Child abuse treatment and follow-up: Can the pediatrician help improve outcome?

The pediatric role in the management of child abuse and neglect has been largely limited to detecting and reporting cases, with little involvement in long-term treatment and follow-up. A review of published clinical experience indicates that customary protective services' “treatment” strategies are all too often ineffective at preventing reabuse, improving child health and developmental status, and improving family functioning. When foster care is used as a treatment modality, children run the added risk of never returning home, nor being freed for adoption, and they may suffer the emotional harm of repeated foster placements. This situation is likely to worsen, in the light of recent cutbacks in social service programs, at a time of rising reports of maltreatment. The pediatrician is widely recognized as an expert in children's health and development, and he can effectively use his position to influence the management of cases and thereby the outcome, by actively participating in treatment decision making and providing close follow-up in a limited but important way. In order to do this, he must first become acquainted with the effects of maltreatment upon children's health and development and with the general principles and available modalities of treatment. He must be sympathetic and supportive of the difficult role of the protective service worker who must make treatment decisions. His role is to assist the worker by making medical resources available in order to adequately define the child's needs and the capacity of the family to meet those needs. Essential to answering these questions is the availability of a child development clinic and mental health resources. After ensuring that the child and family are thoroughly assessed and the treatment plan tailored to the child's and family's needs, the pediatrician provides continual longitudinal follow-up, monitoring the child's health and developmental status. If the child is placed in foster care, the physician observes the child's adjustment and provides advice and consultative assistance when needed to help foster parents manage health, developmental or behavior problems. Periodically he also meets with the natural family to keep them informed about their children's health and development and to ensure they are making good use of treatment. Finally, he communicates closely with the child protective service worker and participates in interdisciplinary staff meetings to review and evaluate treatment progress in the hopes of shortening the time needed to make decisions regarding placement.     

Joining two social institutions to counter rural Alaskan child abuse

Change in social customs and institutions is usually a slow process. This seems particularly true in attitudes about child abuse. Two key elements for change are being utilized for child protection in a rural area of Alaska with a predominantly Caucasian population. First, application of an old church custom of "constructive gossip" by volunteers is changing this rural community attitude about children. Second, use of an innovative federal government health care delivery program has established this community's first obstetric and pediatric service. With the oil boom in Alaska, widespread family disruption with frequent child abuse and neglect has become commonplace. Despite the oil tax wealth, State of Alaska Child Protection Services are strained to keep up with family and community violence. Deliberate cooperation with local community, church and service organization leaders is helping keep up with child protection needs. The obstetric and pediatric specialists of the National Health Service Corps non-profit practice were co-leaders, along with community leaders, in starting a lay volunteer service called "Friends of Families." Working cooperatively with the state child protection office, 24 families have received assistance from parent aides of Friends of Families. The influence of these two key elements of change on rural community attitudes and institutions are described.     

Families at risk of poor parenting: A model for service delivery,assessment, and intervention

The At Risk Parent Child Program is a multidisciplinary network agency designed for the secondary prevention of poor parenting and the extremes of child abuse and neglect. This model system of service delivery emphasizes (1) the coordination of existing community resources to access a target population of families at risk of parenting problems, (2) the provision of multiple special services in a neutral location (ambulatory pediatric clinic), and (3) the importance of intensive individual contact with a clinical professional who serves as primary therapist, social advocate and service coordinator for client families. Identification and assessment of families is best done during prenatal and perinatal periods. Both formal and informal procedures for screening for risk factors are described, and a simple set of at risk criteria for use by hospital nursing staff is provided. Preventive intervention strategies include special medical, psychological, social and developmental services, offered in an inpatient; outpatient, or in-home setting. Matching family needs to modality and setting of treatment is a major program concern. All direct services to at risk families are supplied by professionals employed within existing local agencies (hospital, public health department, state guidance center, and medical school pediatric clinic). Multiple agency involvement allows a broad-based screening capacity which allows thousands of families routine access to program services. The administrative center of the network stands as an independent, community-funded core which coordinates and monitors direct clinical services, and provides local political advocacy for families at risk of parenting problems.     

Child maltreatment in European- and Hawaiian-Americans

The purpose of this study was to investigate the patterns and possible determinants of child abuse and neglect in European- and Hawaiian-Americans. Abuse was overrepresented in the Hawaiian-Americans while neglect was over-represented in the European-Americans. There were several significant results regarding stress and personal factors that played roles in the maltreatment of the children within each culture. For example, family discord, new baby/continuous child care, loss of control and lack of tolerance were important correlates of abuse for Hawaiian-Americans. The stresses of recent relocation, social isolation and family discord as well as the personal factors of mental health problems and alcohol/drug dependence were important correlates of neglect for European-Americans. The results indicate that to understand the patterns, causes, treatment and prevention of child maltreatment, cultural as well as individual factors must be assessed.     

Major findings from the Canadian incidence study of reported child abuse and neglect

OBJECTIVE: To present key findings from the Canadian Incidence Study of Reported Child Maltreatment (CIS) in sufficient detail to provide a basis for international comparisons in terms of forms and severity of maltreatment and the age and sex of victims. METHOD: A survey conducted in a random sample of 51 child welfare service areas across Canada tracked child maltreatment investigations conducted during the months of October to December 1998, produced a national sample of 7672 child maltreatment investigations. Information was collected directly from investigating workers on child and family background, perpetrator characteristics, severity and types of maltreatment and service and court outcomes of investigations. RESULTS: Forty-five percent of investigations were substantiated and in a further 22% of investigations maltreatment remained suspected. Primary reasons for investigation were physical abuse (31%), sexual abuse (11%), neglect (40%), and emotional maltreatment (19%). A larger proportion of physical abuse cases are isolated incidents involving older children and are more likely to lead to injuries. Sexual abuse, neglect and emotional maltreatment involve more chronic situations with children showing signs of emotional harm. Rates of investigated and substantiated maltreatment are lower in Canada compared to the United States, but are higher than rates reported in Australia. CONCLUSIONS: The CIS provides much needed information for developing a better understanding of the profile and needs of children and families investigated by child welfare authorities in Canada. The study also serves as a point from which international comparisons can be made.     

Progress report on the development of child abuse prevention, identification, and treatment systems in Eastern Europe

PROBLEM: After the Soviet Union dissolved in 1989, it became apparent that there was little recognition of the problems of child abuse and neglect, professionally, legally, or societally. There were no effective systems or laws in place to deal with these problems. METHOD: Beginning in 1995 the Children's Mental Health Alliance, in conjunction with the Open Society Institute began conducting trainings in Eastern Europe [Journal of the American Academy of Child Adolescent Psychiatry 39 (2000) 660]. Originally 18 countries from the Baltics to the Balkans participated. A program was elaborated which would proceed in several stages: (1) training mental health professionals to deal with child abuse and neglect (CAN); (2) teaching multidisciplinary team work and fostering the development of multidisciplinary NGOs focused on CAN; (3) promoting the self-sufficiency of these NGO's which would then facilitate social and legal reform and increase public awareness of the problem. Specific methods included multi-national trainings, assignment of mentors to the developing teams who maintained weekly contact with the teams and made yearly site visits to their countries, and overseeing project grants from OSI. RESULTS: NGO's had been established and registered in 11 countries, many establishing a network of programs within their countries. By 2000, over 3800 mental health professional had been trained, either directly by the program or by the trainees of the program. By the end of 2000, over 17,000 other professionals (lawyers, police, judges, educators, other physicians, etc.) had been trained by the network. CONCLUSION: While more work needs to be in this region, the teams in 11 countries have made solid starts.     

Childhood adversity and behavioral health outcomes for youth: An investigation using state administrative data

This study aimed to measure the relative contribution of adverse experiences to adolescent behavioral health problems using administrative data. Specifically, we sought to understand the predictive value of adverse experiences on the presence of mental health and substance abuse problems for youth receiving publicly funded social and health services. Medicaid claims and other service records were analyzed for 125,123 youth age 12–17 and their biological parents. Measures from administrative records reflected presence of parental domestic violence, mental illness, substance abuse, criminal justice involvement, child abuse and/or neglect, homelessness, and death of a biological parent. Mental health and substance abuse status of adolescents were analyzed as functions of adverse experiences and other youth characteristics using logistic regression. In multivariate analyses, all predictors except parental domestic violence were statistically significant for substance abuse; parental death, parental mental illness, child abuse or neglect and homelessness were statistically significant for mental illness. Odds ratios for child abuse/neglect were particularly high in both models. The ability to identify risks during childhood using administrative data suggests the potential to target prevention and early intervention efforts for children with specific family risk factors who are at increased risk for developing behavioral health problems during adolescence. This study illustrates the utility of administrative data in understanding adverse experiences on children and the advantages and disadvantages of this approach.     

An ecological analysis of infant neglect by adolescent mothers

To inform efforts to prevent child neglect, we investigated a wide range of risk factors that have been largely unexamined in relation to infant neglect, the most commonly occurring form of child maltreatment. Using an ecological model of child neglect, we assessed the influence of characteristics at the level of the child, the mother, the family, and broader childrearing contexts on adolescent mothers’ likelihood of being a perpetrator in a substantiated case of neglect against their firstborn infants (n = 383, M = 12 months). Several factors were associated with infant neglect by young mothers: median block income, low infant birth weight, maternal smoking, maternal childhood history of neglect and of positive care, intimate partner violence (IPV) perpetrated by either the mother or her partner, and maternal use of mental health services. In multivariate models, income, a maternal childhood history of positive care, IPV by either a mother or her partner, and mental health service usage made significant contributions to the odds that a mother neglected her infant. Our findings suggest that these factors have particular salience to policymakers’ and practitioners’ efforts to identify high risk families and to intervene during the earliest months of life to prevent child neglect.     

Fatal child maltreatment: Characteristics of deaths from physical abuse versus neglect

This study examined victim, family, and alleged perpetrator characteristics associated with fatal child maltreatment (FCM) in 685 cases identified by child welfare services in the state of Oklahoma over a 21-year period. Analyses also examined differences in child, family, and alleged perpetrator characteristics of deaths from abuse versus neglect. Case information was drawn from child welfare investigation records for all FCM cases identified by the state Department of Human Services. Fatal neglect accounted for the majority (51%) of deaths. Children were primarily younger than age 5, and parents were most frequently the alleged perpetrators. Moreover, most victims had not been the subject of a child welfare report prior to their death. A greater number of children in the home and previous family involvement with child welfare increased children's likelihood of dying from neglect, rather than physical abuse. In addition, alleged perpetrators of neglect were more likely to be female and biologically related to the victim. These results indicate that there are unique family risk factors for death from neglect (versus physical abuse) that may be important to consider when selecting or developing prevention efforts.     

Preventive involvement in child abuse and neglect by general pediatrician in a military community

Thirty-three cases among nineteen troubled families of U.S. Coast Guard personnel with problems of child abuse and neglect in Hawaii were managed by joint U.S. Public Health Service, U.S. Coast Guard, U.S. Army, State and County child protection, social and health staff, and local and area-wide lay volunteers. These cases ranged from inaccurate accusations in an emergency room to abdominal gunshot wounds. The preventive role of primary pediatric involvement in community health areas such as pre-school, day care, prenatal infant care education, parent discussion groups, and lay therapists is stressed. The early intervention therapy of pediatric advocacy for social and psychological services to families in stress is emphasized. Continued pediatric leadership for prevention and early intervention is essential in our times of pervasive family breakdown.     

论现代家庭教育对个体发展的负功能

在家庭教育中,家长溺爱、压制的教育方式、忽视孩子的情感需求、过高的期望、不良的教育方法等,会对孩子健康的个性和心理发展造成障碍。家庭教育负功能存在的根源在于:作为人的教育者本身的未完成性、历史性、主观性,家长本位观念下爱的异化,现实社会中教育的功利导向。     

The services provided during a child abuse and/or neglect case investigation and the barriers that exist to service provision

More than one million cases of child abuse and neglect come to attention of child protection agencies each year. During the course of investigating these cases, social workers are charged with protecting the child while assessing whether or not abuse or neglect has actually occurred. Child welfare philosophy also dictates that at the same time the investigation is being conducted, the social worker strives to maintain the family intact, if at all possible. One way to address this dual responsibility of protecting the child while working towards family stability is through the provision of services during the investigation. The purpose of this paper is to identify the services that are provided during the course of a child abuse and/or neglect case investigation. The paper also identifies the barriers that exist both within an agency and within the external community that discourage the provision of services to children and families. The findings of this research show that in the majority of cases services are not provided during the investigation. In those case investigations where services are provided, a much broader range of services are considered for provision than are actually delivered. The research also found that placement is the most frequently provided service; however, only one-third of those children in placement receive any clinical services while in placement. Finally, this study found that the greatest barrier to service provision is a lack of evidence necessary to intervene in the home situation.     

Child abuse in Nigeria

Although child abuse occurs in Nigeria, it has received little attention. This is probably due to the emphasis placed on the more prevalent childhood problems of malnutrition and infection. Another possible reason is the general assumption that in every African society the extended family system always provides love, care and protection to all children. Yet there are traditional child rearing practices which adversely affect some children, such as purposeful neglect or abandonment of severely handicapped children, and twins or triplets in some rural areas. With the alteration of society by rapid socioeconomic and political changes, various forms of child abuse have been identified, particularly in the urban areas. These may be considered the outcome of abnormal interactions of the child, parents/ guardians and society. They include abandonment of normal infants by unmarried or very poor mothers in cities, increased child labour and exploitation of children from rural areas in urban elite families, and abuse of children in urban nuclear families by childminders . Preventive measures include provision of infrastructural facilities and employment opportunities in the rural areas in order to prevent drift of the young population to the cities. This would sustain the supportive role of the extended family system which is rapidly being eroded. There is need for more effective legal protection for the handicapped child, and greater awareness of the existence of child abuse in the community by health and social workers.     

International perspectives on child abuse

This paper reviews an extensive sampling of the international literature on child abuse. The paper focuses on: (1) where the international research on child abuse is being conducted; (2) similarities and differences in definitions of abuse and violence; (3) the types of research methods and theoretical models used to study abuse; and (4) what we currently know about child abuse in other countries. The paper concludes with a discussion of how we can advance our understanding of child abuse by pursuing cross-cultural research. Awareness of child abuse, internationally, varies a great deal, often depending on the political, social, economic, and cultural milieu of the country. Also, despite noticeable trends within countries, the research techniques and theoretical models used to guide scientific investigations vary considerably from one country to the next. For these reasons, one must draw conclusions about the patterns, causes, and extent of child abuse around the world very tentatively. There is much variation as to the likelihood of children being abused, although western, industrialized nations report the highest rates of abuse. Explanations for the variation of child abuse from one country to the next emphasize cultural differences in attitudes towards, and values placed on children, and the cultural appropriateness of using violence as a means of social control.     

Child maltreatment and problem gambling: A systematic review

This study systematically reviews research on child maltreatment and risk of gambling problems in adulthood. It also reviews adult problem gamblers’ risk of abusing or neglecting their own children. Multiple database searches were conducted using pre-defined search terms related to gambling and child abuse and neglect. We identified 601 unique references and excluded studies if they did not report original research, or did not specifically measure child maltreatment or gambling. Twelve studies that included multivariable analysis of childhood maltreatment exposure and problem gambling were identified. Six of seven studies examining childhood sexual abuse and four of five examining physical abuse showed a significant positive association between abuse and later gambling problems (odds ratios for sexual abuse 2.01–3.65; physical abuse 2.3–2.8). Both studies examining psychological maltreatment and two of three examining neglect identified positive associations with problem gambling. In most studies, risks were reduced or eliminated when controlling for other mental health disorders. The three studies measuring risk of child abuse and neglect among current problem gamblers suggest an increased risk for child physical abuse and medical conditions indicative of neglect although there is a considerable amount of variation among studies. Child abuse is associated with increased risk of gambling problems – gambling treatment providers should ask about maltreatment history as part of their clinical assessment. Problem gamblers may be more likely to physically abuse or neglect their children, but data here are more limited. Child welfare professionals should consider asking questions about parental gambling when assessing family risk.     

Child abuse as an international issue

This paper provides a background and suggests a strategy for an international approach to policy development concerning child abuse. First, child abuse is defined in a way that makes it applicable across cultures and national boundaries as that portion of harm to children that results from human action that is proscribed, proximate and preventable. A number of other dimensions, such as the degree of social sanction or social censure, are outlined that also affect the likelihood that given harm will be regarded as child abuse. Cross-cultural research also reveals that certain categories of children--such as those in poor health, females, unwanted children and those born under difficult circumstances or with disvalued traits or under conditions of rapid socioeconomic change--are more vulnerable to maltreatment in many countries. The paper argues for a two-pronged international strategy that first urges individual countries to make a priority of the particular types of abuse that are in most urgent need of attention in their society as well as participating at the same time in a concerted international focus on three widely occurring forms of child abuse: parental child battering, selective neglect, and sexual abuse.     

高兹的医疗批判及其启示

高兹在<生态政治学>一书中深刻地批判了资本主义的医疗,认为资本主义的医疗是资本主义生产扩大化的新型领域.以追求商业利润为目的,不仅不能让人们正确保持健康反而会让健康问题更加严重,而且破坏社会的正常运行,他主张大力普及卫生学知识,从资本主义的生活方式和消费方式中解脱出来,实现人的健康以及人与自然的和谐,最终实现人的自由解放.