Presentation on theme: "Child Abuse and Neglect: Recognizing, Reporting, and Responding in Early Childhood Ally Burr-Harris, Ph.D. Greater St. Louis Child Traumatic Stress Program."— Presentation transcript:
1Child Abuse and Neglect: Recognizing, Reporting, and Responding in Early Childhood Ally Burr-Harris, Ph.D.Greater St. Louis Child Traumatic Stress ProgramCenter for Trauma RecoveryUniversity of Missouri-St. LouisRevised 10/6/04
2Greater St. Louis Child Traumatic Stress Program Member of National Child Traumatic Stress Network (NCTSN)-www.nctsnet.orgServices provided by Children’s Advocacy Center and Center for Trauma Recovery at UMSLFree assessment and treatment of children and adolescents who have experienced a traumaConsultation and training of education, mental health, and medical professionals in the area of child traumaSchool-based group therapy for children and adolescents exposed to violence
4What 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.
5Physical Abuse Pinching Squeezing Pushing Shaking Cornering RestrainingStrikingThrowing thingsBreaking bonesInternal injuriesUsing weaponsBurningDisablingDisfiguringMaimingMurdering-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 controlStriking okay if open hand
6Sexual Abuse Sexual talk or correspondence Voyeurism Child prostitution, child pornographyExhibitionism (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 activityConsensual sexual activity between minor and significantly older personSexual 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
7Physical Neglect Refusal/delay in medical attention and care AbandonmentExpulsion from home without adequate careInadequate supervisionFailure 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 relationshipMost 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.
8Emotional/Educational Neglect Refusal/delay of needed psychological careFailure to enroll; permitted chronic truancyFailure to access special education servicesPermitting criminal behaviorAllowing child to abuse drugs/alcoholExposure to domestic violenceInadequate nurturance or affectionActs or omissions by caregiver that could cause behavioral, cognitive, emotional, or mental disorders.
9Emotional AbuseVerbal abuse (e.g., demeaning, ridiculing, name-calling)Substance/alcohol abuse of caregiverThreatsExtreme rejectionCorruption, exploitation, brainwashingCruel punishmentsSubstance 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 interveneCorruption: e.g., getting child to shopliftCruel punishment: Putting face in BM, killing pet
10Incidence and Types of Child Maltreatment Nationally, 70% of reports are for NE, and 43% are for PA, SA, or EAFor substantiated cases, 25% for PA, 25% for SA, 6% for EA, 60% for NEMissouri rates are similar to national rates.EA rates have increased due to increased reporting of DV (70% of cases involvechildren)
11Risk Factors for Abuse/Neglect: Child Factors GenderAgeDifficult temperamentDisabilitiesBehavioral difficultiesChronic illness-Child characteristics are not necessary or sufficient in and of themselves to cause abuse; interacts with caregiver characteristicsNIS-3: Girls sexually abused 3x more than boysBoys at greater risk of serious injury and emotional neglectChildren from ages 0-3 accounted for 27.7% of victims-most dangerous period for abuse occurs between ages of 3 mos and 3 yearsvast majority of abuse-related deaths occur before age 5May 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
12Risk Factors for Abuse/Neglect: Caregiver Factors History of AbuseAnger difficultiesPoor impulse controlPsychiatric disordersSubstance abuseSocial isolationPersonal distressUnrealistic expectationsNegative view of childParent chronic illnessPoor parenting skillsMaleYoung 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
14Protective Factors for Abuse/Neglect Caregiver parenting skillsCommunity support of familiesAvailability of emotional, social, and financial support for familiesStable housingConnection to community, faith-based organizationsGood personal safety skills for childrenEasy access to health care, childcare, etc.Wholesome environment
15Possible Signs of Physical Abuse Bruises, welts, burns, fractures, cuts & abrasionsInjuries to multiple body areasVarious stages of healingWearing clothes to cover injuriesReluctance to seek medical help (refuses medical tests)Extensive history of injury (frequent hospital visits)Inconsistent/unbelievable explanation of injuryExcessive fear (or anticipation) of punishmentExcessive fear of caregiverWary of physical contactFrequent school absencesAbusive themes in art/play/conversationChild disclosureAre only indicators, not guaranteesOne of the more easily identified forms of abuseBruises and welts on: (butt, genitalia, back, back of hands)Face, lips, mouth, ears, eyes, neck or headdiagonal lines for slap marks on cheekdark spots on ears if slap on side of head2. Trunk, back, buttocks, thighs, or extremities3. 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 yellowFor 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
16Possible Signs of Sexual Abuse Difficulty walking or sittingVaginal, penile, rectal pain/discharge/bleedingSudden refusal to change clothesInappropriate sexual knowledge/behaviorFrequent urinary tract/vaginal infections, STDWary of physical contactAbnormal fears about bodily functionsAbnormal anogenital exam findingsChild disclosureSexual 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 14Definite SA: gonorreah, syphilis, HIVProbable SA: HSV 2, chlamydial, trichomonasPossible: HSV1, warts97% 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 ( )
17Possible Signs of Physical Neglect Frequent absences from schoolBegs, steals, hoards food/money/small itemsLacks needed medical, visual or dental careConsistently dirty, poor hygieneInsufficient or ragged clothingChild abuses alcohol or other drugsMalnourished, thin, constant hunger; deyhydrationTired, falls asleep (other than nap) during dayChild anticipates being left unattended (e.g., in car)Small for age - FTTChaotic home environmentSerious caregiver problemsLack of supervisionChronic ailmentsChild disclosureParent incarceration, psychiatric disorder, substance abuse
18Possible Signs of Emotional Abuse/Neglect Child very fearful of being punishedSchool absence or non-enrollmentChaotic home environment (frequent moves)Serious caregiver problemsCaregiver misses important child appointmentsCaregiver disinterested in or unresponsive to childUnusual, harsh, demeaning punishments of childAbusive themes in play/art/conversationChild disclosureVerbal dislike for childDrug withdrawalPositive drug screeningUse of inappropriate food, drink, or drugs
19General Indicators That “Something” Is Wrong Anger/irritabilityIncrease in crying, difficult to comfortSymptoms of depression/anxietySudden changes in behaviorSudden changes in sleep/appetiteSudden changes in school performanceSelf-destructive behaviorsDifficulty concentrating/attendingSudden change in activity levelMay not be indicative of abuse; could be just about anything
20“Something” is Wrong (cont.) Developmental delaysRegression (e.g., toileting)Extreme behaviors (passive-violent)Withdrawal, apathy, passivityRunning awayIncreased separation difficultiesNew fearsConsistent reluctance to leave with caretakerTrauma themes in play, art, conversation
21Impact 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
22Predictors of Trauma Effects Low IQFemaleYounger agePassive copingLimited supportUnsupportive caregiverSeverity/chronicity of abuseHigh abuse-related stressRelationship to abuserUse of threat
23Extent of CAN Effects 40-60% have emotional/behavior problems #1 predictor of substance abuse in womenDecreases IQAlters brain development>50% have school problems>25% require SSD services8 point decrease in IQ for high DV exposure (vs. 3 point decrease for lead poisoning)-Koenen et al., 2003
24Growth of the Human Brain from birth to 20 years
27Trauma Symptoms: Preschoolers Regressive behaviorsSeparation fearsEating and sleeping disturbancesPhysical aches and painsCrying/irritabilityAppearing “frozen” or moving aimlesslyPerseverative, ritualistic playReenactment of trauma themesFearful avoidance and phobic reactionsMagical thinking related to traumaPoor concentration, difficulty learningBehavior problems (e.g., tantrums)Withdrawal most pronounced for sexual abuse and neglect groups
29Impact of Physical Abuse Aggression, reactive angerOppositional behaviorSocial immaturityAttachment problemsPosttraumatic stressViolent playDevelopmental delaysNeurological impairmentPoor problem-solvingPhysical injury, deathAggression: most consistent finding; persists into latency/adolescence, towards adults and peersInterpersonal Problems: social skills deficit; problems with peer interactions; poor social problem solving; peer rejectionTrauma Symptoms: anxiety/hypervigilance; depression, suicidality, low self esteem; PTSD (less than 50%), subclinical PTSDRelationships Skills: anxious attachment; limited positive affect; low frustration tolerance; less outgoing; less readiness to learn; difficulty managing conflict with attachment figuresNeurological Impairment: receptive/expressive language; reading ability; low performance in math/reading skills
30Impact of Sexual Abuse Sexualized behavior, play Promiscuity Posttraumatic stressNightmaresRegressionSomatic complaintsPoor self-esteemSelf-destructive behaviorsPoor interpersonal boundariesResists affectionPhysical injuryWithdrawal-on average 32% of SA children develop PTSD-discuss regressive behaviorsBehavior problems could include promiscuity or substance abuseSelf-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
31Impact of Neglect Cognitive/academic deficits Language deficits Developmental delaysSocial withdrawalDecreased moral developmentStealing, lying, hoardingInsecure or disorganized attachmentEmotional volatilityRetarded physical growthDeathPhysical 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).
33Reporting 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 conditionsAs 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 suitsErr on the side of reportingYou 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 reporterNo privilege unless attorneyYou’re immune from prosecution if you make hotline in good faith.
34Numbers to Call Missouri Hotline: 1-800-392-3738 (St. Louis County DFS )Persons calling from outside Missouri should dialText telephone number:Illinois Hotline:National hotline:For other states check:St. Charles County DFSCan 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.
35Information 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 availableAny immediate or continued risk for harm?Extent of injuriesDetails of abuse/neglect (dates, times)Any abuse/neglect witnessed?Other witnesses and their contact information
36After a ReportReport sent to appropriate DFS county officeInvestigation by DFS social worker initiated within 24 hours of the receipt of the report (72 hours if educational neglect).Possible outcomes:InvestigationFamily assessment and servicesProbable causeUnsubstantiated - Preventive services indicatedUnsubstantiatedCaseworker 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.
37Helping Abused/Neglected Children Provide realistic reassurance of safety and securityAllow child to be more dependent temporarily if neededFollow child’s lead (hugs, listening, support)Use typical soothing behaviorsUse security items and goodbye rituals to ease separation from caregiverDistract with pleasurable activitiesLet child know you careMaintain normal routines when possibleAvoid exposing child to unnecessary reminders of the abuse
38Helping Abused/Neglected Children (cont.) Minimize contact with others who upset childContinue to set limits for inappropriate behavior as neededAnticipate temporary increase in problem behaviorsIdentify antecedents of problem behaviors and develop behavior management planRedirect/Stop abuse reenactment play as neededFacilitate resolution of abuse themes in play/art if possibleAssist child in coping with trauma remindersAttempt to alter negative association with nonharmful trauma cuesAssist with trauma reminders - e.g., prep kid for exposure, give calming statementAlter negative associations with nonharmful trauma cues - e.g., help child warm up to male groundskeeper
39Discussing Abuse/Neglect with Children Do not ask leading questions, particularly if investigation is underwayDo not over-interview or bias child’s reportEncourage child to express abusive experience but don’t pressureEmphasize child’s safety nowPraise child for telling; encourage honestyBe an active listenerRemain calm when answering questions and use simple, direct terms
40Discussing Abuse/Neglect with Children (cont.) Don’t “soften” information you give to childHelp child develop a realistic understanding of what happenedGently correct abuse-related distortionsBe willing to repeat yourselfTolerate retellingsProtect other children from exposure to trauma retellings/reenactmentsNormalize “bad” feelings or symptomsDistortions - self-blaming, overgeneralization of danger
41Helping Non-Offending Parents of Abused/Neglected Children Communicate with parents about the childEncourage parents to listen to child closelyEncourage parents to set aside special time for childRecommend maintenance of normal routineEncourage parents to remain calm and get help for themselves if neededEducate parents regarding importance of responding supportivelyNormalize child’s difficulties
42Helping Non-Offending Parents of Abused/Neglected Children Model soothing behaviors with younger childrenAssist in developing plan for behavior mgmt.Guide foster parent in getting to know childAdvocate for continuity of school placement if child is placed out of homeEquip parents with good skills through workshops, references, modelingEncourage parent involvement in classroom
43Helping Potentially Abusive/Neglectful Parents Gently point out concerns by focusing on observable facts and behaviorsOffer assistance, support, resourcesDo not hypothesize, stick to observable factsAcknowledge parents strengths, effortsFocus concern on child’s welfare and present as “common concern”Model effective parenting skillsCatch parent doing well; reinforce successesDon’t get caught in triangles with parents
44When to Refer for Psychological Care Appear depressed, withdrawnStrong resistance to affection or support from caregiversSuicidal or homicidal ideationDangerous behaviors to self/othersIncreased usage of alcohol or drugsRapid weight gain/lossSignificant behavioral changePoor hygieneSignificant acute stress symptoms (e.g., nightmares, startle easily, hypervigilance)
45When to Refer for Psychological Care Intense anxiety or avoidance behavior if reminded of abuseInappropriate social behaviorsUnable to regulate emotionsPoor academic performance and decreased concentrationContinued worry about the abuse (primary focus)Intense separation difficultiesPersistent physical complaints (nausea, headaches)Continued abuse themes in play, art, conversation, behaviorSexualized behavior
46We’re Done!For additional questions, referrals, or references, contact Dr. Ally Burr-HarrisPhone:(314)