Child Abuse and Neglect is Everyone’s Problem

Child Abuse and Neglect is Everyone’s Problem Kara Z. McDaniel, NCC, LPC, PH.D. Fundamentals of Behavioral Medicine Department of Family and Preventive Medicine-PA Program

Objectives • Be able to list and define the four categories of child maltreatment • Discuss child abuse risk factors in addition to the barriers that health care professionals face in identifying child maltreatment • Be able to recognize the symptoms of child maltreatment • Know how to interview and document findings using the ASSERT Model • Learn the legal reporting requirements for health care professionals as well as how to report child maltreatment

Extent of Problem • Child Abuse and Prevention Act (CAPTA) of 1974 • Issued a mandate that federal public organizations monitor the following on an annual basis: • Types and incidence of maltreatment • Types and ages of victims • Types of perpetrators (Public Law 93-247) • Rate of victimization in 1999 • 11.8% • Confirmed cases of maltreatment in 1999 • 826,162 (Victimization rates 1990-1999; US Department of Health and Human Services, 1999)

Extent of Problem, cont. • More children suffer from neglect than any other forms of abuse (Maltreatment rates 1999, US Department of Health and Human Services, 1999) • Children under the age of 1 are of greatest risk for outcomes that are fatal (Maltreatment Fatalities by Age and Sex, 1999, US Department of Health and Human Services, 1999)

Extent of Problem, cont. • Approximately 80% victims • Abused by their parents • mothers committed 44.7% of different types of abuse (Perpetrator Relationship to Victim, 1999, US Department of Health and Human Services, 1999) • Fathers/other male perpetrators • Responsible for 22% of all child abuse and 63% of sexual abuse (Perpetrator Relationship to Victims by Maltreatment Type, 1999, US Department of Health and Human Services) • Children under the age of 1 • 70% of abuse committed by female child care providers • 64% being neglect (Juvenile Justice Bulletin, 1999)

Extent of Problem, cont. • Race and ethnic variables in the incidence of child maltreatment • African Americans • 25.2% • American Indian • 20.1% • Hispanics • 12.6% • Whites • 10.6% • Asian Americans • 4.4% (Victimization Rates by Race and Ethnicity, 1999, US Department of Health and Human Services, 1999)

Categories of Maltreatment • Child Abuse and Prevention Act (ACPTA) recognizes four categories of maltreatment • Physical Abuse • Sexual Abuse • Neglect • Emotional abuse

Definitions • Maltreatment • “Victims of maltreatment are defined as children who are found to have experienced substantiated or indicated maltreatment or are found to be at risk of experiencing maltreatment” (National Clearinghouse on Child Abuse and Neglect Information) • Child Abuse and Neglect • “Any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse, or exploitation, or an act of serious harm” (42 USC 5101 et seq; 42 USC 5116 et seq. West Supp. 1998)

Definitions, cont. • Sexual Abuse • “The employment, use, persuasion, inducement, enticement, or coercion of any child to engage in, or assist any other person to engage in, any sexually explicit conduct or simulation of such conduct for the purpose of producing a visual depiction of such conduct” (42 USCA Par 5106g (4) West Supp, 1998)

Definitions, cont. • Although definition standards have been established by CAPTA, definitions do vary from state to state • For instance, some states have the following: • Poverty exemption • as a cause of abuse/neglect • Religious exemption • “good faith” failure to treat child medically due to religious beliefs (Kirk et al., p. 206, 2003) • Religious practices within some cultures • African Muslim Culture • Female circumcision • Illegal in the United States although sometimes practiced by persons who have immigrated to the U.S. • May result in abuse charges (Kirk et al., 2003)

Elements of Child Maltreatment • Physical Abuse • “Beatings with an object, scalding, burning, severe physical punishment; Munchausen by proxy (inflicting harm to feign or induce illness)” (Kirk et al., 2003) • Sexual Abuse • “Incest, rape, statutory rape, sexual assault by relative or stranger, fondling of sexual areas, exposure to indecent acts, sexual rituals, involvement in child pornography or prostitution, insertion of foreign objects into mouth, anus or vagina, forcing child to perform oral sex or other unnatural acts” (Kirk et al., 2003)

Elements of Child Maltreatment, cont. • Neglect • “Intentional or unintentional failure to perform appropriate parenting or caretaker functions: physical, nutritional, emotional, supervisory, medical, educational neglect or abandonment” (Kirk et al., 2003) • Emotional Abuse • “Verbal abuse, belittlement, symbolic acts to terrorize a child (e.g., locking child in dark closet or basement), lack of nurturance, or availability by caretaker (Kirk et al., 2003)

Child Abuse Risk Factors • Potential of abuse is associated with factors related to the following: • Parents • Children • Families • Environment (Juvenile Justice Bulletin, 1999) • No single psychological profile seems to be characteristic with regard to perpetrators of child maltreatment (Kirk et al., 2003) • Consistent finding within child abuse literature • Maltreating parents often report that they have also been a victim of maltreatment during childhood (Goldstein and Keller, 1985)

Child Abuse Risk Factors, cont. • How may Maslow’s Hierarchy of Needs explain the multigenerational process of child maltreatment? • Abuse/neglect is directly correlated to psychosocial situation of the parent/caregiver (Bethea, 1999) • Low income families • Young single parents have highest poverty rate • Economic resources may be limited • Lacks social support • Few parenting skills (Kirk et al., 2003) • Low income families with large number of children (Sledlak and Broadhurst, 1996) • Within poor communities, medical clinics are often insufficient • Lack of continuity of care • Lack of transportation may be barrier to seeking treatment (Kirk et al., 2003)

Child Abuse Risk Factors, cont. • Some children are more vulnerable to maltreatment compared to other children • Following children are more at risk: • Temperaments that are difficult to manage • Children perceived as different • Children with handicaps/disabilities (Childrens’ Bureau: 10 years of reporting child maltreatment, 1999, DHHS) • Drug abuse by one or both parents • Impacts the parent’s ability to care for child • Creates chaos and dysfunction within familial system (Kirk et al., 2003)

Child Abuse Risk Factors, cont. • Drug use by pregnant mother • Directly related to neonate’s health and temperament • Infants addicted to crack • Hyper excitable, therefore, difficult to parent (Kirk et al., 2003) • Domestic violence within home • Children are at risk for harm in addition to psychological trauma (Kerker, Horwitz, et al., 2000)

Identification of Maltreatment • Recognition by a variety of professionals has improved greatly since 1979 • Due to distribution of materials training professionals on recognition • Improvement in recognition is most noticeable within school environment • School personnel • Largest source of reports (54%) than all other sources combined (Kirk et al., 2003) • Concern is that recognition within medical settings is limited to serious injuries as opposed to psychological and/or behavioral symptoms (Cohn, Salmon, and Stobo, 2001)

Barriers to Identifying Maltreatment • Barriers to identifying child maltreatment in medical setting is similar to those barriers in identifying domestic violence • Training • May feel as though they have not been adequately trained • Emotional barriers • Difficult to understand and/or acknowledge how a parent/caregiver can abuse a child when he/she is supposed to protect the child • May unconsciously block that abuse is occurring as a result of provider’s past history of abuse • Stress associated with treating children who are victims of maltreatment (Kirk et al., 2003)

Barriers to Identifying Maltreatment, cont. • Time constraints • Limit their time to just treating the injuries rather than also addressing the emotional trauma • May feel as though the social worker should further explore/address the emotional trauma associated with the abuse

Team Approach • Make sure there is an office/clinic protocol in place • Who is involved? • How will legal notification be executed? • Recommendation • Designate a pediatric abuse specialist • Trained to interview, conduct examination, and document findings • If needed, set up a referral process to such experts within community (Kirk et al., 2003)

Team Approach, cont. • Referrals • Domestic Violence Coalition or Domestic Abuse Shelter • Trained interviewers • Will know of pediatricians who are trained in conducting examinations with regard to child abuse and collecting forensic evidence • Domestic Abuse Shelter or Child Protective Services (CPS) • trained interviewer may be able to come to medical clinic while child is present • National Child Abuse Hotline • 1-800-352-6513 • Use to locate pediatrician who specializes in child maltreatment or trained interviewer (Kirk et al., 2003)

Symptoms of Child Maltreatment • Physical abuse symptoms are akin to those symptoms observed on adult victims of domestic abuse • Head injuries • Outer areas of arms • Bruises/welts on either torso and/or legs • Broken ribs or long bones • Any identified marks left by an object • Belt buckle marks • Cigarette marks • Often justified by parent(s) as a form of discipline (Kirk et al., 2003)

Symptoms of Child Maltreatment, cont. • Shaken baby syndrome • Does not occur on its own • Associated with other forms of abuse/neglect • May occur in combination • both internal and external injuries • Usually occurs in infants and babies under the age of 2 • Parent has low tolerance level • Gets extremely frustrated • Shakes, hits, or throws baby to stop the crying from occurring (Kirk et al., 2003)

Symptoms of Child Maltreatment, cont. • Shaken Baby Syndrome • Leading cause of serious head injuries to infants under the age of one • Committee on Child Abuse and Neglect of the American Academy of Pediatrics (AAP) • Suggests that if any serious head injury is indicated in children under the age of two, case should be investigated for possible abuse (Jenny, 1999) • Retinal hemorrhages in children under the age of two • Should raise a red flag for possible abuse (Committee on Child Abuse and Neglect, American Academy of Pediatrics, 2001)

Symptoms of Child Maltreatment, cont. • Shaken Baby Syndrome • Behavioral symptoms that may be associated with Shaken Baby Syndrome • Poor feeding • Vomiting • Lethargy • Irritability • Be careful! • Above symptoms may also be attributed to a viral illness • Feeding dysfunction • Colic (Kirk et al., 2003) • Correct diagnosis • Missed up to 1/3 of the cases due to symptoms that may be less obvious (Kivlin, 2001) • AAP Committee suggests that a diagnostic team of specialists be comprised in order to make correct diagnosis (Kirk et al., 2003)

Interviewing • Reassure child • What are some ways in which you may be able to reassure the child? • Use questions that are open-ended and short • Avoid leading questions • Be aware that you may be the first person child has informed of abuse (Kirk et al., 2003) • What are some reasons that the child may have difficulty in confiding in you? • Be cognizant of fact that child may not be able to understand types of questions or lack the vocabulary in which to explain what has occurred (Kirk et al., 2003)

Interviewing, cont. • Guidelines set forth by American Academy of Pediatrics • Suggests not to interview children under the age of 3 (Kirk et al., 2003) • ASSERT Model • Guide used by medical professionals to assess for child/elder abuse and/or neglect, sexual abuse, and domestic violence • Ask • Sympathize • Safety • Educate • Record • Treat

Documentation • What are the two main reasons that careful documentation is vitally important? • Body map • Used to document location of injuries • Estimate and record age of injuries • Note color • For instance • hematoma • Note degree of healing • For example • Burn/abrasion (Kirk et al., 2003)

Reporting Child Maltreatment • Mandated reporters • What is a mandated reporter? • Who is required by law to make a report? • “States mandate reporting child maltreatment from any professional who has reasonable cause to believe that a child is being neglected or abused; or believes upon examination that a child has been seriously physically injured, sexually abused or sexually assaulted; observes a child being subjected to conditions that are likely to result in abuse or neglect; or knows of or suspects institutional abuse and neglect” (Kirk et al., p. 217, 2003)

Reporting Child Maltreatment, cont. • If abuse/neglect is suspected, determine if report has already been made • DO NOT ASSUME that report has already been made • If uncertain, call in report (Kirk et al., 2003) • How to report • Contact Child Protective Service Agency in the county/parish in which abuse occurred • CPS will then begin their investigation and notify police if warranted

Reporting Child Maltreatment, cont. • If you believe that child is in imminent danger, contact 911/local police immediately

Questions or Comments?

Child Abuse and Neglect is Everyone’s Problem