Howard dubowitz md ms university of maryland school of medicine ispcan councilor
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Child protection Around the World Similarities and Differences Advances and Challenges 25th Annual San Diego International Conference on Child and Family Maltreatment January 2011. Howard Dubowitz, MD, MS

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Howard Dubowitz, MD, MS University of Maryland School of Medicine ISPCAN Councilor

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Howard dubowitz md ms university of maryland school of medicine ispcan councilor

Child protection Around the World Similarities and Differences Advances and Challenges25th Annual San Diego International Conference on Child and Family MaltreatmentJanuary 2011

Howard Dubowitz, MD, MS

University of Maryland School of Medicine

ISPCAN Councilor

Child maltreatment a global problem

Child Maltreatment – A Global Problem

  • A common problem, in all countries

  • Definitions, rates, circumstances vary

  • Comparison across countries is tricky

    • Apples and oranges and peaches …..

  • Variation within countries, across cultures

  • This overview does not cover all countries

Child maltreatment 0b e2 80 93 a global problem

Nova Science Publishers

New York

Data on child maltreatment incidence and prevalence

Data on Child Maltreatment Incidence and Prevalence

  • Reported cases

    • Canadian Incidence Study (CIS) of Reported Child Abuse and Neglect

    • US National Child Abuse and Neglect Data System (NCANDS)

    • Limitations

  • Community surveys

    • US National Incidence Study (NIS) of Child Abuse & Neglect

    • Center for Research on Crimes Against Children (USA)

    • Limitations

Lifetime prevalence of contact sexual abuse 15 17 year olds

Lifetime Prevalence of Contact Sexual Abuse15 - 17 Year Olds

Lifetime prevalence physical abuse by caregiver 15 17 year olds

Lifetime Prevalence:Physical Abuse by Caregiver15 - 17 Year Olds

Finkelhor et al, 2010

Percent of university students reporting past neglect

Percent of University Students Reporting Past Neglect

Straus & Savage, Child Maltreatment, 2005; 10:124

Defining child abuse and neglect

Defining Child Abuse and Neglect

Much variation

Corporal punishment vs abuse

Corporal Punishment vs. Abuse

  • Most countries permit corporal punishment considered as “reasonable”

  • Canada considers it abuse if:

    • Child <2 or >12

    • Use of objects or blows to the head

    • Use of force on child incapable of learning from it (eg, disabled child)

    • Force stems from parent’s frustration, loss of temper, or abusive personality

    • Degrading, inhuman or harmful conduct

Physical abuse definitions

Physical Abuse Definitions

  • Any injury lasting 24 hours – Maryland, USA

  • Severe injuries – fracture, burn, death

    Sexual Abuse Definitions

  • Victim must have been a virgin

  • Voyeurism, exhibitionism

Child maltreatment 0b e2 80 93 a global problem

Exposure to Intimate Partner (or Domestic) Violence

Different measures of child maltreatment

Different Measures of Child Maltreatment

  • Infant mortality, malnutrition

  • Female genital mutilation (FGM)

  • Street children

  • Child labor

  • Children kept out of school

  • Children without health insurance

  • ……………………………..

Societal neglect or abuse or structural violence

Societal Neglect or Abuseor Structural Violence

Legal issues

Legal Issues

Legal issues1

Legal Issues

  • Varying legal definitions

    • of child abuse and neglect

    • of age of children covered by child welfare

  • Evolving laws

    • Egypt: new focus on children’s rights, guided by the UN Convention on the Rights of the Child (CRC); the new Child Law discourages corporal punishment

Un convention on the rights of the child crc 1989

UN Convention on the Rights of the Child (CRC) - 1989

  • A valuable blueprint for developing laws to help ensure children’s health, development and safety; work on Article 19

  • Has influenced laws, policies and practice in many countries

  • Huge gap between the CRC and children’s conditions - in many countries

Limitations of legal definitions

Limitations of Legal Definitions

  • Not clearly guided by what’s known about children’s health, development and safety

  • Laws are necessarily broad and cannot cover all situations. Open to interpretation

  • Need agencies to operationalize and implement the laws; these agencies may be weak or nonexistent

    • Mandatory reporting laws, but no means to enforce them

Still laws are essential for developing strategies and systems to protect children

Still, laws are essential for developing strategies and systems to protect children

Mandatory reporting

Mandatory Reporting ???

  • Pro

    • Needed to protect as many children as possible

    • Conveys state’s seriousness about CM, educates the public

    • Places a legal and ethical responsibility on the state

  • Against

    • Unnecessary and rigid burden on professionals

    • Concern for professional immunity

    • Preference for a less adversarial approach (Belgium)

  • Immunity for professionals?

    • USA: yesIsrael: no

  • Investigate all reports?

    • USA: noIsrael: yes

Reporting issues

Reporting Issues

  • Variation in who must report

  • Notable exclusions

    • Lawyers (Canada)

    • Priests (USA)

  • Little feedback to reporting professionals

    • Confidentiality ?

Policy issues

Policy Issues

Political and economic realities

Political and Economic Realities

  • Decentralizedsystems with varying policies and practice (Canada) vs. mostlycentralizedsystems with common policies

  • Rich countries, better resources

  • Poor countries, poorresources

  • Not always true, other factors

Social safety net for children

Social Safety Net for Children

  • Huge variation across countries

  • Relatively comprehensive

    eg, “Building a Europe for and with children”

  • Much variation even in “good” countries

    eg, First Nations people in N. Canada

Child welfare embedded within a larger social services agency ideal

Child welfare embedded within a larger social services agency- ideal?

The need for a child welfare system

The Need for a Child Welfare System

  • Many low income countries have little or no child welfare system

    • Patchwork of local services, NGOs

    • Value of a lead agency (eg, hospitals in Pakistan, Phillipines)

    • Need for associated services. eg, mental health

  • Most middle-high income countries have a child welfare system, but they vary greatly, and …….. advocates point to many weaknesses

Current scope of child welfare

Current Scope of Child Welfare

  • Narrow focus on protection, after maltreatment is suspected (most countries)

  • Broad focus – includes prevention, youth justice, mental health

  • Primary prevention (rarely, funding constraints)

  • Exposure to intimate partner violence

    • An emerging concern for child welfare (USA, Canada)

Future scope of child welfare

Future Scope of Child Welfare?

  • Goal: A broad concern with children’s health, development & safety

  • More resources, and …..

  • More science, better applied

  • Competent professionals

  • More collaboration among agencies, professionals

  • A focus on prevention

Child maltreatment 0b e2 80 93 a global problem

Law enforcement

Judicial system

Responding to Child




Child Protective




Alternative response systems

Alternative Response Systems

  • “Less serious” reported cases referred to community agencies

  • Evaluation vs. investigation

  • Address needs vs. find fault

  • Flexibility to direct cases back to CPS

  • Preliminary findings: somewhat encouraging

Alternative response systems1

Alternative Response Systems

Kohl et al.

Time to leave substantiation behind: findings from a national probability study.

Child Maltreatment. 2009;14(1):17-26.

Need for greater resources

Need for Greater Resources

  • Resources rarely adequate to meet needs

    eg, USA: limited mental health services

  • Impact of poverty on children

    eg, Philippines: 22% report regularly experiencing “moderate to severe hunger”

  • Impact of poverty on families, parents

  • Poverty compounded by HIV/AIDS

  • Need to address underlying systemic issues that contribute to CM (Belgium as a model)

Poverty and neglect

Poverty and Neglect

  • Clearly connected

  • Poverty - a form of societal neglect

  • Child welfare systems focus on situations where parents held responsible for neglect

    • USA: 12 states exclude poverty in legal definition

    • Child welfare can offer a way to obtain services (USA)

  • Addressing poverty – a problem mostly beyond current child welfare systems

Children s advocates

Children’s Advocates

  • Independent from child protection services

  • Semi-independent from the government

  • Goals:

    • advocate for children in the child welfare system

    • Advocate for improvements in the system

Needed an international effort to establish core principles policies and practice for child welfare

Needed ?An international effort to establish core principles, policies and practice for child welfare

Adaptation to meet local circumstances will naturally be necessary

Practice issues

Practice Issues

Core principles

Core Principles

  • Main goal: protect child from harm

  • Best interests of child must be considered

  • Views of children should be considered

  • Continuity of care is important for children

  • State respects family autonomy and parents’ primary responsibility for child rearing

  • Cultural heritage should be respected

Varying principles and practice

Varying Principles and Practice

  • Sanctity of family vs. need to protect

  • How to be minimally intrusive

    • Belgium: working with incestuous families, while trying to avoid the judicial system

    • Argentina: removes perpetrator, not abused child

    • USA: child placed in alternative care

Minority groups

Minority Groups

  • Oppressed, marginalized, abused, neglected

  • Ongoing problems – discrimination, poverty, health and mental health problems

  • Challenges for child welfare

    • How best to address complex and multiple needs in a culturally sensitive way?

    • Separate system, self-government?

  • Immigrants

    • Eg, female genital mutilation (abuse in USA, Canada)

How should we consider the role of different cultural values in considering neglect

How should we consider the role of different cultural values in considering neglect?

Cross cultural issues

Cross-cultural Issues

  • In common: UN CRC, sanctity of the family, high threshold for removing children

  • Should lead to efforts to support family and protect child

  • Varying approaches

    • Parental rights more often terminated than restricted

    • USA: kinship care

    • Institutional or foster care

Cross cultural issues1

Cross-cultural Issues

  • Attention to children’s rights – France

  • In some countries, a child’s death does not trigger an investigation - India

  • Involving children in child welfare policies and practice – Lebanon

  • Cultural differences within countries

  • In a global world, professionals need to know how to approach families from different cultures



Cultural competency

to advance our field and the wellbeing of children

There is hope

There is hope

UN Convention on the Rights of the Child

Need to enhance professional capabilities of all involved

Need to Enhance Professional Capabilities – of all Involved

  • The work is very difficult, and requires well trained and supported child welfare staff

  • Requires training other professionals involved in children’s lives

  • A challenge for most countries

  • This issue is central to ISPCAN’s mission

    • Curricula project



  • UN CRC provides a legal and moral impetus

  • Limited resources often prioritized for responding over preventing CM

  • Some countries have well developed “safety nets”

  • Some countries have low thresholds for involving child welfare

  • Some countries have broad approaches to child protection (tertiary prevention)

  • Role of private agencies, NGOs – important, but limited. Cannot tackle underlying systemic problems

Child maltreatment 0b e2 80 93 a global problem

Much remains to be learned about the effectiveness of different approachesAnd, this may vary across countries and cultures

Evidence informed practice

Evidence-informed Practice

  • Emerging recognition of the need

  • Need more evidence

  • Link policy-makers, researchers and clinicians

Research issues

Research Issues

Need for data on child abuse and neglect

Need for Data on Child Abuse and Neglect

  • Data shows extent of the problem

  • Crucial for building public and political support

  • Guides the development of the response

  • Helps track progress

  • Need clear definitions – eg, WHO (2002)

  • Definitions will likely vary across countries

    • eg, broad definition of psychological abuse in Brazil

Need for research

Need for Research

  • Child welfare policies and practice often guided by philosophical, political and personal preferences and practice experience

  • Need for research and evidence

    eg, home visiting programs

    eg, evaluation of children in kinship care

  • England: a good model where monitoring and evaluation of services are built into the system

  • Research costs - worth learning what works



  • Child maltreatment – a problem in ALL countries

  • Resources never adequate

  • Gap between the law and what’s implemented

  • Struggle to find balance between state intervention and family autonomy

  • Cultural values – importance of childhood



  • Resources

  • Extent of safety net

  • Cultural attitudes. eg, hitting children

  • Legal framework, child welfare system

  • Attention to prevention



  • Influence of UN CRC

  • Increasing awareness of children’s rights

  • Recognition of role of science in guiding “evidence-informed practice”

  • Improved communication across countries

  • Improved conditions for children

Child maltreatment 0b e2 80 93 a global problem




  • Changing public attitudes, culture

    • Reduce child labor, FGM

    • Child abuse often not reported

  • Improving the social safety net for children

  • Improving legal and child welfare systems

  • Developing interventions to prevent and address CM

  • Improving professionals’ attitudes, knowledge, skills

  • Resources, resources, resources

Hdubowitz@peds umaryland edu

Thank you, dank u, danke, merci, shukran, grazzi, gracias, toda, dankie, efcharisto, tak, shukriya, arigato, dziekuje, obrigado

[email protected]



  • Parental vs. child rights

  • Threshold for state intervention into family life

  • Approach to religious and traditional practices

    • eg, criminalization of FGM

  • Not all poverty is equal

    Not All Poverty is Equal

    Needed a sustained commitment by dedicated professionals

    NEEDEDa sustained commitment by dedicated professionals


    Common problems

    Common Problems

    • Crisis driven system

    • Little attention to primary prevention

    • Lack of national leadership

    Transition from foster care to independent living canada

    Transition from Foster Care to Independent Living (Canada)

    • Arbitrary age cut-offs

    • Lack of preparation for adult life

    • Lack of support

    • Lack of funding

    Criminal and civil justice systems

    Criminal and Civil Justice Systems

    • High threshold for proving maltreatment

      • “beyond reasonable doubt”

      • USA, Canada

    • Many more cases involve the civil system



    • Specific Laws on Child Maltreatment

      • Direct

      • Indirect

    Common challenges

    Common Challenges

    • Separation of investigative and therapeutic roles

    • Dual investigation: child welfare and police

    • Advantage of integrating child welfare within a social services agency (Israel)

    Challenges egypt

    Challenges - Egypt

    • Building public support for children’s rights

    • Changing public attitudes, culture

      • Reduce child labor, fight FGM

      • Overcoming the silence on sexual abuse, exploitation

      • Child abuse often not reported

    • Improving professionals’ attitudes, skills

    • Implementing laws

    • Prevention – limited efforts

    • Resources, resources, resources



    • Parental vs. child rights

  • Threshold for state intervention into family life

  • Approach to religious and traditional practices

    • eg, criminalization of FGM

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