1. National Family Safety Program, NGHA
January 28th and 29th 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.

2. 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. Outline Risk Factors, Protective Factors, and Causes
Using Risk Factors to Select and Design Interventions
Organizing Risk Factors
Risk Factors for Child Maltreatment at Different Levels of the Ecological Model
Risk Factors Associated with Specific Types of Abuse
Summary and Conclusion

4. Risk Factors, Protective Factors, and Causes

5. 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. 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. Using Risk Factors to Design Interventions

8. 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. The Public Health Model
1.Define & describe
What is the Problem?
2.Identify risk What are the risk factors and causes?
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
4. Scaling up and cost-effectiveness
Implement on large scale & cost
3.Develop and
evaluate interventions
What works and for whom?

10. Organizing Risk Factors

11. 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. Using the Ecological Model to Organize Risk Factors for Child Maltreatment
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
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
Taken from: World report on violence and health edited by Krug, E. et al. Geneva, World Health Organization, 2002.

13. Risk Factors for Child Maltreatment at Different Levels of the Ecological Model

14. Individual Level Risk Factors

15. Individual Level Risk Factors: Parents and Caregivers
Increased risk of child maltreatment is associated with the presence of certain factors in the parent or other family member, including:
• 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
• Misuse of alcohol or drugs
• Involvement in criminal activity
• Social isolation
• Depression, low self-esteem, or feeling of inadequacy
• Financial difficulties

16. 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. 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. 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. 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. 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. 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. Relationship Level Risk Factors

23. 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. 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. 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. Community Level Risk Factors

27. 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. 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. 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. Society Level Risk Factors

31. 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. 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. Risk Factors Associated with Specific Types of Abuse

34. Risk Factors Specifically Associated with Child Physical Abuse
Strongly related:
Parent anger, hyper-reactivity
Family conflict
Family cohesion

35. 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. 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. 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. Summary and Conclusion

39. Summary and Conclusion
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.

40. 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 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 (9667), The Future of Children. (2009) Preventing Child Maltreatment. 119(2), 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. 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).