy touched her ‘private area.’
Case 11Case 11
• A 13 year old girl tells her friend that her uncle gets in bed with her and makes her do ‘bad things.’
Case 12Case 12
• A 9 year old boy refuses to go to school because one of his teachers forces the boy to ‘kiss his bird’.
Emotional Abuse
• Includes: – Blaming - Belittling – Frightening - Threatening– Spurning - Ridiculing– Discrimination - Rejecting
• These acts have a high probability of damaging the child’s psychological or mental health. They may also damage the child’s physical, mental, spiritual, moral or social development.
(From ISPCAN and WHO, Preventing Child Maltreatment, 2006)
Conditions That Mimic Abuse
• It is important to recognize that most injuries are the result of innocent events.
• Behavior problems occur for many reasons; none are specific for abuse.
• While it is important to consider the possibility of maltreatment; it is important NOT to jump to conclusions.
What Caused This?
Mongolian spots
Evaluating Possible Child Maltreatment: Roles
• Two main groups: – child protection (social services and
civil/family court)– criminal justice (police and criminal court)
• Child Protection: ensure child’s safety, strengthen family
• Criminal Justice: Identify those who commit crimes and hold them accountable
• Multidisciplinary evaluation is ideal
Potential Problems with Separate Evaluations
• Parallel investigations
• No coordination; little information sharing
• Multiple interviews
• Potential contamination of story, evidence
• Potential contradictory conclusions
• Further distrust and increased stress for all involved
What is a Multidisciplinary Evaluation Team
Approach?
• Train and work together
• Understand each other’s roles and strengths
• Establish common protocols for receiving reports, information sharing, interviewing and decision making
Multidisciplinary Training: Why don’t we do it now?
• Groups have different mandates
• Groups have different training
• Ignorance of each other’s jobs, abilities
• Concerns about confidentiality
• Limited resources
• Not considered necessary
Interviewing Children:
An Overview• Requires training and expertise
• Children can give good and accurate information
• Poor interviewing may bias child’s account
Know How Children Communicate
• Children who disclose abuse often tell a trusted adult other than a parent
• Children may tell parts of what happened or pretend it happened to someone else to gauge adult reaction
• Children will often “shut down” and refuse to tell more if you respond emotionally or negatively
(from 7 Steps to Protecting Children published by Darkness to Light, www.DarknessToLight.org)
How to React
If a child tells you that he or she has been abused:
• Believe her. Children rarely lie about abuse. Do not ignore or deny what she is saying.
• Commend the child for telling you. Make sure she understands that the abuse is not her fault.
• Stay calm. Children stop talking if they think what they are saying makes you upset. Make sure the child knows you will listen.
(www.DarknessToLight.org)
How to React• Encourage the child to talk but don’t ask
leading questions (for example, “He touched your private parts, didn’t he?”). This can alter the child’s memory of events.
• Don’t pressure a child to talk if he is not ready.
• Get enough information to determine whether a report is indicated. More detailed questions can be asked later, by professional interviewers.
• Make sure the child is safe and no more abuse can occur while you seek help.
• Contact social services or police.
How to React
Discuss how you would respond to each of these children disclosing their abuse.
• Case 1: a 6 year old with cigarette burns
• Case 2: a 7 year old girl who says that a boy touched her
Treatment and Follow-Up
• Every child must be assessed for effects of maltreatment
• Acute medical therapy must be given as required
• The need for mental health care must be assessed
• Family members should be assessed and provided with necessary services.
What are our Responsibilities?
Defined by many factors:
- Ethical
- Professional and Clinical
- Legal
Reporting Laws
What are the laws in your community?
Roles – Child Welfare
To provide child protective services, including:
- Evaluating reports of alleged child maltreatment
- Ensuring children’s safety
- Facilitating support services
Roles - Police
Responsibilities include:
• Investigating to determine if a crime has been committed
• Bringing charges if evidence suggests a crime.
Roles - Health Care
Responsibilities include:• Prevention • Identify children who may be maltreated• Inform Child Welfare • Evaluate and treat illness and injury• Help ensure medical and mental health support • Collaborate with other professionals, agencies• Testify in court• Advocacy
Roles - Courts/Correctional Services
Responsible for helping ensure the care and protection of children, including:
• Mandating treatment services
• Criminal proceedings and incarceration
Prevention
“….There is sufficient evidence, including in the scientific literature, to state with full confidence that child maltreatment can be prevented.”
(Preventing Child Maltreatment, 2006)
Prevention
Promotion- health, development and safety
Levels of Prevention
• Primary PreventionPrimary Prevention - Prevention of disease (maltreatment) before it occurs
• Secondary PreventionSecondary Prevention – Detection and treatment of disease before signs and/or symptoms occur. For child maltreatment, often refers to identification and amelioration of risk factors.
• Tertiary PreventionTertiary Prevention – Treatment to prevent further morbidity, avoid mortality, and limit disability.
Prevention Strategies for Child Maltreatment
Three levels of programs:
• Individual
• Relationship
• Societal and community
(Preventing Child Maltreatment, 2006)
Individual Prevention Strategies
• Reducing unintended pregnancies
• Increasing access to prenatal and postnatal services
• Training children to avoid potentially abusive situations
(Preventing Child Maltreatment, 2006)
Relationship Prevention Strategies
• Home visitation programs
• Training programs for parents
(Preventing Child Maltreatment, 2006)
Societal and Community Based Prevention Programs
• Legal reforms and human rights
• Beneficial social and economic policies
• Change cultural and social norms that support violence against children
• Reduce environmental risk factors
(Preventing Child Maltreatment, 2006)
“We owe children, the most valuable citizens in any society, a life free from violence and fear”
Nelson Mandela
(World Report on Violence and Health, 2002)
Extent of the ProblemUSA Canada
Population ~300 million ~33 million
# Cases 906,000 115,000
% Neglect 60 30
% Physical Abuse 19 24
% Sexual Abuse 10 3
% Witness Domestic Violence
28
% Other 17
Extent of the Problem:Fatal Cases of Abuse
• ~57,000 deaths of children <15 years • Rate < age 4 is twice that seen in older
children• Rate much higher in poorer areas
(2.2/100,000 boys in highest income groups and 17.9/100,000 in lowest income groups)
• Most common causes: head injury, abdominal injury
(WHO 2000)
Extent of the Problem:Non-Fatal Abuse
• Yelling/screaming at child in 70% to 85% of families
• Threatened with abandonment in 8% to 48%
• Spanking with object 18% to 75%
• Shaking 12% to 59%
UN Convention on the Rights of the Child - Selected Rights
1. All children have the right to what follows, no matter what their race, colour ,sex, language, religion, political or other opinion, or where they were born or who they were born to.
2. You have the special right to grow up and to develop physically and spiritually in a healthy and normal way, free and with dignity.
3.You have the right to a name and to be a member of a country.
4. You have a right to special care and protection and to good food, housing and medical services.
5. You have the right to special care if handicapped in any way.
6. You have the right to love and understanding, preferably from parents and family, but from the government where these cannot help.
UN Convention on the Rights of the Child – Selected Rights
7. You have the right to go to school for free, to play, and to have an equal chance to develop yourself and to learn to be responsible and useful. Your parents have special responsibilities for your education and guidance
8. You have the right always to be among the first to get help.
9. You have the right to be protected against cruel acts or exploitation; for example, you shall not be obliged to do work which hinders your development either physically or mentally. You should not work before a minimum age and never when that would hinder your health or your moral and physical development.
10. You should be taught peace, understanding, tolerance and friendship among all people.
Prevention: the Optimal Goal
• Traditionally consists of early identification of child maltreatment and interventions to protect the child
• A better approach is to identify known risk factors and proactively provide programs and resources to reduce these risks