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Interdisciplinary Curriculum on Child Maltreatment


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Title: Interdisciplinary Curriculum on Child Maltreatment

Interdisciplinary Curriculum onChild Maltreatment
  • International Society for
  • The Prevention of Child Abuse and Neglect

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

Why is child maltreatment a concern?
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)

Extent of the Problem
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
  • (WHO 2000)

Extent of the ProblemNon-Fatal Abuse
  • Yelling/Screaming at child in 70 to 85 of
  • Threatened abandonment in 8 to 48
  • Spanking with object 18 to 75
  • Shaking 12 to 59

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

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
  • 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

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

Why is child maltreatment so common?
Multilevel Risk Factors(WHO)
  • Child factors
  • Parental factors
  • Family factors
  • Community factors
  • Societal factors

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

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

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

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

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

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

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

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

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

What are our Responsibilities?
  • Defined by many factors- Moral Ethical-
    Professional Clinical- Legal

Reporting Laws
  • What are the laws in your community?

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

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
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

Types of Child Maltreatment
  • Physical
  • Neglect
  • Sexual
  • Psychological

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)

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

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
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

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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

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

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

  • 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)

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

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

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

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
  • (From ISPCAN WHO in Preventing
  • Maltreatment,

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
  • Discuss of times they disclose before believed

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.

Case Study Sexual abuse
  • A 7 year old girl tells her mother that a boy
    touched her private area

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

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

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

  • Maltreatment, 2006)

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

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

What is an Interdisciplinary Investigative Team
  • Train and work together
  • Understand each others roles and strengths
  • Establish common protocols for receiving reports,
    information sharing, interviewing and decision

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

Interdisciplinary Training Why dont we do it
  • 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

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

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// )

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// )

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// )

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

Treatment and Follow-Up
  • Every child must be assessed for effects of
  • 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

  • .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)

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

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

Individual Prevention Strategies
  • Reducing unintended pregnancies
  • Increasing access to prenatal and postnatal
  • Training children to avoid potentially abusive
    situations (Preventing Child Maltreatment,

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

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

  • 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,