1. Child Maltreatment 1. Why is maltreatment a major public health problem? 2. How maltreatment came to be defined as a public health problem 3. Child abuse law 4. How child protective services works 5. Consequences of maltreatment 6. Causes of maltreatment 7. Causes of sexual abuse

2. 1. Why is maltreatment a major public health problem? Over 1000 children are killed each year at the hands of their parents Birth defects due to physical abuse of pregnant women cost more than health problems associated with diseases for which children are typically vaccinated Cost of intimate violence (including violence against women as well as against children) rivals that of cancer and heart attacks 2.5 million reports to CPS each year Maltreatment undermines children ’ s ability to achieve their potential.

3. 2. How maltreatment became defined as public health problem Mary Ellen 1874 -- Abuse of Mary Ellen --> Society for prevention of cruelty to children - http://www.nytimes.com/2009/12/15/health/15abus.html?_r= 0 http://www.nytimes.com/2009/12/15/health/15abus.html?_r= 0 https://www.nyspcc.org/nyspcc/history/ http://www.americanhumane.org/about-us/who-we- are/history/story-of-mary-ellen.html

4. Battered child syndrome1962 -- Battered child syndrome: Henry Kempe –Unexplained physical injuries seen by doctors –Journal of the American Medical Association National Child Abuse Prevention & Treatment Law1974 -- National Child Abuse Prevention & Treatment Law: Legal definition of abuse Rape crisis hotlines1980s -- Sexual abuse becomes identified as a problem as many callers to Rape crisis hotlines were children or adults calling to talk about childhood experiences of incest 2000 -- Public Health approach to Preventing CAN

5. Child Abuse Law 1. Defining abuse/maltreatment 2. Determining who has to report 3. Dealing with substantiated cases

6. Types of maltreatment Physical Harm Neglect --- putting child in danger through acts of omission Sexual abuse Emotional abuse

7. Issues in Child Abuse Law 1. Defining abuse/maltreatment -- vague vs. specific wording -- rights of adults vs. rights of children -- Who knows best? sensitivity to need to be tolerant of individual & cultural differences in child rearing -- how can we come up with a general law that can be applied to a wide variety of cases that differ from one another in their specifics -- intentionality vs. accidental

8. 2. Who has to report what? -- What does suspected abuse mean? -- Who should be required to report maltreatment? Protection of children vs. Avoiding police state mentality 3. Dealing with substantiated cases -- Punishment vs. rehabilitation -- Family reunification vs. protection of child from maltreatment by family members 4. Prevention Who pays? What should be mandated?

9. Process leading to action in maltreatment cases

10. Reportsuspicion of abuse Report -- mandated reporters must report suspicion of abuse, -- Who reports? 50% general public 36% education/law enforcement -- Call hotline Influences on reporting Influences on reporting: individual & cultural standards of childrearing concern about involving legal system concerns about effectiveness of CPS

11. Investigation -- carried out by trained person -- interview child, visit residence to determine current danger to child & siblings, gather evidence to determine if abuse has occurred Issues: Is case founded? Is there enough evidence to pursue further enquiry? Influences on investigation thoroughness affected by availability of resources efforts to hide evidence by perpetrators public opinion about family ’ s right to privacy vs. child ’ s right to protection training of investigators

12. Substantiation -- Use legal definition of maltreatment to determine if Abuse or Neglect has occurred -- If yes, notify law enforcement -- consider: intentionality, cultural differences -- 42% of reported cases substantiated -- 33% general public -- 53% law enforcement/education Influences on substantiation thoroughness of report community standards/ resources: urban/rural public opinion high rates of reporting/low rates of substantiation

13. Legal action Issues in determining action: -- protection of child -- need for social services -- Diversion (rehabilitate) or prosecution (punish) Influences on legal action: does public opinion support rehabilitation or deterrence/punishment biases of judge in juvenile court biases of law enforcement officers quality & substance of report from CPS

15. Economic Costs Janet Currie / Kathy Widom

16. Total sample: C & W

17. Gender Differences: C & W

18. Economic analysis of prevention cost Nurse Visit @$4K per child for 3.5m per year -- $14 B If no maltreatment, earnings increased by $5K per year from 18 - 60. Value of extra wages in year of birth 30.8K If Nurse Visit cuts substantiated maltreatment by 50% to 500,000 then savings of $15.5 B

19. Explanations for link between maltreatment and negative outcomes listed above Violence begets violence through social learning: reinforcement & modelling (Bobo doll) -- Does violence beget violence? Widom study

20. Prospective study Found: Children exposed to maltreatment are at increased risk for criminal activity, including violence, if male. Found: Most maltreated children don ’ t end up with a criminal record. Implication: Need to explain why some maltreated children end up with a criminal record and others don ’ t. Implications: Need to explain why physical abuse and neglect appear to have the same outcomes.

22. Psychological process models (Downey, Dodge) psychological mediatorsWhat are psychological mediators linking maltreatment with negative outcomes? How does maltreatment affect how we think and feel and cope in particular situations? psychological message communicated by maltreatmentLook at psychological message communicated by maltreatment: rejection. rejection sensitivity, ablaming orientation, poor coping skillsDevelop rejection sensitivity, a blaming orientation, poor coping skills. Overreact to perceived rejectionOverreact to perceived rejection in harmful ways: depression, aggression, substance abuse, borderline personality disorder

23. Dunedin study: protective effect of High MAOA Activity Genotype against antisocial behavior in men Low MAOA activity: 12%; account for 44% violent convictions Monoamine oxidase A breaks down Ne, S, D

24. Trauma Model (Terr): Trauma creates general vulnerability to a variety of negative outcomes Type 1: Single event Detailed memories Omens Misperceptions Type 2: Repeated experiences of trauma Type 2: Repeated experiences of trauma (child maltreatment) Denial & numbing Self-hypnosis/ Dissociation Rage Profound sadness

25. Causes of maltreatment Parent characteristics Child characteristics Interaction of parent and child characteristics Family characteristics Community Macrosystem: Social-structural / Cultural

26. Parent characteristics Mental illnessMental illness Types: Childhood history of being maltreatedChildhood history of being maltreated Policy implications Policy implications: -- look at parents ’ mental health & family history -- avoid assuming that parent is abusive on the basis of family history or mental health

27. Child characteristics difficult temperament (cries alot, can ’ t be comforted) physical or intellectual problems emotional problems low birth weight unwanted conception young (aged 3 months to 3 years) Policy implications: -- While maltreatment by caretakers is never the child ’ s fault, some children are more vulnerable than others. -- Provide additional resources to parents of young difficult, children

28. Transactional model Difficult child may overwhelm parent with few coping resources Minnesota study: 9/10 mothers who abused premature/low birthweight babies had been abused as children Bugenthal study Policy implications -- treatment plans must take account of characteristics of both parent and child

29. Family structure & conflict Family structureFamily structure -- Single parent (neglect) -- > 4 children -- Children closely spaced Marital conflict/ violenceMarital conflict/ violence -- high rates of child abuse in families where there is marital violence Policy implications: Are family structural variables correlates of abuse or do they contribute to its cause? Pay attention to implications of marital violence for child maltreatment

30. Community Family isolated from community Danger in community Policy implications: Help develop community strengths that reduce danger and reduce isolation. Have resources in community for parents who need a break from their children.

31. Social structural Social class and child abuse: Is there a link? yes -- Evidence suggests yes Poverty --> stress, lack of support --> increased risk of maltreatment Policy implications: -- While correlated with poverty, abuse found in all social class, ethnic, racial, and religious groups. -- Provide access to resources. -- Distinguish lack of resources as cause of abuse that can be overcome by providing resources from causes that are knowledge based, psychopathology based, culturally based.

32. Cultural Some cultures (e.g., U.S.) and subcultures condone violence whereas others do not (e.g., Swedan, Zuni & Cheyanne) Policy implications Policy implications: Difficulty distinguishing cultural practices that harm children from those that may appear to harm children but do not. Avoid cultural biases in interpreting the cause of injuries to children.

33. Sexual abuse

34. Treatment of sexual offenders Lock them up and throw away the key Chemically castrate them Cognitive-behavioral -- a. learn to empathize with victim -- b. learn to recognize stressful situations -- c. develop alternative strategies for dealing with stress