Presentation 2. Step 1 of the Public Health Approach to Child Maltreatment Prevention:

1. Presentation 2. Step 1 of the Public Health Approach to Child Maltreatment Prevention: Defining Child Maltreatment

2. Objectives The core learning objective of this module is to provide a basic understanding of the nature of child maltreatment, part of step 1 of the public health model to child maltreatment, by focusing on definitions of child maltreatment and related concepts.

3. The Four Steps of the Public Health Approach 1.Define & describe What is the Problem? 2.Identify risk What are the risk factors and causes? 4. Scaling up and cost-effectiveness Implement on large scale & cost 3.Develop and evaluate interventions What works and for whom? • Systematic, evidence-based approach with 4 steps: • 1.Define and Describe • 2.Identify Risk • 3.Develop and Evaluate Prevention Programmes • 4. Scaling Up and Cost-Effectiveness

4. Outline • Typology of Violence and Child Maltreatment • Definitions and Characteristics of Child Maltreatment • Concept of Adverse Childhood Experiences • Operational Definitions of Child Maltreatment and Survey Instruments • Summary and Conclusion

5. Typology of Violence and Child Maltreatment

6. Typology of Violence The World Health Organization (WHO) developed a typology that characterizes the different types of violence and the links between them. Graphic: WHO

7. Types of Violence The proposed typology divides violence into three broad categories according to the characteristics of those committing the violent act: • Self-directed violence • Interpersonal violence • Collective violence

8. The Nature of Violent Acts Within the typology of violence categories, four types of violent acts can occur: • Physical abuse • Sexual abuse • Emotional abuse or psychological abuse • Neglect

9. Child Maltreatment within the Typology of Violence Within this typology, child maltreatment is a form of interpersonal violence that often takes place within the family. Violence against children can be: • Physical • Sexual abuse • Psychological (or emotional) • Deprivation and neglect • Commercial or other exploitation

10. Definition and Characteristics of Child Maltreatment

11. Definition of Child Maltreatment Child maltreatment is defined by WHOas the following: “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 the child’s health, survival, development or dignity in the context of a relationship of responsibility, trust, or power.” Report of the consultation on child abuse prevention, 29–31 March 1999. (1999).Geneva, World Health Organization.

12. Perpetrators of Child Maltreatment May include: • Parents and other family members • Caregivers • Friends • Acquaintances • Strangers • Others in authority – such as teachers, soldiers, police officers, and clergy • Health care workers • Other children

13. Four Types of Child Maltreatment by Caregivers This short course focuses primarily on acts of commission and omission by parents or caregivers that result in harm to the child. In particular, it explores the prevalence of, risk factors for, and consequences of four types of child maltreatment by caregivers, namely: • Physical abuse • Sexual abuse • Emotional abuse • Neglect

14. Challenges in Addressing Child Maltreatment Violence against children by adults within the family is one of the least visible forms of child maltreatment. It is nonetheless widely prevalent in all societies. Child maltreatment by parents and caregivers gives rise to difficulties when designing strategies for prevention and victim services, since the perpetrators of the maltreatment are also the source of nurture for the child.

15. Child Maltreatment and Cultural Issues Any global approach to child abuse must take into account the differing standards and expectations for parenting in the range of cultures around the world. Different cultures have different rules about what are acceptable parenting practices. Research indicates that there appears to be general agreement across many cultures that child abuse should not be allowed, and virtual unanimity where very harsh disciplinary practices and sexual abuse are concerned.

16. Child Maltreatment is a Complex Issue The dynamics and factors that drive child maltreatment all differ markedly according to: • The victim’s age • The setting in which the maltreatment occurs • The relationship between victim and perpetrator

17. Exposure to Multiple Types of Child Maltreatment Many children are exposed to multiple types of child maltreatment. This is especially troubling in the context of studies that show the negative effects of child maltreatment rise with the number of types of maltreatment to which a child is exposed

18. Consequences of Child Maltreatment In the majority of situations, physical injuries are of less consequence than the acute and long-term mental and physical health consequences. In extreme cases, child maltreatment can lead to death.

19. Child Maltreatment Often Occurs Alongside Other Types of Violence Child maltreatment by adults within the family is frequently found in the same settings as intimate partner violence.

20. The Concept of Adverse Childhood Experiences

21. Adverse Childhood Experiences by Type Adverse childhood experiences or ACEs is a broader concept than child maltreatment and includes the following 10 types of experiences, grouped into three categories: Abuse • Emotional – recurrent humiliation • Physical – beating, not spanking • Contact sexual abuse Neglect • Physical • Emotional Household dysfunction • Mother treated violently • Household member was alcoholic or drug user • Household member was imprisoned • Household member was chronically depressed, suicidal, mentally ill, in psychiatric hospital • Child not raised by both biological parents

22. Categories of Adverse Childhood Experience Adapted from: Finding Your ACE Score.

23. Operational Definitions of Child Maltreatment and Survey Instruments

24. Operational Definitions of Child Maltreatment The international standard diagnostic classification is the International Classification of Diseases (ICD). Its categories are useful for classifying and recording cases and establishing data collection systems. This course recommends that health care facilities should code child maltreatment cases using the ICD.

25. US Federal Government Department of Health and Human Services Rules for Assigning ICD-9 E-Codes to Known Child Maltreatment Cases The assignment of ICD codes to a case is done only after medical professionals have provided treatment and have done their best to reach a definitive conclusion as to the external causes of the presenting problem. The two main components of an ICD classification concern the nature of the presenting condition (for instance, traumatic subdural haemorrhage) and its external cause. Information is also included about the relationship of the perpetrator to the victim, where this is known.

26. Survey Instruments for Child Maltreatment To define, classify, and measure child maltreatment, a number of survey instruments have been developed. These can be incorporated into more extensive surveys that include assessments of: • Types of abuse • Risk factors • Health, social, and educational consequences

27. Four Screening Tools Among the many types of survey instruments used in population-based studies of child maltreatment, four are particularly suitable for yielding information that is useful for designing prevention polices and programmes. These instruments are: • Parent-Child Conflict Tactics Scale • Adverse Childhood Experiences Questionnaires • Lifetime Victimization Screening Questionnaire • ISPCAN Child Abuse Screening Tools

28. Summary and Conclusion

29. Summary and Conclusion This module reviewed: • The WHO typology of violence and the place of child maltreatment within it • Definitions and characteristics of child maltreatment and the different types of child maltreatment • The concept of adverse childhood experiences • Operational definitions of child maltreatment and survey instruments

30. References Butchart, A. Phinney, A. Furness, T. (2006). Preventing child maltreatment: A guide to taking action and generating evidence. Geneva, World Health Organization. Gilbert, R. Widom, C. Browne, K. Fergusson, D. Webb, E. Janson, S. (2009). Burden and consequences of child maltreatment in high-income countries. Child Maltreatment 1. 373 (9667), 1-14. Felitti, V. Anda, R. (2009). The Relationship of Adverse Childhood Experiences to Adult Health, Well-being, Social Function, and Healthcare v 5-21-07. In Lanius, R. Vermetten, E. (Eds.), The Hidden Epidemic: The Impact of Early Life Trauma on Health and Disease (pp.1-17). Cambridge, UK: Cambridge University Press Finding Your ACE Score. Retrieved June 11, 2010, from http://www.acestudy.org/files/ACE_Score_Calculator.pdf The Future of Children. (2009) Preventing Child Maltreatment. 119(2), 3-21. Krug, E. et al. (2002). World report on violence and health. Geneva, World Health Organization. Report of the consultation on child abuse prevention, 29–31 March 1999. (1999).Geneva, World Health Organization.

31. Discussion: Definitions of Child Maltreatment As a large group, discuss examples of how different ways of defining child maltreatment might affect findings about prevalence rates. What implications might this have for prevention policies and programmes?