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Multidisciplinary Curriculum on Child Maltreatment International Society for the Prevention of Child Abuse and Neglect.

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Presentation on theme: "Multidisciplinary Curriculum on Child Maltreatment International Society for the Prevention of Child Abuse and Neglect."— Presentation transcript:

1 Multidisciplinary Curriculum on Child Maltreatment International Society for the Prevention of Child Abuse and Neglect

2 Multidisciplinary Curriculum Committee Members Robert Morris (Chair)Jingqi Chen Hiroaki Ishikawa (Co-Chair)Anne Hollows Wambui NjugunaElena Volkova Clemencia RamirezEditors: Howard Dubowitz Wendy G. Lane

3 What is Child Maltreatment?

4 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)

5 Why is child maltreatment a concern?

6 Incidence of Child Maltreatment Rate per 1000 Rate per 1000

7 Incidence of Child Maltreatment Rate per 1000 Rate per 1000

8 Known cases of child abuse and neglect are just the tip of the iceberg.

9 Rates of Harsh Physical Punishment Source: WHO WorldSAFE study Runyan, D. Pediatrics. 2010;126:e701-11

10 Rates of Psychological Punishment Source: WHO WorldSAFE study

11 Abusive Head Trauma Shaking of children < 2 years Keenan: ICU admissions & deaths Theodore: parental report Keenan, et al. JAMA. 2003;290:621-6 Theodore, et al. Pediatrics. 2005;115:e331-7

12 Rates of child maltreatment are higher than what most “official” statistics suggest But is child maltreatment more common than other childhood conditions?

13 Comparison to Other Childhood Conditions * Denotes prevalence. All others are incidence rates

14 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

15 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.

16 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.

17 Why is child maltreatment so common?

18 Child Parents Family Community Society Contributors to Child Maltreatment Belsky, Psychological Bulletin. 1993;114:413 Professionals

19 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

20 Parent/Caregiver Risk Factors Young age Single parent Unwanted pregnancy Poor parenting skills Substance abuse Physical or mental illness

21 Family Risk Factors Overcrowded living circumstances Poverty Social isolation Major stress Domestic violence

22 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

23 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

24 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

25 Physical Consequences Injuries (such as fractures, burns, injury to internal organs, lacerations, head injuries) Impaired brain development Short and long-term disability Death

26 Odds of Ischemic Heart Disease By Number of Adverse Childhood Experiences (ACE)

27 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

28 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

29 Short term Emotional Effects Teenagers –Anxiety –Aggression –Risk taking (run away, drug use, sex) –Participate in family violence –Depression –School failure

30 Suicide Risk by ACE Score

31 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.

32 US$ 104 billion annually Prevent Child Abuse America, 2008 Cost of abuse

33 Can we afford NOT to provide funds for prevention?

34 Identifying Maltreated Children

35 Types of Child Maltreatment Physical abuse Neglect Sexual abuse Emotional abuse and neglect Labor Trafficking Others

36 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.

37 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

38 Physical Abuse Physical findings may include: Bruises Cuts Fractures Welts Burns Abdominal trauma Abusive head trauma (includes inflicted injury to brain and/or skull)

39 Case 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!”

40 Case 1 3 month old with bruises Source: AAP

41 Case 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.

42 Case 2 11 year old with bruises Source: AAP

43 Case 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:

44 Case 3 2 month old Not moving arm

45 Case 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

46 Case 4 Case 4 3 month old with excessive crying Source: AAP

47 Case 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.”

48 Immersion Burn Characteristics Sparing of flexoral creases Donut hole – Skin in contact with Bottom of tub “High tide” mark From: Stratman. Arch Dermatol. 2002;138:318-320.

49 Effect of Skin Thickness on Time to Full Thickness Burn Adult 2.5 mm Child 0.56 mm Data from National Burn Victim Foundation

50 Corporal Punishment vs. Abuse

51 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?

52 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

53 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

54 Case 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.”

55 Case 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

56 Case 8 A 10 month old girl was noted by a public health nurse to be thin Her weight is less than 5 th percentile; height is in the 10 th 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

57 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)

58 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

59 Case 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.

60 Case 10 A 7 year old girl tells her mother that a boy touched her ‘private area.’

61 Case 11 A 13 year old girl tells her friend that her uncle gets in bed with her and makes her do ‘bad things.’

62 Case 12 A 9 year old boy refuses to go to school because one of his teachers forces the boy to ‘kiss his bird’.

63 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)

64 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.

65 What Caused This?


67 Mongolian spots


69 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

70 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

71 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

72 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

73 Interviewing Children: An Overview Requires training and expertise Children can give good and accurate information Poor interviewing may bias child’s account

74 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,

75 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. (

76 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.

77 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

78 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.

79 What are our Responsibilities? Defined by many factors: - Ethical - Professional and Clinical - Legal

80 Reporting Laws What are the laws in your community?

81 Roles – Child Welfare To provide child protective services, including: -Evaluating reports of alleged child maltreatment -Ensuring children’s safety -Facilitating support services

82 Roles - Police Responsibilities include: Investigating to determine if a crime has been committed Bringing charges if evidence suggests a crime.

83 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

84 Roles - Courts/Correctional Services Responsible for helping ensure the care and protection of children, including: Mandating treatment services Criminal proceedings and incarceration

85 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)

86 Prevention Promotion - health, development and safety

87 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.

88 Prevention Strategies for Child Maltreatment Three levels of programs: Individual Relationship Societal and community ( Preventing Child Maltreatment, 2006)

89 Individual Prevention Strategies Reducing unintended pregnancies Increasing access to prenatal and postnatal services Training children to avoid potentially abusive situations ( Preventing Child Maltreatment, 2006)

90 Relationship Prevention Strategies Home visitation programs Training programs for parents ( Preventing Child Maltreatment, 2006)

91 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)

92 “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)

93 Extent of the Problem USACanada Population~300 million~33 million # Cases906,000115,000 % Neglect6030 % Physical Abuse1924 % Sexual Abuse103 % Witness Domestic Violence 28 % Other17

94 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)

95 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%

96 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.

97 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.

98 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

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