The relationship of child abuse indicators to the assessment of perceived risk and to the court''s decision to separate

The most serious decision taken in child abuse cases is to formally separate the child and the family. There has been concern that the criteria for making these decisions should be made explicit. The consequences of the separation for the child, family, and society is one set of reasons for this concern. Another is that with the increasing number of cases being reported, there is a need for reliable, consistent, and efficient decisions across cases. This paper operationally defines a set of indicators for the separation decision. One hundred fifty-two cases of suspected child abuse from the Royal Children's Hospital were coded in terms of the indicators and the outcome of the case. The outcome was the court's decision to separate the child. The study investigated whether and in what way these indicators were related to the separation outcome. In addition the perceived risk to the child was operationally defined, and the relationship of the indicators and the court's decision to perceived risk was studied. Statistical analysis of the data showed that the indicators most associated with the separation outcome were severity of abuse, parenting, and the family social system. Two important implications for practice are that information on explicit indicators should be recorded for cases, and that they can provide a base for training of new child protection workers.     

Family patterns and child abuse in a nationally representative American sample

Data on 1, 146 families with a child age 3 through 17 at home are presented. Child abuse information was obtained for a randomly selected child in each family. Child abuse was defined as an attack by a parent involving punching, kicking, biting, hitting with an object, “beating up,” or using a knife or gun. Over 14 out of every 100 American children 3–17 are subjected to abusive violence each year. These figures are at least 26 times greater than those of the National Center For Child Abuse and Neglect. Even so, for reasons outlined in the paper, they are underestimates. Families in which child abuse occurred are compared with other families. The results suggest that child abuse is brought about by the very nature of the society and its family system. This has profound implications for the prevention and treatment of child abuse. Although psychotherapy may be appropriate in some cases, a more fundamental approach lies in such things as a more equal sharing of the burdens of child care, replacement of physical punishment with non-violent methods of child care and training, eliminating the stresses and insecurity which now characterize our economic system, and strengthening the ties of individual families to the extended family and the community.     

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.     

Children and stress: Sources,reactions, and interventions

Stress in childhood is universal, an inevitable part of life. No child reaches adolescence without having to cope with the normal developmental and environmental stresses of weaning, toilet training, entry into school, and the inevitable increasing demands for self-control and responsibility.Diane Shrier is clinical associate professor and director of child and adolescent psychiatry at the New Jersey Medical School in Newark.     

Countertransference and failure to report child abuse and neglect

Though every state has laws requiring the report of suspected child abuse and neglect, failure to report remains a significant problem. Review of previous research on failure to report suggests that the reporters' anxieties about disrupting their relationship with the child's family as well as the reporters' gender, experience, and training affect willingness to report. Countertransference fear, guilt, shame, and sympathy are discussed as a basis for understanding the reporter's anxieties. We suggest that countertransference issues should be addressed in the training and ongoing practice of mandated reporters. The following mechanisms are offered to deal with this issue in training and practice: (1) teaching professionals about how countertransference reactions may arise during the reporting process (this training may include the use of risk management groups for private practitioners); (2) identification of a community child abuse expert for consultation; and (3) educating child protection workers about psychodynamics aspects of case management.     

Do family order and neighbor intervention against intimate partner violence protect children from abuse? Findings from Kathmandu

Drawing on previous research on intimate partner violence, child maltreatment, and informal social control, we hypothesized relationships between child abuse severity and (1) protective informal social control of intimate partner violence (ISC_IPV) by neighbors, (2) intimate terrorism, (3) family order, and (4) the power of mothers in intimate relationships. In what we believe may be a first study of physical child abuse by parents in Nepal, we used a three stage cluster approach to draw a random sample of 300 families in Kathmandu. Random effects regression models were used to test the study hypotheses. The analyses found support for hypotheses one and two, but with an important caveat. Although observed (actual) protective ISC_IPV had the hypothesized negative association with child abuse severity, in one of our models perceived protective ISC_IPV was positively associated with child abuse severity. The models clarify that the overall direction of protective ISC_IPV appears to be negative (protective), but the positive finding is important to consider for both research and practice. A significant relationship between family order and child abuse severity was found, but the direction was negative rather than positive as in hypothesis three. Implications for neighborhood research and typological research on IPV and child maltreatment are discussed.     

The expert witness in child abuse and neglect: An interdisciplinary process

The legal system is an important part of a society's response to child abuse and child neglect. Courts need to be guided in their deliberations by experts from many different professions. Consultation and in-court expert testimony is necessary from medicine, psychology, psychiatry, social work and other professions both to prove child abuse and neglect and establish the power of the court to act on behalf of a child but also to guide the court in the intervention strategy most suited to the needs of the child and his family. Non-lawyers often feel uncomfortable in the legal setting. The adversary process is foreign to their training and professional experience. Collaboration with a lawyer greatly improves their effectiveness in court. Lawyers, on the other hand, need to make maximum use of medical and social-psychological experts in the court process in the interests of their clients; but to do so lawyers need a basic understanding of the other professions. With an emphasis on a process of mutual education, the paper presents a framework for collaboration between lawyers and expert witnesses in child abuse and neglect cases. “Expert witness” is defined; informal consultation is encouraged; suggestions for selecting a collaborator are made; initial contracts between lawyer and expert, case conferencing and preparation for trial are discussed; specific advice on direct and cross examination is provided.     

Law enforcement officers as investigators and therapists in child sexual abuse: A training model

Law enforcement officers, often the first professionals to come in contact with a victim of child sexual abuse, can either increase or decrease the traumatic impact on the child and the family at the time of disclosure. The model for a training program for police officers in handling cases of child sexual abuse outlined in this paper is divided into three sections. The first part is directed towards theoretical issues involved in this problem, including an explanation of the history and background of sexual abuse of children by adults and of the difference in the dynamics of extra- and intrafamilial sexual abuse. The second part consists of a detailed explanation of different types of sex offenses and of standard physical examinations of sexual abuse victims. Graded slides of physical trauma geared towards wound identification are paired with relaxation exercises. The third section focuses on special considerations when interviewing sexually abused children. The difference between interviewing and interrogation, specific questioning techniques, and the use of videotape is explained. Each part of this training procedure is followed by a question and answer period and small group discussions for the purpose of encouraging disclosure and better understanding of the officers' personal reactions to cases of child sexual abuse.     

Three models of child abuse consultations: A qualitative study of inpatient child abuse consultation notes

Child abuse pediatricians have multiple roles in caring for abused children, including prevention, diagnosis, treatment, and, when needed, expert legal opinion. The child physical abuse consultation differs from the traditional medical consultation in that it has medical, investigative and legal audiences, all of whom have different information needs. How child abuse pediatricians approach their cases and how they document their initial inpatient consultations that will be used by such a diverse audience is currently unexplored. We used content analysis to examine 37 child physical abuse consultation notes from a national sample of child abuse pediatricians in order to understand physicians’ approaches to these consultations. Three commonly used models of child physical abuse consultation were identified in the data that we named the base model, the investigative model, and the family-dynamic model. While model types overlap, each is distinguished by key features including the approach used to gather information, the information recorded, and the language used in documentation. The base model most closely mirrors the traditional medical approach; the investigative model concentrates on triangulation of sources of information; and, the family-dynamic model concentrates on physician perceptions of family relationships. The three models of consultations for child physical abuse mirror the areas of child abuse pediatrics: diagnostic, forensic and therapeutic. These models are considered in relationship to best practice from other medical specialties with forensic components.     

Sexual abuse of children in the United Kingdom

Questionnaires were circulated to 1,599 family doctors, police surgeons, paediatricians, and child psychiatrists to determine the frequency and nature of child sexual abuse in the United Kingdom. At least three per 1,000 children are currently being recognized as sexually abused sometime during their childhood. The majority of cases reported involved actual or attempted intercourse, and 74% of the perpetrators were known to the child. Family disturbance was noted in 56% of the cases. The most common outcome (43%) was criminal prosecution of the perpetrator. Area Review Committees had no clear policy for the management of sexual abuse. Before it is possible to protect children and to develop therapeutic services for the family, it will be necessary to acknowledge that sexual abuse is part of the child abuse spectrum.     

Child abuse reporting: teachers' perceived deterrents

OBJECTIVE: There are three general objectives: First, to determine the number of reports of abuse made by teachers, their knowledge of child abuse laws and reporting procedures, and their perceived deterrents in reporting abuse; second, to determine if there were gender or ethnic differences in reporting; and third, to evaluate teachers responses to case vignettes. METHOD: A survey of 197 teachers was conducted. They were given a questionnaire that included demographic information, knowledge of child abuse laws and procedures, and two scenarios of legally reportable child abuse. RESULTS: Seventy-three percent of this sample reported that they had never made a report of child abuse, while those who had made reports made an average of one report. Only 11% of teachers reported that there were instances in which they believed abuse may have occurred, but failed to report. Additionally, these teachers felt that their pre- and post-service training did not adequately prepare them for abuse reporting. The most common reasons cited for not reporting abuse were fear of making an inaccurate report, feeling as though child protective services do not help families, and no apparent physical signs of abuse. There were no gender differences in reporting. The teachers' responses to the case vignettes were not consistent with their previous reports. CONCLUSIONS: In general, most teachers reported having never made a child abuse report. Although only a small percentage of teachers reported failing to report abuse, when presented with legally reportable case vignettes, many failed to report. The majority of teachers report receiving inadequate training in child abuse signs, symptoms, and reporting procedure. There is an obvious need for more education for teachers that addresses their perceived deterrents and aids them in feeling more confident in making reports of child abuse.     

Child sexual abuse prevention: Evaluation of a teacher training model

Teachers are potentially helpful resource persons for large numbers of sexually abused children who may have difficulty disclosing abuse, particularly to family members. In the present study, the effectiveness of a 6-hour teacher training workshop on child sexual abuse prevention was evaluated. Responses of 26 female elementary teachers who participated in the workshop were compared to responses of 19 control teachers on several pre-, post-, and follow-up measures. Relative to controls, trained teachers demonstrated significant increases from pre- to post-testing in knowledge about child sexual abuse and pro-prevention opinions. On a post-only vignettes measure, trained teachers were better able than control teachers to identify behavioral indicators of abuse and suggest appropriate interventions for hypothetical sexually abused children. Over a 6-week follow-up period, trained teachers read more about child abuse than control teachers but did not differ on other behavioral dimensions such as reporting suspected abuse cases. Further research will examine the effects of additional teacher training over an extended follow-up period.     

A socioclinical overview of 28 sex-abused children

A retrospective overview of 28 sexually-abused children evaluated at a university-based child guidance clinic is reported. These 28 cases are scrutinized and empirical data are culled on the following sociodemographic and clinical variables: age, gender, race, family composition, referral source, presenting complaints, type of referral, psychiatric history of the child and family, diagnosis, disposition, type and duration of treatment, and a severity rating (done by parents) of the child's behavioral maladjustment. Historical information about the sexual abuse is presented: molester, type of abuse, duration of abuse and recency of sex abuse. The sociodemographic findings reveal the sex-abused child prototype to be a white girl, 9 years old, from a working class family headed by both parents or by mother alone. She was abused by an adult male relative. If a boy, abuse was by a male age-mate. Genital abuse was the most frequent type with sexual intercourse of very high frequency for children of all ages. Many psychiatric difficulties were reported in the families of these children. Some children had more than one molester. The clinical findings show psychic suffering among all studied children—most of moderate levels, behavior reactions. All but 3 children had therapy recommended to them. Presenting difficulties were for sexual abuse per se and/or for a wide-ranging variety of symptom complaints. The socioclinical overview of sexually molested children compells researchers to look closer at broader, extra-familial, cultural and socio-economic issues in the lives of these children and not just at psychopathologies of individual molesters and family units.     

The influence of childhood sexual abuse,physical abuse,family environment,and gender on the psychological adjustment of adolescents

OBJECTIVE: The primary aim of the current study was to examine the contributions of sexual abuse, physical abuse, family cohesion, and conflict in predicting the psychological functioning of adolescents. Additional analyses were conducted to determine whether adolescent victims of child sexual abuse and physical abuse perceive their family environments as more conflictual and less cohesive than nonabused adolescents. METHOD: Participants were 131 male and female adolescents, ages 16 years to 18 years, receiving services at a residential vocational training program. Participants completed well established psychological assessment tools to assess abuse history, family environment characteristics, and current adjustment. RESULTS: Physically abused adolescent females perceived their family environments as more conflictual and less cohesive than females without physical abuse, and sexually abused females perceived their family environments as more conflictual and less cohesive than females without sexual abuse. Physically abused adolescent males reported more conflict than males without physical abuse, but did not differ with regard to cohesion. Adolescent males with and without a sexual abuse history did not differ on the family dimensions. Multiple regression analyses revealed that both conflict and cohesion, in addition to a history of sexual and physical abuse, predicted depression and distress. Separate analyses by gender revealed these variables differentially impact adjustment in male and female adolescents. Results of a power analysis indicated sufficient power to detect these differences. CONCLUSIONS: Findings indicate that in addition to child sexual abuse and physical abuse, family conflict and cohesion are risk factors for the development of psychological distress and depression in adolescence. Implications for treatment and directions for future research are discussed.     

Professionals' decision-making about out-of-home placements following instances of child abuse

OBJECTIVE: The goal of this research was to study how different groups of child welfare professionals prioritize and use information to make placement decisions following instances of child abuse. METHOD: A total of 90 juvenile court judges and guardians ad litem, Court Appointed Special Advocates (CASA), social workers, and mental health professionals responded to a detailed questionnaire describing four case studies of child physical abuse in which a parent was the perpetrator, the child was either 2 years or 6 years of age, and the abuse was either first time or chronic. Participants rated the impact of specific pieces of information regarding child, family, and system-level characteristics on their decision-making process. RESULTS: Analyses of reactions to these vignettes demonstrate that professional groups use different kinds of information when making decisions about foster care placements. Social workers and mental health providers rely on information about the severity and pattern of abuse and on information about services offered in the past and parental responses to those services. Judges and guardians ad litem rely more heavily on information about the likelihood of a reoccurrence of abuse and the child's ability to recount the abuse, whereas CASA volunteers rely on information about the stability of the family. CONCLUSIONS: Professional group membership, rather than factors such as age or ethnicity of the child or chronicity of abuse, accounts for different patterns of prioritizing and using information when making decisions about whether a child should remain in the home or be placed in foster care. The implications for community-based training and intervention efforts are discussed.     

Genital examinations for alleged sexual abuse of prepubertal girls: findings by pediatric emergency medicine physicians compared with child abuse trained physicians

OBJECTIVE: This study compares abnormal genital examination findings made by pediatric emergency medicine (PEM) physicians to examinations by physicians with training in child sexual abuse in the evaluation of prepubertal girls for suspected sexual abuse. METHOD: A prospective study was performed following the genital examination by a PEM physician of prepubertal girls suspected of being sexually abused. A physician with training in child sexual abuse re-examined those girls whose examinations were interpreted as abnormal by the PEM physicians. The findings and interpretations of the PEM physician were then compared to those by the physicians with training in child abuse. RESULTS: Between October 1994 and October 1998, 46 patients diagnosed by PEM physicians with nonacute genital findings indicative of sexual abuse were re-examined by a physician with training in child abuse. The follow-up examinations were done 2 days-16 weeks (mean 2.1 weeks) after the emergency department visit. The physicians with training in child abuse concluded that only eight of these children (17%) showed clear evidence of abuse. Normal findings were noted in 32 children (70%), nonspecific changes were noted in 4 children (9%), and 2 children (4%) had findings that are more commonly seen in abused children than nonabused children but are not diagnostic for abuse (concerning for abuse). CONCLUSIONS: There was poor agreement between the pediatric emergency medicine physicians and the physicians with training in child sexual abuse. This study suggests that emergency medicine physicians should consider additional training in this area. In addition, all children with abnormal ED examinations should have follow-up examinations by a child abuse trained physician.     

Errorless compliance training with physically abusive mothers: a single-case approach

OBJECTIVE: "Errorless compliance training" is a recently developed, success-based approach for teaching children to comply with parental requests without the use of coercive consequences. Two mothers were trained to use this intervention to reduce severe child defiance that was precipitating mother/child confrontations and physical abuse. METHOD: To determine probability of child compliance to specific requests, we observed mothers delivering requests to their child. We then developed a hierarchy of compliance probabilities for each child. Mothers were trained to deliver a high density of Level 1 requests (those that typically yielded compliance), and provide praise for child compliance. Lower probability request levels were introduced gradually, at a slow enough pace to preclude noncompliant responses, reducing the need for mothers to respond aversively to child behavior. RESULTS: At treatment completion and follow-up, both children demonstrated substantial improvements in compliance. CONCLUSIONS: The errorless approach may be well suited to managing parenting deficits and child opposition commonly associated with family violence.     

The child psychiatric examination of the sexually abused child

Child psychiatric examination of the sexually abused child is strongly indicated as more than two-thirds of these children have concomitant emotional problems. Special considerations which are important in approaching these children but would not be a part of the routine child psychiatric evaluation are highlighted. The approach to the child who has been sexually assaulted by someone outside the family is contrasted with the evaluation of an incestuous family.Five specific expectations of the child psychiatric examination are as follows: 1. The nature of any emotional problem must be defined and an appropriate treatment plan established. 2. An immediate proposal must be made for the care of the child which will provide protection from future abuse while minimizing emotional stress. 3. Long-term planning for the family should be initiated based on an assessment of the likelihood of future recurrence of sexual abuse. 4. The child's reality testing should be evaluated if there is a question regarding the occurrence of the sexual abuse. 5. Psychological characteristics of the child which might influence the success of long-term care proposals should be documented.