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.     

Randomized trial of a statewide home visiting program: impact in preventing child abuse and neglect

OBJECTIVES: To assess the impact of home visiting in preventing child abuse and neglect in the first 3 years of life in families identified as at-risk of child abuse through population-based screening at the child's birth. METHODS: This experimental study focused on Hawaii Healthy Start Program (HSP) sites operated by three community-based agencies. From 11/94 to 12/95, 643 families were enrolled and randomly assigned to intervention and control groups. Child abuse and neglect were measured by observed and self-reported parenting behaviors, all hospitalizations for trauma and for conditions where hospitalization might have been avoided with adequate preventive care, maternal relinquishment of her role as primary caregiver, and substantiated CPS reports. Data were collected through annual maternal interviews (88% follow-up each year of all families with baseline interviews); observation of the home environment; and review of CPS, HSP, and pediatric medical records. RESULTS: HSP records rarely noted home visitor concern about possible abuse. The HSP and control groups were similar on most measures of maltreatment. HSP group mothers were less likely to use common corporal/verbal punishment (AOR=.59, p=.01) but this was attributable to one agency's reduction in threatening to spank the child. HSP group mothers reported less neglectful behavior (AOR=.72, .02), related to a trend toward decreased maternal preoccupation with problems and to improved access to medical care for intervention families at one agency. CONCLUSIONS: The program did not prevent child abuse or promote use of nonviolent discipline; it had a modest impact in preventing neglect. Possible targets for improved effectiveness include the program's implementation system and model.     

Revealing the existence of child abuse in the context of marital breakdown and custody and access disputes

OBJECTIVE: Child abuse in the context of legal and de facto marital breakdown has received little attention internationally. Many believe it does not exist in this context and regard it as just a "gambit in the divorce wars." Recently, however, family courts in a number of countries have become concerned over the management of child abuse allegations in custody and access cases, known more commonly now as residence and contact cases. This article presents a unique research study, which investigated how the Family Court of Australia dealt with such cases. The study, covering all forms of child abuse, sought to discover who were the families bringing these problems to family courts, what precisely the abuse was and how the courts dealt with it. METHOD: The study reviewed court records of some 200 families where child abuse allegations had been made in custody and access disputes in jurisdictions in two states, observed court proceedings and interviewed court and related services' staff. RESULTS: The findings showed that these cases had become a core component of the court's workload without any public or professional awareness of this change, that the abuse was real, that it was severe and serious, and that the courts and child protection services did not provide appropriate services to the families. CONCLUSION: A new specialized intervention system was developed based on the research and it is now being trialed and evaluated. The new intervention system contains features derived from the research findings that may be suitable internationally for implementation.     

Influence of the referral process by a child protective agency on the outcome of psychiatric-psychological assessments of child abuse/neglect cases

Many Child Protective agencies in the United States have guidelines for referring certain kinds of abuse/neglect cases for psychiatric-psychological assessments which leave up to the referring agent such decisions as: choice of assessor (psychiatrist, psychologist, other), purpose of evaluation, and part of the family system to be evaluated. In order to develop a more systematic approach to comprehensive evaluations of abusive families, the referral process from the Hawaii Child Protective Services Agency to a child guidance center was analyzed through chart review, and its influence on the outcome of psychiatric-psychological assessments was examined. Evaluations by psychiatrists were also compared with those of psychologists. The results showed that the great majority of the cases referred for assessment were victim-children and that recommendations paralleled this trend by being child rather than adult or family oriented. In addition, referral questions and resulting recommendations centered more on diagnosis than on issues of intervention (treatment, placement, legal needs), suggesting an underutilization of the assessors' clinical skills. Differences between psychiatrists and psychologists are also reported. These findings point to a need for greater commitment to family pathology. Implications for developing more effective referral guidelines and for training are discussed.     

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.     

Child care quality matters: how conclusions may vary with context

Three studies examined associations between early child care and child outcomes among families different from those in the National Institute of Child Health and Human Development (NICHD) Early Child Care Research Network study. Results suggest that quality is an important influence on children's development and may be an important moderator of the amount of time in care. Thus, the generalizability of the NICHD findings may hinge on the context in which those results were obtained. These studies, conducted in three national contexts, with different regulatory climates, ranges of child care quality, and a diversity of family characteristics, suggest a need for more complete estimates of how both quality and quantity of child care may influence a range of young children's developmental outcomes.     

Identified spouse abuse as a risk factor for child abuse

CONTEXT: There are limited data on the extent to which spouse abuse in a family is a risk factor for child abuse. OBJECTIVE: To estimate the subsequent relative risk of child abuse in families with a report of spouse abuse compared with other families. DESIGN: Cohort study. SETTING: Analysis of a centralized US Army database PARTICIPANTS: Married couples with children with at least one spouse on active duty in the US Army during 1989-95. MAIN OUTCOME MEASURES: The US Army Family Advocacy Program's Central Database was used to identify child and spouse abuse. The exposure was an episode of identified spouse abuse and the main outcome was a substantiated episode of subsequent child abuse.RESULTS: During the study period of an estimated 2,019,949 person years, 14,270 incident child abuse cases were substantiated. Families with an incident case of spouse abuse identified during the study period were twice as likely to have a substantiated report of child abuse compaired with other military families, rate ratio, 2.0, (95% confidence interval [CI] 1.9-2.1). Young parental age had the highest rate ratio, 4.9 (95% CI 4.5-5.3) in the subgroup analysis controlling for rank. Identified spouse abuse was associated with physical abuse of a child, rate ratio 2.4 (95% CI 2.2-2.5), and with sexual abuse of a child, rate ratio 1.5 (95% CI 1.3-1.7). Identified spouse abuse was not associated with child neglect or maltreatment, rate ratio, 1.0 95% CI 0.9-1.1) CONCLUSION: An identified episode of spouse abuse in a family appears to be associated with an increased risk of subsequent child abuse and serves as an independent risk factor. Therefore. care providers should consider the potential risk to children when dealing with spouse abuse.     

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.     

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.     

Family and child factors related to the use of non-maternal infant care: An English study

This paper explores factors related to the use, amount and type of non-maternal child care infants experience in their first year, reporting on a prospective longitudinal study of 1201 families recruited from two different regions in England. The selection and timing of non-maternal child care was investigated within a socio-ecological model that took account of child and family characteristics as well as maternal psychological factors. Family socio-demographic background (education, occupation and income level) was the most consistent predictor of the amount and nature of non-maternal care infants received. Infants who started in non-maternal child care before the age of 3 months were more likely to come from relatively disadvantaged families; in contrast the mothers of infants starting in child care between 4 and 10 months were more advantaged. Disadvantaged families were more likely to use familial care, while more advantaged families were likely to use purchased child care. Children who began non-maternal care later (3–10 months) and spent more hours in care were more likely to be from ethnic minorities (Asian) and have mothers who believed that maternal employment had more benefits and fewer risks for their child. First born children were also more likely to experience non-maternal care after the age of 3 months. Infants rated by their mothers at 3 months as less ‘adaptable’ in temperament and at 10 months as more ‘fussy’ spent more hours in child care. Finally, the type of child care selected was related to the families’ socio-economic background, maternal beliefs and attitudes, and birth order. Findings are compared with the US large scale National Institute of Child Health and Human Development (NICHD) study and considered in the light of national policies.     

Characteristics of hospital-based Munchausen Syndrome by Proxy in Japan

OBJECTIVE: This article explores characteristics of Munchausen Syndrome by Proxy (MSBP) in Japan, a country which provides an egalitarian, low cost, and easy-access health care system. METHODS: We sent a questionnaire survey to 11 leading doctors in the child abuse field in Japan, each located in different hospital-based sites. Child abuse doctors answered questions regarding the characteristics of MSBP cases for whom they had helped care. RESULTS: Twenty-one MSBP cases (20 families) were reported. Characteristics of the victims included: no differences based on sex, 4.6 years of age on average when MSBP was confirmed, and an average of 1.9 years duration of MSBP abuse. Biological mothers were at least one of the perpetrators in 95% of cases. Among the 12 cases (57%) who remained with their families, 2 victims died. Only 5% of perpetrators had a medical background or relatives who engaged in healthcare work. CONCLUSION: There are similar features of MSBP cases between Japan and other English-speaking countries, such as the UK or the US. However, perpetrators of MSBP in Japan did not have a medical background. Easier access to hospital resources in Japan may give greater opportunities for perpetrators to obtain medical knowledge from doctors or nurses. PRACTICE IMPLICATIONS: The findings suggest that perpetrators of MSBP should not be assumed to possess a medical background in a country which provides universal medical care such as Japan. A contributory factor of MSBP may be the high frequency of medical consultations and equal level of accessibility of medical resources for Japanese citizens. Social welfare services that need to decide on custody for MSBP victims should recognize the relatively high risk of life-threatening danger in their family of origin. Further collaboration between hospital staff including pediatricians, nurses, medical social workers and staff at the social welfare services is needed to protect children from MSBP.     

Profile of abused and neglected American Indian children in the Southwest

From both knowledge gained working in Indian communities and a major data collection program, this article examines child abuse and neglect among the Indian tribes in a southwestern state. The period of study covers 1982 through 1985. The study sample consists of 53 children targeted by the local Indian Health Service Hospital Child Protection Team as being abused and/or neglected. In addition, information on the parents, grandparents and, in a number of cases, great-grandparents are examined. The study is a secondary data analysis of clinic and hospital records and interviews with local community health care providers and tribal officials. The results indicate that alcohol abuse was present in 85% of the neglect cases and in 63% of the abuse cases. In addition, child abuse and neglect occurred simultaneously in 65% of the sample. Child abuse and neglect are found to be part of a larger phenomenon of multiproblem families which raises the issue of intergenerational perpetuation of these problems. The results underscore the importance of interagency cooperation in surveillance, treatment, and prevention, as well as more careful and thorough documentation of record maintenance.     

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.     

Family walk-in centre—Eaton socon: Evaluation of a project on preventive intervention based in the community

The Family Walk-In Centre opened November 1978 as a pilot project at Eaton Socon in Cambridgeshire with the aims: to encourage parents to visit the centre on “their terms,” including parents who have abused or who fear they will abuse or neglect their child who may be difficult or handicapped, or because of chronic or acute family problems; further to mobilize “Self Help” groups and offer professional support. “Help” offered to the families included informal and formal group work, family casework and education in social and physical skills. Volunteer and professional support was given at the Centre and at home. Close liaison with specialist agencies was maintained to enable families to receive appropriate help. Periodic reviews and visits were made to maintain contact. An analysis of 50 families who attended the Centre between October 1979 and May 1980 was made to assess: the attendance and reattendance rate which indicated their acceptance of help offered and their motivation to use the Centre; the types of problems presented to the Centre, the types of action taken, the progress made when reviewed after three months and the degree of involvement by the volunteers. A final analysis will comprise 100 families. A preliminary summary found: significant reduction in the registration of new cases of child abuse; self-referrals exceeded significantly other modes of referral; loneliness and parenting difficulties formed the major proportion of families seeking help; 48% of families continued to attend for 3 months or more; work done centered upon discussion of parenting problems in 30% of the cases and involvement in activities with other families in 28%; 18% were assessed as showing improved child care after 3 months. The children are being monitored and will be assessed when they enter the infant school.     

Community characteristics associated with child abuse in Iowa

PROBLEM: Various demographic and community characteristics are associated with child abuse rates in national and urban samples, but similar analyses have not been done within rural areas. This study analyzes the relationships between reported and substantiated rates of child abuse and county demographic, health care resource and social services factors in a predominantly rural state in the US. METHODS: County-level data from Iowa between 1984-1993 were analyzed for associations between county characteristics and rates of child abuse using univariate correlations and multivariate stagewise regression analysis. Population-adjusted rates of reported and substantiated child abuse were correlated with rates of children in poverty, single-parent families, marriage and divorce, unemployment, high-school dropouts, median family income, elder abuse, birth and death rates, numbers of physicians and other healthcare providers, hospital, social workers, and number of caseworkers in the Department of Human Services. RESULTS: Rates of single-parent families, divorce and elder abuse were significantly associated with reported and substantiated child abuse in multivariate analysis, while economic and most health care factors were not. Reporting and substantiation rates differed across districts after adjustment for multiple factors including caseworker workload. CONCLUSIONS: In this rural state, family structure is more significantly associated with child abuse report and substantiation rates than are socioeconomic factors. The level of health care resources in a county does not appear to affect these rates.     

Determinants of foster care placement for the maltreated child

This study examined the records of the North Carolina Central Registry of Child Abuse and Neglect to determine which social, family, and child characteristics were most influential in the decision to place a child in foster care. These records contained all theoretically relevant factors as well as demographic data. Analysis included the computation of odds ratios for foster care for each of 250 variables. A maximum likelihood logistic regression model was constructed to obtain the independent and cumulative contribution of each factor. Some expected variables such as parental stress factors (substance abuse) and types of abuse (burns and scalds) placed a child at a significant risk for placement in foster care (p < 0.01). However, less obvious factors such as referral source (law enforcement agencies) or geographic area also placed children at risk. Overall, the model explained little of the variance of these decisions (R² = 0.168) and poorly predicted placement (sensitivity 66.3 per cent, specificity 74.6 per cent). Using existing data. we were unable to adequately describe the decision process in selecting foster care.     

Child maltreatment and perceived family environment as risk factors for adult rape: is child sexual abuse the most salient experience?

OBJECTIVE: Child maltreatment and family functioning were examined as predictors of adult rape in a sample of 925 college women. METHOD: Information was obtained from retrospective self-report questionnaires. Child sexual abuse (CSA) was assessed with the Life Experiences Questionnaire, child emotional abuse (CEA) and physical abuse (CPA) were assessed with the Childhood Trauma Questionnaire, family functioning was assessed with the Family Environment Scale, and adult rape was assessed with the Sexual Experiences Survey. RESULTS: Approximately 17% of women reported a history of any form of child abuse: 8.9% reported CSA, 4.2% reported CPA, and 8.6% reported CEA. Fifteen percent of participants reported a history of rape since age 17. CSA and CEA, but not CPA, were related to adult rape. Experiencing multiple forms of child abuse increased the risk of adult rape. Logistic regression analyses indicated that CSA predicted adult rape (OR=1.9). Further, low levels of family cohesion predicted adult rape only in the absence of CEA (OR=1.2), and low levels of emotional expressiveness in the family predicted adult rape only in the presence of CEA (OR=1.4). CONCLUSIONS: Findings highlight the need to consider multiple forms of child abuse as well as family functioning in relation to the risk of adult sexual victimization. Findings suggest CSA is a risk factor for adult victimization independent of family functioning, and family dysfunction exerts an impact on rape only in relation to CEA.     

Nine years after child sexual abuse

OBJECTIVE: During 1988-1990, 103 children presented to Child Protection Units (CPU) at two children's hospitals in Sydney, Australia. Nine years later, the psychological adjustment of these young people (mean age=19.1 years, SD=3.4 years; range=14-25 years) was compared with that of non-abused young people of similar age and gender to assess group differences and examine potential risk factors. METHOD: At intake, data on the nature of the index sexual abuse, demographics and the family environment were collected by clinicians. A comparison group, of similar age and gender, was selected from schools in the catchment area of the CPUs. Six years after presentation for the abuse, records of the statutory child protection authority were checked to determine any further notifications for abuse and/or neglect. Nine years after intake, 49 of the abused young people and 68 of the non-abused young people and/or their parents were interviewed and assessed. RESULTS: The sexually abused young people performed more poorly than non-abused young people on psychometric tests of depression (p=.001), self-esteem (p<.001), anxiety (p<.001), behavior (Child Behavior Checklist: p=.01; Youth Self Report: p=.01; Young Adult Self Report: p<.001), and despair (p=.001). They were also more likely to have a history of bingeing (p=.002), self-inducing vomiting (p=.02), smoking cigarettes (p=.01), and using amphetamines (p=.002), ecstasy (p=.002) and cocaine (p=.004). Potential risk factors were in two groups, family and child. Family factors: family functioning, parental drug/alcohol problems, mother's sexual abuse history, mother's depression and socio-economic status. Child factors: despair and hopefulness, number of negative life events, ratings of their father's care, previous notifications for child sexual abuse and placements in out-of-home care by the statutory child protection authority. In the presence of other risk factors, child sexual abuse was a significant predictor of self-esteem, behavior and bingeing. CONCLUSIONS: Rather than focusing only on the individual's child sexual abuse, treatment may also need to address the family's functioning and the individual's feelings of despair.     

Homelessness in the child welfare system: A randomized controlled trial to assess the impact of housing subsidies on foster care placements and costs

Inadequate housing and homelessness among families represent a substantial challenge for child and adolescent well-being. Child welfare services confront housing that threatens placement into foster care with little resources and evidence to guide practice. The present study provides the first rigorous test of the Family Unification Program (FUP) – a federal program that offers housing subsidies for inadequately housed families under investigation for child maltreatment. A randomized controlled trial assesses program impact on foster care placement and costs.The experiment referred intact child welfare-involved families whose inadequate housing threatened foster placement in Chicago, IL to FUP plus housing advocacy (n = 89 families with 257 children) or housing advocacy alone (n = 89 families with 257 children). Families were referred from 2011 to 2013, and administrative data recorded dates and costs of foster placements over a 3-year follow-up. Intent-to-treat analyses suggested families randomly assigned for FUP exhibited slower increases in rates of foster placement following housing intervention compared with families referred for housing advocacy alone. The program generates average savings of nearly $500 per family per year to the foster care system. Housing subsidies provide the foster care system small but significant benefits for keeping homeless families together. Findings inform the design of a coordinated child welfare response to housing insecurity.