Getting evidence into action to tackle institutional child abuse

The Australian Royal Commission into Institutional Responses to Child Sexual Abuse is an example of a government response to survivors’ demands to address the harm they suffered. It is also a major response by a national government to improve child safety in the future. Facing up to child abuse is difficult and in other countries similar inquiries have suffered delays and derailing. This commentary uses an evidence-to-action lens to explore why clear evidence of child sexual abuse may be ignored and side-lined. It argues that where evidence challenges the powerful, is surprising and shocking, or undercuts current institutional and policy arrangements, then that evidence is likely to be ignored, undermined or refuted – all factors which are present in the case of historical institutional child sexual abuse.     

Institutional child abuse in Greece: some preliminary findings

A long-term study on child abuse and neglect in Greece is being carried out at the Institute of Child Health, Athens. A multidisciplinary team is investigating the nature of the problem in Greece, is trying a system of therapeutic intervention to families, is evaluating the adequacy of child protection as it is used in child abuse and neglect, and is examining the efficacy of the law. During a one year period, 5 children cared for in institutions were referred to the program. All were boys. All were children with minor or major handicaps. Two of died from the abusive incident. A study of the circumstances of the injury, and of the conditions in Greek institutions, supports the idea that institutional and family child abuse share many common characteristics. Special mention is made of the Greek circumstances pertaining to child protection and the law.     

Survivors of institutional abuse in long-term child care in Scotland

BackgroundThe Scottish Child Abuse Inquiry (SCAI) commissioned the research project to document the outcomes of institutional abuse in long-term child care in Scotland.ObjectiveTo profile the experiences of survivors abused in long-term child care in Scotland, and to develop a model which linked maltreatment, risk and protective factors, and outcomes.Participants and Setting225 survivors of historical institutional abuse in Scotland, who made witness statements to SCAI.MethodsData were extracted from witness statements using a coding frame developed through a thematic analysis of a subsample of 52 statements.ResultsSurvivors had been in care in predominantly Catholic and non-religious residential institutions in Scotland for an average of 8 years, having entered at an average age of 6.8 years. They had suffered multiple forms of maltreatment. Maltreatment rates were: physical abuse, 95.6%; emotional abuse, 85.3%; sexual abuse, 60.4%; emotional neglect, 51.1%; and physical neglect, 37.3%. Across the lifespan survivors had negative outcomes in psychosocial adjustment (96%), mental health (84%), and physical health (43%). The effect of maltreatment in care on psychosocial problems was mediated by both risk and protective factors; and on mental health was mediated by risk factors, but not protective factors. Maltreatment in care had a direct effect on physical health which was not mediated by risk or protective factors. The effects of the cumulative number of risk factors on adverse mental health and psychosocial outcomes was greater than that of maltreatment, and protective factors had a limited impact on adverse outcomes.ConclusionsEvidence-based child protection policies and practices should be implemented to prevent institutional abuse and treat child abuse survivors in Scotland.     

Mandatory notification training for suspected child abuse and neglect in South Australian schools

OBJECTIVE: The present study provides the first empirical investigation of the South Australian Education Department Mandated Notification Training program. This program, which has been available since 1989, was developed to prepare educators and other mandated reporters to fulfill their reporting obligations for suspected child abuse and neglect. The main objective of the present study was to investigate whether Mandated Notification Training achieved its stated aims. METHOD: A three-sample independent groups design was used. A survey was responded to by 41 teachers and school personnel who had recently completed training, 31 people who had not completed training, and 73 people who had completed training some years previously. RESULTS: The training program increased participants' confidence in their ability to recognize the indicators of abuse, their awareness of their reporting responsibilities, their knowledge of what constitutes reasonable grounds for reporting, and of how to respond appropriately to a child's disclosure of abuse. Training also increased participants' acceptance of the incidence and seriousness of child abuse. CONCLUSIONS: The South Australian Education Department Mandated Notification Training is successful in achieving its stated aims. For some teachers, there is clearly a mismatch between the level of evidence required by law for reporting to occur and the level teachers expect to satisfy their own personal need for confidence in initiating the serious step of a child abuse report. This mismatch remains after training and probably contributes to the significant occurrence of nonreporting or discretionary reporting reported in the literature.     

Interdisciplinary collaboration needed in obtaining high-quality medical information in child abuse investigations

BackgroundDespite reporting legislation, healthcare providers (HCPs) do not always report and collaborate in cases of suspected child abuse. Recognizing this leaves children at risk, the Wisconsin Child Abuse Network (WI CAN) sought to understand barriers to mandated reporting and collaboration with child abuse investigators.ObjectiveThe purpose of the study was to investigate barriers for professionals in providing and obtaining high-quality medical information in child abuse investigations.Participants and settingParticipants included five discipline-specific focus groups: HCPs, child protective services (CPS), law enforcement, lawyers, and judges. All professionals had been directly involved in Wisconsin child abuse cases.MethodsThis qualitative study consisted of discipline-specific focus groups, directed by open-ended interview questions. Data analysis was completed through the narrative inquiry methodology.ResultsBarriers to providing and obtaining high-quality medical information in child abuse investigations were both discipline-specific and universal amongst all groups. Discipline-specific barriers included: HCPs’ discomfort with uncertainty; CPS’ perception of disrespect and mistrust by HCPs; law enforcement’s concerns with HCPs’ overstepping professional boundaries; lawyers’ concern of HCPs’ discomfort with court proceedings; and judges’ perception of a lack of understanding between all disciplines. Universal barriers included: value of high-quality medical information in child abuse investigations, burden of time and money; unequal resources between counties; a need for protocols, and a need for interdisciplinary collaboration.ConclusionFindings from this study suggest several ways to address identified barriers. Possible interventions include equalizing resources between urban and rural counties (specifically financial resources and access to child abuse experts); protocolizing reporting and investigations; and, increasing interprofessional education.     

Serious games for learning: games-based child sexual abuse prevention in schools

In spite of research demonstrating conceptual weakness in many child sexual abuse (CSA) prevention programmes and outdated modes of delivery, students continue to participate in a diversity of initiatives. Referring to the development of a games-based approach to CSA prevention in Australia, this paper examines empirically based attributes of effective CSA prevention programmes for schools including contemporary pedagogies for learning. The paper draws on findings to inform the conceptual development phase of Orbit, an online, free and equal-access, games-based educational approach to CSA prevention for children aged 8–10 years. First, the paper provides a review of CSA prevention in schools and games-based approaches to key learnings in prevention. Second, an overview of Orbit (the Feeling Safe sexual abuse prevention project) is provided. Finally, implications for the development of games-based prevention programmes are offered and an argument is made for the advancement of games-based prevention resources.     

Fatal child abuse in Georgia: the epidemiology of severe physical child abuse

Decisions about the occurrence of child abuse are increasingly difficult to make because concepts of what qualifies as reportable child abuse may be broadening. We examined this question by comparing 51 fatal child abuse cases occurring in Georgia between July 1975 and December 1979 to non-fatal cases and to the Georgia population. Overall rates of fatal child abuse were higher for male perpetrators compared with female and black perpetrators compared with white. However, the latter finding varied with economic and geographic status. The highest child abuse fatality rates were found in poor, rural, white families (3.3/100,000 children) and in poor, urban, black families (2.4/100,000 children). Risk factors for fatal abuse included early childhood (RR 6:1), parental teenage childbearing (RR 4:1), and low socioeconomic status. These characteristics were similar to those of the severe child abuse cases noted in the early child abuse literature. Non-fatal cases did not clearly share these risk factors. Severe abuse, here represented by fatal cases, is a distinct subset of reported child abuse, but characteristics associated with it are frequently attributed to all reportable child abuse. Medical personnel should be aware that they cannot rely on the presence or absence of these characteristics in screening for risk of reportable child abuse. Child abuse research should use restricted, stated case definitions. When intervention and prevention programs are being organized, they should not generalize research findings to all forms of child abuse.     

The relationship between child protection contact and mental health outcomes among Canadian adults with a child abuse history

Despite being a primary response to child abuse, it is currently unknown whether contact with child protection services (CPS) does more good than harm. The aim of the current study was to examine whether contact with CPS is associated with improved mental health outcomes among adult respondents who reported experiencing child abuse, after adjusting for sociodemographic factors and abuse severity. The data were drawn from the 2012 Canadian Community Health Survey-Mental Health (CCHS-2012), which used a multistage stratified cluster design (household-level response rate = 79.8%). Included in this study were individuals aged 18 years and older living in the 10 Canadian provinces (N = 23,395). Child abuse included physical abuse, sexual abuse, and exposure to intimate partner violence (IPV). Mental health outcomes included lifetime mental disorders, lifetime and past year suicidal ideation, plans, and attempts, and current psychological well-being and functioning and distress. All models were adjusted for sociodemographic factors and severity of child abuse. For the majority of outcomes, there were no statistically significant differences between adults with a child abuse history who had CPS contact compared to those without CPS contact. However, those with CPS contact were more likely to report lifetime suicide attempts. These findings suggest that CPS contact is not associated with improved mental health outcomes. Implications are discussed.     

Training program in child abuse for community health workers

A wide range of health workers in the community provide care for families that abuse or have a potential for abusing their children. Frequently these workers are unable to work effectively because of difficulty dealing with feelings aroused by contact with such families.An experimental child abuse training program for community health workers was designed by a pediatrician, a social worker, a public health nurse and two child psychiatrists. This program included a six-month study group which met weekly to focus on feelings and conflcts aroused during the course of work with abusing or potentially abusing families.Through analysis of the group experience, the leaders identified eleven sets of feelings or conflicts which seemed to interfere consistently with effective delivery of care: 1)anxieties about a) being physically harmed by angry parents and b) about the effects of a decision; 2) denial and inhibition of anger; 3) need for emotional gratification from clients; 4) lack of professional support; 5) feelings of incompetence; 6) denial and projection of responsbility; 7) feeling total responsibility for assigned families; 8) difficulty separating personal from professional responsibility; 9) feelings of being a victim; 10) ambivalent feelings a) toward clients and b) about one's professional role; 11) need to be in control.This type of group experience seems to be an effective method for exploration and resolution of feelings and conflicts.     

Child protective services utilization of child abuse pediatricians: A mixed methods study

Several children’s hospitals and medical schools across Texas have child abuse pediatricians (CAPs) who work closely with child protection workers to help ensure accurate assessments of the likelihood of maltreatment in cases of suspected abuse and neglect. Since the state does not mandate which cases should be referred to a CAP center, we were interested in studying factors that may influence workers’ decisions to consult a CAP. We used a mixed methods study design consisting of a focus group followed by a survey. The focus group identified multiple factors that impact workers’ decision-making, including several that involve medical providers. Responses from 436 completed surveys were compared to employees’ number of years of employment and to the state region in which they worked. Focus group findings and survey responses revealed frustration among many workers when dealing with medical providers, and moderate levels of confidence in workers’ abilities to make accurate determinations in cases involving medical information. Workers were more likely to refer cases involving serious physical injury than other types of cases. Among workers who reported prior interactions with a CAP, experiences and attitudes regarding CAPs were typically positive. The survey also revealed significant variability in referral practices by state region. Our results suggest that standard guidelines regarding CAP referrals may help workers who deal with cases involving medical information. Future research and quality improvement efforts to improve transfers of information and to better understand the qualities that CPS workers appreciate in CAP teams should improve CAP-CPS coordination.     

Cultural factors in decision-making about child physical abuse: identifying reporter characteristics influencing reporting tendencies

OBJECTIVE: This study examined cultural factors that may influence child physical abuse reporting. Relevant cultural factors such as the respondents' ethnic identity and corporal punishment acceptability were investigated as proximal variables of ethnicity that affect child physical abuse reporting tendencies. METHOD: Participants consisted of 378 Caucasian, Hispanic, and African American college students. Participants read 12 vignettes that varied the ethnicity of the child and described a parent using physical punishment with the child. Participants' level of ethnic identity and their acceptance of different discipline practices were also assessed. Data were analyzed using multiple regression procedures. RESULTS: The ethnicity of the respondent was a significant predictor of reporting tendencies for African American respondents only. For African Americans, higher levels of ethnic identity and acceptance of corporal punishment were significant mediators of reporting tendencies, which influenced the relationship between ethnicity and likelihood to report a child of the same ethnicity. CONCLUSION: The results of this study indicate that ethnic minorities may not share similar cultural values and may differ in their degree of adherence to certain cultural variables. These results demonstrate how cultural variables that influence reporting tendencies may not apply across ethnic groups. Therefore, specifying relevant cultural variables is essential to understanding the relationship between ethnicity and reporting tendencies.     

Childhood history of abuse and child abuse potential: The role of parent's gender and timing of childhood abuse

It has been suggested that being physically abused leads to someone becoming a perpetrator of abuse which could be associated to parents’ gender, timing of the physical abuse and specific socio-demographic variables. This study aims to investigate the role the parents’ gender, timing of childhood abuse and socio-demographic variables on the relationship between parents’ history of childhood physical abuse and current risk for children. The sample consisted of 920 parents (414 fathers, 506 mothers) from the Portuguese National Representative Study of Psychosocial Context of Child Abuse and Neglect who completed the Childhood History Questionnaire and the Child Abuse Potential Inventory. The results showed that fathers had lower current potential risk of becoming physical abuse perpetrators with their children than mothers although they did not differed in their physical victimization history. Moreover, the risk was higher in parents (both genders) with continuous history of victimization than in parents without victimization. Prediction models showed that for fathers and mothers separately similar socio-demographic variables (family income, number of children at home, employment status and marital status) predicted the potential risk of becoming physical abuses perpetrators. Nevertheless, the timing of victimization was different for fathers (before 13 years old) and mothers (after 13 years old). Then our study targets specific variables (timing of physical abuse, parents’ gender and specific socio-demographic variables), which may enable professionals to select groups of parents at greater need of participating in abuse prevention programs.     

The handicapped child and child abuse

For a group of children with handicaps, growth and development are also affected by abuse or neglect. Our understanding of the problems of the abused, handicapped child emerges from experience with 37 children with cerebral palsy who have been maltreated, coupled with a review of the literature in related areas. We identify the following four problems as crucial to the study of abuse and neglect to the child with handicaps: (1) abuse that causes handicaps, (2) abuse that occurs to the handicapped child, (3) compromises in care that can occur when the handicapped child becomes involved with the medical and legal systems, and (4) arrangements for foster care or other out-of-home placement for the child with handicaps. We conclude that the very systems designed to protect and care for the child often fail, leaving the handicapped child without opportunity to reach developmental potential. In light of our observations, we recommend that the pediatrician not only be aware of the existence of abuse and neglect in the population of handicapped children, but also serve in the dual role of coordinator of services and advocate for these children.     

The use of telemedicine in child sexual abuse evaluations

OBJECTIVE: To describe the advantages, disadvantages and current status of child abuse consultations conducted through telemedicine networks. METHOD: The results of a telephone survey of seven statewide telemedicine networks are reported and discussed with respect to goals, funding, technical support and expertise, infrastructure, and extent of use. Quality assurance and liability issues concerning telemedicine child abuse consultations are also reviewed. RESULTS: The goals of telemedicine networks in child abuse are to provide (1) expertise to less experienced clinicians primarily in rural areas; (2) a method for peer review and quality assurance to build consensus of opinions particularly in sexual abuse cases; and (3) support for professionals involved in an emotionally burdensome area of pediatrics. Problems encountered by existing networks include: (1) funding for equipment and reimbursement for consultation; (2) consistent technical support: (3) clinician lack of technical expertise, knowledge, or motivation; and (4) lack of network infrastructure. Legal considerations include licensure exemptions for consulting across state lines, potential for malpractice, patient confidentiality and security of images forwarded over modem lines, and liability of the equipment, consulting site, and the consultant in criminal proceedings. CONCLUSIONS: Telemedicine consultations offer a unique opportunity to raise the standard of care in child abuse evaluations, but success depends on clinician motivation, appropriate infrastructure, and ongoing funding and technical support.     

The incidence and prevalence of intrafamilial and extrafamilial sexual abuse of female children

Data obtained from a random sample of 930 adult women in San Francisco provide the soundest basis heretofore available for estimating the prevalence of intrafamilial and extrafamilial sexual abuse of female children. This article describes the methodology of this survey, as well as some of the key findings. For example: 16% of these women reported at least one experience of intrafamilial sexual abuse before the age of 18 years; 12% reported at least one such experience before the age of 14 years; 31% reported at least one experience of extrafamilial sexual abuse before the age of 18 years; and 20% reported at least one such experience before the age of 14 years. When both categories of sexual abuse are combined, 38% reported at least one experience before the age of 18 years; and 28% reported at least one such experience before the age of 14 years. Only 2% of the cases of intrafamilial and 6% of the cases of extrafamilial child sexual abuse were ever reported to the police. A plea is made for the urgent need to recognize the magnitude of the problem of child sexual abuse, and to act to prevent it.     

A survey of state efforts in gathering information on child abuse and neglect in handicapped populations

This paper reports the extent to which states assemble information on the incidence of abuse and neglect among handicapped populations. Data were collected from all states on the types of pre-existing disabilities cited on child abuse reporting forms and the perceived accuracy of this information. The study also sought to identify specific methods used to provide assistance to local agencies regarding the problems associated with abuse of the handicapped. Surveys were distributed to and completed by representatives of the designated child protection agencies within each state and the District of Columbia (n = 51). General findings were that although it is generally acknowledged in research that handicapped children represent a disproportionate number of abuse and neglect victims, nearly half of the states do not collect any information on “special characteristics.” Forms from the remaining states exhibited much variation in style and in the competency of collection techniques. These results suggest a significant lack of services specifically designed to improve the awareness of field representatives on the influence of exceptionalities in abusive cases. This information indicates that training and prevention programs will remain basically inadequate until the relationship between handicapped conditions and abuse/neglect is more clearly defined.     

Online child sexual exploitation and abuse: A community diagnosis using the social norms theory

This study focused on the drivers of online child sexual exploitation and abuse (OCSEA) among Filipino children and youth, with emphasis on community norms. An ethnographic qualitative study was conducted in two communities in MetroManila that are considered “hotspots” for child sexual abuse. One hundred and forty-four (144) males and females from various age groups served as key informants. Political officials, Internet shop managers, professionals and police officers were also interviewed. Non-participant observations and mapping were used to provide context regarding OCSEA in the communities.The results revealed that OCSEA was committed online by heterosexual and same sex attracted men in their 40s–50s. The usual victims were girls aged 13–17 years, although boys were also noted. The victims came from poor families and were out-of-school. The various forms of online activities leading to OCSEA included sexual chatting, showing of child sex photos and live videos as well as sextortion. The online transactions were usually initiated by the peer group and some enablers. In general, online sexual activities were perceived as “normal” among young people, although regarded as “disgusting”. Online sex activities had become a source of “easy money” for the child and family. They were perceived as not harmful because of anonymity and the absence of any actual physical contact. People in the community tolerate these online practices and do not report the incidence to authorities. The effects on children and youth were predominantly social and psychological, albeit perceived as economically beneficial. Some preventive and mitigating actions were recommended to curb the incidence of OCSEA in the communities.     

An examination of trends in child sexual abuse investigations in Ontario over time

BackgroundChild sexual abuse (CSA) rates have been declining since the 1990s (Dunne et al., 2003; Finkelhor & Jones, 2004, 2012; Jones et al., 2001). Discrepancies in contexts and measures complicate comparing CSA rates across jurisdictions and studies, and there is limited literature about trends in CSA in Canada.ObjectiveUsing data from the Ontario Incidence Study of Reported Child Abuse and Neglect (OIS), the only source of provincially aggregated data in Ontario, Canada, that describes child welfare investigations, this paper provides information on reported and investigated CSA over the past 20 years.Participants and settingThe OIS uses a file review methodology; information is collected directly from investigating child welfare workers.MethodsA sample of child welfare agencies is selected for the study, and data are collected over a three-month period. Weights are applied to produce annual provincial estimates.ResultsThe rates of investigated CSA in Ontario decreased between 1993 and 2013, from 5.20 (95% CI [3.94, 6.47]) to 1.81 (95% CI [0.97, 2.66]) children per 1000. During this time, the rate of all child maltreatment-related investigations doubled, from 21.41 (95% CI [18.38, 24.42]) to 53.32 ([29.61, 77.03]) children per 1000.ConclusionsUnlike other forms of child maltreatment, the incidence of investigated CSA in Ontario declined since 1993. Substantiation rates for CSA investigations decreased more dramatically than the rate of all CSA investigations, which could indicate a true decline in rate or an inability to accurately identify cases of CSA.     

Diagnostic agreement when comparing still and video imaging for the medical evaluation of child sexual abuse

Still photo imaging is often used in medical evaluations of child sexual abuse (CSA) but video imaging may be superior. We aimed to compare still images to videos with respect to diagnostic agreement regarding hymenal deep notches and transections in post-pubertal females. Additionally, we evaluated the role of experience and expertise on agreement. We hypothesized that videos would result in improved diagnostic agreement of multiple evaluators as compared to still photos. This was a prospective quasi-experimental study using imaging modality as the quasi-independent variable. The dependent variable was diagnostic agreement of participants regarding presence/absence of findings indicating penetrative trauma on non-acute post-pubertal genital exams. Participants were medical personnel who regularly perform CSA exams. Diagnostic agreement was evaluated utilizing a retrospective selection of videos and still photos obtained directly from the videos. Videos and still photos were embedded into an on-line survey as sixteen cases. One-hundred sixteen participants completed the study. Participant diagnosis was more likely to agree with study center diagnosis when using video (p < 0.01). Use of video resulted in statistically significant changes in diagnosis in four of eight cases. In two cases, the diagnosis of the majority of participants changed from no hymenal transection to transection present. No difference in agreement was found based on experience or expertise. Use of video vs. still images resulted in increased agreement with original examiner and changes in diagnostic impressions in review of CSA exams. Further study is warranted, as video imaging may have significant impacts on diagnosis.