Child Abuse and Maltreatment

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

Child Abuse Presentation
“Child abuse and neglect in the United States now represents a national emergency... Protection of children from harm is not just an ethical duty; it is a matter of national survival.” U.S. Advisory Board on Child Abuse and Neglect, 1990 The U.S. Advisory Board on Child Abuse was created by an amendment to CAPTA (Child Abuse Prevention & Treatment Act). This Board in in charge of assessing the Nation’s effort to achieve the goal of the act. This amendment also created a National Data Collection and Analysis Program Maria Beatriz Alvarez

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

The Problem • Child Maltreatment 2001
Child Abuse Presentation The Problem • Child Maltreatment 2001 Nationally, an estimated 903,000 children were victims of abuse and neglect 57.2 % of victims suffered neglect, 18.6 % were physically abused 9.6 % were sexually abused 26.6 % were associated with additional types of maltreatment, 27.7 % were under 3 years old 50.2% were White 25.0% were African-American 14.5 % were Hispanic 2.0 % were American Indians, Alaska Natives 1.3 % were Asian-Pacific Islanders This information has been gathered by the National Child Abuse and Neglect Data System, which is part of the Department of Human Services. Located in Cornell University. According to the U.S. Department of Health, children of single parents have 87% greater risk of being harmed by physical neglect. Children who had been victimized were more than twice as likely to experience recurrence compared to children without history. Maria Beatriz Alvarez

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

Types of Child Maltreatment
Child Abuse Presentation Types of Child Maltreatment Maria Beatriz Alvarez

Reports Child protection service (CPS) agencies receive more than 50,000 referrals per week. Nationally, 67.4% of all referrals approximately (1,802,000 )were screened in, 32.5 % were screened out. 56.5% of the screened in referrals were from professionals. NYS received 152,671 reports, 31% were confirmed as cases of child abuse. Most states have established time standards for initiating the investigation of the reports. The average response time from submission to investigation was 50 hours More than ¼ of the investigations resulted in substantiated reports. Approximately 87,000 cases were screened out Maria Beatriz Alvarez

Fatalities Nationally, an estimated of 1,300 children died of abuse or neglect, 40.9% were under 1 year old, 35.6% of the maltreatment deaths were associated with neglect. Data recorded by Child Protection Agencies, the Coroner’s office, or Fatality Review Boards. Less than 10% of the families of child fatality victims had received family preservation services in the 5 years prior to the death, while less than 1% of child fatality victims had been in foster care and returned to their families within 5 years prior to their deaths Source: U.S. Department of Health and Human Services. The Administration for Children Services. Based on responses from the States to the 2001 National Abuse and Neglect Reporting System (NCANDS). Maria Beatriz Alvarez

New York Statistics Abuse/Neglect Reports and Number of Children in Reports for FY ACS or Administration for Children’s Services was created by Major Giuliani in 1996 after “Elisa’s Law”, a 6-year-old girl murdered by her mother, Elisa Izquierdo, who had been though the city’s myriad of protective services Maria Beatriz Alvarez

History of Child Abuse Prevention
Child Abuse Presentation History of Child Abuse Prevention 1850’sChild Labor first became an issue in the U.S. 1870, the first census reported child laborers: 750,000 workers 1904 The National Labor Committee advocated to eliminate child labor 1916 The Keating Owen Act banned all articles produced by child labor 1918 Supreme Court declared the Keating Owen Act un-constitutional 1938 The Fair Labor Standards Act limited the age of child laborers to 16 and over. For centuries society condoned infanticide, physical abuse, sexual abuse and exploitation of children’s labor. The prevalence of child maltreatment has endured throughout time and has cultivated tenacious legacies that shaped societal response to child abuse. Those legacies include the tenet that the children are the property of their parents. These traditions contributed to a slow societal response in defining and responding to child abuse. The problem of child labor was greater in the large Northern cities like New York. The problem worsened with the increase of industrialization The 750,000 child-workers does not include the children working in business and farms. Representative Keating from Colorado and Senator Owen from Oklahoma sponsored an act to ban all articles produced by child labor which was signed by President Woodrow Wilson. By 1900 approximately 2 million children were working in mills, mines, factories, fields, and stores. Maria Beatriz Alvarez

The National Labor Committee hired the photographer Lewis W. Hine to document Frequent accidents. Noise polution Some boys and girls were so small they had to climb up on to the spinning frame to mend broken threads and to put back the empty bobbins. (Bibb Mill No. 1, GA) Maria Beatriz Alvarez

The dust penetrated the boys’ lungs. A kind of slave driver stands over the boys prodding or kicking them into obedience View of the Ewen Breaker of Pa. Coal Co. The dust was so dense at times as to obscure the view. (South Pittston, PA) Maria Beatriz Alvarez

The slippery floors and careless bumping into each other increased the liability of accidents Cutting fish in a sardine cannery. Large sharp knives are used with a cutting and sometimes chopping motion (Eastport, ME) Maria Beatriz Alvarez

Wheaton Glass Works, Millville, NJ
Child Abuse Presentation A furnace is about 2200 F. Wheaton Glass Works, Millville, NJ Maria Beatriz Alvarez

The Discovery of Child Abuse
Child Abuse Presentation The Discovery of Child Abuse 1962, Dr. Henry Kempe’s “battered child” syndrome. By 1966 all states have passed legislation regulating child abuse reporting 1973, in New York, the Child Protective Act established protective services 1974, first Federal legislation: Child Abuse Prevention and Treatment Act (CAPTA) 1988, CAPTA was completely rewritten. In the 1940’s there was some documentation of physical abuse cases appearing in hospital settings. The first article stating the possibility of parental maltreatment was written by Caffey in 1946, a radiologist who cited subdural hematomas in infants who had atypical fractures of the limbs and ribs Skepticism prevailed about the extent of this problem until 1962 when Kempe conducted a survey of 88 hospitals. He identified 302 who had been “battered”. His report ignited a broad-based national effort to find ways to protect children. Maria Beatriz Alvarez

Definition of Child Abuse
Child Abuse Presentation Definition of Child Abuse An “abused child” is a child less than eighteen years of age whose parent or other person legally responsible for his care: Inflicts or allows to be inflicted, Creates or allows to be created, Commits or allows to be committed: - Physical Abuse - Neglect - Sexual Abuse - Sexual Exploitation - Emotional/Mental Injury - Abandonment This definition also applies to children residing in group residential care and children older than 18 with handicap conditions Emotional or mental injury are behaviors such as belittling, terrorizing, rejecting, isolating, inconsistent parenting, witnessing domestic violence Neglect is defined as a failure to exercise a minimum degree of care, supplying food, clothing, shelter, education, medical and dental care, supervision. E.g. misusing drugs to the extent of caretaker losing control Maria Beatriz Alvarez

Monster drawing by a six-year old boy at a battered women’s shelter.
Child Abuse Presentation Monster drawing by a six-year old boy at a battered women’s shelter. Many times de children break the silence through their drawings. Cathy Malchiodi, who is an art therapist with a long experience with abused children compiled these drawings in her book “Breaking the silence” It is common among children of battered women to use the metaphor of monsters. These monsters are powerful expressions of pain, anger, fear or loneliness Maria Beatriz Alvarez

Drawing/collage by a 12-year old boy whose paranoid/schizophrenic father performed satanic rituals on him and his sister. This child told the therapist “I hate my dad, he tried to kill himself once but I stopped him. Now I wish he was dead” Maria Beatriz Alvarez

Drawing by a 6-year-old boy who was physically abused and witnessed his mother being abused by his father. Children who are being attacked or witnessed others being attacked would display their feelings about violence as wanting to attack or being attacked. Maria Beatriz Alvarez

Drawing of a 6-year-old physically abused boy who drew himself “calling for his mommy to stop his daddy from beating him, but his mother does not come.” The drawings of the house, tree and person. The human figure can elicit powerful feelings if there has been some kind of recent physical abuse. This child gave no verbal confirmation of the abuse but he made this drawing. Maria Beatriz Alvarez

Drawing by an 8-year-old boy who was repeatedly physically abused by alcoholic parents. This child in earlier sessions depicted mostly aggressive themes. At this point in treatment he began to express a deeper pain. There was a deeper feeling of depression beneath the hostility. Maria Beatriz Alvarez

Drawing by an 8-year-old boy sexually abused by his mother who became a perpetrator himself. In the expressions of sexually abused children a certain degree of sexual connotation may appear. These mountains have the definite quality of female breasts Maria Beatriz Alvarez

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

Drawing by a 13-year-old girl who depicted a dream she had about being dead and buried, showing her overwhelming depression concerning her multiple sexual abuse experiences and helplessness. This drawing shows an example of encapsulation or graphic enclosure. She has visually isolated herself in the coffin lines from future traumatic experiences Maria Beatriz Alvarez

Drawing of a 13-year-old girl who was repeatedly sexually abused by her mother and her many “boyfriends” since the age of six. There might be a disorganization of body parts in the art expressions of children who have been sexually abused. Maria Beatriz Alvarez

Abuse Indicators Physical Indicators of Child Physical Abuse Bruises Burns Lacerations Skeletal injuries Missing or loosened teeth Human bite marks Bald spots Abrasions Appearance of injuries after school absences, weekend or vacation. The bruises may be in various stages of healing or in unusual patterns. Burns in the shape of cigarettes, ropes, iron, or glove or sock, due to the immersion in hot water Maria Beatriz Alvarez

Loop mark bruises inflicted by a double cord
Child Abuse Presentation Loop mark bruises inflicted by a double cord Maria Beatriz Alvarez

Bruises inflicted at different times on the buttocks
Child Abuse Presentation Bruises inflicted at different times on the buttocks Maria Beatriz Alvarez

Immersion burn of a child’s hand
Child Abuse Presentation Immersion burn of a child’s hand Maria Beatriz Alvarez

Retinal hemorrhages in a patient with shaken-baby syndrome
Child Abuse Presentation Retinal hemorrhages in a patient with shaken-baby syndrome Because the muscles in the neck of an infant are weak and the brain is smaller than the skull cavity, when the baby is shaken it is said that the brain “sloshes” back and forth in the skull. Sudbural hemorrhage is the pool of blood that collects on the brain. The shaking mechanism produces acceleration/deceleration and rotational injuries (retinal hemorrhages) Maria Beatriz Alvarez

Multiple healing posterior rib fractures from a compression injury of the chest Maria Beatriz Alvarez

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

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

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

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

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

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

Mandated Reporters in NY State
Child Abuse Presentation Mandated Reporters in NY State Physicians Surgeons Medical Examiners Coroners Dentists, Dental Hygienists Osteopaths Optometrists Chiropractors Podiatrists Residents, Interns Psychologists Registered Nurses Hospital Personnel Engaged in Admission, Examination, Care or Treatment of Persons Christian Scientists Practitioners School Officials Social Services Workers Day Care Center Workers Providers of Family and Group Family Day Dare Employees & Volunteers in Residential Care Facilities Any Other Child Care Worker Foster Care Workers Mental Health Professionals Peace Officers, Police Officers or Other Law Enforcement Officials District Attorneys, Assistant District Attorneys, or Investigators Employed in the office of a District Attorney Substance Abuse Counselors Alcoholism Counselors Physician Assistants Immunity from liability The penalty for failure to report if “willfully fails to report” is a Class A misdemeanor Maria Beatriz Alvarez

Outline of Procedures for Mandated Reporting
Child Abuse Presentation Outline of Procedures for Mandated Reporting When you have a reasonable cause to suspect that a child coming before you in your professional capacity is an abused or maltreated child: Call the New York State Central Registry Telephone No (mandated reporters) or (general public). Include the following information: Caller’s name, title, name of institution and telephone number Information required on Form DSS-2221-A Actions taken by the person reporting, e.g. protective custody Obtain the following information Name of person to whom report is being made Phone number of local office to which the case will be assigned State Registry Number assigned to the case Names of State Central Registry staff to be consulted, if necessary Parents should be informed of the report, whenever possible Ethically is always recommended to inform the caretaker The written form must be submitted within the 48 hours following the oral report Reasonable cause: You may feel that the injury or condition was caused by neglect or non-accidental means Suspicion of abuse: you distrust or doubt what you observe or are told. When should you report? IMMEDIATELY Maria Beatriz Alvarez

Mediators in the effects of child abuse
Child Abuse Presentation Mediators in the effects of child abuse Age of the child and time of the abuse Chronicity Severity Relationship to Offender Level of Threats Emotional Climate of the Child’s Family The Child Mental/Emotional Health The Guilt the Child Feels The Sex of the Victim Parental Responses to the Child’s Victimization Age: There is a discrepancy in the research on the effect of the child’s age on later outcome, however, a trend exists toward viewing the younger child as more vulnerable. Van der Kolk: “the uncontrollable terrifying experience may have their most profound effects when the central nervous system and cognitive functions have not yet fully matured, leading to global impairment” Chronicity: There is a consensus in the research that the more chronic the abuse, the greater the impact. Dissociation. Severity: The more extensive the abuse, the greater the damage. Physical abuse: risk of death. Sexual abuse: penetration: greater damage. Relationship to the offender: The closer the relationship the greater the resultant trauma. The child learns that the person who loves him is also the hurtful person. Nowhere to go for help. Level of Threats: The use of threats, force and violence also worsens the trauma. Threats may produce generalize anxiety. Emotional climate of family: The family dysfunction includes patterns of intergenerational abuse, inappropriate child rearing patterns and parenting skills, social incompetence and isolation from support systems, emotional distress, inaccurate perception and high expectations of children, and emotional arousal and reactivity to child provocation. The Child Mental/Emotional Health: If good psychological health prior to abuse, better position to resist the damaging effects. Guilt the child feels: If the child experiences some pleasure during the sexual contact or feels somehow responsible for causing the abuse. Guilt is associated with greater impact. Sex of the Victim: Recent research supports earlier speculation that male victims show long-range serious problems and greater psychopathology Parental responses to child victimization: Many researchers have emphasized the pivotal role the non-abusive parent plays in healing the child (Leaman, James & Nasjleti, Sgroi, Summit, Kryso) Maria Beatriz Alvarez

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

Posttraumatic Stress Disorder DSI-V-TR
Child Abuse Presentation Posttraumatic Stress Disorder DSI-V-TR Exposure to traumatic event The person experience, witnessed or was confronted with and event or events that involved actual death or serious injury, or a threat to the physical integrity of self or others The person’s response involved intense fear, helplessness or horror. Note: in children this may be expressed instead by disorganized or agitated behavior Studies of the prevalence of PTSD have demonstrated that this condition is the fourth most common psychiatric disorder, afflicting as many as 10.3% of men and 18.3% of women at some time in their lives. Breslau, N, Kessler, RC, Chilcoat, HD et al. Trauma and posttraumatic stress disorder in the community: 1996 Detroit Area Survey of Trauma. Arch Gen Psychiatry 1998, 55: Recent estimates suggest that the majority of the population will experience at least one extremely traumatic event during the course of their lives, and about 25% of trauma survivors will develop PTSD. Breslau, N. Epidemiology of trauma and posttraumatic stress disorder. In Psychological Trauma. Edited by R. Yehuda. Washington, DC, American Psychiatric Press, 1998, 1-27 In addition to PTSD, trauma survivors are at considerable risk for the development of other psychiatric conditions such as: Major Depression Panic disorder, Generalized anxiety disorder, Substance abuse disorder. Those who are exposed to traumatic events during childhood, and those who are exposed to chronic or repeated traumatic events are also at risk of developing physical illness such as hypertension, asthma, and psychosomatic illnesses Maria Beatriz Alvarez

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

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

PTSD Hyperarousal Difficulty falling asleep Irritability
Difficulty concentrating Hypervigilance Exaggerated startle response

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

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

Child Abuse and Maltreatment

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