1. Child Abuse and Neglect: Recognizing, Reporting, and Responding in Early Childhood
Ally Burr-Harris, Ph.D.
Greater St. Louis Child Traumatic Stress Program
Center for Trauma Recovery
University of Missouri-St. Louis
Revised 10/6/04

2. Greater St. Louis Child Traumatic Stress Program
Member of National Child Traumatic Stress Network (NCTSN)-
Services provided by Children’s Advocacy Center and Center for Trauma Recovery at UMSL
Free assessment and treatment of children and adolescents who have experienced a trauma
Consultation and training of education, mental health, and medical professionals in the area of child trauma
School-based group therapy for children and adolescents exposed to violence

4. What is Child Abuse and Neglect?
Missouri Child Abuse Law definitions:
ABUSE : Any physical injury, sexual abuse, or emotional abuse inflicted on a child other than by accidental means by those responsible for the child’s care, custody and control except that discipline including spanking, administered in a reasonable manner shall not be construed to be abuse;
NEGLECT: Failure to provide, by those responsible for the care, custody, and control of the child, the proper or necessary support, education as required by law, nutrition or medical, surgical, or any other care necessary for the child’s well-being.
-RSMo (1), (8)
-”reasonable cause to suspect that a child has been or may be subjected to abuse or neglect”
-care, custody and control of the child, includes but is not limited to the parents or guardian of a child, other members of the child’s household, or those exercising supervision over a child for any part of a twenty-four hour day. Those responsible for the care, custody and control shall also include any adult, who, based on their relationship to the parents of the child, members of the child’s household or the family, has access to the child.
Mandated reporter must report abuse of child by any other person as well.

5. Physical Abuse Pinching Squeezing Pushing Shaking Cornering
Restraining
Striking
Throwing things
Breaking bones
Internal injuries
Using weapons
Burning
Disabling
Disfiguring
Maiming
Murdering
-Physical abuse occurs on a continuum.
-Munchausen Syndrome by Proxy: refers to physical and psychological harm either through direct attack by the parent or as a function of being subjected to painful and numerous unnecessary medical assessment procedures. Prevalence rates have not been determined. Typically involves the mother, but father may be passive colluder.
Pinching, squeezing, pushing -- leave marks?
Restraining okay if done correctly with child out of control
Striking okay if open hand

6. Sexual Abuse Sexual talk or correspondence Voyeurism
Child prostitution, child pornography
Exhibitionism (e.g., exposure to adult genitalia, adult sexual acts, pornography)
Molestation (e.g., touching, fondling or kissing child for adult’s sexual gratification)
Coerced sexual activity
Consensual sexual activity between minor and significantly older person
Sexual penetration (digital, object, genitalia)
Rape
-sexual abuse involves:
Lack of consent: a child cannot consent to behavior if they do not have the developmental understanding of the possible consequences of the behavior and of the appropriateness of the behavior. Just because a child cooperates or complies with the perpetrator’s requests, she/he is not necessarily consenting.
COOPERATION does not equal CONSENT.
Lack of equality: this refers to the balance of power or authority in the relationship. Thus, a perpetrator and child are considered to lack equality when the perpetrator is old, larger in size, functioning at a higher intellectual level, in charge of the child, in a leadership role, or stronger.
Coercion: this can include manipulation, trickery, peer pressure, threats, bribes, physical force, weapon threats, or actual violence.
Physical force is rarely necessary to engage a child in sexual activity because children are trusting and dependent. They want to please others and gain love and approval. Children are taught to not question authority and they believe that adults are always right.
Penetration: digital, object, genitalia into child’s body

7. Physical Neglect Refusal/delay in medical attention and care
Abandonment
Expulsion from home without adequate care
Inadequate supervision
Failure to provide for basic needs of child (e.g., food, clothing, shelter, hygiene)
Failure to thrive (FTT)
-neglect tends to be a chronic problem
-neglect usually permeates a family, with all children subject to similar treatment.
-FTT: related to failure of the infant to gain weight due to inadequate caloric intake due to poor caregiving. FTT is considered to be a factor if a child gains weight with hospitalization or after age 2, when children are better able to obtain food for themselves
-FTT associated with significant disruptions in mother-child relationship
Most common types (in order): inadequate supervision leading to harm of child, physical neglect, permitting criminal behavior, abandonment, and Educ. Neglect.
Truancy=If the parent does not intervene after 5 notified absences in one month.

8. Emotional/Educational Neglect
Refusal/delay of needed psychological care
Failure to enroll; permitted chronic truancy
Failure to access special education services
Permitting criminal behavior
Allowing child to abuse drugs/alcohol
Exposure to domestic violence
Inadequate nurturance or affection
Acts or omissions by caregiver that could cause behavioral, cognitive, emotional, or mental disorders.

9. Emotional Abuse
Verbal abuse (e.g., demeaning, ridiculing, name-calling)
Substance/alcohol abuse of caregiver
Threats
Extreme rejection
Corruption, exploitation, brainwashing
Cruel punishments
Substance abuse: allowing substance use by the child, or being aware of the problem, but choosing not to intervene.
Truancy: if the parent has been informed that the child averages at least 5 absences a month and the the parent does not intervene
Corruption: e.g., getting child to shoplift
Cruel punishment: Putting face in BM, killing pet

10. Incidence and Types of Child Maltreatment
Nationally, 70% of reports are for NE, and 43% are for PA, SA, or EA
For substantiated cases, 25% for PA, 25% for SA, 6% for EA, 60% for NE
Missouri rates are similar to national rates.
EA rates have increased due to increased reporting of DV (70% of cases involve
children)

11. Risk Factors for Abuse/Neglect: Child Factors
Gender
Age
Difficult temperament
Disabilities
Behavioral difficulties
Chronic illness
-Child characteristics are not necessary or sufficient in and of themselves to cause abuse; interacts with caregiver characteristics
NIS-3: Girls sexually abused 3x more than boys
Boys at greater risk of serious injury and emotional neglect
Children from ages 0-3 accounted for 27.7% of victims
-most dangerous period for abuse occurs between ages of 3 mos and 3 years
vast majority of abuse-related deaths occur before age 5
May be another peak in incidence rates during adolescence.
Younger children more likely to be reported for neglect, school-age children for emotional neglect, and teens for physical abuse.
Sexual abuse rates are relatively constant from age 3 and up\
Temperament: cries a lot, hight energy, less sleep, night wakening

12. Risk Factors for Abuse/Neglect: Caregiver Factors
History of Abuse
Anger difficulties
Poor impulse control
Psychiatric disorders
Substance abuse
Social isolation
Personal distress
Unrealistic expectations
Negative view of child
Parent chronic illness
Poor parenting skills
Male
Young age
-intergenerational transmission in about 30% of cases
-in SA, perpetrator is frequently not a primary care giver (approx 50%).
-Females more likely to neglect, Males more likely to abuse (particularly SA-89%)
PUNITIVE, RIGID Discipline style

13. Characteristics & Risk Factors: Family Environment
Single-parent families
Blended families
Poverty
Domestic violence
Family crises
Chaos/instability
Housing problems
Social isolation
Family size (neglect)

14. Protective Factors for Abuse/Neglect
Caregiver parenting skills
Community support of families
Availability of emotional, social, and financial support for families
Stable housing
Connection to community, faith-based organizations
Good personal safety skills for children
Easy access to health care, childcare, etc.
Wholesome environment

15. Possible Signs of Physical Abuse
Bruises, welts, burns, fractures, cuts & abrasions
Injuries to multiple body areas
Various stages of healing
Wearing clothes to cover injuries
Reluctance to seek medical help (refuses medical tests)
Extensive history of injury (frequent hospital visits)
Inconsistent/unbelievable explanation of injury
Excessive fear (or anticipation) of punishment
Excessive fear of caregiver
Wary of physical contact
Frequent school absences
Abusive themes in art/play/conversation
Child disclosure
Are only indicators, not guarantees
One of the more easily identified forms of abuse
Bruises and welts on: (butt, genitalia, back, back of hands)
Face, lips, mouth, ears, eyes, neck or head
diagonal lines for slap marks on cheek
dark spots on ears if slap on side of head
2. Trunk, back, buttocks, thighs, or extremities
3. Multiple body surfaces
-look for patterns such as shapes of the article used to inflict the bruise or welt.
U-shaped marks suggest looped item such as cord.
-age of bruises: red, blue, black-purple, green tint dark, pale green to yellow
For Dark skin, welts and bruises are still seen but harder to see.
Burns: Cigar and cigarette burns are common; often appear on soles, palms, back or buttocks, look for patterned burns that resembles shapes of appliances such as irons

16. Possible Signs of Sexual Abuse
Difficulty walking or sitting
Vaginal, penile, rectal pain/discharge/bleeding
Sudden refusal to change clothes
Inappropriate sexual knowledge/behavior
Frequent urinary tract/vaginal infections, STD
Wary of physical contact
Abnormal fears about bodily functions
Abnormal anogenital exam findings
Child disclosure
Sexual behavior: sex play, sex comments, inappropriate touching, sexual gestures, unusual friendliness to adults, masturbation (with items)
Pregnancy/VD especially indicative of SA when under age 14
Definite SA: gonorreah, syphilis, HIV
Probable SA: HSV 2, chlamydial, trichomonas
Possible: HSV1, warts
97% of children with highly likely SA penetration had normal anogenital exam findings
(Berenson et al. 2000)
Timoth Kutz, Dir. Child Protection Division at Cardinal Glennon’s ( )

17. Possible Signs of Physical Neglect
Frequent absences from school
Begs, steals, hoards food/money/small items
Lacks needed medical, visual or dental care
Consistently dirty, poor hygiene
Insufficient or ragged clothing
Child abuses alcohol or other drugs
Malnourished, thin, constant hunger; deyhydration
Tired, falls asleep (other than nap) during day
Child anticipates being left unattended (e.g., in car)
Small for age - FTT
Chaotic home environment
Serious caregiver problems
Lack of supervision
Chronic ailments
Child disclosure
Parent incarceration, psychiatric disorder, substance abuse

18. Possible Signs of Emotional Abuse/Neglect
Child very fearful of being punished
School absence or non-enrollment
Chaotic home environment (frequent moves)
Serious caregiver problems
Caregiver misses important child appointments
Caregiver disinterested in or unresponsive to child
Unusual, harsh, demeaning punishments of child
Abusive themes in play/art/conversation
Child disclosure
Verbal dislike for child
Drug withdrawal
Positive drug screening
Use of inappropriate food, drink, or drugs

19. General Indicators That “Something” Is Wrong
Anger/irritability
Increase in crying, difficult to comfort
Symptoms of depression/anxiety
Sudden changes in behavior
Sudden changes in sleep/appetite
Sudden changes in school performance
Self-destructive behaviors
Difficulty concentrating/attending
Sudden change in activity level
May not be indicative of abuse; could be just about anything

20. “Something” is Wrong (cont.)
Developmental delays
Regression (e.g., toileting)
Extreme behaviors (passive-violent)
Withdrawal, apathy, passivity
Running away
Increased separation difficulties
New fears
Consistent reluctance to leave with caretaker
Trauma themes in play, art, conversation

21. Impact of Abuse & Neglect
-every year 1,400 cases of fatal child abuse are reported
-costs for direct medical care to children injured by parents is 20 million/year, the majority of which is paid by taxpayers through medicaid
-special education services cost about 7 million/year
-460 million spent on foster care for children removed from their homes due to abuse and neglect

22. Predictors of Trauma Effects
Low IQ
Female
Younger age
Passive coping
Limited support
Unsupportive caregiver
Severity/chronicity of abuse
High abuse-related stress
Relationship to abuser
Use of threat

23. Extent of CAN Effects 40-60% have emotional/behavior problems
#1 predictor of substance abuse in women
Decreases IQ
Alters brain development
>50% have school problems
>25% require SSD services
8 point decrease in IQ for high DV exposure (vs. 3 point decrease for lead poisoning)
-Koenen et al., 2003

24. Growth of the Human Brain from birth to 20 years

25. Normal Brain Development Age 5 – 20 Years

26. Trauma Symptoms: Infants and Toddlers
Pattern A: Withdraws, rejects affection, stops exploring environment, lacks trust in others, appears “unattached” Pattern B: Clingy, anxious, sleep disturbances, toileting problems, temper tantrums, regressed, disorganized, rages/aggression, crying irritability

27. Trauma Symptoms: Preschoolers
Regressive behaviors
Separation fears
Eating and sleeping disturbances
Physical aches and pains
Crying/irritability
Appearing “frozen” or moving aimlessly
Perseverative, ritualistic play
Reenactment of trauma themes
Fearful avoidance and phobic reactions
Magical thinking related to trauma
Poor concentration, difficulty learning
Behavior problems (e.g., tantrums)
Withdrawal most pronounced for sexual abuse and neglect groups

28. Trauma Symptoms: Elementary School-Age
Sadness, crying
Irritability, aggression
Nightmares
Trauma themes in play/art/conversation
School avoidance
Behavior/academic problems
Physical complaints
Concentration problems
Regressive behavior
Eating/sleeping changes
Attention-seeking behavior
Withdrawal

29. Impact of Physical Abuse
Aggression, reactive anger
Oppositional behavior
Social immaturity
Attachment problems
Posttraumatic stress
Violent play
Developmental delays
Neurological impairment
Poor problem-solving
Physical injury, death
Aggression: most consistent finding; persists into latency/adolescence, towards adults and peers
Interpersonal Problems: social skills deficit; problems with peer interactions; poor social problem solving; peer rejection
Trauma Symptoms: anxiety/hypervigilance; depression, suicidality, low self esteem; PTSD (less than 50%), subclinical PTSD
Relationships Skills: anxious attachment; limited positive affect; low frustration tolerance; less outgoing; less readiness to learn; difficulty managing conflict with attachment figures
Neurological Impairment: receptive/expressive language; reading ability; low performance in math/reading skills

30. Impact of Sexual Abuse Sexualized behavior, play Promiscuity
Posttraumatic stress
Nightmares
Regression
Somatic complaints
Poor self-esteem
Self-destructive behaviors
Poor interpersonal boundaries
Resists affection
Physical injury
Withdrawal
-on average 32% of SA children develop PTSD
-discuss regressive behaviors
Behavior problems could include promiscuity or substance abuse
Self-destructive behaviors: SIB, overeating, etc.
Depends on force, severity of abuse, chronicity of abuse, relation of perpetrator, age of child (more sx if older), maternal support, and child’s coping style

31. Impact of Neglect Cognitive/academic deficits Language deficits
Developmental delays
Social withdrawal
Decreased moral development
Stealing, lying, hoarding
Insecure or disorganized attachment
Emotional volatility
Retarded physical growth
Death
Physical neglect and emotional neglect: High number of pathological behaviors in preschool years such as tics, tantrums, stealing, soiling, self-punitive behaviors, clinginess, negativistic.
-Poor emotional control in compliance situations.
-Relative to PA, more severe academic/cognitive deficits, social withdrawal, limited peer interactions, and internalizing problems (Hilyard & Wolfe, 2002)
Egeland (91) - Minnesota Mother-Child Program with high-risk mothers/infants. All of physically neglected kids were referred to SSD by 2nd grade.
EN particularly detrimental in infancy (sharp declines in dev. If caregiver unresponsive).

32. Impact of Emotional Abuse
Extreme behaviors
Developmental delays
Overly compliant
Self-critical
Flat, negative affect
Passive, dependent
Self-destructive behaviors
Antisocial/violent behaviors
Indiscriminately friendly
Poor social skills
Pseudomature behavior
Attachment disorders
-psych disorder include: depression, PD, anxiety

33. Reporting Suspected Child Abuse/Neglect
You are required to report abuse if you have reasonable cause to suspect that a child has been or may be subjected to abuse or neglect or if you observe a child subjected to these conditions
As a mandated reporter, failure to report is a misdemeanor that could result in a fine or jail time, loss of professional license, and possible civil suits
Err on the side of reporting
You can call hotline anonymously and describe situation first to determine if you are required to report the incident. Must identify self when making hotline as mandated reporter.
Typically, if you are paid to provide services to children and/or their families, that makes you a mandated reporter
No privilege unless attorney
You’re immune from prosecution if you make hotline in good faith.

34. Numbers to Call Missouri Hotline: 1-800-392-3738
(St. Louis County DFS )
Persons calling from outside Missouri should dial
Text telephone number:
Illinois Hotline:
National hotline:
For other states check:
St. Charles County DFS
Can also report to another state if that’s where abuse occurred.
Can also report suspicions to law enforcement, school administrators, juvenile authorities but this does not replace mandated hotline.

35. Information for the Report
Name of the child and parent(s)
Contact information for child (must have this)
Name of the alleged abuser and contact information if available
Any immediate or continued risk for harm?
Extent of injuries
Details of abuse/neglect (dates, times)
Any abuse/neglect witnessed?
Other witnesses and their contact information

36. After a Report
Report sent to appropriate DFS county office
Investigation by DFS social worker initiated within 24 hours of the receipt of the report (72 hours if educational neglect).
Possible outcomes:
Investigation
Family assessment and services
Probable cause
Unsubstantiated - Preventive services indicated
Unsubstantiated
Caseworker should call reporter back within 48 hours to make sure that information is complete. Reporter will also be notified of status of investigation within five days of its completion.

37. Helping Abused/Neglected Children
Provide realistic reassurance of safety and security
Allow child to be more dependent temporarily if needed
Follow child’s lead (hugs, listening, support)
Use typical soothing behaviors
Use security items and goodbye rituals to ease separation from caregiver
Distract with pleasurable activities
Let child know you care
Maintain normal routines when possible
Avoid exposing child to unnecessary reminders of the abuse

38. Helping Abused/Neglected Children (cont.)
Minimize contact with others who upset child
Continue to set limits for inappropriate behavior as needed
Anticipate temporary increase in problem behaviors
Identify antecedents of problem behaviors and develop behavior management plan
Redirect/Stop abuse reenactment play as needed
Facilitate resolution of abuse themes in play/art if possible
Assist child in coping with trauma reminders
Attempt to alter negative association with nonharmful trauma cues
Assist with trauma reminders - e.g., prep kid for exposure, give calming statement
Alter negative associations with nonharmful trauma cues - e.g., help child warm up to male groundskeeper

39. Discussing Abuse/Neglect with Children
Do not ask leading questions, particularly if investigation is underway
Do not over-interview or bias child’s report
Encourage child to express abusive experience but don’t pressure
Emphasize child’s safety now
Praise child for telling; encourage honesty
Be an active listener
Remain calm when answering questions and use simple, direct terms

40. Discussing Abuse/Neglect with Children (cont.)
Don’t “soften” information you give to child
Help child develop a realistic understanding of what happened
Gently correct abuse-related distortions
Be willing to repeat yourself
Tolerate retellings
Protect other children from exposure to trauma retellings/reenactments
Normalize “bad” feelings or symptoms
Distortions - self-blaming, overgeneralization of danger

41. Helping Non-Offending Parents of Abused/Neglected Children
Communicate with parents about the child
Encourage parents to listen to child closely
Encourage parents to set aside special time for child
Recommend maintenance of normal routine
Encourage parents to remain calm and get help for themselves if needed
Educate parents regarding importance of responding supportively
Normalize child’s difficulties

42. Helping Non-Offending Parents of Abused/Neglected Children
Model soothing behaviors with younger children
Assist in developing plan for behavior mgmt.
Guide foster parent in getting to know child
Advocate for continuity of school placement if child is placed out of home
Equip parents with good skills through workshops, references, modeling
Encourage parent involvement in classroom

43. Helping Potentially Abusive/Neglectful Parents
Gently point out concerns by focusing on observable facts and behaviors
Offer assistance, support, resources
Do not hypothesize, stick to observable facts
Acknowledge parents strengths, efforts
Focus concern on child’s welfare and present as “common concern”
Model effective parenting skills
Catch parent doing well; reinforce successes
Don’t get caught in triangles with parents

44. When to Refer for Psychological Care
Appear depressed, withdrawn
Strong resistance to affection or support from caregivers
Suicidal or homicidal ideation
Dangerous behaviors to self/others
Increased usage of alcohol or drugs
Rapid weight gain/loss
Significant behavioral change
Poor hygiene
Significant acute stress symptoms (e.g., nightmares, startle easily, hypervigilance)

45. When to Refer for Psychological Care
Intense anxiety or avoidance behavior if reminded of abuse
Inappropriate social behaviors
Unable to regulate emotions
Poor academic performance and decreased concentration
Continued worry about the abuse (primary focus)
Intense separation difficulties
Persistent physical complaints (nausea, headaches)
Continued abuse themes in play, art, conversation, behavior
Sexualized behavior

46. We’re Done!
For additional questions, referrals, or references, contact Dr. Ally Burr-Harris
Phone:
(314)