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1 Child Abuse and Maltreatment Maria Beatriz Alvarez, CSW Pediatric Psychiatry Children’s Hospital of New York- Presbyterian.

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Presentation on theme: "1 Child Abuse and Maltreatment Maria Beatriz Alvarez, CSW Pediatric Psychiatry Children’s Hospital of New York- Presbyterian."— Presentation transcript:

1 1 Child Abuse and Maltreatment Maria Beatriz Alvarez, CSW Pediatric Psychiatry Children’s Hospital of New York- Presbyterian

2 2 “Child abuse and neglect in the United States now represents a national emergency... Protection of children from harm is not just an ethical duty; it is a matter of national survival.” U.S. Advisory Board on Child Abuse and Neglect, 1990

3 3 Child Abuse and Neglect Presentation Outline The Problem History of Child Abuse Prevention Definition of Child Abuse Abuse themes in children’s drawings Abuse Indicators Reporting Child Abuse: Who and How. Effects of Child Abuse Posttraumatic Stress Disorder Treatment Considerations

4 4 The Problem Child Maltreatment 2001 Nationally, an estimated 903,000 children were victims of abuse and neglect 57.2 % of victims suffered neglect, 18.6 % were physically abused 9.6 % were sexually abused 26.6 % were associated with additional types of maltreatment, 27.7 % were under 3 years old 50.2% were White 25.0% were African-American 14.5 % were Hispanic 2.0 % were American Indians, Alaska Natives 1.3 % were Asian-Pacific Islanders

5 5 Child Maltreatment In 2001, nationally an estimated of 903,000 children were victims of abuse and neglect

6 6 Types of Child Maltreatment

7 7 Reports Child protection service (CPS) agencies receive more than 50,000 referrals per week. Nationally, 67.4% of all referrals approximately (1,802,000 )were screened in, 32.5 % were screened out. 56.5% of the screened in referrals were from professionals. NYS received 152,671 reports, 31% were confirmed as cases of child abuse.

8 8 Fatalities Nationally, an estimated of 1,300 children died of abuse or neglect, 40.9% were under 1 year old, 35.6% of the maltreatment deaths were associated with neglect. Source: U.S. Department of Health and Human Services. The Administration for Children Services. Based on responses from the States to the 2001 National Abuse and Neglect Reporting System (NCANDS).

9 9 New York Statistics Abuse/Neglect Reports and Number of Children in Reports for FY

10 10 History of Child Abuse Prevention 1850’sChild Labor first became an issue in the U.S. 1870, the first census reported child laborers: 750,000 workers 1904 The National Labor Committee advocated to eliminate child labor 1916 The Keating Owen Act banned all articles produced by child labor 1918 Supreme Court declared the Keating Owen Act un-constitutional 1938 The Fair Labor Standards Act limited the age of child laborers to 16 and over.

11 11 Some boys and girls were so small they had to climb up on to the spinning frame to mend broken threads and to put back the empty bobbins. (Bibb Mill No. 1, GA)

12 12 View of the Ewen Breaker of Pa. Coal Co. The dust was so dense at times as to obscure the view. (South Pittston, PA)

13 13 Cutting fish in a sardine cannery. Large sharp knives are used with a cutting and sometimes chopping motion (Eastport, ME)

14 14 Wheaton Glass Works, Millville, NJ

15 15 The Discovery of Child Abuse 1962, Dr. Henry Kempe’s “battered child” syndrome. By 1966 all states have passed legislation regulating child abuse reporting 1973, in New York, the Child Protective Act established protective services 1974, first Federal legislation: Child Abuse Prevention and Treatment Act (CAPTA) 1988, CAPTA was completely rewritten.

16 16 Definition of Child Abuse Inflicts or allows to be inflicted, Creates or allows to be created, Commits or allows to be committed: - Physical Abuse - Neglect - Sexual Abuse - Sexual Exploitation - Emotional/Mental Injury - Abandonment An “abused child” is a child less than eighteen years of age whose parent or other person legally responsible for his care:

17 17 Monster drawing by a six-year old boy at a battered women’s shelter.

18 18 Drawing/collage by a 12-year old boy whose paranoid/schizophrenic father performed satanic rituals on him and his sister.

19 19 Drawing by a 6-year-old boy who was physically abused and witnessed his mother being abused by his father.

20 20 Drawing of a 6-year-old physically abused boy who drew himself “calling for his mommy to stop his daddy from beating him, but his mother does not come.”

21 21 Drawing by an 8-year-old boy who was repeatedly physically abused by alcoholic parents.

22 22 Drawing by an 8-year-old boy sexually abused by his mother who became a perpetrator himself.

23 23 Drawing by a 10-year-old sexually abused girl of bees with stingers (considered phallic) that are “painful to her behind.”

24 24 Drawing by a 13-year-old girl who depicted a dream she had about being dead and buried, showing her overwhelming depression concerning her multiple sexual abuse experiences and helplessness.

25 25 Drawing of a 13-year-old girl who was repeatedly sexually abused by her mother and her many “boyfriends” since the age of six.

26 26 Abuse Indicators BruisesBurnsLacerations Skeletal injuries Missing or loosened teeth Human bite marks Bald spots Abrasions Appearance of injuries after school absences, weekend or vacation. Physical Indicators of Child Physical Abuse

27 27 Loop mark bruises inflicted by a double cord

28 28 Bruises inflicted at different times on the buttocks

29 29 Immersion burn of a child’s hand

30 30 Retinal hemorrhages in a patient with shaken-baby syndrome

31 31 Multiple healing posterior rib fractures from a compression injury of the chest

32 32 Behavioral Indicators That Indicate Physical Abuse Avoids physical contact Apprehensive when other children cry Wears clothing to purposely conceal injury Refuses to undress for gym or physical exams Gives inconsistent versions about occurrence of injuries Seems frightened by parents Irregular school attendance Has difficulty getting along with others Overly compliant or withdrawn Plays aggressively Has a history of running away from home Reports abuse by parents Learning problems, poor academic performance, short attention span, language delayed

33 33 History Indicators of Abuse Parents inconsistent versions about occurrence of injuries Multiple visits to various hospitals Social histories involving multiple family problems Reluctance of parents to give information Delay in seeking medical help Parent’s inappropriate reaction to severity of injury Facts of social histories vary Blame for the abuse is usually placed upon a third party

34 34 Physical Indicators of Child Sexual Abuse Difficulty in sitting/walking Torn, stained or bloody underclothing Genital/anal itching, pain, swelling and/or burning Genital/anal bruises or bleeding Frequent urinary or yeast infections Pain during urination Vaginal/penal discharge Poor sphincter control Venereal disease Pregnancy Chronic unexplained sore throats Frequent psychosomatic illnesses

35 35 Behavioral Indicators of Child Sexual Abuse Sudden, radical behavior change Destructive to self and others Depressed/apathetic or suicidal Poor social relations Inappropriate display of affection Extreme clinginess Sleep problems Refuses to change for gym class Acts in a sexually aggressive manner Regressive behaviors Runs away from home Delinquent behavior Reports sexual assault by parent or guardian

36 36 Physical Indicators Of Emotional Maltreatment & Neglect Failure to thrive or poor growth pattern Wetting of bed/pants Speech disorders Dirty skin Offensive body odor Unwashed, uncombed hair, lice Inappropriate clothing Left unsupervised or alone for periods of time Unattended physical problems or medical needs Falls asleep in school Consistent hunger, malnutrition Frequent diarrhea

37 37 Behavioral Indicators of Emotional Maltreatment and Neglect Negative statements about self Destructive to self and others Highly aggressive Depressed, apathetic, cries easily Hyperactive Overly adaptive behavior Delinquent behavior Cruelty, vandalism, stealing, cheating. Frequent school absences or tardiness Overly demanding Regressive behaviors Obesity, overeating junk foods Hoarding food Infant and toddlers do not tend to parent for help or comfort

38 38 Mandated Reporters in NY State PhysiciansSurgeons Medical Examiners Coroners Dentists, Dental Hygienists OsteopathsOptometristsChiropractorsPodiatrists Residents, Interns Psychologists Registered Nurses Hospital Personnel Engaged in Admission, Examination, Care or Treatment of Persons Christian Scientists Practitioners School Officials Social Services Workers Day Care Center Workers Providers of Family and Group Family Day Dare Employees & Volunteers in Residential Care Facilities Any Other Child Care Worker Foster Care Workers Mental Health Professionals Peace Officers, Police Officers or Other Law Enforcement Officials District Attorneys, Assistant District Attorneys, or Investigators Employed in the office of a District Attorney Substance Abuse Counselors Alcoholism Counselors Physician Assistants

39 39 Outline of Procedures for Mandated Reporting Call the New York State Central Registry Telephone No (mandated reporters) or (general public). Include the following information: Caller’s name, title, name of institution and telephone number Information required on Form DSS-2221-A Actions taken by the person reporting, e.g. protective custody Obtain the following information Name of person to whom report is being made Phone number of local office to which the case will be assigned State Registry Number assigned to the case Names of State Central Registry staff to be consulted, if necessary Parents should be informed of the report, whenever possible When you have a reasonable cause to suspect that a child coming before you in your professional capacity is an abused or maltreated child:

40 40 Mediators in the effects of child abuse Age of the child and time of the abuse ChronicitySeverity Relationship to Offender Level of Threats Emotional Climate of the Child’s Family The Child Mental/Emotional Health The Guilt the Child Feels The Sex of the Victim Parental Responses to the Child’s Victimization

41 41 Effects of Child Abuse DepressionAnxiety Behavioral problems Sexualized behaviors PTSD Smaller total brain and corpus callosum volumes and lower IQ (DeBellis MD et al, 1999, Developmental Traumatology Part II: brain development. Biol Psychiatry 45: )

42 42 Posttraumatic Stress Disorder DSI-V-TR Exposure to traumatic event 1. The person experience, witnessed or was confronted with and event or events that involved actual death or serious injury, or a threat to the physical integrity of self or others 2. The person’s response involved intense fear, helplessness or horror. Note: in children this may be expressed instead by disorganized or agitated behavior

43 43 PTSD Re-experiencing/Intrusion 1. Recurrent and intrusive distressing recollection of the event, including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed 2. Recurrent distressing dreams of the event. Note: In children, there may be frightening dreams without recognizable content. 3. Acting out or feeling as if the traumatic event were occurring. Note: In young children, trauma-specific reenactment. 4. Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event. 5. Physiological reactivity on exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

44 44 PTSD Avoidance/Numbing 1. Efforts to avoid thoughts, feelings, or conversations associated with the trauma 2. Efforts to avoid activities, places, or people that arouse recollections of the trauma. 3. Inability to recall an important aspect of the trauma 4. Markedly diminished interest or participation in significant activities 5. Feelings of detachment or estrangement from others 6. Restricted range of affect 7. Sense of foreshortened future

45 45 PTSD Hyperarousal 1. Difficulty falling asleep 2. Irritability 3. Difficulty concentrating 4. Hypervigilance 5. Exaggerated startle response

46 46 Treatment Considerations in Working with Abused Children Multidimensional Approach: Monitoring risk factors Coordination with a variety of agencies Adherence to request for periodic reports Focus on processing the child and family’s trauma Interventions in intricate family dynamics Observations of parent-child interactions Work with foster families or other temporary caretakers Advocacy efforts Testifying in Court

47 47 Child and Parent Trauma-Focused Cognitive Behavioral Therapy Treatment Psycho-education Skills Building Trauma Narrative Sharing the Child’ Trauma Narrative Cohen JA, Deblinger E, Mannarino A., Steer R, (2004), A Multisite, Randomized Controlled Trial for Children with Sexual Abuse-Related PTSD Symptoms, J Am Acad Child and Adolescent Psychiatry, 43:4,


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