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Lecture: Maltreatment

by: Brianda Hickey

Lecture: Maltreatment V05.0203

Brianda Hickey

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A detailed set of notes covering the maltreatment of children
When the Nightmare Is Real: Trauma In Childhood and Adolescence
Adam Brown
Class Notes
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This 12 page Class Notes was uploaded by Brianda Hickey on Wednesday March 9, 2016. The Class Notes belongs to V05.0203 at NYU School of Medicine taught by Adam Brown in Spring 2016. Since its upload, it has received 18 views. For similar materials see When the Nightmare Is Real: Trauma In Childhood and Adolescence in Cinema And Media Studies at NYU School of Medicine.


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Date Created: 03/09/16
Lecture: Maltreatment Physical: The use of physical forces against a child Sexual Abuse: engaging a child in sexual acts. It includes folding, rape, and exposing a child to other sexual activities forcing a cild to watch porn, live sex, media sex Emotional Abuse : behaviors that harm a chi;d’s self-worth or emotional well-being. name calling shaming rejection Neglect: failure to meet a child’s basic needs housing, food, clothing, education, access to medical care Over lap between Emotional Abuse and Emotional Neglect Emotional Neglect: withholding positive affection Emotional Abuse: name calling, cruelty Why is Understanding, Detecting and Treating Child Abuse So Important? Epidemiology 3 million referrals made to child protective services (CPS) agencies each year approx. 1 mil are substantiated cases of child maltreatment General Public: have the option to report child maltreatment, do not have to People’s whose job it is to be responsible for the welfare of children: are mandated to report child maltreatment to CPS Licensed professionals can jeopardize their license if they do not call ex. Police officiers, doctor, camp counselor CPS may or may not accept the call Is not accepted…. evidence is too weak Is accepted… the local field office will go to investigate Can still be unsubstantiated... the call was made falsely The parents quickly cover up the maltreatment There was actually no abuse Three main arms of CPS: Preventive Services: Try to keep family together instead oaf removing the child, supports are put in to help the caregiver to be a better parent Child Protection: Investigate Foster Care: Child is reassigned Many children were victims of more than one time In 2012, 1,640 children in the US died due to child abuse or neglect Not all instances of maltreatment are reported to CPS and not all reports are verifiable Effects of Child Maltreatment 55% of child and adolescent inpatients have a history of abuse Nearly two thirds of people in drug treatment programs reported being abused as children Puts you at great risk: Arrest Drug/alcohol addiction Psychological damage Defining Abuse and Neglect There is a lack of consensus on what constitutes child maltreatment Maltreatment definition and classification schemes vary over time, across cultures and geographic boundaries, and by professional discipline Every state has its own legal def. of child abuse Is it neglect if the family does not believe in medical medicine/blood transfusions? Definition: AACAP Neglect: caretakers fail to provide for and protect child (ex. failing to meet the child’s nutritional supervision or medical needs) If a child is getting their basic needs met, but need a little more attention: creates a fuzzy line of if the call to CPS will accept or not The child may not really be at risk of harm Physical Abuse: Intentional injury of a child by a caretaker (ex. skiing, beating, or other types of violence that lead to injury) Sexual Abuse: Sexual behavior between child and an adult or between two children when one is significantly older Is it sexual abuse if two 7 year olds play doctor and one goes home saying the other 7 year old made them…is that sexual abuse? If an 17 year old and 18 year old have sex, the 18 year old may go to prison…the 17 year old is not legally considered able to give consent Gender plays a factor Psychological Abuse: When a caregiver repeatedly conveys to a child that he or she is worthless defective unloved or unwanted Physical Abuse-New York ‘Abused child’means a child younger than age 18 whose parent or other person legally responsible for his or her care Inflicts or allows to be inflicted upon such child physical injury by other than accidental means that causes or creates a substantial risk of death, serious or protracted disfigurement, protracted impairment of physical or emotional health, or protracted loss or impairment of the function of any bodily organ. Creates or allows to be created a substantial risk of physical injury to such child by other than accidental means that would be likely to cause death, serious or protracted disfigurement, protracted impairment of physical or emotional health, or protracted loss or impairment of the function of any bodily organ Thoughts: What about developmental level? what if someone is in their 20s and they are functioning at a level of a child? There is Adult Protection Services The line between neglect vs accidental can be blurry need to learn when to be concerned and when not to be concerned Children can fall, hurt themselves on accident “inflect or allows to be inflicted” Not only the person who inflicted the abuse, but also the consent for someone else to inflict upon the child Physical Abuse - Texas ‘Abuse’means the following acts or omissions by a person: Physical injury that results in substantial harm to the child or the genuine threat of substantial harm from physical injury to the child, including an injury that is at variance with the history or explanation given and excluding an accident or reasonable discipline by a parent, guardian, or conservator that does not expose the child to a substantial risk of harm Failure to make a reasonable effort to prevent an action by another person that results in physical injury or substantial harm to the child The current use by a person of a controlled substance in a manner or to the extent that the use results in physical, mental, or emotional injury to a child Causing, expressly permitting, or encouraging a child to use a controlled substance Exception: Abuse does not include reasonable discipline by a parent that does not expose the child to substantial risk of harm. Thoughts: The exception allows for a lot of uncertainty, allows the parent to decide how to parent their child (including abusing the child) This general of a law makes it difficult to apply it over everyone Physical Abuse- Hawaii Child exhibits evidence of any of the following injuries: and such not justifiably explained, or when the history given concerning such condition or death is at variance with the degree or type of such condition, or circumstances indicate that such condition or death may not be the product of an accidental occurrence: Substantial or multiple skin bruising or any other internal bleeding Any injury to skin causing substantial bleeding Malnutrition or failure to thrive Burns or poisoning Fracture of any bone Subdural hematoma or soft tissue swelling Extreme pain or mental distress Gross degradation Death Thoughts: A big focus on physical injuries, but mental distress is low/diminished Complexity of the Definition Some consider physical punishment a necessary and effective form of discipline whereas for others any type of corporal punishment is unacceptable Cultural considerations A hispanic family spanks kids and believes it is okay to, although it is against the law Preventive Services can step in to educate the family that although it is okay int heir culture/country, it is not healthy/healpful for the child Implications of socioeconomic status The perception of the person doing the investigation changes per socioeconomic status Race, Culture, and Maltreatment Children with similar maltreatment histories may be more or less likely to come into contact with CPS based on race/ethnicity African American, Latino, and Native American children are overrepresented in CPS Asian American children may be underrepresented AA children in CWS report lower rates of moderate/severe maltreatment than White children W children more likely to report severe emotional abuse After controlling for demographics and maltreatment history, AA children 12 times more likely to be played in foster care Asian/Pacific Islander youth less likely to subjectively label emotionally and physically punitive parental acts as “abuse” Whether punitive practices were labeled as “abuse” did not matter Negative consequences access groups Stronger relationship between parent behavior and youth distress in ethnic minority youth Is Corporal Punishment Always Abusive? Corporal Punishment Until recently physical punishment was considered an appropriate form of discipline In 1992, 70% of family physicians and 59% of pediatricians supported mild spanking in some situations Spanking still remains a controversial issue Spanking is more likely to be used by parents who are younger, less educated of lower income, single, and/or more dressed and stressed Some child characteristics place them t higher risk of being spanked (ex. developmental delays, disruptive behavior) A study followed 2,500 toddlers from low income While, AA< MA families to determine if non-abusive spanking caused increased aggression children The researchers reported a difference in rates of spanking according to race and level of acculturation younger maternal age, maternal depression, lower family income, living alone, having a male child and a child’s “fussiness”predicted frequent spanking spanking at age of 1 predicted child aggressive behavior problems at age 2 and lower cognitive development scores at age 3 When spanked at 1, the brain is much more under developed than a child spanked at 2 years old and thus is developmentally delayed A meta-analysis of 88 studies found that, almost without exception, there is a negative relationship between "normative" physical punishment and children's mental health Although spanking is usually followed by short term compliance, it does not lead to new learning, it can lead to more aggressive children and the desired behavior is not usually present when the punitive parent is not around The American Academy of Pediatrics “Although spanking may immediately reduce or stop an undesired behavior, its effectiveness decreases with subsequent use. The only way to maintain the initial effect of spanking is to systematically increase the intensity with which it is delivered, which can quickly escalate into abuse.” Effects of child Maltreatment Physical punishment has been consistently associated with poorer child and adult mental health, including depression, aggression, poor attachment, poor school achievement, unhappiness, anxiety and feelings of hopelessness rather than teaching children right from wrong, physical punishment predicts weaker internalization more values ex. empathy, altruismo, resistance to temptation Parental Thoughts on Child Abuse Child physical maltreatment most often results not from sadism or desire to harm, but from intent to punish or teach The strongest predictor of adult approval of a particular punishment is having experienced that punishment as a child Many times parents are unaware of normal development and have unrealistic expectations on what their child is able to understand or control (e.g. bed wetting, motor control, impulse -control, social rules and expectations) How can parental beliefs be changed in a positive way? A study looked at factors that predicted less physical punishment in a group of parents Three key factors that led to positive change were identified The first was parents' realization of how their children feel when they are spanked The second was some parents' acknowledgement of their own childhood memories of being hit The third was the availability of information and instruction through a supportive context to help parents adopt new approaches to disciplining their children Prevention Services for Child Maltreatment Start by detecting it Traumatized children are often identified and/or mislabeled as 'behavior and discipline problems' in childcare and school settings, where their maltreatment is also routinely unrecognized. Providers in all of these diverse service systems have not been sufficiently trained to know and identify the traumatic origins of the children's presenting difficulties. Detection and Disclosure of Abuse extremely rare for an abused child to report the abuse spontaneously Many children are unable to see it as abuse and frequently blame themselves for it The rate of detection increases dramatically when children are asked directly, with open ended questions and are allowed time to answer When a child discloses abuse, it is the health provider’s obligation to report it to the authorities and to determine if the child is in imminent danger to return home Fear of entering the system, police reports, or more marital tension affect parent’s decision to seek help for their children Child Protective Services Most reports from schools, social service providers Allegations: 61% neglect, 12% physical abuse, 7% educational neglect, 2% sexual abuse, 3% medical neglect, 15% other Many reports duo not result in indicated cases only 19% of investigations lead to filing a court petition Only 40% of court cases result in removal all removals have to approved by Family Court Most removals proceeded by Child Safety Conference Preventive Servises In-home services to families at risk of foster care placement- functions as social safety net most services voluntary 75+% of families referred by child protection joint focus on needs of parents and safety of children Case management, some on-site services new levels of care in 2011 contracts mandates for health and mental health not as strong as for foster care 12-month length of service goal In-Home general preventive Family treatment/rehabilitation Specialized Programs EBPs/EIPs Medical and DD Deaf/hard of hearing Sexually exploited youth SAOY Community-Based family-based respite center-based respite both have 21-day limit Foster Care Services Adoption and Safe Families Act – 1997 Designed to keep children from “growing up in care” Must file to terminate parental rights if child has been in foster care for of past 22 months Exceptions for various circumstances Privatized system in NYC – foster care agencies responsible for meeting day-to- day needs of child Range of placements, from “regular”family foster care to residential placements Focus on family placements, permanency for all ages New levels of care in 2011 contracts Foster care agencies must provide initial and routine health and mental health screenings, including trauma screening Foster Care regular -recruited and kinship homes Treatment Family Foster Care (TFFC) Specialized Family Foster Care medical needs ID/DD Sexually exploited youth SAOY Residential Programs group homes rapid intervention centers residential treatment centers (RTCs) SED Medical needs ID/DD sexually exploited youth SAOY Foster Care System How does a child enter the system? Investigation and assessment of family circumstances result in recommendations about what the family needs Such plans may include parenting classes, substance abuse treatment Compliance with plan and concern about risk to children determine whether children remain in foster care, are returned to biological family, or are placed for adoption Facts about foster care About 600, 000 children are in foster care in any given year 6% are younger than 1 year 26% are between 1-5 years 20% are between 6-10 years 28% are between 11-15 years 18% are between 16-18 years Bridges to Health (B2H) Medicaid Waiver Program home and community based services available to children in foster care, can continue after reunification/adoption services also available to children in juvenile justice system Three service populations seriously emotionally disturbed ID/DD Medically fragile Designed to support - not replace- existing clinical and child welfare services What happens to children while they are in foster care? Facts about foster care The average number of foster homes a child is in while in care is 3 59% return to birth parents 16% are adopted 10% are living with other relatives 7% are emancipated 3% in guardianship 5% other Since 1997, there is a federal law requiring that children achieve permanency within one year of being removed from home Due to this law, adoptions increased by 78% from 1996 to 2000 However, most kids in foster care wait years before being adopted Factors that Increase Risk of Child Maltreatment and Entry into Foster Care Factors that lead to child removal Stress parental substance use psychopathology poverty and violence are frequently present in cases of child abue Maternal Mental Illness Serious mental illness in mothers is associated with poor parenting and decreased nurturance Maternal well being is very important in the development of psychopathology in young children Parenting effects of maternal mental illness on children attachment cognition: maternal depression associated with lower IQ and attention problems in offspring Behavior: behavioral problems are more common among children of women with mental illnesses Excessive/ineffective discipline Abuse/neglect Parental Substance Use Substance abuse is a factor in at least 75% of all cases in children in out of home care Data form the 1996 National Household Survey on Drug Abuse (NHSDA) reveal that 8.3 million or 11% of all children in the US live in household in which at least one parent is either alcoholic or in nee do substance abuse treatment Children of parents with substance abuse problems who are in the CWS tend to be younger are more likely to be victims of severe and chronic neglect have families with more problems overall Adults with a history of alcohol or drug problems 3 times more likely to physically abuse their children more than 4 times more likely to neglect compared to control subjects How does alcohol lead to abuse? Miscommunication among family members overestimation of a perceived threat underestimation of consequences for aggression Increase int he likelihood of violence Suppression of brain centers responsible for the control of socially unacceptable behaviors Parental Substance abuse 64% of substance abusing women report having been sexually or physically abused (3x the general rate) Even with interventions, 50% of children of drug-abusing women enter Child Protective Services after 5 years of follow-up Alcohol and nicotine most commonly used during pregnancy Domestic Violence Children who have been exposed to domestic violence are 158% more likely to be victimized by violence themselves than counterparts from non-violent households Battered women are more likely to abuse their children than non-battered women Battered women frequently don’t seek out help direct threat to the integrity of her family removal of the violent partner possible removal of her children Treatment of domestic violence is challenging couple therapy approaches concern about ongoing violence anger management Barriers to seeking services stigma, poverty, financial insecurity, inadequate housing, scarcity of jobs, and lack of reliable and affordable childcare needed to take on regular employment New York State - Child Abuse Definition An "abused child" is a child whose parent or other person legally responsible for his/her care inflicts upon the child serious physical injury, creates a substantial risk of serious physical injury, or commits an act of sex abuse against the child. Not only can a person be abusive to a child if they perpetrate any of these actions against a child in their care, they can be guilty of abusing a child if they allow someone else to do these things to that child. Child Abuse is defined in law at Section 412 of the Social Services Law and at Section 1012 of the Family Court Act. New York State- Maltreatment Definition Maltreatment refers to the quality of care a child is receiving from those responsible for him/her. Maltreatment occurs when a parent or other person legally responsible for the care of a child harms a child, or places a child in imminent danger of harm by failing to exercise the minimum degree of care in providing the child with any of the following: food, clothing, shelter, education or medical care when financially able to do so. Maltreatment can also result from abandonment of a child or from not providing adequate supervision for the child. Further, a child may be maltreated if a parent engages in excessive use of drugs or alcohol such that it interferes with their ability to adequately supervise the child. Neglect is defined in law at Section 1012 of the Family Court Act. Maltreatment is defined in law at Section 412 of the Social Services Law. Trauma and the Child Welfare System Impact of Trauma Among children in foster care - The cycle 1. Youth experiences trauma 2. youth feels unsafe 3. youth reacts 4. caregiver, system feels unable to manage 5. replacement 6. begin again at step one Impact of Trauma Among Children Welfare - Involved Parents child abuse potential punitive behavior psychological aggression distorted perception of one’s child personalize negative behavior misunderstanding of developmental limitations/delays Increased behavior problems Impact of Trauma Among Child Welfare Staff Cognitive Effects: negative bias, pessimism loss of perspective, critical thinking skills threat focus - see clients, peers, supervisors as enemy decreased self-monitoring Social Impact: reduction in collaboration withdrawal and loss of social support factionalism Emotional Impact Helplessness Hopelessness Feeling overwhelmed Physical Impact headaches tense muscles stomachaches Fatigue/sleep difficulties Factors that result in poor child welfare outcomes impact on ability to assess safety and risk distrust among colleagues and supervisors, between staff and foster parents decreased motivation, increased absenteeism and attrition inability to manage children’s reactions lack of psychological after for children, caregivers, staff Challenges providing Trauma Treatment to Child Welfare-Involved Children most existing treatments focus on needs of children and assume stability of parent Lack of consistency in caregivers challenges in cross-system communication, coordination some aspects of trauma ongoing, hard to process/resolve trauma while child is still feeling unsafe Adult mental health treatment and child welfare clients adults mental health treatment does not typically involve family focus barriers to engagement of child welfare-involved parents lack of flexibility from the mental health agencies, stigma and other issues Limited availability of adult trauma treatment services Efforts to Advance Trauma- Informed Child Welfare Practice Atlas Project Applying a trauma lens across the system guide for the staff that work with children and families who have experienced trauma and other mental health challenges support to children and families as they move towards safety and permanence National Child Traumatic Stress Network The mission of the National Child Traumatic Stress Network (NCTSN) is to raise the standard of care and improve access to services for traumatized children, their families and communities throughout the United States Child Welfare Practice Laboratories CWPLs are partnerships between NCTSN sites and child welfare partners where innovative practices, processes, and other improvement vehicles related to child welfare systems are developed, implemented, and evaluated with a view to wide spread scale-up CWPLs are established locally and implement approaches to improve quality in the local setting so that both child welfare clients and workforce members may benefit The ultimate goal is to develop knowledge based on the local implementation that can lead to much broader scale up of quality trauma-focused improvement initiatives NCTSN Child Welfare Committee Helping children in the Child Welfare System Heal From trauma: A System Integration Approach (2005) Caring for Children Who Have Experienced Trauma: A Workshop for Resource Parents (2010) Breakthrough Series Collaborative focused on foster care placement stability (2010-2012) Fact sheets on birth parent trauma (2011-2012) Child Welfare Trauma Training Tool Kit (2013)


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