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Multidisciplinary Curriculum on Child Maltreatment. International Society for the Prevention of Child Abuse and Neglect. Multidisciplinary Curriculum Committee Members. Robert Morris (Chair) Jingqi Chen Hiroaki Ishikawa (Co-Chair) Anne Hollows Wambui Njuguna Elena Volkova

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Multidisciplinary Curriculum on Child Maltreatment


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multidisciplinary curriculum on child maltreatment

Multidisciplinary Curriculum onChild Maltreatment

International Society for the

Prevention of Child Abuse

and Neglect

multidisciplinary curriculum committee members
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

child maltreatment definition
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)

rates of harsh physical punishment
Rates of Harsh Physical Punishment

Source: WHO WorldSAFE study

Runyan, D. Pediatrics. 2010;126:e701-11

rates of psychological punishment
Rates of Psychological Punishment

Source: WHO WorldSAFE study

abusive head trauma
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

rates of child maltreatment are higher than what most official statistics suggest

Rates of child maltreatment are higher than what most “official” statistics suggest

But is child maltreatment more common than other childhood conditions?

comparison to other childhood conditions
Comparison to Other Childhood Conditions

* Denotes prevalence. All others are incidence rates

un convention of the rights of the child uncrc
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)
un convention on the rights of the child selected rights
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.
un crc
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.

slide18

Contributors to Child Maltreatment

Society

Community

Family

Parents

Child

Professionals

Belsky, Psychological Bulletin. 1993;114:413

slide19

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
slide20

Parent/Caregiver Risk Factors

  • Young age
  • Single parent
  • Unwanted pregnancy
  • Poor parenting skills
  • Substance abuse
  • Physical or mental illness
family risk factors
Family Risk Factors
  • Overcrowded living circumstances
  • Poverty
  • Social isolation
  • Major stress
  • Domestic violence
community societal factors
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
professional factors
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
impact of maltreatment on children
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
physical consequences
Physical Consequences
  • Injuries(such as fractures, burns, injury to internal organs, lacerations, head injuries)
  • Impaired brain development
  • Short and long-term disability
  • Death
psychological consequences
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
short term emotional effects
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

short term emotional effects1
Short term Emotional Effects

Teenagers

Anxiety

Aggression

Risk taking (run away, drug use, sex)

Participate in family violence

Depression

School failure

behavioral consequences
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.
slide32

Cost of abuse

US$ 104 billion annually

Prevent Child Abuse America, 2008

slide35
Physical abuse

Neglect

Sexual abuse

Emotional abuse and neglect

Labor

Trafficking

Others

Types of Child Maltreatment

physical abuse
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.

slide37

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
slide38

Physical Abuse

  • Physical findings may include:
  • Bruises • Cuts
  • Fractures • Welts
  • Burns • Abdominal trauma
  • Abusive head trauma (includes inflicted injury to brain and/or skull)
case 1
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!”
slide40

Case 1

3 month old with bruises

Source: AAP

case 2
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.
slide42

Case 2

11 year old

with bruises

Source: AAP

case 3
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:
slide44

Case 3

2 month old

Not moving arm

case 4
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
case 5
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.”
slide48
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.

effect of skin thickness on time to full thickness burn adult 2 5 mm child 0 56 mm
Effect of Skin Thickness on Time to Full Thickness BurnAdult 2.5 mm Child 0.56 mm

Data from National Burn Victim Foundation

physical discipline corporal punishment
Physical Discipline“Corporal Punishment”
  • Controversial and ingrained: “Spare the rod, spoil the child”
  • Widespread: “a parent’s right”

Questions:

  • Is it effective?
  • Is it a form of abuse?
  • What are the possible outcomes?
  • What forms of discipline are preferable?
slide52

WHO (1999) Definition of Neglect

  • Inattention or omission by the caregiver to provide for the child: health, education, emotional development, nutrition, shelter and safe living conditions
  • In the context of resources reasonably available to the family or caretakers
  • And causes, or has a high probability of causing, harm to the child’s health or physical, mental, spiritual, moral or social development
  • Includes the failure to properly supervise and protect children from harm
child centered definition of neglect
Child-Centered Definition of Neglect

Neglect occurs when a child’s basic needs are not met, resulting in potentialor actual harm.

Basic needs include adequate:

Food - Clothing

Supervision - Protection

Health care - Education

Love and nurturance - Home

case 6
Case 6
  • A 10 year old boy with diabetes
  • Brought to an emergency department - dehydrated, lethargic
  • He has not taken his insulin for 2 days.
  • His mother explains “We ran out.”
case 7
Case 7

A 9 year old girl is seen for repeated injuries over a 6 month period, including

  • fell from a tree causing minor head injury
  • major laceration on forearm when climbing through a broken window
  • burns to her hands from handling hot fat
case 8
Case 8
  • A 10 month old girl was noted by a public health nurse to be thin
  • Her weight is less than 5th percentile; height is in the 10th
  • Her mother describes an adequate diet and the child feeds well in front of the nurse
  • A month later she is has not gained weight and is very irritable
  • The child is admitted to hospital, investigations for diseases are negative. She eats well, puts on weight and is more active
child sexual abuse
Child Sexual Abuse
  • Involvement of a child in sexual activity that he/she:
    • does not fully comprehend,
    • is unable to give informed consent to,
    • is not developmentally prepared for,
    • violates laws and taboos of society.
  • Children can be sexually exploited by an adult or other child who by virtue of age or development is in a position of responsibility, power or trust.

(From ISPCAN & WHO in, “Preventing Child Maltreatment”, 2006)

child sexual abuse1
Child Sexual Abuse
  • Often a ‘hidden’ assault
  • All forms of sexual activity are included, not just intercourse and other physical types
  • Includes child prostitution and exposure to pornography
case 9
Case 9
  • A 6 month old girl is brought to a local nurse because her mother found blood in her diaper. She is happy and healthy looking, with no obvious medical findings upon examination.
  • Mom says only she and her 17 year old sister care for the baby. The sister babysat the previous evening.
case 10
Case 10

A 7 year old girl tells her mother that a boy touched her ‘private area.’

case 11
Case 11
  • A 13 year old girl tells her friend that her uncle gets in bed with her and makes her do ‘bad things.’
case 12
Case 12
  • A 9 year old boy refuses to go to school because one of his teachers forces the boy to ‘kiss his bird’.
emotional abuse
Emotional Abuse
  • Includes:
    • Blaming - Belittling
    • Frightening - Threatening
    • Spurning - Ridiculing
    • Discrimination - Rejecting
  • These acts have a high probability of damaging the child’s psychological or mental health. They may also damage the child’s physical, mental, spiritual, moral or social development.

(From ISPCAN and WHO, Preventing Child Maltreatment, 2006)

conditions that mimic abuse
Conditions That Mimic Abuse
  • It is important to recognize that most injuries are the result of innocent events.
  • Behavior problems occur for many reasons; none are specific for abuse.
  • While it is important to consider the possibility of maltreatment; it is important NOT to jump to conclusions.
evaluating possible child maltreatment roles
Evaluating Possible Child Maltreatment: Roles
  • Two main groups:
    • child protection (social services and civil/family court)
    • criminal justice (police and criminal court)
  • Child Protection: ensure child’s safety, strengthen family
  • Criminal Justice: Identify those who commit crimes and hold them accountable
  • Multidisciplinary evaluation is ideal
potential problems with separate evaluations
Potential Problems with Separate Evaluations
  • Parallel investigations
  • No coordination; little information sharing
  • Multiple interviews
  • Potential contamination of story, evidence
  • Potential contradictory conclusions
  • Further distrust and increased stress for all involved
what is a multidisciplinary evaluation team approach
What is a Multidisciplinary Evaluation Team Approach?
  • Train and work together
  • Understand each other’s roles and strengths
  • Establish common protocols for receiving reports, information sharing, interviewing and decision making
slide72

Multidisciplinary Training: Why don’t we do it now?

  • Groups have different mandates
  • Groups have different training
  • Ignorance of each other’s jobs, abilities
  • Concerns about confidentiality
  • Limited resources
  • Not considered necessary
interviewing children an overview
Interviewing Children: An Overview
  • Requires training and expertise
  • Children can give good and accurate information
  • Poor interviewing may bias child’s account
know how children communicate
Know How Children Communicate
  • Children who disclose abuse often tell a trusted adult other than a parent
  • Children may tell parts of what happened or pretend it happened to someone else to gauge adult reaction
  • Children will often “shut down” and refuse to tell more if you respond emotionally or negatively(from 7 Steps to Protecting Children published by Darkness to Light, www.DarknessToLight.org)
how to react
How to React

If a child tells you that he or she has been abused:

  • Believe her. Children rarely lie about abuse. Do not ignore or deny what she is saying.
  • Commend the child for telling you. Make sure she understands that the abuse is not her fault.
  • Stay calm. Children stop talking if they think what they are saying makes you upset. Make sure the child knows you will listen.

(www.DarknessToLight.org)

how to react1
How to React
  • Encourage the child to talk but don’t ask leading questions (for example, “He touched your private parts, didn’t he?”). This can alter the child’s memory of events.
  • Don’t pressure a child to talk if he is not ready.
  • Get enough information to determine whether a report is indicated. More detailed questions can be asked later, by professional interviewers.
  • Make sure the child is safe and no more abuse can occur while you seek help.
  • Contact social services or police.
how to react2
How to React

Discuss how you would respond to each of these children disclosing their abuse.

  • Case 1: a 6 year old with cigarette burns
  • Case 2: a 7 year old girl who says that a boy touched her
treatment and follow up
Treatment and Follow-Up
  • Every child must be assessed for effects of maltreatment
  • Acute medical therapy must be given as required
  • The need for mental health care must be assessed
  • Family members should be assessed and provided with necessary services.
what are our responsibilities
What are our Responsibilities?

Defined by many factors:

- Ethical

- Professional and Clinical

- Legal

reporting laws
Reporting Laws

What are the laws in your community?

roles child welfare
Roles – Child Welfare

To provide child protective services, including:

  • Evaluating reports of alleged child maltreatment
  • Ensuring children’s safety
  • Facilitating support services
slide82

Roles - Police

  • Responsibilities include:
  • Investigating to determine if a crime has been committed
  • Bringing charges if evidence suggests a crime.
slide83

Roles - Health Care

  • Responsibilities include:
  • Prevention
  • Identify children who may be maltreated
  • Inform Child Welfare
  • Evaluate and treat illness and injury
  • Help ensure medical and mental health support
  • Collaborate with other professionals, agencies
  • Testify in court
  • Advocacy
slide84

Roles - Courts/Correctional Services

  • Responsible for helping ensure the care and protection of children, including:
  • Mandating treatment services
  • Criminal proceedings and incarceration
prevention
Prevention

“….There is sufficient evidence, including in the scientific literature, to state with full confidence that child maltreatment can be prevented.” (Preventing Child Maltreatment, 2006)

levels of prevention
Levels of Prevention
  • Primary Prevention - Prevention of disease (maltreatment) before it occurs
  • Secondary Prevention – Detection and treatment of disease before signs and/or symptoms occur. For child maltreatment, often refers to identification and amelioration of risk factors.
  • Tertiary Prevention – Treatment to prevent further morbidity, avoid mortality, and limit disability.
prevention strategies for child maltreatment
Prevention Strategies for Child Maltreatment

Three levels of programs:

  • Individual
  • Relationship
  • Societal and community (Preventing Child Maltreatment, 2006)
individual prevention strategies
Individual Prevention Strategies
  • Reducing unintended pregnancies
  • Increasing access to prenatal and postnatal services
  • Training children to avoid potentially abusive situations

(Preventing Child Maltreatment, 2006)

relationship prevention strategies
Relationship Prevention Strategies
  • Home visitation programs
  • Training programs for parents

(Preventing Child Maltreatment, 2006)

societal and community based prevention programs
Societal and Community Based Prevention Programs
  • Legal reforms and human rights
  • Beneficial social and economic policies
  • Change cultural and social norms that support violence against children
  • Reduce environmental risk factors (Preventing Child Maltreatment, 2006)
slide92
“We owe children, the most valuable citizens in any society, a life free from violence and fear”

Nelson Mandela

(World Report on Violence and Health, 2002)

slide94

Extent of the Problem:Fatal Cases of Abuse

  • ~57,000 deaths of children <15 years
  • Rate < age 4 is twice that seen in older children
  • Rate much higher in poorer areas(2.2/100,000 boys in highest income groups and 17.9/100,000 in lowest income groups)
  • Most common causes: head injury, abdominal injury
  • (WHO 2000)
slide95

Extent of the Problem:Non-Fatal Abuse

  • Yelling/screaming at child in 70% to 85% of families
  • Threatened with abandonment in 8% to 48%
  • Spanking with object 18% to 75%
  • Shaking 12% to 59%
un convention on the rights of the child selected rights1
UN Convention on the Rights of the Child - Selected Rights

1. All children have the right to what follows, no matter what their race, colour ,sex, language, religion, political or other opinion, or where they were born or who they were born to.

2. You have the special right to grow up and to develop physically and spiritually in a healthy and normal way, free and with dignity.

3.You have the right to a name and to be a member of a country.

4. You have a right to special care and protection and to good food, housing and medical services.

5. You have the right to special care if handicapped in any way.6. You have the right to love and understanding, preferably from parents and family, but from the government where these cannot help.

un convention on the rights of the child selected rights2
UN Convention on the Rights of the Child – Selected Rights

7. You have the right to go to school for free, to play, and to have an equal chance to develop yourself and to learn to be responsible and useful. Your parents have special responsibilities for your education and guidance

8. You have the right always to be among the first to get help.

9. You have the right to be protected against cruel acts or exploitation; for example, you shall not be obliged to do work which hinders your development either physically or mentally. You should not work before a minimum age and never when that would hinder your health or your moral and physical development.

10. You should be taught peace, understanding, tolerance and friendship among all people.

prevention the optimal goal
Prevention: the Optimal Goal
  • Traditionally consists of early identification of child maltreatment and interventions to protect the child
  • A better approach is to identify known risk factors and proactively provide programs and resources to reduce these risks