Multidisciplinary Curriculum on Child Maltreatment

1. Multidisciplinary Curriculum onChild Maltreatment International Society for the Prevention of Child Abuse and Neglect

2. Multidisciplinary Curriculum Committee Members Robert Morris (Chair) Jingqi Chen Hiroaki Ishikawa (Co-Chair) Anne Hollows Wambui Njuguna Elena Volkova Clemencia Ramirez Editors: Howard Dubowitz Wendy G. Lane

3. What is Child Maltreatment?

4. Child Maltreatment Definition All forms of physical and/or emotional ill treatment, sexual abuse, neglect or negligent treatment, or commercial or other exploitation, resulting in actual or potential harm to a child’s health, survival, development or dignity in the context of a relationship of responsibility, trust or power. (World Health Organization 1999)

5. Why is child maltreatment a concern?

6. Incidence of Child Maltreatment Rate per 1000

7. Incidence of Child Maltreatment Rate per 1000

8. Known cases of child abuse and neglect are just the tip of the iceberg.

9. Rates of Harsh Physical Punishment Source: WHO WorldSAFE study Runyan, D. Pediatrics. 2010;126:e701-11

10. Rates of Psychological Punishment Source: WHO WorldSAFE study

11. Abusive Head Trauma • Shaking of children < 2 years • Keenan: ICU admissions & deaths • Theodore: parental report Keenan, et al. JAMA. 2003;290:621-6 Theodore, et al. Pediatrics. 2005;115:e331-7

12. Rates of child maltreatment are higher than what most “official” statistics suggest But is child maltreatment more common than other childhood conditions?

13. Comparison to Other Childhood Conditions * Denotes prevalence. All others are incidence rates

14. A child: under age 18 CRC has been signed by almost all members of the United Nations UN Convention of the Rights of the Child (UNCRC)

15. UN Convention on the Rights of the Child - Selected Rights • You have the right to grow up and to develop physically and spiritually in a healthy and normal way, free and with dignity. • You have a right to special care and protection and to good food, housing and medical services. • You have the right to special care if handicapped in any way.

16. UN CRC 4. You have the right to love and understanding, preferably from parents and family, but from the government where these cannot help. 5. You have the right to go to school for free, to play, to develop, and to learn to be responsible and useful. 6. You have the right to be protectedagainst cruel acts or exploitation. This includes work which may hinder physical and/or mental development.

17. Why is child maltreatment so common?

18. Contributors to Child Maltreatment Society Community Family Parents Child Professionals Belsky, Psychological Bulletin. 1993;114:413

19. Child Risk Factors • Age - younger children • Gender - • - girls: higher risk for infanticide, sexual abuse, educational and nutritional neglect • - boys: higher risk for physical abuse • Special Characteristics – twins, children with handicaps, prematurity, unwanted pregnancy

20. Parent/Caregiver Risk Factors • Young age • Single parent • Unwanted pregnancy • Poor parenting skills • Substance abuse • Physical or mental illness

21. Family Risk Factors • Overcrowded living circumstances • Poverty • Social isolation • Major stress • Domestic violence

22. Community/Societal Factors • No or poorly enforced child protection laws • Limited value of children • Social acceptance of violence (family, community or society – including war) • Cultural norms • Social inequities - poverty

23. Failing to: Acknowledge that child maltreatment exists Identify and address child maltreatment Offer necessary services to children and families Help prevent maltreatment By promoting health, development and safety By addressing major risk factors Professional Factors

24. Impact of Maltreatment on Children • Every child is affected – extent varies • Several factors determine the impact: • Nature of maltreatment • Child’s personality • Protective factors • Consequences can be: • Physical • Psychological • Behavioral • Societal

25. Physical Consequences • Injuries(such as fractures, burns, injury to internal organs, lacerations, head injuries) • Impaired brain development • Short and long-term disability • Death

26. Odds of Ischemic Heart Disease By Number of Adverse Childhood Experiences (ACE)

27. Psychological Consequences • Common • May include: • Immediate issues of isolation, fear and lack of trust • lifelong problems of depression, low self-esteem, relationship difficulties • Impaired cognitive development

28. Short-term Emotional Effects Infants/Toddlers Sleep disturbance Irritability Separation anxiety Language, toileting regression School age Difficulty regulating emotion Trouble getting along with peers – hostile intent Difficulty concentrating

29. Short term Emotional Effects Teenagers Anxiety Aggression Risk taking (run away, drug use, sex) Participate in family violence Depression School failure

30. Suicide Risk by ACE Score

31. Behavioral Consequences • Increased rates of delinquency, drug use, and criminal acts involving violence • Intergenerational abuse. It is estimated that 1/3 of maltreated children will abuse their own children.

32. Cost of abuse US$ 104 billion annually Prevent Child Abuse America, 2008

33. Can we afford NOT to provide funds for prevention?

34. Identifying Maltreated Children

35. Physical abuse Neglect Sexual abuse Emotional abuse and neglect Labor Trafficking Others Types of Child Maltreatment

36. Physical Abuse The use of force against a child that results in harm for the child’s health, survival, development or dignity Modified from ISPCAN & WHO in, “Preventing Child Maltreatment” 2006.

37. Indicators of Physical Abuse • Injury inconsistent with history or child’s development • Shape of lesions (for example, hand prints or cigarette burns) • Multiple injuries in various stages of healing • Family history of abuse • Child’s report

38. Physical Abuse • Physical findings may include: • Bruises • Cuts • Fractures • Welts • Burns • Abdominal trauma • Abusive head trauma (includes inflicted injury to brain and/or skull)

39. Case 1 • 3 month old baby • Bruises on her face and arms • Mother: “I saw the bruises when I fed her this morning. They were not there when she was put to bed last night. She must have fallen from the crib!”

40. Case 1 3 month old with bruises Source: AAP

41. Case 2 • An 11 year old boy • Uncomfortable in his seat at school • Tells the teacher, “I was beaten by my father. I was rude to him.” • He shows her his back.

42. Case 2 11 year old with bruises Source: AAP

43. Case 3 • A grandmother notices that her 2 month old grandson is crying a lot and not consolable • She says, “he is not moving his left arm and cries harder when I try to move it.” • She brings him to be examined. • X-ray shows:

44. Case 3 2 month old Not moving arm

45. Case 4 • A young, single mother complains that her 3 month old son is “a difficult child”, always fussy, crying, difficult to feed and irritable • A week later the boy is brought to the hospital unconscious and breathing poorly

46. Case 4 3 month old with excessive cryingSource: AAP

47. Case 5 • A 22 month old brought to hospital with burns to her buttocks. • Her mother says, “she got into a hot bath when I was out of the room.”

48. Immersion Burn Characteristics “High tide” mark Sparing of flexoral creases Donut hole – Skin in contact with Bottom of tub From: Stratman. Arch Dermatol. 2002;138:318-320.

49. Effect of Skin Thickness on Time to Full Thickness BurnAdult 2.5 mm Child 0.56 mm Data from National Burn Victim Foundation

50. Corporal Punishment vs. Abuse