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Multidisciplinary Curriculum on Child Maltreatment

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1 Multidisciplinary Curriculum on Child Maltreatment
Most of us have difficulty understanding why children are maltreated. The purpose of this introductory seminar is to offer information on child maltreatment to a general audience, especially those who have regular interaction with children. This includes teachers, clergy and members of governmental and non-governmental agencies. It is not a training course for those actively involved in the assessment of child maltreatment, such as police officers or social workers. They require a much more detailed course of training. However, this would be a good introduction to the topic for students of social work and police cadets as well as medical, nursing and law students. We will define the various forms of child maltreatment; identify risk factors; describe common presentations; discuss the impact on the child, family and community; suggest what you should do when maltreatment is suspected; and talk about prevention strategies. 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 Njuguna Elena Volkova Clemencia Ramirez Editors: 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) This slide gives the formal definition of Child Abuse as developed by WHO in The key point is that acts of omission or commission that interfere with a child reaching his or her full potential are considered maltreatment. Acts of commission include physical and sexual assault as well as commercial and sexual exploitation, while acts of omission include various forms of neglect, such as nutritional neglect (lack of adequate food), educational neglect (lack of adequate education), and medical neglect (lack of adequate medical care, including mental health care). This is a good time to ask “What do you consider Child Maltreatment?” This is also the correct time to discuss terminology. The term child maltreatment will be used to include both abuse and neglect throughout this seminar.

5 Why is child maltreatment a concern?
This first slide asks the question “Why is child maltreatment a concern? The audience should be encouraged to offer suggestions. This can set up the process for the rest of the session by getting participants actively involved. Reasons for concern include: moral responsibility to protect children, legal responsibility to protect children, financial costs of medical care, financial costs of mental health care, societal costs (lost productivity, crime, incarceration).

6 Incidence of Child Maltreatment
Rate per 1000 Incidence of Child Maltreatment Determining the frequency of child maltreatment is challenging. There are many sources of data on maltreatment, and some capture more cases than others. Here is an example of multiple data sources from the United States. NCANDS is the National Child Abuse and Neglect Data System. It includes only cases of maltreatment that are reported to state Child Protective Service (CPS) agencies. NIS-4 is the 4th National Incidence Study on Child Abuse and Neglect. It contains cases of child maltreatment reported to CPS and also cases of maltreatment that are known to professionals but not reported. The self-report data comes from an anonymous telephone survey conducted in North and South Carolina, United States. As you can see, many incidents of maltreatment never come to the attention of CPS or other professionals.

7 Incidence of Child Maltreatment
Rate per 1000 Incidence of Child Maltreatment Data source: World Health Organization (WHO): World Report on Violence and Health, Chapter 3, Child Abuse and Neglect by Parents and Other Caregivers. While official rates of child maltreatment in Canada are similar to those of the United States, worldwide estimates of physical and sexual abuse are much higher.

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

9 Rates of Harsh Physical Punishment
Rates and types of harsh physical punishment show much variation from one country to another. Actions considered acceptable by most people in one community, state, or country may be considered abusive elsewhere. Source: WHO WorldSAFE study Runyan, D. Pediatrics. 2010;126:e701-11

10 Rates of Psychological Punishment
Some forms of psychological maltreatment are extremely common around the world. Again, the rates of different types of psychological maltreatment vary from country to country. Source: WHO WorldSAFE study

11 Abusive Head Trauma Shaking of children < 2 years
Keenan: ICU admissions & deaths Theodore: parental report Ask the audience why they think the rates are so different. Possible explanations might include: Keenan study: Does not include non-ICU hospital admissions, emergency department, outpatient visits, and children who don’t receive any medical attention. Theodore study: shaking incidents may include many children who are not obviously injured from more minor shaking. Keenan, et al. JAMA. 2003;290:621-6 Theodore, et al. Pediatrics. 2005;115:e331-7

12 But is child maltreatment more common than other childhood conditions?
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
These comparisons are taken from U.S. data, but make the point that child maltreatment is more common than many other childhood medical 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 Ask the audience “What frameworks are there to protect children?” The audience may respond with local or national laws, religious views, etc. The UN CRC is highlighted because it identifies that nearly every country in the world recognizes that a child is a human being with all the rights of every human. It also defines childhood by age. UNICEF’s website says that 191 of 193 countries and territories have ratified the UNCRC.

15 UN Convention on the Rights of the Child - Selected Rights
You have the right to grow up and to develop physically and spiritually in a healthy and normal way, free and with dignity. You have a right to special care and protection and to good food, housing and medical services. You have the right to special care if handicapped in any way. This slide and the next slide summarize some of the most important rights included in the UNCRC. The CRC begins by stating that children have rights. Ask the audience why they think that this statement is important. The onus is placed not just on parents or guardians to ensure a child receives these rights but also on the community at large, including governments. These rights apply regardless of race, religion, politics or place of birth.

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?
Ask the audience “ Why is child maltreatment such a common problem?” We think of parents as loving their children, we talk about how important children are to us and yet we see how common maltreatment is. Why? Have the audience offer ideas and then lead them into the next series of slides.

18 Contributors to Child Maltreatment
Society Community Family Parents Child Developmental-Ecological theory posits that there are multiple and interacting factors that contribute to child maltreatment. These begin with the child and extend outward to the society at large. Each level may interact with all other levels. Use this theory to begin a discussion about specific risk factors that might be included in each level. Professionals Belsky, Psychological Bulletin. 1993;114:413

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 Factors that increase a child’s risk for maltreatment include anything that might make a child more difficult to care for. These may include young age, handicap, or excessive crying. Gender is also a risk in specific ways. Provide the audience with the following example: A couple have a 6 week old baby who has become increasingly colicky. He cries incessantly throughout the evening. The parents cannot console the child for long despite feeding, rocking and walking with him. He wakes several times at night, leaving both parents exhausted. The baby gets more irritable as the day goes on and is at his worst when the father gets home from work in the evening. Ask the audience “what do you think might happen?”

20 Parent/Caregiver Risk Factors
Young age Single parent Unwanted pregnancy Poor parenting skills Substance abuse Physical or mental illness Any parent or caregiver characteristics that may increase stress in their lives may increase the risk of maltreatment of their children. Some of these are lack of knowledge and experience in dealing with children and others are from outside pressures. Younger, single parents with little or no support are one group that appears to have a high level of stress in their lives. Parents with substance abuse problems, mental health issues, relationship difficulties or who have work related stresses are also at higher risk to lose control. To continue the example of the colicky infant, imagine the effect of her constant crying and the general difficulty in consoling her on a caregiver who is drunk or angry with a spouse. Later on we will discuss prevention, but take a minute and ask the audience to “consider what we could do to help the parents and lessen the possibility of the child being maltreated.”

21 Family Risk Factors Overcrowded living circumstances Poverty
Social isolation Major stress Domestic violence Family factors that increase stress can also contribute to maltreatment. Remind the audience about the parents with the colicky infant. Now assume that the family lives in a low income apartment building where every sound is heard in the next apartment. The child cries for hours. Neighbors complain to the building superintendent, who tells the family they will have to move if the baby continues to cry. The parents fight over how to stop the crying. This wakes the child, who begins to cry again. The neighbor bangs on the wall and shouts that if they can’t control the child, he will come over and do something about it. Ask the audience “What happens now?”

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 Note that limited value of children can apply to all children or to specific groups of children (e.g. disabled, minority, or females). Many societies look at physical discipline as every parent’s right and often their obligation. “Spare the rod, spoil the child” is a common saying. In some places, children are not valued until they are old enough to contribute to the family. Still other cultures will restrict educational opportunities due to poverty and a lack of understanding of the need and value of education. On the other hand, there are cultures where success is measured by the level of education of children and parents justify harsh discipline as a tool to enforce scholastic achievement. It is the weak groups in society, such as the elderly, women, the infirm and children, who suffer the most from war, crime and violence in general. To continue the example of the crying infant, ask the audience “What if the father did beat or shake the child and no one cared?”

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 In this section we will look at the impact of child maltreatment on children. This slide notes the important point that every child is affected by maltreatment; however, it recognizes the degree of the impact is variable dependant on the type and intensity of the abuse and the presence of protective factors. Ask the audience “What are some examples of these consequences?”

25 Physical Consequences
Injuries (such as fractures, burns, injury to internal organs, lacerations, head injuries) Impaired brain development Short and long-term disability Death Some of the consequences, such as those associated with physical maltreatment, are more obvious. Broken bones, lacerations and other physical injuries are easily identified. Longer term effects, such as impaired brain development secondary to head injury, may not be obvious initially but cause life long difficulty for the child who was injured.

26 Odds of Ischemic Heart Disease By Number of Adverse Childhood Experiences (ACE)
This slide looks specifically at how increasing adverse childhood experience (ACE) scores influence the odds of ischemic heart disease in adults. The authors controlled for medical and psychosocial risk factors, as these can also contribute to ischemic heart disease.

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 Children may develop both short-term and long-term psychological consequences from maltreatment. Some examples are listed in this slide. More details follow in subsequent slides.

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 Immediate or short-term emotional effects of maltreatment may vary by the age of the child. Ask the audience to imagine ways that a maltreated infant or toddler might express fear or hurt. Ask the audience to imagine how a school child might behave if he learns by observing adults in an abusive home, or how a child might learn if he is focused on how to avoid abuse at home instead of the lesson in school.

29 Short term Emotional Effects
Teenagers Anxiety Aggression Risk taking (run away, drug use, sex) Participate in family violence Depression School failure Teenagers who are maltreated may respond through internalizing behavior (e.g. depression or withdrawal) or externalizing behavior (e.g. aggression, sexual promiscuity, drug use).

30 Suicide Risk by ACE Score
Child maltreatment can lead to long-term mental health consequences. This data is also from the ACE study. In this study, adults with 4 or more adverse childhood experiences had 12 times the odds of suicide compared to adults with no adverse childhood experiences.

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. Behavioral consequences include delinquency, substance abuse and criminal acts of violence. Intergenerational maltreatment is one result of this. People who are subjected to maltreatment as children are more likely to use similar maltreatment with their own children than those who were not exposed to it - though it is important to point out that the majority of abused children do not go on to abuse their own children.

32 Cost of abuse US$ 104 billion annually
There are financial consequences to our societies as well, although exact costs are difficult to determine. Prevent Child Abuse America, a nongovernmental organization, studied the costs and estimated direct and indirect costs. They estimated these costs (in 2003 dollars) as follows: $24 billion for direct services (for example, maintaining a child welfare system; judicial, law enforcement, mental health and health care services required to respond to and treat victims of child maltreatment). $68 billion in indirect costs (for example, increased juvenile and adult criminal activity, mental illness, substance abuse and further domestic violence, loss of productivity due to unemployment and underemployment and the provision of special education). The cost-effectiveness of many child abuse prevention programs have not been studied. However, some, such as the Nurse Family Partnership home visiting program, have proven cost-effective. US$ 104 billion annually Prevent Child Abuse America, 2008

33 Can we afford NOT to provide funds for prevention?

34 Identifying Maltreated Children
We will now move on to a discussion of how to identify children who have been maltreated. This will include identifying children who have been victims of specific types of maltreatment. We will define each type of maltreatment before discussing how to identify it.

35 Types of Child Maltreatment
Physical abuse Neglect Sexual abuse Emotional abuse and neglect Labor Trafficking Others This list includes the types of maltreatment that are most commonly discussed and addressed. Ask the audience whether they are aware of any country-specific examples not included in this list.

36 Physical Abuse The use of force against a child that results in harm for the child’s health, survival, development or dignity This definition of physical abuse comes from Preventing Child Maltreatment (WHO & ISPCAN 2006). Ask the audience to provide examples of ways that children can be physically abused. These may include hitting, kicking, shaking, biting, strangling, scalding, burning, poisoning and suffocating. The original document defines physical abuse as, “the intentional use of force…” Ask the audience to define intent. Ask them whether they believe that physical abuse is “intentional.” Remind the audience that most physical abuse occurs in the context of discipline. 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 There are a number of common ”red flags” that should raise a suspicion of maltreatment. It is very important to stress that while these are clues that raise suspicion, they are not proof. Care must always be taken to carefully and fully evaluate these situations. The evaluation must be carried out by trained and experienced social workers, police and health care workers. Injuries are not unusual in children but there are clues that suggest that they may be due to maltreatment. These clues can include explanations involving activities that the child is not capable of doing, repeated injuries, distinctive bruises or other markings that suggest the use of a particular object. We also cannot forget the child’s own report. Unfortunately, this may be ignored or disbelieved. Although not a direct clue, a history of the use of violence within a family also increases the possibility of physical abuse. It is important to stress that these are clues only and not evidence of abuse; they should raise concerns and lead to further investigation.

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) There are many ways that physically abused children present. Common types of injuries seen are bruises, fractures and burns. Some of the more severe types of injuries are the result of trauma to the head or to the abdomen. Direct blows such as from a punch or a kick may cause major damage depending on the force used and the body part affected. For example, a slap in the face may leave an obvious bruise while shaking a baby may cause severe injury to the brain but not leave any visible marks.

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
Ask the audience what they think of this history and exam findings. You may want to prompt them by asking what a 3 month old is developmentally capable of doing. This is a classic example where the story given is not believable. A 3 month old baby is not mobile and cannot stand up; many 3 month olds are not yet able to roll over, although they may be able to wiggle a bit. It is not possible for this child to extensively bruise herself. The linear appearance of the bruises also indicate an external cause – multiple lines may be from the slap of a hand or hitting with an object. Some relatively rare medical conditions can cause spontaneous bruising. However, spontaneous bruising in a linear pattern would still be unusual. If there is any question, blood tests for bleeding disorders can be obtained. KEY POINTS: Bruises in non-mobile children should always raise concerns of abuse. Children who don’t cruise shouldn’t bruise. Key issues in determining the likelihood of abuse are the age/developmental status of the child and the history of the injury.

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
The second example shows a much more vivid example of bruising. In this case, it is the result of punishment for disrespect of his father but the extent of the discipline is extreme. Ask the audience about the use of this form of discipline. Do they agree with slapping, hitting and flogging as acceptable forms of punishment? If so when does punishment become abuse? Don’t answer this yet as we will discuss this later.

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
Note to the audience that in this case there is no explanation given for the injury (broken arm). In fact the mother did not seem to notice that there was something wrong. Only when the grandmother visited and saw that the baby was crying loudly, not consolable and not using his arm was a concern raised. She also noted that the baby became more upset when picked up to be cuddled and was happier when he was left lying in his crib and he held the arm close to his side. Later when assessed in the hospital a fracture of his forearm was found. Again, remember the key points in distinguishing child abuse from non-inflicted injury: The age/developmental status of the child: does he/she have the developmental skills to cause this injury? The history of injury: is the history plausible?

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 3 month old with excessive crying Source: AAP
Ask the audience if they have any suggestions as what may have happened. Infant crying can be very stressful for parents and can increase the risk for maltreatment. Excessive crying may lead to caregiver fatigue and feelings of frustration, anger, and/or inadequacy when efforts to soothe the baby are unsuccessful. The caregiver may direct this anger and frustration toward the baby, leading to abusive acts such as shaking, and/or slamming the baby down. The child has a subdural hematoma (bleeding in the space between the brain and skull – photo top right), fractured ribs (photo – bottom right) and extensive retinal hemorrhages (bleeding in the back of the eye – photo bottom left); these are classic findings of abusive head trauma or Shaken Baby Syndrome. This collection of findings is due to shaking the child forcefully while tightly squeezing the ribcage. The result is injury to the brain and eyes and rib fractures. Injuries to the ends of the arm and leg bones (metaphyseal fractures) can also occur from flailing of the extremities during shaking. The severity of symptoms is directly related to the force used. Often there may be a number of minor episodes of shaking with less severe symptoms initially, such as irritability, poor feeding, lethargy and crying even more. This can lead to further episodes of shaking. 20 to 30% of babies who are injured this way die and many who survive have life long disabilities.

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.” Another common type of burn caused by immersion in hot water. Toilet training is a common trigger. A child soils her clothes and, as punishment, is place into a bath with very hot water causing a scalding burn. Hot water from an electric hot water heater will be greater than 160 degree F and can cause 3rd degree burns in less than 1 second. In this case the child must have been place into the water rather than getting in and out by herself. If she stepped into the hot water her feet would be affected and they are not. Burns may be a form of maltreatment. In the case given here, the 22 month old child sustains an immersion scalding burn but the story given does not make sense. Ask the audience why. You must consider how a child of this age is able to get in and out of a bathtub. There is no way she could get herself into the tub without first placing her feet or hands in the water. Even if this was possible, she could not get out of the bathtub without placing her feet in the water. The only way she could get a scalding burn to her buttocks is if she was placed into the hot water and then removed by an adult. This type of maltreatment is most often a result of a child who is being toilet trained soiling her clothes. As punishment, they are placed in a hot bath with very hot water. The message in this case is that the injury does not fit the history and requires evaluation by someone with expertise in assessing child maltreatment.

48 Sparing of flexoral creases
Immersion Burn Characteristics “High tide” mark Sparing of flexoral creases This slide demonstrates how an immersion burn gets its classic appearance. Dunking a child into a tub of hot water will leave a “high tide mark” or line at the top of the water. Depending on how deep the water is, the knees may or may not be burned. In places where skin meets skin, such as in flexoral creases, there is less contact with hot water, and therefore sparing of this skin from burn. The skin on the buttocks that contacts the bottom of the tub will also be spared. Donut hole – Skin in contact with Bottom of tub From: Stratman. Arch Dermatol. 2002;138:

49 Data from National Burn Victim Foundation
Effect of Skin Thickness on Time to Full Thickness Burn Adult 2.5 mm Child 0.56 mm This figure shows the difference in the time needed to generate a full thickness burn in a child compared to an adult. Note that at a temperature of 127 degrees Fahrenheit, it will take a full minute to develop a full thickness burn. At 130 degrees, it will take 35 seconds for an adult to develop a full thickness burn, but only 10 seconds for a child to do so. Therefore, dunking a child in hot water can quickly cause severe burns. It is for this reason that the recommended setting for hot water heaters in the United States is below 120 degrees F. 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? The use of corporal punishment has been common in many societies throughout history. It is also controversial. A number of countries have banned all forms of it while others encourage its use for cultural and religious reasons. Ask the audience for their opinions. Many believe that spanking is an effective form of discipline. Others say there is inadequate evidence to demonstrate its effectiveness. Several studies have shown long-term negative effects on mental health. Ask the audience: “When does discipline cross the line and become maltreatment?” and “Do you believe that the earlier example of the boy who was whipped for being disrespectful represents discipline or abuse? Most people would agree that the boy’s injuries were abusive.

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 Neglect is a form of child maltreatment that may be difficult to identify. The definition given is from the World Health Organization (1999). It highlights the obligation to provide children with the essentials of health, education, nutrition, emotional development, shelter and safe living conditions that they are entitled to. Often, though not always, the neglect is not intentional but rather a result of lack of resources and the aim must be to support families rather than blaming them.

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 Rather than blaming a caregiver for what they fail to do, many experts advocate for using a child-centered definition, described above. Review the definition, then have the audience come up with a list of basic needs. Sometimes the entire responsibility can be ascribed to a single individual (or set of parents). Often, however, the situation is more complicated and the responsibility for ensuring children’s basic needs lies in many hands, including health care providers, schools, and government. To reinforce this point, have the audience think about situations where neglect may involve the responsibility of multiple individuals and/or organizations/institutions. Some examples might include: A subsistence farming family who cannot afford adequate food for the children because of a severe drought; (2) A child living in a violent, drug infested neighborhood, but the parents cannot afford to move elsewhere; (3) A child without adequate safe drinking water because the local water supply has been contaminated by a factory that discharges chemical waste into the local river; (4) A child with severe asthma whose doctor is not aware of current treatment recommendations and does not prescribe preventive medications.

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.” A 10 year old boy, known to have diabetes, is seen in a hospital emergency with lethargy and dehydration. His blood sugar is markedly elevated. His mother tells you his supply of insulin ran out 2 days ago. The question here is why the insulin ran out. Have the audience consider possible reasons why the family may not have gotten more medication. In this case the family was poor and did not have money to buy the insulin. Ask the audience what they would do now. Some might feel the parents should be held responsible. A more effective approach is to acknowledge the reality of the family’s financial circumstances and work with them using a positive and supportive approach to develop a way to get this boy his insulin without adversely affecting the rest of the family.

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 A young girl is seen in hospital on 3 occasions with significant injuries. The injuries when looked at in isolation are not unusual. Each of these types of injuries are common. What is not common is the number of injuries she has sustained. The initial concern was that she was physically maltreated but it turned out that the nine year old was responsible for the younger children while the single mother was working. Each of the injuries was related to this. The fall from the tree and the cut on her arms both happened when she forgot her house key and was trying tried to get in through an upstairs window. The burn happened when she was cooking for herself and her siblings. To make ends meet, her mother was working two jobs and couldn’t afford babysitters. Ask the audience what they would do now. This is neglect but is due to a lack of resources. One solution in this case might be to arrange for free after school care for the children.

56 Case 8 A 10 month old girl was noted by a public health nurse to be thin Her weight is less than 5th percentile; height is in the 10th 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 Occasionally we do identify malicious neglect; in this case, a 10 month old child was intentionally underfed. She was first identified as thin by a public health nurse who visited the home. Her mother expressed no concerns. When the nurse later followed up, the child was thinner and sickly. When admitted to hospital for investigation, the child thrived when given a normal diet and investigations for medical conditions were all negative. The mother later admitted to intentionally not feeding the child but wouldn’t say why. You can ask the audience “What do you think should happen now? The first priority must be the safety of the child but it is also important to determine why this occurred in the first place. Does the mother have mental health issues? Does the family need support? We know nothing about the rest of the family. Is there a husband? Are there other children? This situation would ideally be assessed by an multidisciplinary team.

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) This definition of sexual maltreatment of children is also from Preventing Child Maltreatment (WHO and ISPCAN, 2006). Simply stated, it says that the involvement of children in sexual activity of any sort, by an adult or older child in a position of trust or power, is maltreatment. This form of maltreatment is often very difficult type to identify and difficult to prove. Ask the audience if sexual maltreatment is an issue in their community. In some communities, sexual maltreatment, whether involving children or adults, is such a taboo that it is not accepted as something that happens there.

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 Sexual maltreatment not only includes the usual physical acts; it also includes exposure to pornography and child prostitution. One point to make is that children are frequently reluctant to disclose sexual maltreatment and often not believed when they do. Studies indicate a child often has to tell several adults before someone listens to them. Even when they are believed, most often there are no physical findings to prove a sexual contact took place. It is their word against that of the adult. The child may feel they have done something bad and be reluctant to disclose for this reason.

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. The father’s job requires him to be away for 2 weeks and then home for 2 weeks. He will be home in 4 days. The mother stays at her parents’ home when her husband is away. Her parents and her younger sister are the only babysitters. Ask the audience if they can suggest possible causes of the blood in the diaper. Blood in a diaper is not an unusual finding. The most common cause is an anal fissure, which is a small superficial crack in the skin around the anus. It is usually associated with constipation and does not cause any real harm and heals quickly. Food material like beets and medications such as Rifampin might cause a red discoloration of urine or stool that can be mistaken for blood. There are also a number of medical conditions where blood can be passed in urine or stool causing blood in the diaper. Again these can usually be ruled out quickly by a medical examination and basic testing. Injuries to the vagina, penis, anus and perineum can occur as a result of trauma. This trauma can be non-sexual and not deliberately inflicted, such as might happen with a straddle injury. It can also be the result of a sexual assault. About 95% of pre-pubertal girls who have been sexually abused have normal exams. This is because: The abuse often does not involve hymenal penetration. Disclosure is often delayed by days, weeks, months, or even years. Genital tissues heal quickly and any injuries may be gone by the time a child discloses and is examined. If penetration does occur, the degree of abnormal findings will be a function on the type of penetration, the frequency of penetration and the time since the last incident. Great care must be taken to not over diagnose sexual assault without a disclosure by the child unless there are definite injuries or findings that cannot be explained by any other reason. Pregnancy and sexually transmitted diseases are absolute indicators of sexual activity but may not be the result of an assault if a teenage girl has consensual sex with a male of the same age. In this case the baby had actually been left in the care of mom’s sister and her boyfriend the night before. Closer examination of the genitalia showed a minor superficial disruption of the hymen at the 9 o’clock position and scratch marks along the labia. A referral was made to a multidisciplinary child protection team who investigated. When the boyfriend was questioned, he admitted putting his finger in the girl’s vagina to see what it was like.

60 Case 10 A 7 year old girl tells her mother that a boy touched her ‘private area.’ This 7 year old girl tells her mother that a boy touched her ‘private area’. There are several issues here. Ask the audience what other information is needed. It is important to define exactly what she is saying. Is she talking about her vaginal area, her breast area or some other part of her body? What does she mean by touching? Who is the boy? How old is he? What is the context? Was it innocent contact while playing or does there appear to have been true sexual aggression? We must remember that it is normal for children to be curious about the physical differences between males and females. This does not have a sexual or sensual component. But if there is any suggestion of maltreatment, further assessment is required. If the boy did sexually maltreat her, we must consider where he learned this behavior. Has he been maltreated the same way?

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.’ In this case, the girl is disclosing very worrisome information. This requires further evaluation and investigation by child protection workers and police. In general, children do not make up these stories. However, it is very important not to just assume the uncle or anyone might have committed a sexual assault. A careful assessment, by trained investigators, of all information is required. This would be an ideal situation for a multidisciplinary team assessment.

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’. Again this is a very worrisome statement that requires assessment. The main point of this slide is to clearly state that boys may be sexually assaulted as well as girls.

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) This definition of emotional maltreatment is taken from Preventing Child Maltreatment (WHO and ISPCAN 2006). It results when the child is not provided with the developmentally appropriate and supportive environment he or she requires. Often emotional maltreatment is not taken seriously and it may not even be considered a form of maltreatment. However, it can have devastating effects on the child with life-long damage to self-esteem and personal development. Emotional abuse includes a variety of behaviors that convey to the child that he or she is worthless, flawed, unloved, endangered or only valuable in meeting someone else’s needs. Emotional abuse includes spurning, terrorizing, isolating, corrupting/exploiting and denying emotional responsiveness.

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. It is important to emphasize that the majority of childhood injuries have reasonable explanations and are not due to maltreatment. Many innocent findings can mimic abusive injury. It is necessary to fully evaluate any suspicious situation before a determination of abuse is made. The following slides are examples of situation where abuse was suspected but proven not to be an issue.

65 What Caused This? These lesions were originally thought to be caused by an intentional cigarette burn. In fact, they were caused by impetigo, a superficial skin infection. Photo from the AAP program The Visual Diagnosis of Child Physical Abuse.

66 This is a sub-conjunctival hemorrhage
This is a sub-conjunctival hemorrhage. While it does look scary, it is nothing more than a bruise to the sclera, the white part of the eye. It does not affect vision. Common causes are secondary to coughing such as whooping cough, or just getting a speck of dust in the eye. They frequently happen spontaneously without any obvious cause. However, it can also be caused by trauma, both abusive and non-inflicted. A good history is very important in determining the cause. Photo from the AAP program The Visual Diagnosis of Child Physical Abuse.

67 The grey-blue mark on this child’s leg was initially thought to be a bruise. In fact, this is an area of normal pigmentation that this boy has had all his life. They are commonly referred to as Mongolian spots and are common in Black and Hispanic infants. This type of pigmentation can occur anywhere on the body, most often on the lower back. It may be difficult to tell the difference between natural pigmentation and a bruise. Unlike bruises, Mongolian spots will not be swollen or tender. If you wait a day or two, a bruise will start to change color and eventually fade. In contrast, Mongolian spots will take months or years to fade. Photo from the AAP program The Visual Diagnosis of Child Physical Abuse. Mongolian spots

68 The marks seen here are due to Coin-Rubbing, a form of traditional medicine.
Photo from the AAP program The Visual Diagnosis of Child Physical Abuse.

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 Child maltreatment is considered a crime in most jurisdictions. Ask the audience to tell you about the agencies involved in evaluating child maltreatment in their area. Generally, both child protection services and the criminal justice system have mandates that involve them. This is certainly so in cases of sexual abuse, severe physical abuse and severe neglect. However, each of these agencies has a much different focus. The child protection system provides for general well-being of children and offers safety and support for the child and family. The main aim of the criminal justice system is to identify crime and to hold the one who commits the crime accountable. In many jurisdictions there are also Family Courts, which are involved with such issues as custody and access, guardianship, marital separation and divorce. They have a major role in the protection of children’s rights and dictating that necessary services are provided.

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 This slide discusses some of the potential problems when police and child protection agencies do not work collaboratively. Because the mandates of child protection and police appear to be so different, there is potential for conflict about how to investigate and manage the case. Unless a cooperative interdisciplinary evaluation process is in place, information may not be shared, decisions may be made in isolation, and repeated interviews of the child may occur. This may also lead to frustration by and lack of cooperation from the caregiver.

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 Ask the audience: “what do you think is needed to help professionals from different agencies work better together?” A well structured multidisciplinary team overcomes most of the confusion and conflict. They establish simple protocols that state how they proceed when a report is received. Information is shared openly, the investigation and interviews are coordinated, and they look at all the information together and decide what to do. The team can be limited to social workers and police but many also have representatives from health, the legal system and involved non-governmental agencies depending on the needs of that community. These teams do not just coordinate with each other but ideally also train together in such areas as interviewing.

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 Ask the audience “What issues interfere with formation of multidisciplinary teams?” Let the audience offer suggestions and then let the key points appear reinforcing the discussion. The reality in many areas is that the various groups do not work in a multidisciplinary team format. This slide lists some of the barriers that must be dealt with before such an effective team can be developed.

73 Interviewing Children: An Overview
Requires training and expertise Children can give good and accurate information Poor interviewing may bias child’s account This is meant to be a general overview of the importance of proper techniques when interviewing children. When children are approached in an appropriate manner, they can provide accurate information. In contrast, a poor approach may confuse and bias a child’s story. This is not intended to provide the attendees training in interviewing but rather to give them an idea of how an effective interview is done and what the major pitfalls are so they will not inadvertently do something that might introduce bias. At the same time, we will discuss what they can do when a child discloses information that raises a suspicion of abuse.

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, Children frequently react to events in ways that adults do not normally understand. We must recognize this and understand how children deal with stressful situations, such as maltreatment, and how they communicate. A group called Darkness to Light has a website that discusses how children disclose maltreatment. The same group has a publication called 7 Steps to Protecting Children that offers suggestions as to how adults should react when the child discloses.

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. ( It is important for an untrained adult to understand the importance of supporting the child while at the same time taking care not to introduce any biases. Generally, children, especially young children, do not lie about abuse. It is important that you listen to what he or she is saying in a non-judgmental way. These slides give hints on how to react, what to say and how to provide support.

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 Present these two case examples. The first is a 6 year old girl who has obvious burn injuries on her arms. In this case there is a need for medical attention to treat the injuries. You must decide how to intervene. Should you call the parent and ask him or her to take the child to a doctor? Should you take the child yourself? Should you contact the police or child protection social workers? What do you say to the child? How do you record comments the child makes? The second case needs some clarification. You must start by clarifying what is meant by touching and the age of the boy. In both cases an open ended question like “tell me what happened” is probably all that is needed to determine if abuse may have occurred. It is important to obtain enough information to determine if this requires reporting to authorities. However, an extensive interview is not necessary or appropriate. Also, if the child does not want to talk, do not pressure the child to speak.

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. Every child who is maltreated is affected in some way. The multidisciplinary team should ensure that children receive all needed acute and follow-up medical and mental health services. Coping with a child’s maltreatment may also be challenging and stressful for family members. The multidisciplinary team should also assess the needs of family members and help them obtain necessary services.

79 What are our Responsibilities?
Defined by many factors: - Ethical - Professional and Clinical - Legal We have responsibilities as individuals, as members of certain professions, and as defined by legal statutes. We must be able to identify situations in which a child is at risk for maltreatment or has been maltreated. We must know what resources are available to children and families to prevent or stop the maltreatment.

80 Reporting Laws What are the laws in your community?
Most jurisdictions have criminal laws against the maltreatment of children. Many also have specific child welfare laws. However, there is great variation in the requirement to report. Where such laws exist, it requires individuals to report any suspicion of maltreatment. It is not required for the reporting individual to have concrete proof. The investigation will be done by the agencies with the mandate to do so. As we stated before, generally these are police and child welfare and ideally work using a multidisciplinary team approach. Reporting laws differ greatly among jurisdictions. At this point, ask the audience What are the laws in your area?” If they don’t know, be prepared to inform them. In North America, all states and provinces have some form of reporting law but who must report varies. In some states/provinces, anyone with a suspicion must report. In others, only professionals who deal with children have to report. In a recent poll via the ISPCAN listserv, Malaysia, Hungary, France, Israel, Brazil, Sweden, Denmark, Norway and South Africa were identified as places where at least professionals must report. In Australia, some states, like New South Wales, have mandatory reporting while others don’t. When reporting is mandated, the laws usually also state that the reporter is immune from liability as long as the report was done without malice. It is important for us to understand the somewhat different roles of the professionals who are involved with assessment when maltreatment is suspected and to also recognize that these roles overlap. This includes police, child welfare and health care.

81 Roles – Child Welfare To provide child protective services, including:
Evaluating reports of alleged child maltreatment Ensuring children’s safety Facilitating support services Child welfare agencies have a mandate to ensure that children receive the care and support to which they are entitled. As part of this mandate, child welfare professionals evaluate allegations of child maltreatment, ensure that the child is safe, and put in place any remedial services that are necessary. These services may include mental health care for the child and caregiver, financial and housing assistance if the perpetrator was responsible for most of the family income, and/or services for victims of intimate partner violence.

82 Roles - Police Responsibilities include:
Investigating to determine if a crime has been committed Bringing charges if evidence suggests a crime. In many countries, police have a major role in the investigation of suspected child abuse. Their major mandate is to identify possible crimes, determine who may have committed the crime and to lay criminal charges. They work with child protection social workers in the investigation of abuse. The court system may also be directly involved in the investigative process in some jurisdictions. In many areas, the police also work with social workers, health care workers and other interested groups to reduce the risks of abuse by establishing community outreach programs that support families at risk.

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 Physicians, nurses and other health care professionals (for example, hospital-based social workers, dieticians and psychologists) also play roles in the evaluation and management of child abuse and neglect. While their primary role is to assist parents in maintaining the overall health of their children, they have a unique opportunity to aid in the prevention of maltreatment as well as to identify it when it occurs. In their routine assessments of children, doctors, nurses and other health care workers may identify maltreatment concerns. They may identify physical injury, nutritional deficits, or emotional and psychological problems that may arise from maltreatment. They may be told outright of situations that indicate maltreatment. The physician’s primary mandate is to provide necessary medical care. However, physicians also have the responsibility to inform child welfare and police if required by local laws and to make referrals to community services to provide support for the child and family. Ask the audience to identify types of community services that might be useful. These might include things like community centers, child care programs, parent support groups, or religious organizations. In addition there are some health care workers; physicians, nurses, social workers and psychologists who have specific expertise in the evaluation of cases of suspected child maltreatment. They work closely with police and child welfare as part of an Interdisciplinary Team. In addition to investigating the report, this team often provides support and treatment for the child and family.

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
Prevention of child maltreatment is directly tied to the promotion of children’s health, development, and safety. Many programs that focus on the prevention of child maltreatment may also result in improvements in child health, development and safety. The reverse may also be seen.

87 Levels of Prevention Primary Prevention - Prevention of disease (maltreatment) before it occurs Secondary 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 Prevention – Treatment to prevent further morbidity, avoid mortality, and limit disability. In public health, prevention is often described as having three distinct levels. Primary prevention refers to prevention of disease (child maltreatment in this case) before it occurs. Secondary prevention refers to the detection and treatment of disease before signs and/or symptoms occur. In the case of child maltreatment, secondary prevention often refers to the identification of parental or community factors that increase the risk of maltreatment. These may include parental factors such as intimate partner violence, substance abuse, depression, or lack of social support. They may also include community factors such as community violence, or lack of community cohesiveness. Tertiary prevention refers to treatment after the illness or child abuse has occurred. This may include treatment of physical injuries, physical and occupational therapy to limit disability, and mental health treatment to prevent or manage the long-term mental health effects of maltreatment.

88 Prevention Strategies for Child Maltreatment
Three levels of programs: Individual Relationship Societal and community (Preventing Child Maltreatment, 2006) There are 3 main components to the proactive approach. They consist of strategies aimed at the individual, relationships and the society and community at large.

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) Strategies aimed at the individual are designed to change an individual’s attitudes, beliefs and behaviors directly. Examples include reducing unwanted pregnancies, increasing access to prenatal and postnatal services, and directly training children to avoid potentially abusive situations. Unwanted pregnancies are associated with substandard prenatal care and higher infant mortality and maltreatment. Prenatal and postnatal programs have been shown to be beneficial in the prevention of maltreatment in children up to age 3. Also by educating children to recognize threatening situations and teaching them skills to protect themselves, maltreatment, particularly sexual abuse, may be reduced. The children learn they own and control their bodies. They also learn how to tell an adult if they are asked to do or see something they find uncomfortable.

90 Relationship Prevention Strategies
Home visitation programs Training programs for parents (Preventing Child Maltreatment, 2006) Relationship strategies are aimed at parents and guardians. Risk factors for child maltreatment include inadequate parenting, lack of knowledge of normal child development, belief in the effectiveness of harsh physical punishment, and lack of quality child care. Quality home visitation programs may reduce child maltreatment and may also have other benefits such as reduced child injuries and decreased dependence on government support. Common features of home visitation programs are educating parents about child health and development, promoting positive discipline strategies, and assisting families in obtaining needed resources. Providing parents with education and training about child development helps them improve their skills in managing their child’s behavior. They learn to identify problematic behavior, use positive reinforcement techniques and non-violent discipline methods. Ask the audience to suggest forms of non violent forms of discipline. Common forms are removal of privileges and ‘time outs’.

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) Societal and community based strategies aim to reduce underlying risk factors for maltreatment and strengthen protective factors. Risk factors include economic, social, health and education policies that allow economic and social inequality, norms that support use of violence, poor preventive health care, inadequate social welfare and a weak criminal justice system. The introduction of reforms that accept that each person has an equal right to an adequate standard of living, security, education and freedom from discrimination is a major step in the reduction of risk. This is done by the provision of early childhood education and care, establishment of a universal education system, and a social protection system that includes provision of adequate housing as well as income and food supplements for families in need, unemployment and health insurance. The reduction of environmental risk factors, such as lead and other toxins, also reduces child maltreatment. Children exposed to excessive lead levels are associated with brain damage and cognitive disorders that place them at increased risk for maltreatment. Alcohol and drug misuse by parents is associated with brain injury such as fetal alcohol syndrome, as well as placing children at increased risk for physical and sexual maltreatment. Ask the audience to suggest ways their community can reduce these risks. Suggestions might include laws that restrict the use of leaded gasoline and paints and measurements of lead in the ground where children play. Restriction of alcohol is difficult but some communities where it is a large problem do restrict or limit its availability with success in reducing violence in all areas, including child maltreatment.

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) TITLE?

93 Extent of the Problem USA Canada Population ~300 million ~33 million
# Cases 906,000 115,000 % Neglect 60 30 % Physical Abuse 19 24 % Sexual Abuse 10 3 % Witness Domestic Violence 28 % Other 17 This slide and the next two look at the extent of the problem of child maltreatment. There are many sources of statistics but none are really accurate. This is due to such things as underreporting and the reality that there are different ideas of what actually is maltreatment. All we expect to do with these slides is to identify that maltreatment of children is common, is found in all societies and socioeconomic groups. WHO, in 2000, tried to quantify types of maltreatment and we give a summery of their findings in both fatal and non-fatal forms of maltreatment.

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. These next 2 slides are shortened versions of the UNCRC outlining the rights of children in 10 main points. First they state that children have rights and then define what these rights are. These rights include the right to grow up in a healthy environment, with food, shelter and medical services. They also have the right to love, attend school, to play and to develop. They have the right not to be abused. The onus is placed not just on parents or guardians to ensure a child receives these rights but also on the community at large, including governments. Some of the points you may want to highlight include that these rights apply regardless of race, religion, politics or place of birth and include the right to be loved, be educated, to play and not to be subjected to cruel acts or exploitation.

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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