Interdisciplinary Curriculum on Child Maltreatment

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Interdisciplinary Curriculum onChild Maltreatment

• International Society for
• The Prevention of Child Abuse and Neglect

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Developed by ISPCAN Interdisciplinary Curriculum
Development Taskforce

• Members Dr Robert Morris (Chair), Dr. Hiroaki
  Ishikawa (Co-Chair), Dr. Wambui Njuguna, Dr. Reem
  Abu Hassan, Prof. Jingqi Chen, Prof. Elena
  Volkova, Dr. Anne Hollows, Ms. Clemencia Ramirez
• Dr. Howard Dubowitz, Facilitator
• Dr. Barbara Bonner, Editor
• Ms. Kimberly Svevo and Dr. George Palamattam,
  ISPCAN Staff Support

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Why is child maltreatment a concern?
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Child Abuse

• All forms of physical /or emotional ill
  treatment, sexual abuse, neglect or negligent
  treatment or commercial or other exploitation,
  resulting in actual or potential harm to a
  childs health, survival, development or dignity
  in the context of a relationship of
  responsibility, trust or power
• (World
  Health Organization 1999)

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Extent of the Problem
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Extent of the ProblemFatal Cases of Abuse

• 57,000 deaths of children lt15 years
• Rate lt age 4 is twice that seen in older children
• Rate much higher in poorer areas(2.2/100000 boys
  in highest income groups and 17.9 in lowest
  income groups)
• Most common causes head injury, abdominal
  injury
• (WHO 2000)

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Extent of the ProblemNon-Fatal Abuse

• Yelling/Screaming at child in 70 to 85 of
  families
• Threatened abandonment in 8 to 48
• Spanking with object 18 to 75
• Shaking 12 to 59

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UN Convention of the Rights of the Child (UNCRC)

• A child is every human lt age 18 years
• Signed by most members of the United Nations

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UN Convention on the Rights of the Child

• 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.
• . 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 a 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 way6. You have the right to
  love and understanding, preferably from parents
  and family, but from the government where these
  cannot help

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UN Convention on the Rights of the Child

• 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
  usefulYour 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, e.g. you shall not be
  obliged to do work which hinders your development
  both physically and mentallyYou should not work
  before a minimum age and never when that would
  hinder your health, and your moral and physical
  development
• 10. You should be taught peace, understanding,
  tolerance and friendship among all people

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Why is child maltreatment so common?
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Multilevel Risk Factors(WHO)

• Child factors
• Parental factors
• Family factors
• Community factors
• Societal factors

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Childrens Risk Factors

• Age - younger children
• Gender - girls at higher risk for infanticide,
  sexual abuse, forced prostitution, educational
  and nutritional neglect - boys at
  higher risk for harsh physical punishment
• Special Characteristics twins, children with
  handicaps, prematurity, unwanted pregnancy

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Parental/Caregiver Risk Factors

• Young age
• Single parent
• Unwanted pregnancy
• Poor parenting skills
• Early exposure to violence
• Substance abuse
• Inadequate prenatal care
• Physical or mental illness
• Relationship problems

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Family Risk Factors

• Overcrowded living circumstances
• Poverty
• Social isolation
• Major stress
• Domestic violence

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Community/Societal factors

• Non-existent or poorly enforced child protection
  laws
• Decreased value of children (minority, disabled,
  gender)
• Social acceptance of violence
• Cultural norms
• Media violence
• Social inequities
• Organized violence (wars, high crime rates)

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Impact of Maltreatment on Children

• Every child is affected
• Several factors determine degree of impact - the
  type and intensity of the abuse - the
  personality of the child - the presence of
  protective factors
• There can be Physical, Psychological, Behavioural
  and Societal consequences

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Physical Consequences

• injuriesi.e fractures, lacerations, head injury,
  death
• Impaired brain development

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Psychological Consequences

• Common
• Immediate issues of isolation, fear and lack of
  trust
• lifelong problems of depression, low self-esteem,
  relationship difficulties
• Impaired cognitive development

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Behavioural Consequences

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

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Societal Costs

• Direct costs in USA estimated at 24 Billion US
  in 2003
• Indirect Costs estimated to be 69 Billion
  (Prevent Child Abuse America)
• Can we afford not to provide funds for
  prevention?

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What are our Responsibilities?

• Defined by many factors- Moral Ethical-
  Professional Clinical- Legal

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Reporting Laws

• What are the laws in your community?

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Roles Child Welfare

• To provide child protective services
  including- to evaluate reports of alleged child
  maltreatment- to ensure childrens
  safety- to facilitate remedial services

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Roles - Police
Responsible for law enforcement This includes-
investigating to determine if a crime has been
committed - laying of charges when evidence
suggests a crime has been committed
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Roles - Health Care

• To provide general medical care
• To identify children at risk
• To inform Child Welfare when suspicions of child
  abuse arise
• To investigate and treat illness injury
• To provide ongoing medical mental support
  directly and through referral to available
  community services

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Types of Child Maltreatment

• Physical
• Neglect
• Sexual
• Psychological

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Physical Abuse

• The intentional use of force against a child
  that results in harm for the childs health,
  survival, development or dignity
• (From ISPCAN WHO in Preventing Child
  
• Maltreatment 2006)

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Clues of Physical Maltreatment

• Injury inconsistent with history or childs
  development
• Shape of lesions i.e. hand print, cigarette burns
• Multiple Injuries at various stages of healing
• Family history of abuse
• Childs report

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Physical Abuse
Common Presentations a) bruises b)
fractures c) burns d) head trauma i.e. Shaken
Baby Syndrome or direct blows to the head
e) abdominal trauma
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Case Study Bruises

• 3 month old has bruises on her face and arms.
  Mother says she noticed them when she fed her
  this morning They were not there when put to bed
  last nightShe says the baby must have fallen
  from the crib

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Case Study Bruises

• An 11 year old boy is noted to be uncomfortable
  in his seat at school. He tells the teacher that
  he was strapped by his father for rudenessHe
  shows her his back with many bruises and strap
  marks

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Case Study Fracture

• A grandmother notices that her 2 month old
  grandson is crying a lot and not consolable
• She also says he is not moving his left arm and
  cries harder when she tries to move it. She
  brings him to a be examined.
• An x-ray shows a fracture of the forearm

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Case Study Abusive Head Injury

• A young, single mom complains that her 3 month
  old daughter is a difficult child, always
  fussy, crying, difficult to feed and irritable
• A week later the girl is brought to the hospital
  unconscious and breathing poorly

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Case Study Burns

• A 22 month old comes to hospital with burns to
  her buttocks only. His mom says she got into a
  hot bath when mom was out of the room and scalded
  herself

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Physical Discipline

• Controversial and ingrainedSpare the rod, Spoil
  the child
• Widespread, a parents right
  BUT
• Is it effective?
• Does it perpetuate child maltreatment abuse?
• What other forms of discipline are effective?

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Neglect

• Failure, by a parent or other family members, to
  provide for the development and well-being of a
  child, where they are in a position to do so, in
  one of the following areas health, education,
  nutrition, emotional development, shelter and
  safe living conditions
• (From ISPCAN WHO in Preventing Child
• Maltreatment, 2006)

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Case Study Neglect

• A 10 year old boy known to have diabetes is
  brought to an emergency department because of
  dehydration and lethargy. You learn that he has
  not taken his insulin for 2 days because it has
  run out

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Case Study Neglect

• A 9 year old girl is seen for repeated injuries
  over a 6 month period- 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

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Case Study Neglect

• A 10 month old girl is seen by a public health
  nurse and is noted to be thin
• Her weight is much less than the 5th percentile,
  her height at the 10th percentile
• 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

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Child Sexual Abuse

• Involvement of a child in sexual activity that
  he/she- does not fully comprehended, - is
  unable to give informed consent to,- for which
  they are not developmentally prepared- 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)

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Sexual Abuse

• Understand often a hidden assault
• All forms of sexual activity are included, not
  just intercourse other physical types
• Includes child prostitution and exposure to
  pornography
• Discuss of times they disclose before believed

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Case Study Sexual Abuse

• A 6 month old girl is brought to a local nurse
  because mom found blood in her diaper. She is
  happy and healthy looking.
• Mom says only she and her 17 year old daughter
  care for the baby. The daughter babysat the
  previous evening.

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Case Study Sexual abuse

• A 7 year old girl tells her mother that a boy
  touched her private area

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Case Study Sexual Abuse

• A 13 year old girl tells her friend that her
  uncle gets in bed with her and makes her do bad
  things.

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Case Study Sexual Abuse

• A 9 year old boy refuses to go to school because
  one of his teachers forces the boy to kiss his
  bird.

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Emotional Psychological Abuse

• Failure of a parent or guardian to provide a
  developmentally appropriate supportive
  environment.
• These acts have a high probability of damaging
  the childs physical or mental health or his
  physical, mental, spiritual, moral or social
  development
• Types include restriction of movement,
  belittling, blaming, threatening, frightening,
  ridiculing, discrimination, rejection
  (From ISPCAN WHO in Preventing Child
• 
  Maltreatment, 2006)

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Conditions That Mimic Abuse

• Important to recognize that most injuries are the
  result of innocent events
• Behavioural changes occur for many reasons. While
  it is important to consider maltreatment when
  assessing this, it is most important to remember
  that maltreated children do not exhibit any
  specific behaviour

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Evaluating Possible Child Maltreatment

• Two main groups - child protection (Social
  Workers)- criminal justice (Police and Courts)
• Child Protection focus is reducing risk to child
  and strengthening family
• Criminal Justice focus is to identify those who
  commit crimes and hold them accountable
• Interdisciplinary evaluation is ideal

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Potential Problems with Separate Evaluations

• Investigations run parallel
• No coordination little sharing of information
• multiple interviews
• Potential contamination of story or evidence
• Potential contradictory conclusions
• Further distrust and increased stress for all
  involved

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What is an Interdisciplinary Investigative Team
Approach?

• Train and work together
• Understand each others roles and strengths
• Establish common protocols for receiving reports,
  information sharing, interviewing and decision
  making

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Interdisciplinary Training Why should we do it?

• Efficient
• Less stress
• Each group brings its strengths
• Better outcome for child family
• Not difficult if started early in training

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Interdisciplinary Training Why dont we do it
now?

• each groups primary mandate is different
• each groups training is different
• ignorance of each others jobs abilities
• concern about confidentiality
• limited resources
• not considered important
• designed to react to abuse, not to prevent it

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Overview of Interviewing Children

• Requires training and expertise
• Children can give good accurate information
• Poor interviewing may bias childs account

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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 From Darkness to Light
  found at HTTP//Darknesstolight.org )

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How to React

• If a child tells he or she has been abused-
  Believe the child. Children rarely lie about
  abuse. Do not ignore or deny what they are
  saying.- commend the child for telling you
  about the experience. Make sure the child
  understands that abuse is not their fault.-
  Stay calm. Recognize how you respond accept the
  information is critical to the child. Children
  stop talking if they think what they are saying
  makes you upset. Make sure the child knows you
  will listen.(from 7 Steps to Protecting
  Children published by From Darkness to Light
  found at HTTP//Darknesstolight.org )

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How to React

• - Encourage the child to talk but dont ask
  leading questions about details. This can alter
  the childs memory of events- Make sure the
  child is safe and no more abuse can occur while
  you seek help.- Contact social services or
  police. Let trained skilled professionals talk to
  your child in a non-threatening way.(from
  7Steps to Protecting Children published by
  Darkness to Light)
• found at HTTP//Darknesstolight.org )

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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 that says a boy touched her

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Treatment and Follow-Up

• Every child must be assessed for effects of
  maltreatment
• Acute medical therapy must be given as required
  for physical injury
• Need for mental health support must be assessed
• Family members should also be assessed and
  provided counseling when required

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Prevention

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

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Prevention the Optimal Goal

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

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Prevention Strategies for Child Maltreatment

• Three levels of programs - Individual-
  Relationship- Societal Community(Preventing
  Child Maltreatment, 2006)

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Individual Prevention Strategies

• Reducing unintended pregnancies
• Increasing access to prenatal and postnatal
  services
• Training children to avoid potentially abusive
  situations (Preventing Child Maltreatment,
  2006)

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Relationship Prevention Strategies

• Home visitation programs
• Training programs for parents (Preventing
  Child Maltreatment, 2006)

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Societal Community Based Prevention Programs

• Implementation of legal reform human rights
• Introduction of beneficial social economic
  policies
• Change cultural social norms that support
  violence against children
• Reduce environmental risk factors (Preventing
  Child Maltreatment, 2006)

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• We owe children, the most valuable citizens in
  any society, a life free from violence and fear
• Nelson Mandela
• (from World Report on Violence Health,
  2002)