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

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



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 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



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



Different measures of child maltreatment
Different Measures of Child Maltreatment Violence

  • 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 Abuse Violenceor Structural Violence


Legal issues

Legal Issues Violence


Legal issues1
Legal Issues Violence

  • 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 Violence

  • 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 Violence

  • 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



Mandatory reporting
Mandatory Reporting ??? systems

  • 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: yes Israel: no

  • Investigate all reports?

    • USA: no Israel: yes


Reporting issues
Reporting Issues systems

  • Variation in who must report

  • Notable exclusions

    • Lawyers (Canada)

    • Priests (USA)

  • Little feedback to reporting professionals

    • Confidentiality ?


Policy issues

Policy Issues systems


Political and economic realities
Political and Economic Realities systems

  • 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 systems

  • 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



The need for a child welfare system
The Need for a Child Welfare System agency

  • 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 agency

  • 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? agency

  • 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


Law enforcement agency

Judicial system

Responding to Child

Maltreatment

- USA

CPS

Child Protective

Services

Community

Resources


Alternative response systems
Alternative Response Systems agency

  • “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 agency

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 agency

  • 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 agency

  • 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 agency

  • 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 ? agencyAn international effort to establish core principles, policies and practice for child welfare

Adaptation to meet local circumstances will naturally be necessary



Core principles
Core Principles agency

  • 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 agency

  • 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 agency

  • 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)



Cross cultural issues
Cross-cultural Issues in considering neglect?

  • 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 in considering neglect?

  • 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


Needed

NEEDED in considering neglect?

Cultural competency

to advance our field and the wellbeing of children


There is hope

There is hope in considering neglect?

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


Prevention
Prevention Involved

  • 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


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


Evidence informed practice
Evidence-informed Practice different approaches

  • Emerging recognition of the need

  • Need more evidence

  • Link policy-makers, researchers and clinicians


Research issues

Research Issues different approaches


Need for data on child abuse and neglect
Need for Data on Child Abuse and Neglect different approaches

  • 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 different approaches

  • 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


Similarities
Similarities different approaches

  • 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


Differences
Differences different approaches

  • Resources

  • Extent of safety net

  • Cultural attitudes. eg, hitting children

  • Legal framework, child welfare system

  • Attention to prevention


Advances
Advances different approaches

  • 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


Challenges different approaches


Challenges
Challenges different approaches

  • 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, different approachesdanke, merci, shukran, grazzi, gracias, toda, dankie, efcharisto, tak, shukriya, arigato, dziekuje, obrigado

[email protected]


Controversies
Controversies different approaches

  • 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 different approaches


    Needed a sustained commitment by dedicated professionals

    NEEDED different approachesa sustained commitment by dedicated professionals

    Us


    Common problems
    Common Problems different approaches

    • 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) different approaches

    • 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 different approaches

    • High threshold for proving maltreatment

      • “beyond reasonable doubt”

      • USA, Canada

    • Many more cases involve the civil system


    Needed1
    Needed different approaches

    • Specific Laws on Child Maltreatment

      • Direct

      • Indirect


    Common challenges
    Common Challenges different approaches

    • 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 different approaches

    • 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


    Controversies1
    Controversies different approaches

    • 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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