1. Violence and Injury Prevention Short Course National Family Safety Program, NGHA January 28 th and 29 th 2013 Presentation 5. Step 2 of the Public Health Approach to Child Maltreatment Prevention: Risk Factors for Child Maltreatment Presented by Alaa Sebeh, MD Ph.D. Independent International Consultant, Child Protection & Disability. alaa1234@gmail.com

2. Violence and Injury Prevention Short Course Objectives The core learning objective of this module is to provide a basic understanding of risk and protective factors for child maltreatment organized according to the ecological model – the second step of the public health model as applied to child maltreatment prevention.

3. Violence and Injury Prevention Short Course Outline 1.Risk Factors, Protective Factors, and Causes 2.Using Risk Factors to Select and Design Interventions 3.Organizing Risk Factors 4.Risk Factors for Child Maltreatment at Different Levels of the Ecological Model 5.Risk Factors Associated with Specific Types of Abuse 6.Summary and Conclusion

4. Violence and Injury Prevention Short Course Risk Factors, Protective Factors, and Causes

5. Violence and Injury Prevention Short Course Definitions: Risk Factors and Protective Factors A risk factor refers to characteristics, events, or experiences shown to precede an undesirable outcome and to be associated with an increase in the likelihood of that outcome. A protective factor refers to characteristics, events, or experiences shown to precede an undesirable outcome and be associated with a decrease in the likelihood of that outcome.

6. Violence and Injury Prevention Short Course Definitions: Causes and Markers A cause refers to a risk factor that, when altered, has an impact on the likelihood of the outcome. A marker is a risk factor that is not causally involved in the outcome. It refers to characteristics that identify (or mark) the likelihood of a disorder but, if changed, do not influence the likelihood of the outcome.

7. Violence and Injury Prevention Short Course Using Risk Factors to Design Interventions

8. Violence and Injury Prevention Short Course Identifying Risk and Protective Factors to Implement Interventions Step 2 of the public health model involves identifying risk and protective factors and underlying causes with a view to designing or selecting interventions that target and reduce those risk factors most strongly associated with child maltreatment. Ideally and in theory, the risk factors targeted by the interventions should be causal risk factors and not just markers.

9. Violence and Injury Prevention Short Course 1.Define & describe What is the Problem? 2.Identify risk What are the risk factors and causes? 4. Scaling up and cost-effectiveness Implement on large scale & cost 3.Develop and evaluate interventions What works and for whom? Systematic, evidence-based approach with 4 steps: 1. Define and Describe 2. Identify Risk 3. Develop and Evaluate Interventions 4. Scaling Up and Cost- Effectiveness The Public Health Model

10. Violence and Injury Prevention Short Course Organizing Risk Factors

11. Violence and Injury Prevention Short Course Ways of Organizing Risk Factors for Child Maltreatment Risk factors can be organized by: Level of ecological model. Developmental stage: Infanthood (<3 years), childhood (3–11 years), adolescence (12–17 years), and adulthood (≥ 18 years). Type of child maltreatment: Child physical abuse, sexual abuse, emotional or psychological abuse, and neglect. Strength of association: Some risk factors are more likely than others to be associated with child maltreatment than others. Victim or perpetrator.

12. Violence and Injury Prevention Short Course Using the Ecological Model to Organize Risk Factors for Child Maltreatment Taken from: World report on violence and health edited by Krug, E. et al. Geneva, World Health Organization, 2002. Lack of adequate legislation Social, economic and health policies that lead to poor living standards or socio-economic inequality Cultural norms that promote or glorify violence, including physical punishment Social and cultural norms that diminish the status of the child in parent-child relationships Tolerance of violence Gender and social inequality in the community Lack of services to support families High levels of unemployment Lack of parent-child attachment Family breakdown Intimate partner abuse Being socially isolated Breakdown in support in child rearing from extended family Parent was maltreated as child Parent misuses drugs or alcohol Parent is socially isolated Child was unwanted as a baby Child shows symptoms of mental ill-health

13. Violence and Injury Prevention Short Course Risk Factors for Child Maltreatment at Different Levels of the Ecological Model

14. Violence and Injury Prevention Short Course Individual Level Risk Factors

15. Violence and Injury Prevention Short Course Individual Level Risk Factors: Parents and Caregivers Difficulty bonding with a newborn child and are insufficiently nurturing A history of victimization as a child Inadequate knowledge of child development Poor parenting skills Inappropriate and excessive reactions to perceived misbehaviour by the child Approval and use of physical punishment to discipline children Physical or mental health problems A lack of self-control or an inability to manage anger M isuse of alcohol or drugs Involvement in criminal activity Social isolation Depression, low self-esteem, or feeling of inadequacy Financial difficulties Increased risk of child maltreatment is associated with the presence of certain factors in the parent or other family member, including:

16. Violence and Injury Prevention Short Course Individual Level Risk Factors: Parents and Caregivers (continued) Whether abusers are more likely to be male or female, depends, in part, on the type of abuse. Women report using more physical discipline than men. Men are the most common perpetrators of life-threatening head injuries, abusive fractures and other fatal injuries. Sexual abusers of children are predominantly men in many countries.

17. Violence and Injury Prevention Short Course Individual Level Risk Factors: Parents and Caregivers (continued) Physically abusive parents are more likely to be young, single, poor, and unemployed and to have less education than their non-abusing counterparts. In both developing and industrialized countries, poor, young, single mothers are among those at greatest risk for using violence towards their children. Studies have also found that low education and a lack of income to meet the family’s needs increase the potential of physical violence towards children.

18. Violence and Injury Prevention Short Course Individual Level Risk Factors: Parents and Caregivers (continued) Stress and social isolation of the parent have also been linked to child abuse and neglect. Child maltreatment has also been linked to alcohol and drug misuse, though further research is needed to disentangle the effects of misuse from the related issues of poverty, overcrowding, mental disorders and health problems associated with this behaviour.

19. Violence and Injury Prevention Short Course Individual Level Risk Factors: Child Risk factors related to the child do not mean that the child is responsible for the maltreatment he or she suffers, but rather that the child may be more difficult to parent because he or she: Was an unwanted baby or failed to fulfill the parent’s expectations or wishes Is an infant with high needs Cries persistently and cannot be easily soothed or comforted Has physical features, such as facial abnormalities Shows symptoms of mental ill-health Demonstrates personality or temperament traits that are perceived by the parent as problematic Is one child out of a multiple birth which has taxed the parent’s ability to support the child Has a sibling or siblings who are demanding of parental attention Is a child that either exhibits or is exposed to dangerous behaviour problems

20. Violence and Injury Prevention Short Course Individual Level Risk Factors: Age of the Child Vulnerability to child abuse – whether physical, sexual, or through neglect – depends in part on a child’s age. Fatal cases of physical abuse are found largely among young infants. Young children are also at risk for non-fatal physical abuse, though the peak ages for such abuse vary from country to country. While infants and young children are sexually abused, the rate of sexual abuse victimization tends to rise at puberty and is highest during adolescence.

21. Violence and Injury Prevention Short Course Individual Level Risk Factors: Sex of the Child In most countries, girls are at higher risk than boys for infanticide, sexual abuse, educational and nutritional neglect, and forced prostitution. Findings from several international studies show rates of sexual abuse to be 1.5– 3 times higher among girls than boys. Male children appear to be at greater risk of harsh physical punishment in many countries. Wide cultural gaps that exist between different societies with respect to the role of male and female children could account for many of these differences.

22. Violence and Injury Prevention Short Course Relationship Level Risk Factors

23. Violence and Injury Prevention Short Course Risk Factors at the Level of Close Relationships Risk factors for child maltreatment linked to relationships with family, friends, intimate partners, and peers include: Lack of parent–child attachment and failure to bond Physical, developmental or mental health problems of a family member Family breakdown Violence in the family Gender roles and roles in intimate relationships that are disrespectful Being isolated in the community Lack of a support network to assist with stressful or difficult situations in a relationship Breakdown of support in child rearing from the extended family Discrimination against the family Involvement in criminal or violent activities in the community

24. Violence and Injury Prevention Short Course Risk Factors at the Level of Close Relationships: Co-Occurrence of Intimate Partner Violence and Child Maltreatment Increasing attention is being given to intimate partner violence and its relationship to child abuse. Among known victims of child abuse, 40% or more have also reported domestic violence in the home. The relationship may be even stronger, since many agencies charged with protecting children do not routinely collect data on other forms of violence in families.

25. Violence and Injury Prevention Short Course Risk Factors at the Level of Close Relationships: Size and Household Composition The size of the family can also increase the risk for abuse. However, it is not always simply the size of the family that matters. Data from a range of countries indicate that household overcrowding increases the risk of child abuse. Unstable family environments are a feature particularly noted in cases of chronic neglect.

26. Violence and Injury Prevention Short Course Community Level Risk Factors

27. Violence and Injury Prevention Short Course Community Level Risk Factors for Child Maltreatment Community risk factors include the following: General tolerance of violence Gender and social inequality Inadequate housing Lack of support services for families High levels of unemployment Inadequate policies and programmes Poverty Harmful environmental levels of lead or other toxins Transient population Easy availability of alcohol Presence of a local drug trade Social capital

28. Violence and Injury Prevention Short Course Community Level Risk Factors : Poverty Numerous studies across many countries have shown a strong association between poverty and child maltreatment. Rates of abuse are higher in communities with high levels of unemployment and concentrated poverty. Such communities are also characterized by high levels of population turnover and overcrowded housing. Research shows that chronic poverty adversely affects children through its impact on parental behaviour and the availability of community resources. Photo: WHO

29. Violence and Injury Prevention Short Course Community Level Risk Factors : Social Capital Social capital represents the degree of cohesion and solidarity that exists within communities. Children living in areas with less ‘‘social capital’’ appear to be at greater risk of abuse and have more psychological or behavioural problems. Social networks and neighbourhood connections have been shown to be protective of children. This is true even for children with a number of risk factors – such as poverty, violence in the family, substance or alcohol abuse by parents, and parents with low levels of educational achievement.

30. Violence and Injury Prevention Short Course Society Level Risk Factors

31. Violence and Injury Prevention Short Course Societal Level Risk Factors for Child Maltreatment Societal level risk factors for child maltreatment include: Social, economic, health, and education policies that lead to poor living standards or to socioeconomic inequality or instability Social and cultural norms that promote or glorify violence towards others Social and cultural norms that demand rigid gender roles for males and females Social and cultural norms that diminish the status of the child in parent-child relationships The existence of child pornography, child prostitution, and child labour Lack of a strong legal framework on the issue of child maltreatment

32. Violence and Injury Prevention Short Course Protective Factors In the same way that there are factors that increase the susceptibility of children and families to child maltreatment, there are also factors that may offer a protective effect. Factors that appear to facilitate resilience include: Secure attachment of the infant to the adult family member High levels of paternal care during childhood Absence of associating with delinquent or substance-abusing peers A warm and supportive relationship with a non-offending parent A lack of abuse-related stress Based on the current understanding of early child development, the risk factors for child maltreatment and evidence of the effectiveness of certain prevention strategies, it is clear that stable family units can be a powerful source of protection for children.

33. Violence and Injury Prevention Short Course Risk Factors Associated with Specific Types of Abuse

34. Violence and Injury Prevention Short Course Risk Factors Specifically Associated with Child Physical Abuse Strongly related: Parent anger, hyper-reactivity Family conflict Family cohesion

35. Violence and Injury Prevention Short Course Risk Factors Specifically Associated with Child Sexual Abuse Strongly related: Perpetrators less educated, poorer, and from outside family Prior victimization Having a parent with a history of sexual victimization Poor parent-child, especially mother-daughter, relationship

36. Violence and Injury Prevention Short Course Risk Factors Specifically Associated with Child Emotional or Psychological Abuse Research suggests that the following risk factors are associated with this type of abuse: Child aggression Child interpersonal problems Parent aggression, hostility, and neuroticism Less caring fathers Martial conflict and aggression

37. Violence and Injury Prevention Short Course Risk Factors Specifically Associated with Child Neglect Strongly related: Poor parent-child relation Parent perceives child as problem Parent’s level of stress Parent anger, hyper-reactivity Low parental self-esteem

38. Violence and Injury Prevention Short Course Summary and Conclusion

39. Violence and Injury Prevention Short Course This module reviewed: Risk Factors, Protective Factors, and Causes Using Risk Factors to Select and Design Interventions Ways of Organizing Risk Factors Risk Factors for Child Maltreatment at Different Levels of the Ecological Model Risk Factors Associated with Specific Types of Abuse Understanding the underlying causes of and risk factors for child maltreatment is critical for developing prevention strategies that target these risk factors in order to effectively prevent child maltreatment and reduce its consequences and costs. Summary and Conclusion

40. Violence and Injury Prevention Short Course References Butchart, A. Phinney, A. and Furness, T. (2006). Preventing child maltreatment: A guide to taking action and generating evidence. Geneva, World Health Organization. Child Maltreatment. TEACH-VIP E-Learning. Retrieved March 17, 2010, from http://teach- vip.edc.org/course/view.php?id=23 Gilbert, R. Widom, C. Browne, K. Fergusson, D. Webb, E. Janson, S. (2009). Burden and consequences of child maltreatment in high-income countries. Child Maltreatment 1. 373 (9667), 1-14. The Future of Children. (2009) Preventing Child Maltreatment. 119(2), 3-21. Krug, E. et al. (2002). World report on violence and health. Geneva, World Health Organization. Pinheiro, P.S. (2006). World report on violence against children. Geneva, World Health Organization.

41. Violence and Injury Prevention Short Course Activity: Identifying Risk Factors for Child Maltreatment Identify risk factors at the level of the ecological model your group has been assigned for your particular country or community. Pinpoint risk factors that appear to be culturally specific to a country or community and those which appear to be more widely shared (at regional or global level).