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Child Abuse and Neglect: Recognizing, Reporting, and Responding in Early Childhood Ally Burr-Harris, Ph.D. Greater St. Louis Child Traumatic Stress Program.

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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:

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)

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